Over the last decade, access to competent medical care has been among the primary demands of those seeking to improve the lives of transgender Americans. Multiple studies have demonstrated what many trans- people know from experience: trans- folks are more likely than others to be denied primary and emergency care because of their gender non-conformity; they’re often required to teach well meaning but undereducated providers about their healthcare needs; and they frequently struggle to find clinicians who can provide transition-related mental health, medical, and surgical care. These challenges are exacerbated for those living outside urban centers and those lacking financial resources including relevant insurance coverage.
Multiple institutions across the US are struggling to meet a growing demand for transgender healthcare. In addition to the logistical challenges of integrating a form of medicine that has been explicitly excluded for decades—building clinical capacity, drafting policies, streamlining workflows, and hiring personnel—they are also confronting the many ways that the practice of trans- medicine has shifted since the last time trans- clinics were centered in major hospitals in the 1960s–70s. During that period, patient eligibility was determined by clinicians whose idiosyncratic and conservative views of gender earned them reputations as antagonistic gatekeepers. Prospective patients received treatment on the condition of repeating well-worn scripts about their motivations and intentions for transition, and the medical and surgical care they received was equally scripted. University-based gender clinics in the US closed down in the early 1980s, and decades of private-practice medicine, political activism, and patient advocacy have changed what it means to receive and provide transition-related care today.
The clinician-centric gatekeeping model is increasingly giving way to approaches that privilege patients’ informed consent and prioritize harm reduction. Once strict rules that regarded patients with suspicion, now the World Professional Association for Transgender Health’s Standards of Care are guidelines that leave room for clinical judgment and patient experience. These changes reflect a number of factors, principal among them are an evolving American discourse about sex and gender as concepts and embodied realities.
It is not surprising that when it became possible for trans- people to deviate from the script that had been required to access care, they did. As a result, what it means to “transition” has changed considerably since the diagnosis and treatment for transsexualism was first developed in the 1950s. My research on the politics and practice of transgender medicine is focused in clinical spaces and centers the requests that (prospective) trans- surgical patients make in their efforts to transition. In doing so, I move away from entrenched questions about diagnosis and justification and let patients’ desires and requests drive my understanding about what trans- medicine is and what it aims to do.
My book, The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine (set for publication this August by Duke University Press) examines the growing contemporary practice of facial feminization surgery (FFS), a set of bone and soft tissue reconstructive procedures intended to feminize the faces of trans- women. Often considered auxiliary and cosmetic in relation to the therapeutic change of sex enacted by genital reconstruction surgeries, patients who undergo FFS and the surgeons who perform their procedures argue that in changing their facial appearance and thus how they are recognized, FFS changes trans- women’s sex. FFS, I show in the book, is surgical sex reassignment for a performative theory of gender, one that understands sex and gender not as properties of individual bodies—as treatments for transsexualism once did—but as produced through acts of recognition. The central argument of the book is that as ideas shift about the kinds of things that sex and gender are, so do the interventions required to change them and the logic of medical practices intended to do so. Clinicians and administrators working to grow capacity for trans- medicine are confronting that shifting logic. With a constantly evolving definition of what trans- is as a diagnosis, what do medical interventions undertaken in its name aim to do? In practical terms, what is the trans- medicine for which advocates work? How would you or could you know that you’re doing it right?
Answers to that question form the core of any clinical practice. They anchor treatment justifications and schedules, and are critical to claims that particular procedures are “medically necessary” and thus covered by insurance. FFS advocates argue that if the aim of trans- medicine is to reduce the felt distress of gender dysphoria—and psychological documents argue that it is—then if facial surgery effectively reduces that distress, it ought to be considered not only clinically therapeutic but also medically necessary. Those claims, logical as they may be, push back against decades of trans- medicine that have focused on sex and gender as properties of individual bodies rather than products of social life. They also irritate boundaries between cosmetic and reconstructive procedures, and force parity-based arguments for trans- healthcare into a troubling cul-de-sac. If gender—and therefore potential gender distress—can be located throughout the body and differently for each person, how can technocratic medicine organize a response to trans- patients’ bodily dissatisfaction without also authorizing full body gender interventions for non-trans- people? Such bureaucratic and actuarial concerns determine the kind of thing gender distress is in the clinic and which interventions are legitimate responses to it.
In this new moment of institutionalization, anthropologists can play a crucial role in linking pasts and presents, and seeing how investments from patients, clinicians, administrators, and policy makers will shape how, as what, and to whom trans- medicine is available.
Eric Plemons is a medical anthropologist researching the politics and practice of transgender medicine. He is assistant professor in the school of anthropology at the University of Arizona.
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Cite as: Plemons, Eric. 2017. “Transforming Transgender Medicine in the US Prompts Questions of its Aims.” Anthropology News website, August 31, 2017. doi: 10.1111/AN.591