Gender Subjectivism and the Construction of Transsexualism

by Ann Bolin Ph.D.

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Transsexuals are a medically colonised minority who are subject to sexism in diagnosis and treatment by medical caretakers, especially the psychiatric sector. My understanding of this phenomenon comes from two years of participant­ observation and advocacy with a group of male-to-female transsexuals affiliated through a grass-roots organisation, and from interview and correspondence with their medical caretakers (see Bolin 1982, 1983). Sexism emerges in two broad categories of caretaker and client interrelations: diagnosis and evaluation of the client as a bona fide transsexual and hence someone in need of treatment, and treatment itself, which includes therapy, hormonal management, and ultimately, surgery. A point of clarification is in order before proceeding. Transsexuals are defined here as genetic males who are actively pursuing or who have completed the surgery in which a physical sex change and gender reassignment will occur. Because transsexuals think of themselves as females trapped in male bodies, feminine pronouns are used in reference throughout this paper.

Transsexuals are inexorable intertwined with medical practitioners through the establishment of medical policy. Medical policy is consolidated through the Harry Benjamin International Gender Dysphoria Association, Inc (1969 - present) in the form of guidelines known as the "Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons" (Berger, et al. 1980). This document outlines minimal requirements for the care of transsexuals and includes a prescribed agenda and compulsory medical surveillance.

In order for a transsexual to qualify for the coveted surgery, she must acquire two psychological evaluations stating that she is indeed a transsexual and a good surgical risk. The recommendations for surgery can be made only by psychiatrists or psychologists. One of the two evaluators must have know the client as a primary therapist for a minimum of six months. In addition, the transsexual must have been hormonally reassigned as a female and have lived in the female role for one year prior to the surgical conversion.

Medical policy has created a situation where the recommendation "for surgery is completely dependent upon caretakers" psychological evaluations. The client is vulnerable to caretakers' conceptions about what constitutes evidence for classification as transsexual and a good risk for surgery. Ultimately, "...diagnosis remains based on the psychiatrist's subjective evaluation of patient's behaviour and what patients say they are experiencing" (Torry, 1983, p.A7). It is where evaluation and diagnosis intersect that problems of embedded sexism contribute to theoretical misconception and stereotypical expectation.

The medical profession struggles to understand a phenomenon that in its surgical resolution is only thirty-nine years old. In order to treat a client, caretakers must rely on research in the relatively recent field of gender dysphoria. This research includes alleged commonalties of transsexualism that have become elevated to the level of diagnostic criteria. These criteria, consisting of etiological correlates and behavioural characteristics, clearly reflect male preconceptions about females. Two such diagnostic attributes are the etiological correlate of dominant and over-protective mothers in association with physically or emotionally absent fathers (Stoller, 1968. 102., pp.263-­264; Green, 1974a, p. 216-250; Green, 1974b, pp.47,51) and behavioural characteristic of heterosexual orientation (Benjamin, 1966, p.26; Walinder, et al., 1978, pp.16-20; Pomeroy, 1975, p.220; Kado, 1973, pp.13, 145; Raymond, 1979, p.84).

I have found no support in my research that these attributes are predictive of or invariably associated with transsexualism. Both these notions are, however, firmly entrenched in traditional notions about gender and sexuality reiterated and perpetuated by psychoanalytic theory.

For example, the dominant and over-protective mother in conjunction with the absent father is a staple of "mother blame" theories that have been popular since Freud. One is reminded of Miner's tongue-in-cheek expose of the Nacireman belief that parents (actually fathers to a lesser extent) bewitch their children (Miner, 1985, p.13). Of course it is believed that dominant and over-protective mothers cause transsexualism, after all, earlier in the history of psychiatry, these same mothers were responsible for causing homosexuality in their sons. But dominant and over-protective mothers can really be blamed on a more basic level. Do they not violate the roles of the traditional family, whose hallmark is the dominant, controlling father? In the dominant mother-absent father model, the father, too, is seen as deviated form his role as a profound presence in the family. If the father is absent, then de facto, he has relinquished control to the mother, who will undoubtedly adversely affect the gender development of her growing boy. This type of model, so representative of mother-blame theories in general, can be seen as an idiom for expressing traditional cultural premises about sex roles in the family second only to "Father Knows Best".

Another characteristic often cited in the literature on transsexualism is heterosexuality: that is, a heterosexual object choice for a male-to-female transsexual is a male, while a lesbian object choice is female, based on the transsexual's feminine identity. A long-term and deeply abiding attraction to genetic males is viewed by caretakers as an index of true transsexualism. My data indicate that this is a dubious assertion. Of seventeen transsexuals who provided data on sexual orientation, one was exclusively heterosexual. Six were exclusive lesbians, nine were bisexual and one didn't know. Underling the diagnostic criterion of homosexuality is the belief that there is only one sexual object choice for women, genetic or transsexual, and that is men. This view denies the dignity and human rights of those who choose the same gender in sex and/or love. In the case of male-to-female transsexuals, not only are they denied their dignity and human rights, but the revelation of homosexuality or bisexuality to a psychiatric evaluator could seriously jeopardise qualifying for surgery.

Without belabouring the issue, one vignette illustrates this point. Tanya, a preoperative transsexual, saw a psychiatrist as part of an employment agency requirement. Because this psychiatrist was not involved with her evaluation for surgery, Tanya felt free to discuss a recent lesbian encounter and her openness to a lesbian relationship post­operatively. The psychiatrist was incredulous. He asked: "Why do you want to go through all the pain of surgery if you are going to be with a woman lover?" Such attitudes, coupled with the inquiry in power relations between caretaker and client, foster a situation where transsexuals inadvertently contribute to the maintenance of these sexist conceptions by telling their psychiatrists exactly what they want to hear. Transsexuals are avid readers of the medical literature and are well-versed in caretaker expectations, augmented by the transsexual grapevine. This should not deflect, however, from the central argument that these alleged attributes are part of more general psychiatric thinking that is far older than the classification of transsexualism itself as a psychiatric syndrome.

Another reoccurring theme prominent in the literature is transsexual hyper-femininity, defined in a variety of ways (Kando, 1973, pp.19, 24-25; Raymond, 1979, p.78; Money & Tucker, 1975, p.206; Driscoll, 1971, pp. 66, 68). Transsexuals are described as conforming more to the feminine role than natural born women in every respect (Raymond, 1979, p.79). Again, my research, using a variety of instrument along with ethnographic method, questions this concomitant to transsexualism. What can account for the prevalent stereotype in the literature?

Hyper-femininity, in general terms, may be an artifact of the medical caretaker system. A number of researchers have pointed out that the medical and psychiatric communities reinforce sex role stereotypes in Sunday ways (e.g. Raymond, 1979; Chesler, 1973). In regard to transsexuals, this is undoubtedly a product of the psychological evaluation procedures in which the male-dominated medical, especially psychiatric sectors, employ their own stereotypes of women in judging how well transsexuals' appearances, presentation, and sex role performance fit into their conceptions of womanhood. In this regard, Kessler and McKenna report that one clinician: said that he was more convinced of the femaleness of male-to-female transsexual if she was particularly beautiful and was capable of evoking in him those feelings that beautiful women generally do. Another clinician revealed that he uses his own sexual interest as a criterion for deciding whether a transsexual is really the gender she claims (1978, p.118).

One transsexual in my research population, an ardent feminist who preferred wearing T-shirts and jeans, stated: "Shrinks have the idea that to be a transsexual you must be a traditionally feminine women: shirts, stockings, the whole nine yards". A number of transsexuals confirmed this view of their male psychiatrists.

Transsexuals, through their knowledge of caretaker expectations, knew that hyper-femininity was anticipated by many psychiatrists. They were aware that many male caretakers were relying on their own male versions of females, utilising cultural stereotypes of women. Rather than re-educating their male caretakers, many chose to superficially conform to caretaker expectations, realising this would facilitate the desperately desired surgery.

Other factors contributed to the stereotype of the hyper-feminine transsexual. Space does not permit an in-depth discussion of these. Suffice it to say that the process whereby transsexuals are chosen for complete gender identity programs of sex reversal selects for those individuals who are either more hyper-feminine or who know how to play the game. The result is the same: male psychological evaluators employing stereotypes of women in selecting transsexuals for gender clinics, will undoubtedly find what they expect to see. Thus transsexual hyper-femininity may be a result of a system in which "transsexual candidates [for surgery] are judged on the basis of what a man's view of a real woman is" (Raymond, 1979, p.92).

One might reasonably ask: "Where are the women practitioners who might mediate the sexism in the diagnosis and treatment of transsexuals?"

There are in fact, a number of women who are the therapists of transsexuals. They, however, dominate the helping mental health professions such as social work, guidance and counselling, and master's level clinical psychology. The helping mental health professionals are not eligible to act as psychological evaluators of the transsexual's request for surgery. The "Standards of Care" explicitly state that: "The analysis or evaluation of reasons, motives, attitudes, purposes, etc., requires skills not usually associated with the professional training of persons other than psychiatrists and psychologists." Furthermore, of the two recommendations for surgery which must be made by psychologists and psychiatrists, one of the two must be a psychiatrist (Berger, at al., 1980). (The current [1989] Standards of Care do not require that one of the two therapists be a psychiatrist, but do require that one of the two hold a doctoral degree Ed.) The apparent medical and psychological (in many states a psychologists is only legal with an Ph.D.) imperialism is discriminatory towards not only the helping mental health professions, but towards women as well, since psychiatry and psychology (in terms of Ph.D. psychologists) are dominated by males Chesler, 1972, pp.62-63; Syverson, 982, p.1204; Raymond, 1979).

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