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Needed: A New Literature for a New Century (1997)

Needed: A New Literature for a New Century (1997)

©1997, 2013 by Dallas Denny

Source: Denny, Dallas. (1997). Needed: A new literature for a new century: A critique of the medical and psychological literature of transsexualism. Paper presented at the XV Harry Benjamin International Gender Dysphoria Association 15th Symposium: The State of Our Art and the State of Our Science, Vancouver, British Columbia, Canada, 10-13 September, 1997.

 

 

This paper was the basis for the above poster. I would like to thank Dr. Vern Bullough and Dr. Sandra Cole for their comments on an earlier version of this manuscript.

 

 Needed: A New Literature for a New Century

A Critique of the Medical and Psychological Literature of Transsexualism

By Dallas Denny

 

 International Journal of Transgenderism Web Page (PDF)

Related Presentation: “You Make Me Sick”

Abstract

The medical and psychological literature of transsexualism, which began in earnest in the wake of Hamburger et al.’s announcement of Christine Jorgensen’s sex reassignment some 48 years ago, consists chiefly of clinical reports and studies written by individuals without gender identity issues. It is a literature which has been historically based on a number of unfounded assumptions: that those with gender identity disorder (as transsexualism is now called) are mentally disturbed; that their destinies are best determined by mental health professionals; that only those who are profoundly unhappy in their birth gender should be allowed access to body-changing medical technologies, and then only after passing various tests required by psychotherapists; and that body-changing medical technologies should be used only in the service of altering bodies to resemble as closely as possible those of the “other” sex, with no intermediate states allowed or even conceivable. Only in the last few years has the literature begun to challenge its own assumptions.

The usually-unspoken assumptions which have driven the literature arose from the often unconscious attitudes of researchers and clinicians and have colored both public and private perceptions of transsexuals and transsexualism and set the course for the literature itself by determining not only the research questions asked, but the ways in which the resulting data have been interpreted. Cautionary voices of anthropologists, feminists, occasional clinicians, and transsexual people themselves have been virtually ignored by researchers and clinicians, and authors outside the medical and psychological mainstream have been forced to publish in journals not ordinarily read by physicians and psychologists. Questions of sexism, homophobia, experimenter bias, subject selection, and the imbalanced power dynamics of the client-caregiver relationship have not been addressed in the medical and psychological literature.

Until recently, the voices of transsexual and transgendered scholars were entirely absent from the discourse. Not surprisingly, the literature of transsexualism is largely pejorative, tending to blame and otherwise stigmatize transsexuals not only for their very transsexualism, but for shortcomings in research design and treatment. More than one researcher has blamed transsexuals for disappearing from follow-up— overlooking both past adversarial relationships between transsexual and researcher and the fact that transsexual subjects were told that to be successful they would have to break ties with their pasts and integrate into society, passing as nontranssexual (see Lothstein, 1982).

When the assumptions underlying this literature are understood, the literature’s failings can be seen to lie not so much in the inadequacies of transsexuals as in the inadequacies of researchers, in the shortcomings of the system which rose to treat and study transsexuals, and in the disenfranchisement of transsexuals themselves, who have been considered unworthy of contributing to the literature.

Much of the existing literature addresses in detail questions which no longer seem relevant. For instance, many studies have been designed to determine the ways in which transseuals vary from controls (i.e., “normal” individuals), and a great deal of effort has been expended in attempts to “manage” transsexualism and transsexuals themselves. Meanwhile, other, more important, questions remain unaddressed. We do not need further studies about the relative performance of transsexuals vs. control groups on the scales of the MMPI; we need studies which will define a new literature which is less bound to the notion of the inevitability of genital surgery and Ken and Barbie stereotypes of masculinity and femininity, which empowers transsexual people rather than degrading or stigmatizing them, and which asks new questions relevant to a new century.

 

Part I

Although people we would today characterize as gay, lesbian, bisexual, transgendered, and transsexual have always existed (cf. Feinberg, 1996; Taylor, 1996), it was not until the nineteenth century that they were came under the scrutiny of the medical profession [1]; that is, physicians selected them as fitting subjects for study and ascribed pathology to them. This is perhaps best exemplified in Krafft-Ebing’s (1894) Psychopathia Sexualis, in which one can read grim clinical depictions of century-ago analogs of modern-day homosexuals, transvestites, and transsexuals (Bullough & Bullough, 1993, pp. 204-207).

Initially, variations in sexual orientation and gender expression were considered by physicians to be different facets of the same disorder, a sort of “third sex” (Ulrichs, 1994). It was not until the publication in 1910 of Hirschfeld’s Die Transvestiten that the two were adequately differentiated.

During the first half of the twentieth century, the professional literature almost uniformly viewed homosexuality as a mental disorder. The work of Evelyn Hooker (cf. Hooker, 1957), the removal of homosexuality from the DSM-III in 1980 (Bayer, 1987), the pioneering work of Masters & Johnson (Vern Bullough, personal communication), and the rise of the gay liberation movement following the Stonewall Rebellion of 1969 (Duberman, 1993) did much to change this literature. These days, the acknowledged and unacknowledged assumptions of researchers about gay men and lesbians are quite different than in the past, and from the contemporary perspective much of the earlier literature seems naive and biased. The few medical professionals, like Charles Socarides, who continue to stubbornly insist without benefit of data that homosexuals are mentally ill are forced to seek alliances with organizations like the right-wing American Family Association and in fact begin to look rather troubled themselves (cf Socarides, 1996). This sort of change of paradigm (Kuhn, 1962) is not uncommon in science; in fact, it is perhaps our only real evidence that science actually works.

Since 1980, transsexualism (now called Gender Identity Disorder) has been codified in the DSM. Although gender-variant people have been heavily involved in the homosexual liberation movement since its earliest days, transsexuals have not benefitted, as have gay men and lesbians, by becoming demedicalized. Christine Jorgensen’s sex reassignment and its attendant publicity brought transsexualism firmly into the medical camp (Hamburger, et al., 1952). Suddenly there was a new type of person, one who sought access to medical technologies such as hormonal therapy and genital sex reassignment surgery in order to modify the body to resemble that of the other sex. Much of what has been published in professional journals since Jorgensen’s heyday concerns the medical management of these individuals. Papers abound on the morality—or lack thereof—of sex reassignment, the etiology, incidence, prevalence, mental state, and treatment of such people, and the outcome of sex reassignment surgery. The primary assumption of this medical and psychological literature is that anyone who wishes to have sex reassignment has an underlying mental disorder which causes great anguish, and that physicians and other professionals, who have been unable to cure this “disorder” with their armamentarium of psychoanalysis, behavior modification, pharmaceuticals and psychosurgery may be able to alleviate the pain of a select few individuals by granting them access to body-changing technologies. A corollary of this assumption is that psychological and mental health professionals must guard the gates, vigorously safeguarding those technologies, lest they be used by those who have not met the tests imposed on them by the medical and psychological community and are therefore undeserving of treatment. [2]

Harry Benjamin’s 1966 The Transsexual Phenomenon was the first serious attempt to provide a name and a theoretical framework to explain people who wished to gain access to these medical technologies. He called them transsexuals. The psychiatric condition he presumed them to have was first called transsexualism, then gender dysphoria (Fisk, 1973), and is now known as gender identity disorder (DSM-IVTR). By whatever name, transsexual people remain dependent upon the psychological and medical communities for often desperately desired medical treatment.

Transsexualism and Sex Reassignment, Green & Money’s 1969 edited text, was a multidisciplinary look at the newly conceived phenomenon of transsexualism; it provided a multidisciplinary treatment model followed by gender programs to this day. Benjamin’s and Green & Money’s volumes were milestones, holding up well after more than 30 years, but much of what has followed has been a virtual rehash. Denny (1993) has called this literature “a collection of papers by clinicians explaining to other clinicians how to deal with such troublesome people.” It is a literature bothersome in a variety of ways, but its primary shortcoming is that it has never examined in a systematic and rational way Benjamin’s model of transsexualism or looked at alternatives to the treatment system described in Transsexualism and Sex Reassignment. Consequently, the literature has come to consider transsexualism a condition discovered rather than invented (Denny, 1997a).

The existing literature has many problems. Its terms, its themes, its assumptions, and its language make it nearly impossible to discuss transsexuals or transsexualism in a healthy way. It is on the whole profoundly disrespectful of transsexual people, who are portrayed as sexual stereotypes, ridiculed for their behavior and manner of dress, and insulted in a variety of other ways both overt and covert. It actively promotes a model disempowering to transsexuals, who have been expected to surrender their autonomy to mental health professionals and then disavow their transsexualism by disappearing into the woodwork and passing as nontranssexuals after their gender transitions. And it has historically limited choices by recognizing only two options: remaining in the sex of original reassignment, or emulating as closely as possible the other sex. Much of the literature continues to ignore the fact that many transgendered individuals find it more comfortable in the nether ground between the two commonly acknowledged sexes.

 

The Enforced Absence of Transsexual Voices

One of the most profound but virtually unremarked problems with the literature of transsexualism is that it has excluded people with transsexualism from the discourse. Pat Califia (1997) writes:

… Transsexuals are stereotyped as patients undergoing sex reassignment, the troubled clients of psychotherapists…. This gives the experts a privileged voice and disenfranchises differently-gendered people. In autobiographical or fictional accounts, they may set down what they perceive to be true about themselves and the world around them, but it is the medical doctor, therapist, academic, or feminist theoretician who interpret “them” for the rest of “us,” and thus claim to be the voice of reality…. To be differently-gendered is to live within a discourse where other people are always investigating you, describing you, and speaking for you; and putting as much distance as possible between the expert speaker and the deviant and therefore deficient subject. (pp. 1-2)

Except for relating strictly autobiographical experiences, transsexuals have been considered to have had nothing important to say about transsexualism. I recently noted that until recently

“all major theoretical papers, all of the descriptive studies, and all of the textbooks about transsexualism were written by nontranssexual persons. This situation is analogous to the study of Black history and identity without the involvement of Black scholars, or of gay and lesbian history and identity without gay and lesbian scholars” (Denny, 1997b, p. 75).

The transgender revolution of the ’90s made it clear many transsexual persons view themselves in ways other than depicted in the medical and psychological literature (cf. Bornstein, 1994; Boswell, 1991), but have until recently been unable to share it with the world because their transsexualism had silenced them: first, under the prevailing reign, if they spoke the truth they were considered not to be “true” transsexuals and risked being denied access to body-changing medical technologies (see Bolin, 1988; Denny, 1992; Kessler & McKenna, 1978; and Stone, 1991 for critiques); and second, no one would publish their work. Is it any wonder perceptions of transsexuals and transsexualism have entered a period of profound change now their voices are being heard?

Even words that seemed as if they might have been written by transsexuals have been excluded from peer-review publications. Both Denny (1997b) and Cromwell (1997) have documented the rejection of a paper by Bolin; on the margin of one of the copies returned to her was the scrawled comment of a reviewer: “Obviously a transsexual.” Unwritten were the words, “… and so, this paper is inherently biased and not worthy of publication”). Acknowledging this problem, Richard Green (1997) noted of Denny’s 1997c edited text, “Startling as it is for me to think it, I wrote the conclusion to Transsexualism and Sex Reassignment about 25 years ago…. I am struck at the outset that the biggest change with this new text may be that it is edited by a transsexual.”

In the past few years, transsexual and transgendered scholars have begun to contribute meaningfully to the literature— and much of what they— I should say we, as I am proudly transsexual— have to say is dramatically different from what has previously been published. We tend to be influenced not only by the medical and psychological literature, but by feminist and queer theorists, by each other, and of course by our own experiences. Queer and transsexual and transgendered scholars bring a different vision to the table, for we tend to look at the desire to change one’s body and social role not as a sign of psychopathology, but as a form of self-expression not dissimilar to getting a tattoo or having a rhinoplasty. The problem, if any, is seen to lie not within the individual, but within a hostile and rejecting society (Califia, 1997; Wilchins, 1997). Gender identity disorder is a term coined by the medical community to ascribe pathology to what many transsexuals see as a healthy process of self-discovery and personal growth. In this view, much of the literature is flawed by the presumption of psychopathology, which causes in its adherents a peculiar tunnel vision in which transsexualism is considered a journey from one restrictive gender role to the other, equally restrictive role, and defines as nontranssexual any gender-variant person who does not fit the mold (Bolin, 1988; Denny, 1992; Stone, 1991). Transsexual and transgendered scholars reject this bipolar model, considering that acceptable gender space lies anywhere along the continuum between male and female, or off the continuum altogether (Boswell, 1991). The idea is not to produce new males and females who conform as closely as possible to sexist gender norms, but to help people unhappy in their assigned gender role find gendered space they find comfortable — wherever that may be.

My ultimate purpose in this paper is not to debate the merits of lack thereof of social-constructionist vs. essentialist approaches to transsexualism [3], but to give notice that it is time to turn a critical eye on the shortomings of the medical and psychological literature.

In Part II of this article, I will give examples of the ways in which the medical and psychological literature has pathologized, vilified and stereotyped transsexual men and women. I will use representative selections from the medical and psychological literature to illustrate my points; however, my quarrel is not with the individual authors, but with the literature itself. I have excluded, for the sake of space, as many passages as I have included.

Fortunately, as I will discuss in Part III, the medical and psychological literature is beginning to change.

 

Part II

Pejorative Passages in the Literature

Benjamin’s (1966) model of transsexualism has been attacked from a variety of perspectives, including psychiatry (Wiedemann, 1953; Socarides, 1976; McHugh, 1992), feminism (Greer, 1989; Raymond, 1979); social constructionism (Billings & Urban, 1982; MacKenzie, 1994) and Christianity (O’Donovan, 1982, 1984). The hostility of authors like Socarides, McHugh, Greer, and Raymond is without parallel in any field of science. Raymond (1979), for instance, writes of Dr. Renée Richards, “It takes (castrated) balls to play women’s tennis” (p. xiii). McHugh (1992) cited “the confusions imposed on society where these [transsexual] men/women insist on acceptance” and the sad caricature of the sexual reassigned” (pp. 503, 509). Socarides says of sex reassignment surgery, “The creation of Mary Shelley’s Frankenstein monster pales in comparison with this grotesque spare-parts, Tinker-Toy type of surgery practiced on living, suffering, and desperate human beings” (1976, p. 138).

Not surprisingly, none of these authors cite empirical evidence to document their outrageous claims, and none offer data of their own. [1] Their work is opinion disguised as science, allowed into print, apparently, by editors who either share their views or who were unable to see that their attacks were political, and not scientific, in nature.

But if the enemies of transsexualism have been uncritically critical, so, too, have many of its supposed proponents. Much of the supposedly objective literature is characterized by moral pronouncements, outrageous attacks on the nature and appearance of transsexual people, and the use of nomenclature and pronouns which are offensive (deliberately, in some cases) to transsexual people. This is but the visible tip, however, of what lies under the surface of a literature which presumes transsexuals are what the medical community has always supposed them to be: manipulative, dishonest, maladjusted, sexual stereotypes. It is a literature which gives permission to its authors to write whatever they wish about transsexuals, with no fear of censure.

Occasionally, authors will unabashedly state their moral distaste for sex reassignment. In 1974, Donald Laub and Norman Fisk began an article in the journal Plastic and Reconstructive Surgery with this sentence: “To change an individual’s God-given anatomic sex is a repugnant concept.” It goes without saying that such a gratuitous remark has no place in a surgical journal— or does it? Apparently, this amazing statement went entirely unremarked until 1991, when I pointed it out in an article in the journal Chrysalis.

Sometimes an author’s distaste for transsexuals will suddenly surface like a Freudian slip in an otherwise nonjudgemental descriptive passage, as in the second sentence of the following:

The realistic assessment of gender-dysphoric patients must take into account that there are some individuals who could never pass as members of the opposite sex, regardless of how skillfully they are dressed and made up. A six-foot-five, 300-pound trucker will never pass as a woman, but will always look like “a guy in drag.” — Steiner, 1990, p. 102

Less subtle was psychoanalyst Robert Stoller, who frequently and vociferously made known his concerns about sex reassignment. He punned, of transsexuals and sex reassignment, “After 30 years… both the treatments and the patients (of both sexes) have been, at most, near misses” (Stoller, 1982, p. 283). In this sentence, Stoller informs the reader of his opinion not only that sex reassignment is an ineffectual treatment, but that male-to-female transsexuals are not “really” women.

Tongue-in-cheek remarks like Stoller’s, above, are not uncommon. Witness Money and Primrose’s (1968) sly put-down of transsexuals:

Transsexuals… are distinguishable from females at large by their lack of special attraction to the helpless newborn and their imagery in coital fantasies. It is possible, though, that transsexuals will change their conception of the female stereotype to include these features after reading this article, since they are often influenced by reading about their condition. (p. 472)

Money & Primrose’s (1968) remark illustrates a phenomenon pointed out by sociologist Irving Goffman (1961, 1963): when an individual is stigmatized, whatever he or she does is interpreted and interpretable as problematic in light of the stigma. Thus, when transsexuals endeavor to learn more about their situation—a behavior that would be considered admirable in expectant mothers or individuals with sickle-cell anemia—their resourcefulness is viewed as emblematic of their condition and this view is shared in print with other medical and psychological professionals.

 

Terminology and Language Usage

Although not generally used maliciously, the medical and psychological literature is replete with terms which are considered offensive by transsexual and tarnsgendered people. The word transvestite has appeared frequently in the literature, but is used only infrequently in the transgender community, which used the less haughty term crossdresser. A survey and focus groups conducted by Cromwell, Green, & Denny (2001) found the terms male transsexual and female transsexual (which refer, respectively, to those assigned at birth as male and female) were considered offensive by transsexuals and nontranssexual transgendered people, who prefer terms like transsexual woman, transwoman, transman, and FTM.

In the medical and psychological literature, authors have wielded pronouns like swords, using them to express their disapproval and pronounce the “true” sex of transsexual people. By far the worst offenders are Janice Raymond and Leslie Lothstein. Raymond’s (1979) book is a political manifesto unconvincingly (and in my opinion unethically) disguised as science. Lothstein’s (1983) book on female-to-male transsexualism is egregiously offensive. He not only uses female pronouns to refer to subjects who have been living as men for years, but refuses to use their male names, calling them by their original female names, even though they no longer match either their appearance or the realities of their lives. “It was hard to believe that the cocky, self-assured ‘male’ sitting in the waiting room was really a biological female” (Lothstein, 1983, p. 95). Note how Lothstein uses quotation marks to tell the reader his subject is not “really” male.

Considering that Lothstein is a male with the first name of Leslie, one might think that he would be aware of the pain pronoun misattribution can cause. Should I turn the tables and refer to Ms. Lothstein and her regrettable book, turning Lothstein into a female on paper, it becomes clear to the reader just how disrespectful such pronoun misuse really is, and that I am attacking Lothstein on a personal basis. This is because it has long been considered appropriate for others to make decisions about which pronoun to use with transsexuals, regardless of the self-perception of the transsexuals themselves, but it is decidedly not okay to do so with nontranssexuals. Quite simply, the usual rules of propriety do not apply to transsexuals, and no one seems to notice that they have been set aside, even in the hallowed pages of medical and psychological journals.

 

The Blame Game

The behavior and appearance of transsexuals have been oft-criticized in the literature. Consider these passages:

The severity and intensity of some patients’ psychopathology and acting out were… revealed within the group, for example, two members brought loaded guns into the group (One member had to be forcibly restrained from using it!); auto- and mutual masturbation; exposure of breasts; an attempted kidnaping; several near-violent confrontations among group members which carried over outside the group (in which patients threatened each other physically and one patient drew a knife); innumerable sexual overtures to the therapists; patients bringing in pets (two dogs and a menagerie of land crabs); serious psychosomatic symptoms (including ulcerative, arthritic, hyperventilative, and cardiac distress). — Lothstein, 1979, p. 73 [2]

Most of our surgically treated patients had a long history of arrests and convictions for minor nonviolent crimes, especially prostitution…. In addition to a long history of petty criminal offenses, they dressed in dramatic seductive fashion, passed convincingly as women, had a history of passive participation in homosexual activity, and seemed to have fully adopted the feminine gender role late in adolescence. In addition they were manipulative, demanding, and therefore troublesome in their behavior…. Most of the patients in our series had histories of having taken drug overdoses and some had been hospitalized psychiatrically during their turbulent years preceding and just after beginning to live fulltime in the feminine role. — Stone, 1977, p. 26

In the literature, the choice of words, especially when used to describe transsexuals, has tended to reinforce the prejudices of authors and readers alike. Take a look at the word usage of Lothstein (1979) and Stone (1977), in the passages above. They tailor their language carefully to paint strong word pictures of clearly deviant individuals. Consider also the previous passage by Steiner, and the following, also from Steiner (1990):

Some biological males cross-dress in such a convincing manner, with discrete makeup and tasteful jewelry, that they “pass” as women without ever having commenced feminizing hormones. Others would pass if they were not so flamboyant! Strange esoteric hairdos and immensely long artificial nails like talons— usually painted a bright scarlet— may grossly exaggerate such patients’ appearance in a caricature of “femininity.” (p. 101)

It goes without saying that many nontranssexual women wear long nails, or are less than discrete with their hairdos, makeup and jewelry. The zeitgeist of the medical and psychological literature clearly gives Steiner license to ridicule the appearance and grooming of transsexual women in language she would never use if she were talking about nontranssexuals. Can you imagine the stir the above paragraph would have caused had it been applied to African-American or Republican women?

Of course, gender professionals’ own appearance is appropriate, whatever they choose to wear. For your amusement, the following, from a transgender community flyer, circa 1980:

She arrived late, having been delayed in a “clinic.” Most of the audience was slightly taken aback as she appeared in a tight figure-hugging fire-engine red dress with sides slit up her thighs and beige spike heels, her long straight very, very blonde hair falling sensuously over her eyes. [Name deleted] had definitely out-transvestited the transvestites, who wondered what kind of “clinic” she had just left!

The literature is filled with sweeping generalizations of transsexuals; the sky is the limit: “These (secondary transsexual) individuals do not pass easily in the opposite gender role without the aid of hormones and electrolysis. Their natural voice is quite masculine, numerous expensive cosmetic procedures are often necessary before they can approach the ‘total femininity’ they seek.” (Dolan, 1987). “All transsexual biological females are homosexual in erotic object choice, and all of them wish to have a penis…” (Steiner, 1985, p. 353). It goes without saying that many secondary transsexuals and some male crossdressers are quite passable and in fact rather attractive without hormones or electrolysis, and many female-to-male transsexuals identify as gay men (cf Allen, 1989; Cameron, 1996).

Generalizations about transsexuals go beyond appearance to presumptions about lifestyle. As late as 1993, one gender program’s application included the question, “How often have you used prostitution as a means of supporting yourself?” Not the presumption that that male-to-female applicants had of course prostituted themselves. It’s difficult to imagine such a question being asked of persons seeking treatment for other conditions; it is simply all right to ask such questions of transsexuals—but of course not appropriate to do the same with persons with heart disease or diabetes.

 

More Inappropriateness

Professional journals contain any number of articles which should never have been published. By portraying transsexuals as deviant, the literature opens publishing avenues for articles which reinforce this perception, however unwittingly. Milliken (1982) opened a paper titled “Homicidal Transsexuals: Three Cases” by stating transsexuals are known to be overall less violent than the general population; he nevertheless then searched until he found three transsexuals who had committed or attempted to commit murder. Psychiatrists are arguably less violent than the general population; however, I know of no papers titled “Homicidal Psychiatrists: Three Cases.” If I wrote one, do you suppose there would be a change of it being accepted for publication in a peer-review journal?

Because the literature presumes transsexuals to be incapable of making informed judgements about altering their bodies with hormones and surgery, they are assumed to be unable to make other decisions for themselves. Special precautions are needed even for transsexuals who ask for a rhinoplasty:

With patients over the age of 30, great care must be taken not to alter nasal contours or size too greatly, as the older patient may experience a sense of “loss of identity” with associated postoperative crisis. — Edgerton, 1974 (emphasis in original)

Indeed, professionals have not only told transsexuals what to wear and how to behave, and what to do with their noses, they have been so presumptuous as to tell them what names to use, what sort of jobs they should have, and who they should be sexually attracted to, and have even insisted that legally married transsexuals must divorce (Denny, 1992). Although they are generally vouchsafed in the literature as “recommendations” (cf Clemmensen, 1985), these are generally requirements, with the price of noncompliance being the withholding of hormones or surgery or rejection from the program. The following is an excerpt from Denny (1992); LeAnn is talking about the very clinic Clemmensen (1985) described as “recommending” its transsexual clients assume gender nonambiguous names:

 

Chrysalis Qquarterly: Didn’t you have a name that worked in both genders?

LeAnn: Yes. My first name was Lonnie— I had started to spell it Loni— and my second named worked, too. But the clinic told me I had to change it.

CQ: Wasn’t it just a suggestion? (In the chapter on real-life test in [Blanchard & Steiner, 1990] Leonard Clemmensen writes that the Clarke Institute of Psychiatry “encourages” transsexual people to replace unisex names with more clearly sex-typed names….)

L: No, they told me I had to change it or forget about the program.

— p. 16

The evidence is overwhelming that transsexuals have been and continue to be forced to make lifestyle choices in order to receive medical treatment. Following is a paragraph from “What’s Wrong with Stanford?” a one-page flyer distributed around 1980 by Golden Gate Girls & Guys, a transgender support group. It describes a question-and-answer session with Judy Van Maasdam of the Gender Dysphoria Program in Palo Alto (formerly the Stanford Gender Program).

Ms. Van Maasdam gave three criteria by which a person is diagnosed as “transsexual”: (1) the inner feeling of being from the other sex; (2) a past history of activities usually associated with the other sex; and (3) a heterosexual orientation post-operatively. This last point raised much dissent in the group, and Ms. Van Maasdam curtly explained that her Program made this distinction and that those who disagreed with it were more than welcome to take their business elsewhere.

Clearly, this “our way or the highway” mentality is a measure of professional arrogance. And of course, responding to this type of manipulation, transsexuals learned to lie to their caregivers about their sexual orientation (Stone, 1991). Needless to say, they were then blamed for being manipulative and dishonest:

The preoperative individual recognizes the importance of fulfilling caretaker expectations in order to receive a favorable recommendation for surgery, and this may be the single most important factor responsible for the prevalent mental-health medical conceptions of transsexualism. Transsexuals feel that they cannot reveal information at odds with caretaker expectations without suffering adverse consequences. They freely admitted to lying to their caretakers about sexual orientation and other issues. — Bolin, 1988, p. 63 (emphasis mine)

Soon it became conspicuously and disturbingly apparent that far too many patients presented a pat, almost rehearsed history, and seemingly were well-versed in precisely what they should or should not say or reveal. (Fisk, 1973)

Abuse of the client/caregiver relationship by professionals has been widespread. The literature shows transsexuals have been denied access to hormones and surgery because clinicians felt they would not be available for follow-up [“… the probability of being able to maintain (postsurgical) contact with the patient is one of the factors assessed before sex reassignment” (Steiner, Zajac, & Mohr, 1974)], or even for refusing to participate in experimental programs:

In an effort to upgrade the services, to improve the rapport between clinic physicians and these patients, and to provide the material for this report, the following prospective study was undertaken…. All transsexual patients receiving hormone therapy at the clinic were asked to submit to a semi-structured interview, including a medical history, and a problem-specific physical examination. Participation in the study was mandatory if the patients wished to continue to receive hormone therapy at the clinic. — Cooper, 1984, p. 142 (emphasis mine)

I wrote Dr. Cooper about this paragraph, and he assured me that participation in his study was not mandatory in order to receive hormonal therapy. His article, however, argues otherwise.

Under the medical model, transsexuals are seen as blameworthy, not only for their condition, but for other things that are wrong with the world. Raymond (1970) scolds transsexuals for perpetuating the binary gender system; it’s as if she expects transsexuals to be some sort of gender heroes/heroines, and is lashing out at them because they have somehow disappointed her (one wonders why, if Raymond believes traditional gender roles should be deconstructed, she colors so carefully within the gender lines in her gendered personal presentation). Transsexuals are also sometimes considered at fault for the shortcomings of the medical model, most notably for the well-known problems with follow-up (Stoller, 1982). It;s hardly surprising that transsexuals, who were trained by gender programs to assimilate into society, did so, thereby becoming “lost to follow-up.” It’s perhaps to be expected that transsexuals who were frequently manipulated by the gender programs would have some enmity towards them, and so would be motivated to make themselves less than available for follow-up for which they were often expected to pay the cost (see Stone, 1991). Such eventualities were, of course, never considered by the gender programs workers. Denny & Bolin (1997), who are conducting a follow-up study outside the clinical setting, recently reported a rather surprising finding— almost 100% of more than 100 members of a transsexual support group were available for follow-up, some as many as five years after leaving the group. Group members in fact were part of a cohesive social support network which maintained long after their gender transitions. It would seem likely that the infamous problem with follow-up is actually a problem with the medical model which was used in previous studies; transsexuals have been unfairly blamed.

More insidious than overt hostility toward transsexuals is the way in which the presumptions about transsexuals’ pathological states can overshadow clinical judgement. Consider the following:

It is interesting to note that no female-to-male transsexual has currently requested [cosmetic surgery in addition to genital sex reassignment surgery and breast reduction for female-to-males]. This request appears limited to the male-to-female transsexual, which is in keeping with the greater frequency of personality disorders such as narcissistic or histrionic types, which occur more frequently in males. (Steiner, 1985, p. 339)

Steiner chooses to interpret the differential rates with which male-to-female and female-to-male transsexuals request cosmetic surgery as due to differences in personality factors; she overlooks the fact that cosmetic surgery is often necessary if male-to-females are to present successfully as female— a trait Steiner considers important; note her passages above. Female-to-male transsexuals typically pass quite well without any intervention other than hormones and top surgery. Feminine features like a small nose or lack of an Adam’s apple are unlikely to cause an otherwise masculine individual to be perceived as female, but the observe is not true (Kessler & McKenna, 1978). Males in our society only occasionally have plastic surgery to make them appear more ruggedly masculine, but surgeons are frequently called upon by women to feminize their faces and bodies. When transsexuals follow the same pattern, male-to-females are characterized as having personality disorders, and female-to-males as being psychologically healthy.

Because the literature views gender variance as undesirable, it has eschewed exploration of “third-gender”roles or androgyny in favor of binary gender norms. Transgendered and transsexual persons must either be cured or helped to assimilate as members of the “other” gender; there is no middle ground. It is only appropriate to use techniques, however intrusive, to eradicate transgender behavior, however benign. Even exorcism is worthy of consideration as a tool to “cure” transsexualism (Barlow, et al., 1977).

The excesses of behaviorists, in particular, have been legion (see Denny, 1994d, for a review of the literature with adults). Some of the experiments have been more than a little reminiscent of Stanley Kubrick’s “A Clockwork Orange.” Cooper (1963), in an attempt to control a man’s crossdressing, kept him awake for one week with amphetamines and gave him drugs every hour to make him violently nauseous while requiring him to view pictures of himself crossdressed. The subject developed cardiac problems and had to be hospitalized for a month. Incredibly, while the author lamented not having scheduled regular EKG, neither he nor his contemporaries considered that his treatment may have been a bit overzealous. For example, Barker, in 1965 in comparing the effectiveness of electrical shock and purgatives in the treatment of transvestism, never mentioned the use of nonaversive techniques, and he certainly never discussed the possibility that the subjects might be counseled to accept their need to crossdress and integrate their crossdressing into their lives rather than being repeatedly shocked or made nauseous.

In the literature behaviorists, who are ordinarily extremely sensitive to the fears of their critics that they will use behavioral techniques for purposes of social control, have engaged in just that sort of social engineering with adult transsexuals and crossdressers, and with almost no printed debate about its appropriateness. [3] This has not been true with other subject populations. For example, the use of aversive procedures with persons with developmental disabilities now requires multiple levels of peer and external review, and is discouraged both by administrative regulations and by consensus of those working in the field (LaVigna & Donellan, 1986). As usual, gender-transgressive individuals are exempt from protections afforded other vulnerable populations

Because professionals rather than those with lived experience have been considered the ultimate authorities on transsexualism, the literature has tended to perpetuate myths and misinformation. Transsexuals themselves have been unable to correct these mischaracterizations. It has frequently been claimed that transsexuals have stereotyped notions of manhood and womanhood (see Bolin, 1988, Ch. 8 for a review). In my experience, and in the experience of those who have taken the trouble to study transsexuals outside the clinical setting, this is no more true for transsexuals than for anyone else, although transsexuals frequentely report feeling they had to dress and behave in gender-stereotypical ways in order to please their caregivers (Bolin, 1988, 1994; Cromwell, 1997; Denny, 1997d). Nor do all transsexuals hate their genitals, as has been frequently claimed. Many masturbate frequently, a trait generally considered to be a contraindication for surgery, and a behavior about which a great many transsexuals have lied to a great many clinicians (Stone, 1991). In a thousand ways, transsexuals are unlike what has until recently been written about them, but they have been forced to conform or risk being denied access to hormones and surgery.

The hubris of professionals can be almost without bounds. For decades, it was assumed that almost all male-to-female and all female-to-male transsexuals were heterosexual after surgery. Lou Sullivan, a female-to-male transsexual who identified as a gay man and refused to hide or lie about his sexual orientation, was able to obtain surgery only after a concerted and energetic campaign to educate professionals (Pauly, 1992; Sullivan, 1989). The reality of Sullivan’s sexual orientation was too apparent; he died of AIDS in 1991— and yet in 1996, a clinician insisted to me that were no gay-identified female-to-male transsexuals. Ironically, I must even now cite a professional source as well as Sullivan’s own work in order to document the fact of his homosexuality.

In retrospect, it is professionals, and not transsexuals, who were more likely to have been stuck in a Rambo/Bimbo limboland. They have consistently projected their often sexist notions onto transsexuals. Kessler & McKenna (1978) have noted that those turned away by one program included Puerto Ricans, who “looked like fags” to the gender clinic doctors (p. 118). They note also that one prominent clinician turned away male-to-female transsexuals whom he did not find sexually appealing (p. 118). When transsexuals, desperate for treatment, conformed to professionals’ Ken and Barbie notions, it merely confirmed the expectations generated by the literature (Denny, 1992).

 

The Impact of the Medical and Psychological Literature on the Standards of Care and the DSM

While a thorough discussion of the ways the literature has impacted transsexual lives would be enlightening, it would be a formidable task. I would like, however, to mention the effect the literature has had on two widely-disseminated and often-referenced protocols. The Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc. (Walker, et al., 1984), which were first introduced in 1980 as a set of minimum consensual guidelines for the hormonal and surgical treatment of transsexualism. They presuppose that transsexuals are incapable of making their own decisions about treatment and give gatekeeping power to mental health professsionals for treatments which are available to nontranssexuals without such gatekeeping. Nearly twenty years after their introduction, the same suppositions rule and have even gained in strength; the most recent proposed revision increases the gatekeeping power of mental health professionals over transsexuals (Levine, 1997). The proposed guidelines continue to define the breasts of female-to-male transsexuals as “genitals,” which they clearly are not. Bolin (1992) has pointed out that such characterizations are based on the view of female bodies as commodities. Transsexuals themselves become commodities under the Standards of Care. For example, a recent flyer for a professional workshop called “Managing the Transsexual” (a vision of a lion-tamer with a whip and chair comes immediately to mind) enticed professionals by promising a highly motivated audience which was willing to pay cash for psychological and medical treatment.

Not only do transsexuals find their autonomy limited by treatment protocols; they now have a mental illness. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, 3rd edition (DSM-III, 1980) saw the inclusion of gender identity disorders for the first time. DSM-IV (1994) includes categories for both Transvestic Fetishism (302.8) and gender identity disorder (302.85), replacing the DSM III-R’s (1987) diagnosis of Transsexualism. The DSM-IV’s language has been roundly criticized by Wilson (1997) who finds that it and its supporting materials (Spitzer, ed., 1994) perpetuate negative stereotypes about transgendered and transsexual persons by the use of demeaning images and terminology. Wilson notes among other things that (1) the DSM-IV casebook describes a male who crossdresses as “The Fashion Plate;” (2) the DSM-IV categorizes transvestic fetishism with criminal behaviors like pedophilia and exhibitionism; and (3) the DSM-IV “blames the victim” for discrimination suffered by gender-variant people at the hands of society. Inclusion in the DSM is of little benefit to transsexuals, who, despite psychiatric diagnosis, are routinely denied insurance benefits for hormones, surgery, and counseling, and who, because they are categorized as mentally ill, frequently find themselves losing their jobs or custody of their minor children. Several years ago, Dierdre McCloskey, a prominent economist, was involuntarily psychiatrically hospitalized when she announced her decision to undergo sex reassignment. While it’s unclear what, if any, role the DSM played in McCloskey’s hospitalization, it was certainly available to provide a psychiatric label for what was in fact a well-considered and rational decision (McCloskey, 1996).

The Standards of Care and the DSM were prepared by committees which drew heavily upon authoritative published material about transsexualism. Now they in turn are considered authoritative. They are nevertheless based upon a flawed and pejorative literature, and continue the faulty assumptions, sexism, and negative stereotypes of that literature. There is little doubt that they will come under increasing attack from activists, and little doubt that they will fall under the weight of their own shortcomings.

The medical and psychological literature of transsexualism is self-influencing, like a snake swallowing its own tail. It invites a certain understanding of transsexualism, and suggests certain directions for future research, which is done in due course and which in turn finds its way into the literature. Those most directly influenced by it are those who produce it; they tend not to see its recursive nature; they are simply too close to it.

The careful reader may note that most of the articles and books I have chosen to use as examples predate 1991. There are two reasons for this. First, time, even a few years, gives us a perspective that is lacking with the more recent literature; and second, there has been considerable improvement during the past ten or so years. Certainly, however, the literature continues in large part in its previous vein; it is simply disparaging transsexuals in more subtle ways. We will probably have to wait a decade or so to document that fact. However, I will give one recent example of a paper which is colored by an author’s assumptions about transsexuals.

Lothstein (1997), argues that interacting with prospective clients outside the consulting room can be “dangerous to our profession” (p. 273). That seems strange enough to those of use who are both transsexual and professionals and who have not considered ourselved in danger from transsexual acquaintances, friends, relatives, or lovers, or when we look in our bathroom mirrors — and for those trained in ethology, anthropology, or other disciplines which have as their mainstay naturalistic observation. However, insight into Lothstein’s thinking is perhaps best gained by the following sentence: “Person and Ovesey (1978) even visited transvestite and transsexual support groups to learn more about the phenomenon and to clinically inform their psychoanalytic perspective on how gender is experienced outside the consulting room” (p. 273, italics mine). Lothstein’s use of the word even shows how daring, dedicated, and perhaps foolish he considers Person & Ovesey to have been for venturing into transsexual space; he makes it sound as if they were Daniel, going into the den to beard the lion. None of the more than 300 transsexual support group, group therapy, and national transgender meetings I have attended have been anything other than polite gatherings; certainly none were anything like the circus Lothstein described in his 1977 paper (see above).

 

A New Literature for a New Century

It will come as no surprise to the reader that it is my belief the literature needs to be reformed. In fact, reform is underway, and I expect it would continue without any help from me. I am, however, not adverse to hurrying things along.

We are in need of a new literature for a new century, a literature which is respectful to transsexual and transgendered people, and which will explore new territory without being bound by limiting beliefs. Before this can happen, the contributions of non-clinicians— anthropologists, sociologists, queer and feminists scholars, and transgendered and transsexual authors— who have been for the most part been ignored by medical and psychological professionals, must be acknowledged and their viewpoints and data incorporated into the clinical Zeitgeist. Morover, we must learn to talk about transsexuals as human beings rather than patients, for only then will we be able to discuss then in terms that do not endow them with pathology. There has been resistance among clinicians to other voices (Denny, 1993). But the literature must change, and the literature will change. My hope is that it will happen sooner rather than later.

 

Notes, Part I

[1] This has been described by anthropologists as medical “colonization.” In much the same way European powers invaded foreign lands, subjugating the inhabitants and claiming sovereignty, nineteenth physicians and mental health professionals staked out gender and sexual variance as their own. Denny (1999) has written:

Transsexualism is rather like a land that has been colonized by conquistadors from across the seas. For nearly 50 years now this transsexual country has been flying the flag of our masters. It’s not the flag of Spain or France or Portugal or England, or even the United States. The flag of the transsexual land is a caduceus, a staff entwined by serpents. Our flag is the symbol of the medical profession. Physicians have owned this land and its inhabitants—transsexuals—registered, copyrighted, trademarked, lock, stock, and barrel, signed, sealed, and delivered.

[2] This approach can be useful when dealing with individuals who have psychological or psychiatric problems; however, the model makes it impossible to look at any transsexual or transgendered person without a presumption of psychopathology, and colors the very language used (Cromwell, Denny, & Green, 2001).

[3] Well, maybe just a bit. While postmodern theory can be difficult to read and sometimes seems to have its own rather opaque language, it has much of worth to say. Unfortunately, some medical and psychological professionals reject it in its entirety, usually with claims that it is antiscientific. “The difficulty with social constructionism is that it impedes science and the collection of knowledge” (Hershberger, 1997, p. 560). Hershberger is being shortsighted, for he presumes scienctists and therfore science to have no social agendas—and of course they do.

What social constructionism actually attempts to do is to cast loose the moorings of science, to challenge unchallenged and often unconscious assumptions that scientist may not even know they have. In this regard, it is indeed scientific, for it enables new viewpoints that result in reinterpretation of existing data. What essentialists are actually arguing for is to maintain the status quo, which impedes science, which is really all about the major shifts in perspective that social constructionism can facilitate.

 

Notes, Part II

[1] Transsexuals have found themselves, unenviably, used as pawns in wars of ideology, often by writers who have little or no personal or professional experience with transsexual people. I have a photocopy of a letter from McHugh to a transsexual physician, written in 1994, in which he expresses his profound disbelief that a post-operative male-to-female transsexual could be sexually attracted to other women. If McHugh had ever worked with male-to-female transsexuals, he would have known that a significant percentage (probably about one-third) of post-op male-to-females self-identify as lesbians. Yet McHugh obviously feels qualified to rage about transsexualism in the pages of American Scholar.

[2] I have attended hundreds of transsexual and transgender support groups and more than 50 transgender conferences. Collectively, I have certainly seen some inappropriate behavior, but no more than in other assemblages of human beings. It seems clear Lothstein is venting his frustration with his transsexual clients, and clear also that it is inappropriate to do so in the pages of a journal of psychotherapy. 

[3] In contrast to the behavioral treatment of adults, which has gone unremarked, the behavioral treatment of children (attempting, of course, to cure them for their own good) has come under heavy fire. See Zucker & Bradley (1995) for an overview and Burke (1996) for an anti-treatment position.

 

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