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Unsettled lives: Medicine, culture, and transgender subjects
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UNSETTLED LIVES:
CULTURE, MEDICINE, AND TRANSGENDER HEALTH
by
Demetrios Psihopaidas
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIOLOGY)
August 2018
Copyright 2018 Demetrios Psihopaidas
ii
Dedication
To the numerous teachers, mentors, family, and friends who inspired me to believe
someone like me could make a difference.
iii
Acknowledgements
This dissertation is truly a product of the immense network of support I am fortunate to
have. Adam and Erica spent seemingly billions of hours sitting with me in coffee shops
and paused the TV too many times to listen to the half-baked ideas I called
“breakthroughs.” Artin worked intensely alongside me for the bulk of the writing,
endlessly inspiring me with his passion and work ethic, and always reminding me when I
had writer’s block that writing – and English in general – is really hard. Foopa, Nakhi,
and Ziki reminded me that life is about the little things. Jeff and Laura reminded me how
proud they were every day; Brent and Tony reminded me how long it was taking me to
finish (lovingly… I think). Nina G. could always take my mind off the stress of writing
by quoting one of our favorite movies. Carlos and William endlessly guilt-tripped me into
putting down the books, painting on my face, and going out in this bizarre thing known as
“public.” Kushan, Megan, Michela, Sandra, and Yu-Kang forged friendships with me
when I was at my most awkward and vulnerable. Betty, Helen, Jim, Panchita, Tony, and
Veronica didn’t get to see me cross the finish line, but never doubted I would. Sharon
gave me a healthy dose of cynicism and a love for long-dead theorists. Stacy was
understanding and supportive (in her own way) when I came to work on very little sleep
because I was up all night writing. Without fail, Amber, Lisa, Melissa, and Stachelle
made me laugh every single time I saw them and accepted documents from me even
when they were past due. My dissertation committee, particularly my chair Nina E.,
trusted me while I frolicked the globe in search of data, and nudged me (hard) when I
needed to stop contemplating the findings and just write. Rhacel demystified academia
and taught me to be proud of my work. Lynne interrupted her romantic remote getaway
to drive to the nearest town with cell service to make sure I got the dream job that made
this all worthwhile. So many others called, texted, emailed, or showed up at my front
door to remind me they were there. Without each of you, this dissertation might have
been written, but what would have been the point?
Finally, this research would not have been possible without the financial support from the
John Money Fellowship at the Kinsey Institute, the University of Victoria National
iv
Transgender Archive Research Travel Grant, the USC Graduate School Research
Enhancement Fellowship, the USC Center for Feminist Research Diana Meehan
Fellowship, the USC Dana and David Dornsife Academic Merit Fellowship, the USC
Center for Law, History, and Culture Fellowship, USC Emory Bogardus Research
Enhancement Grants, as well as generous travel support from the USC Department of
Sociology and the USC Graduate School.
v
Abstract
In a curiously sudden and remarkably consistent shift since the turn of the
century, health policymakers on a global scale have, with some urgency, devoted
increasing amounts of time and energy to reconsidering established policies about or
affecting transgender persons – those for whom moving away from the sex/gender
assigned to them at birth is a significant life project. Since medical technologies may be
used to adjust one’s body to be more in line with one’s gender identity, the medical,
legal, and political implications of cross-gender identification, referred to variously as
transsexualism, transgenderism, trans*, and others in different eras, have periodically
emerged in local health policy debates since the early 1900s. Yet the degree of attention
to transgender related policies is unprecedented. “We can barely keep up with all of the
new improvements in access to [health]care,” declared the director of the National Center
for Transgender Equality in the summer of 2014. Importantly, this shift has occurred in
the absence of any significant changes to transgender population size, health, or the
quality, availability, and cost of technologies of gender transition.
To understand this peculiar shift, this dissertation examines the broader historical
and cultural contexts in which transgender gets constructed as a public problem. One
might take for granted that one is entitled to a “right to health,” that transgender persons
necessarily need access to medical technologies governed by health institutions in order
to be their “authentic selves,” and that it is quite inevitable, therefore, that “transgender
rights” organizing would entail health advocacy as a central component. A classic
“medicalization” perspective would suggest that the category transgender only exists
because of medical science and through medical technology, thereby making it inevitable
that health institutions would have to grapple with the proper way to regulate access to
medical interventions for a newly politically powerful transgender community. But none
of these associations are inevitable; health as human right and medical intervention as a
route to authenticity of the self have come to be understood through processes of
meaning-making, meanings that must be articulated across time, institutions, and
interactional settings. This dissertation explains how certain kinds of meanings in certain
vi
settings became patterned enough that they might be taken for granted; that process is the
process by which public problems are constructed.
In chapter two, I advance our understanding of the shifts in transgender health
policy in the contemporary moment by analyzing a similar surge of interest among
scientists, providers, and health policymakers that occurred nearly 50 years earlier. In the
mid-twentieth century, Johns Hopkins Hospital opened the first gender identity clinic in
the United States. This clinic reflected and participated in efforts to (re)define the
“proper” relationship between transgender subjects, medicine, and health policy at the
time. Drawing from international archival research, this chapter identifies discursive
patterns in the language used to (re)shape the relationship between transsexuals and
health policy. I show that there was a consistent imperative to produce scientific evidence
and to base transgender health policy upon that evidence. Specifically, actors called for
the production, interpretation, and application of evidence to specify a diagnosis and to
regulate and standardize gender transition-related care. I use the concept “discursive
repertoires” to situate these patterns in the broader cultural context of the time. I argue
that the discursive patterns during this period, as well as the available evidence about
transsexual persons, are remarkably similar to that of the contemporary moment;
however, due to differences in the discursive repertoire of scientists and providers at the
time, dramatically different conclusions were reached.
In chapter three, I argue that research showing how strategic claims of
transgender advocates and allies have driven these shifts does not address the formative
role cultural context has played in strategic claims-making. Drawing from participant
observation at a national convening of providers, I show that one symbolic maneuver was
central to claims-making; in this maneuver, participants mixed together symbolic
categories reflecting commitments as both activists and objective scientists. Specifically,
when the content of a particular claim was not based on scientific evidence, the claim was
articulated in a way that reflected a primary obligation to objective science. Conversely,
claims that emphasized objective scientific evidence reflected an obligation, not to
objective scientists, but to transgender communities or social justice. This symbolic
maneuver allowed participants to make claims that were understood as both transgender-
affirming and scientifically objective. This blending of categories and obligations is
vii
conceptualized here as “hybrid styling” and implications of this concept for future
research are discussed. These findings demonstrate that cultural context plays a role in
the ongoing organization of scientific consensus regarding the “proper” relationship
between transgender subjects, clinical medicine, and health policy.
In chapter four, I examine how the meanings that shape medical decision-making
and health policy also affect the way transgender persons understand and communicate
their sense of self. I argue although recent scholarship focuses on the increasing
significance of processes of standardization in contemporary social life, much less
attention has been given to how standardization impacts intimate life, and how intimate
standards are made meaningful in interaction. Drawing from participant observation in
online transgender groups, I examine how the medical standardization of transsexuality,
known as the ‘wrong-body’ model, impacts the way users understand and communicate
their gendered self. I show how rather than simply adopting the wrong-body model,
participants use its language and logic in ironic and playful ways that carve out spaces for
ways of knowing the self that feel authentically their own. This case shows how intimate
standards become part of the language of the self in ways that may be unexpected.
This dissertation’s robust theoretical framework and multi-method research
design permit an unusually comprehensive analysis of the broad and complex social
forces behind the curious emergence and diffusion of transgender-affirmative health
policies since the turn of the century. The broader implications of this project are that it
advances an understanding of how the perceived strategic interests of the many actors
that converge in the making of health policy – scientists, medical care providers, patients,
advocates, policymakers, and others – are shaped by and in turn shape broader social
forces. The intellectual merit of this project is that it innovates a mixed-methods
approach including traditional and virtual ethnography, digital and print archival
research, survey methods, and in-depth interviews. Through this triangulation of
methods, this dissertation is capable of balancing analytic depth and generalizability,
historical grounding and contemporary relevance. The practical implications of the
findings are of significant interest to community organizations, policymakers, and
medical care providers, while the theoretical implications inform scholars of
science/medicine, culture, gender, organizations, and public health.
viii
ix
Table of Contents
Dedication .......................................................................................................................... ii
Acknowlegments ............................................................................................................... iii
Abstract ............................................................................................................................... v
Table of Contents ............................................................................................................... ix
Chapter 1: Unsettled lives: An introduction .................................................................. 1
Introduction .................................................................................................................... 1
Unsettled lives: the case of transgender health .............................................................. 2
Meaning-making in transgender identity and science .................................................... 5
Seeing culture in action .................................................................................................. 9
What lies ahead ............................................................................................................ 12
Chapter 2: Undone transgender science: The culture of evidence production in the
making of the first gender identity clinic in the United States ................................... 17
Introduction .................................................................................................................. 17
The political sociology of “undone science” ................................................................ 19
Boundary work in science studies ................................................................................ 20
Methods ........................................................................................................................ 25
Transsexualism: An emergent science, an emergent self ............................................. 26
The birth of the gender identity clinic: Johns Hopkins Hospital and the search for a
cure ............................................................................................................................. 28
Specifying a diagnosis .................................................................................................. 28
Regulating and standardizing gender transition-related care ....................................... 32
Declaring transsexual science "done" .......................................................................... 36
Conclusion .................................................................................................................... 38
Chapter 3: Hybrid styling: How culture shapes the relationship between
transgender subjects, medicine, and health policy ...................................................... 42
Introduction .................................................................................................................. 42
Seeing culture in claims-making .................................................................................. 43
Scene styles and scene-switching ................................................................................. 45
Methods ........................................................................................................................ 47
Organizing for transgender health: The case of THNC ............................................... 49
x
Styles of THNC ............................................................................................................ 51
Mixing symbolic categories: Community affirmation and scientific objectivity ......... 57
Style violations at THNC ............................................................................................. 62
Hybrid styling ............................................................................................................... 66
Chapter 4: Intimate standards: Medical knowledge and self-making in digital
transgender groups ......................................................................................................... 71
Introduction .................................................................................................................. 71
Standardization, medicalization and intimate life ........................................................ 73
(De)medicalizing transgender ...................................................................................... 76
Methods ........................................................................................................................ 77
Virtual intimacies ......................................................................................................... 79
A self authentically their own ...................................................................................... 82
De-privileging the wrong-body .................................................................................... 82
Avoiding the logic of justification ................................................................................ 85
Intimate standards ......................................................................................................... 89
Chapter 5: Mapping the cultures of transgender health policy ................................. 92
Future research ............................................................................................................. 97
References ................................................................................................................. 100
Appendix I ................................................................................................................. 108
Appendix II ............................................................................................................... 110
1
Chapter 1
Unsettled lives: An introduction
Introduction
In a curiously sudden and remarkably consistent shift since the turn of the century, health
policymakers on a global scale have, with some urgency, devoted increasing amounts of time
and energy to reconsidering established policies about or affecting transgender persons – those
for whom moving away from the sex/gender assigned to them at birth is a significant life project.
Since medical technologies may be used to adjust one’s body to be more in line with one’s
gender identity, the medical, legal, and political implications of cross-gender identification,
referred to variously as transsexualism, transgenderism, trans*, and others in different eras, have
periodically emerged in local health policy debates since the early 1900s. Yet the degree of
attention to transgender related policies in recent years has been unprecedented.
i
“We can barely
keep up with all of the new improvements in access to [health] care,” declared the director of the
National Center for Transgender Equality in the summer of 2014. Importantly, this shift has
occurred in the absence of any dramatic changes to transgender population size, health, or the
availability and cost of medical technologies of gender transition.
To understand this peculiar shift, this dissertation examines the broader historical and
cultural contexts in which transgender gets constructed as a public problem. One might take for
granted that one is entitled to a “right to health,” that transgender persons necessarily need access
to medical technologies governed by health institutions in order to be their “authentic selves,”
and that it is quite inevitable, therefore, that “transgender rights” organizing would entail health
2
advocacy as a central component. A classic “medicalization” perspective would suggest that the
category transgender only exists because of medical science and through medical technology,
thereby making it inevitable that health institutions would have to grapple with the proper way to
regulate access to medical interventions for a newly politically powerful transgender community.
But none of these associations are inevitable; health as a human right and medical intervention as
a route to authenticity of the self have come to be understood through processes of meaning-
making, meanings that must be articulated across time, institutions, and interactional settings.
This dissertation explains how certain kinds of meanings in certain settings became patterned
enough that they might be taken for granted; that process is the process by which transgender
health has been constructed as a public problem.
Unsettled lives: The case of transgender health
This dissertation is about how social forces shape our recognition and understanding of
certain phenomena as public problems, but it is also about transgender identity. Since the 1950’s
headlines of Christine Jorgensen, public interest in cross-gender identification across the West
has surged and faltered. Periods of surging interest have often unsettled the lives of those who
refuse to remain settled in the sex they were assigned at birth. The contemporary moment marks
one such period of surging interest. This dissertation, while inevitably contributing to that surge,
emerges not out of mere interest in transgender subjects; rather, there are at least three reasons
why transgender represents a compelling case for this analysis.
First, it might seem that the ascendance of transgender issues at the turn of the century is
simply a familiar story in the social movements and organization theory literature. That story
would go something like this: transgender marginalization leads to the formation of a collective
3
movement; transgender activists and their allies frame their marginalization in a particular logic
of injustice that resonates in some way with broader cultural structures; activists adapt that frame
to particular settings to make claims against major institutions and policymakers using a variety
of tactics; finally, these institutions respond to and absorb the movement’s demands in some
way.
ii
This familiar formula, however, does not work for this case. For a movement to emerge, it
has to have a certain kind of member.
iii
Most categories that interface with medical institutions –
seniors, African-Americans, veterans – have established structures of meaning, where the
boundaries of the category are perceived to be clear and stable, making it possible to organize
around them.
iv
However, in this case the boundaries of an embodied gender category
transgender, an authoritative apparatus for regulating and producing scientific knowledge about
the category, and a collective sense of political community, are all mutually constituting each
other. Transgender health activism has not just sought to effect policy and practice change, it has
been self-consciously involved in contested, intimate processes of transgender identity
construction.
Second, the recent debates over transgender subjects in health institutions and
policymaking circles seems to have occurred in many cases in the absence of any real contact at
all with transgender patients and activists, suggesting that the emergence and diffusion of
transgender health policies has occurred through broader social and organizational forces rather
than direct social movement action. Health movements scholars have developed helpful tools for
analyzing direct strategic action of social movement actors, but these studies do not help us
understand the social contexts that give rise to certain kinds of social movement action. That is,
they have difficulty explaining how social phenomena emerge as social problems worthy of
policymaker attention to begin with. The literature on agenda-setting in public policy helpfully
4
draws concepts from political communication and media studies to account for some of the
lurking variables at work in the emergence of social problems. But this literature also focuses
often on the strategic actions of policymakers and vague notions of changing cultural “ethos.”
Drawing from cultural sociology’s concept “cultural repertoires,” this dissertation sheds light on
the cultural contexts that drive contemporary transgender policymaking and social movement
action.
Third, this case is historically unique relative to most other well-known health
movements. Feminist
v
, black power
vi
, and gay and lesbian
vii
health movements of the 1960s and
1970s identified institutions of medicine as tools of social control, where community-based
knowledge production and alternative methodologies for formulating knowledge claims were
understood as necessary means to remedying injustice.
viii
Preventing or reversing
“medicalization,” or the extension of medical jurisdiction, authority, and practices into formerly
unremarkable areas of social life (Zola 1972, 1991), was a central goal of these movements.
ix
Transgender health activists have indeed sought to eliminate the stigma, pathology, and even the
diagnostic criteria that historically has underwritten the scientific credibility of surgical and
hormonal sex reassignment as legitimate treatments for transgender patients.
x
At the same time,
however, these activists have carefully crafted their claims in order to sustain transgender’s
medicalized status.
xi
This understanding implicitly affirms the authority of scientific knowledge
but challenges the authority of scientists in producing that knowledge.
HIV/AIDS activism of the 1980s and 1990s is perhaps a similar case. AIDS activists
demanded inclusion in, rather than alternatives to, official centers for scientific knowledge
production. Advocates challenged the authority of scientists in producing knowledge about the
virus and the institution of medicine’s regulatory power over access to treatment, while
5
upholding the authority of scientific knowledge as the route to finding an effective treatment.
xii
However, no authoritative voice challenged the status of HIV/AIDS as a disease, and therefore
its fit within the domain of scientific knowledge production and medical treatment. In contrast,
an understanding of cross-gender identification (originally designated as “gender identity
disorder” and later “gender dysphoria”) as a medical condition for which hormonal and surgical
sex reassignment are legitimate medical treatments has been heavily contested. AIDS activists
could count on AIDS remaining understood as a disease while demanding changes to research
policy and scientific knowledge production-as-usual. Without that same leverage, transgender
health advocates have rather remarkably managed to challenge the authority of scientists without
eroding their hard-won medicalized status.
Building a better understanding of the meaning-making processes that have shaped the
actions of transgender health advocates, policy makers, and transgender subjects themselves will
significantly advance knowledge in the health movements literature. Additionally, this analysis
will inform recent debates over transgender subjects in trans studies, queer theory, feminist
theory, and gay and lesbian studies that often theorize from diverging perspectives on the
entanglement of transgender subjects with the institutions of medicine.
xiii
Meaning-making in transgender identity and science
Two broad approaches to analyzing meaning-making in transgender health are what I will
call the “ethos” approach and the “culture-in-action” approach. In this section I use an illustrative
example of the former approach and then dissect this example in order to make a case for the
importance of the culture-in-action approach taken in this project.
6
The following example of an ethos approach to cultural analysis is drawn from the
writings of Dr. Ethel Person. Person, renowned psychiatrist and friend of Drs. Harry Benjamin
and Charles Ihlenfeld, two foundational figures in the emergence of a distinct field of
transgender science in the West, wrote extensively about her work with transsexual clients. In
The Sexual Century, Person (1999) writes transsexualism, as it exists in its current historical
formation, participates in the construction of a shared cultural fantasy that is only possible in the
context of a “unique constellation of cultural attitudes, values, and technological innovations.”
This constellation, she explains, is one of “self-realization,” of “extending life, of changeability,
of living without limits” in which we assume, in part because of “increasingly astonishing
scientific advances” that “little of external reality is unalterable,” and that altering external reality
in the pursuit of some internal reality is understood to be a civil liberty (and perhaps even an
injunction). “The general public often romanticizes transsexualism as an extreme demand for
liberation” and “transsexuals themselves… make extraordinary demands for their ‘freedom’ to
pursue sex conversion.” However, she argues:
“Paradoxically… [transsexuals] almost invariably favor extremely conservative gender
stereotypes, so much so that they have been called the ‘Uncle Toms’ of the sexual
movement. They subscribe to social values fundamentally at odds with the liberationist
demands of either feminists or gays. Ironically, then, while transsexualism found
acceptance as part of our liberationist ideals, most transsexuals themselves are among the
gender reactionaries of our century” (366).
7
This conclusion is partly a reflection of its time, resonating well with much feminist and
queer theorists’ writings about cross-gender identification at the time. However, Person’s
analysis of transsexuals’ as “almost invariably” “gender reactionaries” draws from her interviews
with Dr. Harry Benjamin’s patients. During those interviews, patients consistently drew from
what Person describes as “extremely conservative gender stereotypes” to communicate their
experience of gender dysphoria. But Person, whose writing otherwise regularly points to
contextual factors, surprisingly divorces these data from their institutional and cultural context,
rendering them merely the “truth” of transsexual experience. At the time of her interviews,
access to transition-related medical technology and legal recognition was dependent upon such
stereotypical admissions, given the stringent criteria used at the time for establishing gender
identity disorder. Moreover, Person is herself a psychiatrist, precisely the sort of medical
professional that anyone seeking hormones or sex reassignment surgeries was, at the time,
accustomed to needing to satisfactorily convince of the “authenticity” of one’s gender identity.
Thus, Person’s findings say more about the institutional and interview contexts in which
the data were gathered than they do about the “nature” of transsexualism; in other words, this
institutional and cultural context shaped the narratives patients constructed to communicate their
desires and life histories. While these contexts inevitably shaped the way clients actually
experienced cross-gender identification (more on this in chapter four), as a source of data they’re
selectively biased against individuals who weren’t legible as transsexuals because of their non-
binary narrative and experience.
xiv
Person does make connections to the cultural contextual factors underlying the
emergence of a science of gender transgression; she concludes “in essence, the identification of
transsexualism as a separate entity took place in the context of an ongoing liberalization of sex
8
practices and increasing fascination with studies of sex. In turn, the very discovery (or invention)
of transsexualism fostered a change in the way we regard gender” (366). Indeed, a society with
liberalized sex practices and a growing authoritative apparatus for their study is, ipso facto, one
in which the cultural authority of a science of gender transgression expands; thus, an emboldened
science of sex with this new branch of research contributes to a further liberalization of sex
practices. But with this insight we are left a classic chicken-and-egg dilemma. If prevailing
cultural ethos and transsexual science are mutually reinforcing, how can we gain leverage to
make claims about the effect of culture?
Culture does have an independent effect that can be analyzed, but Person’s analysis
draws on an approach to culture that analyzes it as an ethos, an impersonal, abstract structure of
values. This approach typically permits an author to make broad claims, but comes at the
expense of situational nuance. For instance, Person attempts to explain the legitimacy and
authority eventually garnered by Harry Benjamin and other medical care providers (hereafter
referred to as “providers”) that advocated for what eventually came to be the dominant
programme of care for transsexuals. She argues the legitimacy they eventually received resulted
from being on the “right side of history.” She identifies their approach to care as a “civil-
libertarian position” that fit nicely within this broader cultural ethos of self-realization. This is an
important finding. The problem is that it leaves many questions unanswered and overlooks too
many complicating factors.
Person’s analysis has to assume stability of the “cultural ethos of self-realization” across
institutions, settings, and moments, yet here are no specific actions that emerge inherently from
the concept self-realization. Rather, in particular moments, “self-realization” must be made
meaningful in a particular way while eschewing other possible meanings. Self-realization could
9
very well mean realizing the “truth” of the flesh, the gonads, the chromosomes, and finding ways
to affirm that truth, despite what could be understood as merely psychological “hang-ups” of
would-be transsexuals. That is, only in hindsight can we say that affirming one’s gender identity,
regardless of one’s morphology, genetic makeup, or social sex assignment, pairs nicely with an
ethos of self-realization like an old cabernet and an especially putrid block of blue cheese. We
can say this because this pairing has been mapped for us, because the meaning-making process
of identifying this stuff over here as self-realization and that stuff over there as self-denial has
been repeated, by particular actors, although never in precisely the same way, in specific settings
over time. To understand the role of culture and avoid this chicken-and-egg problem, we need to
pay attention to that cultural work. We need a theory for seeing culture in action, one that
focuses on uncovering vocabularies of motive and meaning-making rather than finding
psychological “truth.”
Seeing culture in action
To address the limits of the ethos approach to cultural analysis, this project borrows from
the culture-in-action approach. In this approach, culture is understood as a set of constraining and
enabling contexts, that is, symbolic contexts, that shape what actors can do and say together in
specific settings. Cultural symbols or representations shape actors’ ability to make sense of their
experiences; those representations take on different meanings in different contexts, and in
specific settings actors have to filter cultural symbols to create a shared ground for interaction
(Ricoeur 1974; Swidler 1986; Goffman 1974; Schudson 1989; Kane 1997). The cultural symbols
associated with specific settings are culturally patterned, such that actors most often move
through settings quite smoothly, filtering a small number of possible cultural symbols that might
10
define the situation (Becker 1999; Hallett and Ventresca 2006). These patterns help actors
understand what are the available conceptual linkages in a given situation; those linkages,
therefore, shape action.
The cultural symbols that shape what actors can say and do together in particular settings
make up the cultural contexts that enable and constrain strategic action. Shifts in these cultural
contexts, or what Swidler (1995) calls “cultural recodings,” shift the meanings of social life.
These shifts in meanings have a significant impact on organizations and institutions (Davis et al.
2005). Previous research identifies two “levels” at which culture operates to shape action. First,
cultural meanings shape action by creating broad symbolic potential for action. Scholars have
conceptualized this potential for action using the notion of “repertoires.” Steinberg (1998) posits
the concept “discursive repertoires” to explain how actions are shaped by broader historical and
cultural context. Actors selectively draw from available systems of meaning in interaction, he
argues, in order to drive collective action; in the process, they actually impose order upon that
system of meaning (Steinberg 1998). Discursive repertoires, then, can be understood as sets of
discourse that emerge through interaction when actors make use of larger systems of meaning.
The concept allows us to see action oriented by broader cultural symbols rather than as purely
based on rationally understood interests. Similarly, in their analysis of the gay rights movement,
Scully and Creed (2005) argue “repertoires of action” that took shape and diffused across
organizations contributed pressure in the organizational field to adopt gay-friendly policies, even
though many organizations contributing to that pressure had yet to adopt such policies
themselves.
Second, cultural meanings shape action in specific settings by orienting actors sense of
who they are and what obligations they share. Lichterman and Eliasoph (2014) conceptualize
11
these symbolic contexts as “scene styles.”
xv
Scene styles are patterned ways of filtering and
using cultural symbols in interaction; they provide a frame of reference for actors to define the
situation they are in and who they are in relation to imagined others in that situation. This
information helps actors recognize what is appropriate for them to say and do in that situation.
Scene styles emerge in specific settings, but they are not determined by settings; actors can enter
the same setting and yet be oriented by different scene styles. Actors may enter a setting and
define the situation in the same way, but may recognize a very different sense of who they are in
the situation. However, in many settings a particular scene style tends to be dominant, allowing
actors to operate in that setting with relative ease.
xvi
The scene styles concept provides an up-
close understanding of how cultural contexts shape the kinds of claims actors imagine are
possible to make, in advance of their ability to act strategically.
The chapters that follow analyze cultural meanings that shape action at both of these
levels. This approach overcomes the limits of the ethos approach to cultural analysis by
connecting broad cultural forces with interaction. Broad cultural contexts are captured through
(digital and traditional) archival research and literature support, while observations of meaning-
making captured through (virtual and traditional) ethnography. In order to make generalizations
from the evidence of interaction, this project uses theory and an historical method of
triangulating the broad cultural contexts of contemporary observations through primary archival
materials. This avoids the limits of the ethos approach by analyzing meaning-making processes
in interaction and permits theory-building and general claims without the need for a comparison
case.
12
What lies ahead
In chapter two, I advance our understanding of the shifts in transgender health policy in
the contemporary moment by analyzing a similar surge of interest among scientists, providers,
and health policymakers that occurred nearly 50 years earlier. In the mid-twentieth century,
Johns Hopkins Hospital opened the first gender identity clinic in the United States. This clinic
reflected and participated in efforts to (re)define the “proper” relationship between transgender
subjects, medicine, and health policy at the time. Drawing from international archival research,
this chapter identifies discursive patterns in the language used to (re)shape the relationship
between transsexuals and health policy. I show that there was a consistent imperative to produce
scientific evidence and to base transgender health policy upon that evidence. Specifically, actors
called for the production, interpretation, and application of evidence to specify a diagnosis and to
regulate and standardize gender transition-related care. I use the concept “discursive repertoires”
to situate these patterns in the broader cultural context of the time. I argue that the discursive
patterns during this period, as well as the available evidence about transsexual persons, are
remarkably similar to that of the contemporary moment; however, due to differences in the
discursive repertoire of scientists and providers at the time, dramatically different conclusions
were reached.
In chapter three, I argue that research showing how strategic claims of transgender
advocates and allies have driven these shifts does not address the formative role cultural context
has played in strategic claims-making. Drawing from participant observation at a national
convening of providers, I show that one symbolic maneuver was central to claims-making; in
this maneuver, participants mixed together symbolic categories reflecting commitments as both
activists and objective scientists. Specifically, when the content of a particular claim was not
13
based on scientific evidence, the claim was articulated in a way that reflected a primary
obligation to objective science. Conversely, claims that emphasized objective scientific evidence
reflected an obligation, not to objective scientists, but to transgender communities or social
justice. This symbolic maneuver allowed participants to make claims that were understood as
both transgender-affirming and scientifically objective. This blending of categories and
obligations is conceptualized here as “hybrid styling” and implications of this concept for future
research are discussed. These findings demonstrate that cultural context plays a role in the
ongoing organization of scientific consensus regarding the “proper” relationship between
transgender subjects, clinical medicine, and health policy.
In chapter four, I examine how the meanings that shape medical decision-making and
health policy also affect the way transgender persons understand and communicate their sense of
self. I argue although recent scholarship focuses on the increasing significance of processes of
standardization in contemporary social life, much less attention has been given to how
standardization impacts intimate life, and how intimate standards are made meaningful in
interaction. Drawing from participant observation in online transgender groups, I examine how
the medical standardization of transsexuality, known as the ‘wrong-body’ model, impacts the
way users understand and communicate their gendered self. I show how rather than simply
adopting the wrong-body model, participants use its language and logic in ironic and playful
ways that carve out spaces for ways of knowing the self that feel authentically their own. This
case shows how intimate standards become part of the language of the self in ways that may be
unexpected.
Taken together, these chapters permit an unusually comprehensive analysis of the
meaning-making processes that scaffold the contemporary rise of transgender-affirmative health
14
policies. The broader implications of this project are that it advances an understanding of how
the perceived strategic interests of the many actors that converge in the making of health policy –
scientists, providers, patients, advocates, policymakers, and others – are shaped by and in turn
shape broader social forces. The intellectual merit of this project is it innovates a mixed-methods
approach including traditional and virtual ethnography, digital and print archival research, survey
methods, and in-depth interviews. Through this triangulation of methods, this dissertation is
capable of balancing analytic depth with generalizability, and historical grounding with
contemporary relevance. The practical implications of the findings are of significant interest to
community organizations, policymakers, and providers, while the theoretical implications inform
scholars of science/medicine, culture, gender, organizations, and public health.
15
Notes
i
Chapter two explores the middle to late twentieth century, another time period in which there was sudden,
unprecedented interest in transgender science and policy. Despite the significance of this earlier period,
contemporary interest has certain surpassed any previous point in time, thanks, in part, to the global spread of
information technology, the growing interconnectedness of nations globally, and the influence of international
organizations.
ii
For an overview of movement tactics see Della Porta and Diani (1999); for movement framing see Benford and
Snow (2000); for movement demands and organizational response see Schneiberg and Soule (2005). For a recent
example that brings together these elements to explain the assimilation of radical black activism into mainstream
educational institutions, see Rojas (2007).
iii
Although individual members are likely to be more dynamic than the mass of participants might suggest.
Armstrong (2002), for example, has shown that even in the gay and lesbian rights movement, where celebrating
individual member differences was paramount, forming a unified group identity was critical to the movement’s
success. A certain kind of member had to form the basis of the movement, even if members also carried and
celebrated markers/identities they held beyond that unifying basis.
iv
Even though, again, in practice they may be more fluid than is readily apparent.
v
By the 1970s, women’s health circles had emerged in nearly every major city in the US (Murphy 2012). Feminist
health activists were unified in their view that bodily experiences specific to women had come under the authority
and jurisdiction of medicine as a form of social control over “the most intimate dimension of woman’s personhood,
her body” (Moore 2010: 97). Undermining the authority of medical experts and affirming women’s self-knowledge,
self-help manuals such as the iconic Our Bodies Our Selves (Boston Women’s Health Book Collective 1976)
politicized reproductive medicine, encouraging women to seize control over their bodies by “looking together” in
small, empowering communities of women who would build intimate knowledge and expertise of each other’s
bodies (Murphy 2012).
vi
During that same period, Black Panther community health projects mirrored women’s health activism by offering
not just nonprofit alternatives to mainstream institutions of medicine, but also by providing services seemingly
specific to “African American health” such as sickle-cell anemia screenings (Nelson 2003). These projects emerged
out of a longer history of African American organizing around health beginning in the early 1960s. Standing before
the Medical Committee for Human Rights in 1966, Dr. Martin Luther King, Jr. proclaimed that “of all forms of
inequality, injustice in healthcare is the most shocking and inhumane” (see Dittmer 2009). By the time of his speech,
civil rights leaders were actively involved in establishing alternative health institutions, desegregation of (or
inclusion in) the healthcare system, and critical analysis and reinterpretation of scientific research, which posed
epistemological challenges to medical claims about race (Nelson 2011).
vii
While studies of the historical relationship between homosexuality and medicine have shown that gay- and
lesbian-identified persons also often cooperated with doctors for strategic purposes (Terry 1999; Minton 2002),
homophile activists and later gay liberationists ultimately fought for complete demedicalization of homosexuality,
long categorized as a mental health disorder in the DSM (Conrad 2007; D’Emilio 1983; Hurewitz 2008).
viii
According to Starr, “medical science epitomized the post-war vision of progress without conflict” in the 1950s,
enjoying seemingly impregnable authority over claims to truth in the eyes of the public (see also Moore 2008; Terry
1999). But these radical health movements reflected and contributed to a sharply different view of medicine as a tool
of control and repression that would prevail in various forms throughout the second-half of the twentieth century.
For early theorizations in sociology of medicine as social control see Zola 1972, 1991; Conrad and Schneider 1980;
Conrad 1992, 2000.
ix
Medicalization, or more recently biomedicalization, is argued by sociologists to be one of the most striking
features of the last half of the twentieth century in the West (Clarke et al. 2003; Clarke and Olesen 1999; Conrad
1992, 2000). Conrad and Schneider (1980) argue that medicalization steps in to replace explicitly racist, sexist, or
homophobic legal statutes as a new, more covert form of social control. Additionally, feminist scholars Ehrenreich
and Ehrenreich (1978) added that medicalization also supports the capitalist interests of an ever-expanding “medical
industrial complex” (a term adapted from “military industrial complex” coined by President Dwight D. Eisenhower
in the 1950s to describe the dangers of astronomical military growth and expenditures following the end of World
War II).
x
This point I demonstrate in the first half of the project.
16
xi
Unlike radical feminists and early gay and lesbian activists, transgender health advocates have not sought the total
demedicalization of trans identity; rather, the legitimating authority of the “gender dysphoria” diagnosis has been
used as leverage to demand competent, legal, and respectfully provided medical services, as well as rights and
protections against discrimination more broadly (Currah et al 2006, Meyerowitz 2002, Stryker 2008, Teich 2012,
Wilchins 2004). Significant changes were made, however, in DSM-5 (published May 18, 2013), reflecting the
demands for reducing the stigma associated with the diagnosis and making the diagnostic process different for
children and adults. Primarily these changes include a terminology change from ‘Gender Identity Disorder’ to
‘Gender Dysphoria’ and a removal of this diagnosis from the ‘Sexual Disorders’ category. While some early
transgender studies scholars rejected the idea of a healthy relationship between medicine and transgender subjects,
urging gender-variant persons to remain visibly outside of the binary positions of male/female (Feinberg 1993,
Bornstein 1994), ultimately transgender politics and transgender scholarship affirmed the crucial connection
between transgender identities and medicine. Namaste (2005) argues that taken to its logical extreme, the beyond-
the-binary model advocated by Feinberg and Bornstein identifies any gender-variant person who does not wish to
remain visibly outside of the categories of man or woman as the victim of a sort of false consciousness and
represents a threat to a formidable transgender rights movement. Prosser (1998) argues this model reduces gender to
nothing more than an oppressive cultural construct, while most transgender persons identify as transgender precisely
because their gender identity seems so visceral, so resistant to being (re)shaped by cultural expectations.
Organizations like the Center for Excellence in Transgender Health and the World Professional
Association for Transgender Health have sought to advance transgender health through publications (especially the
Standards of Care), health conferences, and provider trainings in “trans competency” and “trans inclusivity” across
the globe (see www.wpath.org). National and regional surveys, such as the National Transgender Discrimination
Survey in the U.S. and Trans PULSE Project in Ontario, Canada, have been constructed to build data about
transgender populations, including specific questions about health behaviors and clinical experiences.
Thus, transgender health is part of a larger story of contemporary organizing of marginalized groups. It
does, however, represent an unusually abrupt “bend in the river” of minority organizing and visibility under the
banner of health. This project draws out the cultural meanings that shape this historical moment.
xii
In the 1980s as the “plague years” of the AIDS epidemic was devastating gay communities, a somewhat different
approach to health activism took shape. AIDS activists and many of their allies in the health professions demanded
access to unapproved, experimental treatments, contested and reinterpreted scientific research on AIDS, refused to
accept traditional clinical trial procedures (most notably the use of a placebo group), and even set up illegal
distribution clinics to disseminate drugs not yet approved in the US to their communities (Epstein 1995, 1996;
Fetner 2008: 51). Although AIDS activism extended and benefitted from earlier health activism, it was unique in its
alignment with the institutions of medicine. Returning to an integrationist approach like that advocated by WEB Du
Bois, AIDS activists demanded inclusion, not separate institutions. Inclusion, Epstein (2008) argues, has since
become the dominant paradigm that governs the politics of medical research. The work of AIDS and other advocacy
groups, health professionals, and Congressional Acts have forced the diversification of medicine and to some extent
created opportunities for underserved groups to gain access to adequate care.
xiii
Recently, growing emphasis has been placed on reconsidering the historically antagonistic relationship between
feminist theory, feminist politics, and transgender subjects; some noteworthy examples of this work include: Heyes
(2003, 2007), Namaste (2009); Salamon (2010); and Connell (2012). This project also speaks to two critiques of
queer theory; first, sociologists have critiqued the tendency of queer theory to be very textualist, overlooking
important structuring factors, such as social structure, political organization, and historical context (Seidman 1993,
Epstein 1996). Second, transgender studies scholars have critiqued the bias in queer theory toward gender fluidity as
the central liberating form of agency, which tends to erase the radical possibilities of transgender subjects (Namaste
1996, 2000; Cromwell 1999; see also Bryant 2007).
xiv
A similar analysis of transsexuality was famously and controversially articulated in Janice Raymond’s
Transsexual Empire. A growing body of research in transgender studies, however, has shown how even through
processes of gender, trans persons are engaged in heavily complex projects of the self that work toward disrupting
sexist stereotypes and creating possibilities for a new gender order (Heyes 2003, 2007; Namaste 2009; Salamon
2010; Connell 2012).
xv
In their original formulation, the concept was termed “group style” as it pertained to patterns within groups (see
Eliasoph and Lichterman 2003). However, the authors later drew from the work of Erving Goffman to refine the
concept as “scene style.” makes the concept more flexible for analyzing diverse and hybrid settings.
xvi
To say that actors are able to operate in a setting with ease is not to say that conflicts are absent. Conflicts are not
necessarily more or less likely to occur in settings where a particular scene style is dominant.
17
Chapter 2
Undone transgender science: The culture of evidence production in the
making of the first gender identity clinic in the United States
Introduction
Since the turn of the twenty-first century, national governments across the West have
rather suddenly begun rolling back legal barriers to gender transition-related medical care
i
for
transgender persons.
ii
and international health organizations have declared transgender persons
an urgent policy priority.
iii
These shifts in medical practice and health policy have occurred so
rapidly that in the summer of 2014, Mara Keisling, Executive Director of the National Center
for Transgender Equality, declared, “we can barely keep up with all of the new improvements in
access to [health] care… within five years there will likely be no transgender exclusions” in
private and public health insurance policies in the US. Although this shift is unprecedented in
many ways, nearly 50 years earlier a similarly sudden shift in medical practices and health
policies about or affecting transgender persons occurred. In January 1967, famed physician
Walter C. Alvarez published an editorial in Modern Medicine lauding the opening of the first
Gender Identity Clinic in the United States at Johns Hopkins Hospital. "Now that the board of
one of the greatest hospitals in the land is permitting its surgeons to perform the operations of
complete castration, with the shaping of a urinary meatus, and the making of a vagina,” he wrote,
“all other hospital boards should feel free to permit such work to be done." Dr. Alvarez’s
enthusiasm wasn’t quite the official position of the American Medical Association at that time,
but it did reflect a rather sudden surge of interest among scientists, medical care providers, and
health policymakers in the lives of what were then known as transsexuals.
18
These snapshots depict two historical moments in which scientists, medical care
providers (hereafter referred to as “providers”), and health policymakers became unusually
focused on (re)defining the “proper” relationship between transgender subjects, medicine, and
health policy. This chapter helps us understand what is unique about the contemporary changes
to transgender health policy by analyzing the shift that occurred nearly 50 years earlier. Drawing
from international archival research, this chapter identifies discursive patterns in the language
used to (re)shape the relationship between transsexuals and health policy. I show that there was a
consistent imperative to produce scientific evidence and to base transgender health policy upon
that evidence. Specifically, actors called for the production, interpretation, and application of
evidence to specify a diagnosis and to regulate and standardize gender transition-related care. I
use the concept “discursive repertoires” to situate these patterns in the broader cultural context of
the time. I argue that the discursive patterns during this period, as well as the available evidence
about transsexual persons, are remarkably similar to that of the contemporary moment; however,
due to differences in the discursive repertoire of scientists and providers at the time, dramatically
different conclusions were reached.
For scholars of health movements, this chapter shows that a cultural lens capable of
identifying the symbolic contexts in which scientific evidence is deployed, are crucial for
understanding how that evidence is informing the interpretation and application of that evidence.
For transgender health advocates and their allies working in policy and medicine, this chapter
offers reason to be cautious about the recent shift toward transgender-affirmative policies,
showing that such policies are vulnerable to reinterpretations that might once again reorganize
scientific consensus regarding the “proper’ relationship between transgender subjects, medicine,
and health policy.
19
The political sociology of “undone science”
In recent years, scholarly interest has grown significantly in understanding the politics of
calling for the production of scientific evidence by various actors. While sociologists of science
have long recognized that complex social forces shape scientific research agendas,
iv
recent
scholarship in the new political sociology of science, has reinvigorated this line of inquiry. This
new research focuses on the politics of drawing attention to the lack of scientific evidence, or
“undone science” as it is called in the literature, and its impact on public policy, health
movement action, governmental and nongovernmental agency priorities, and research agendas.
In particular, this research addresses the ways in which choices about what kind of scientific
knowledge to produce are the result of clashes and coalitions between scientists, medical
providers, patients, policymakers, private industries, and social movements (Frickel and Moore
2006). Studies have shown that a wide range of actors seek to drive or forestall specific areas of
research, including religious organizations trying to prevent stem cell research (Frickel, et al.
2010), scientists trying to prevent certain kinds of research for the military (Moore 2008) or on
subjects considered taboo within a discipline (Kempner, Bosk, and Merz 2008), environmental
groups confronting governmental regulatory agencies to drive research into the safety of
commonly used chemicals (Howard 2004) and air pollution (Ottinger 2005), and strategic
avoidance of certain potentially fruitful areas of research by activist groups in order to sustain
momentum in other areas of knowledge production (Gibbon 2007).
To create a framework for analysis, studies in this literature have drawn heavily from the
concept “boundary work” in science studies. In the following section I detail the boundary work
concept and discuss how this chapter contributes to this body of work.
20
Boundary work in science studies
Three approaches to boundary work in particular have served as the theoretical basis for
these works, namely the conflict, cooperative, and social worlds approaches.
As Latour (1987) famously contended, scientific authority emerges out of an agonistic
power struggle, through processes of demarcation, competition, and division. This famous claim
reflects the conflict approach. For example, research on the development of the professions has
demonstrated how boundary-drawing, or “closure,” permits particular organizational forms to
maintain control over legitimate access to particular resources and authority over training or
credentialing processes (Parkin 1974, Sarfatti-Larson 1979, Manza 1992, Collins 2004). While
Latour and others see this conflict playing out in professional settings, Gieryn (1999) argues that
the cultural or epistemic authority of science does not lie “upstream” in its epistemological
practices, but rather, it lies “downstream” where scientific knowledge is made useful in specific
settings. Through his concept “boundary work,” Gieryn demonstrates how scientists employ
strategic interpretive strategies to construct a cultural space for science, or as Gieryn describes it,
a “cartographic representation of practices, skills, [and] accumulated knowledge of science” (35).
In those settings, “credibility struggles” – popular challenges against and internal conflicts over
the authority to make scientific knowledge claims – are resolved by engaging in strategic
boundary work that re-establishes the collectively understood boundaries and epistemic authority
of science, affirming its monopoly in making claims to truth and knowledge.
While conflict certainly is important to this history, some scholars have challenged this
approach to thinking about boundary work. Moore (2008), for example, argues that the focus on
boundary work as being driven primarily by professional advantage and monopoly is its own
21
kind of boundary work. She argues that since the 1950s scientists’ monopoly over claims to truth
has indeed been undermined, sometimes by the efforts of scientists themselves. But, crucially,
she argues not to conflate this with a reduction in the cultural authority of scientific knowledge,
which shows no signs of having lost its monopoly on truth. Through her analysis of scientists’
involvement in activism against the financial and political relationship between science and the
military between 1945 and 1975, Moore shows the multiple and sometimes competing interests
and commitments of scientists that sometimes drive them to work against their own monopolistic
authority over knowledge claims. This insight is particularly helpful in the case of transgender
science. Until only recently it has likely not been in the interests of scientists to engage in the
care of or production of scientific knowledge about transgender persons; that is, if we only see
interests narrowly as professional advancement and monopoly. Some scientists put their own
careers at risk to work with transgender patients, and some, such as Dr. Harry Benjamin, joined
with their patients in critiquing scientists’ monopolistic authority over claims to knowledge of
the etiology of, and appropriate care for, gender transgressive patients.
v
This paper starts from
the assumption that scientists and providers involved with transgender patients have complex
lives with multiple interests and commitments.
Another approach that challenges us to think more broadly about the significance of
boundaries is what I will call the cooperative approach. This approach argues that the
significance of boundaries lies less in their ability to “close” professions and knowledge
production to outsiders, but in creating interdependence and cooperation (Barnes 1985, Collins
1992, Shapin 1994). Abbot (1988), for example, argues that boundaries between professions are
not stable or closed, but are constantly having to be redrawn through competition over
jurisdiction and authority, creating an interdependent system of professions. Vallas (2001)
22
extends this to contests among workplace managers and subordinates, showing how despite
significant overlap in expectations and tasks, symbolic boundaries are deployed to affirm
distinctions that sustain workplace structures. Boundaries have also been shown to make
scientific knowledge easily portable and applicable across society. Boundaries establish a sense
of trust that allows non-science actors as well as other scientists to mobilize scientific knowledge
for various purposes (Barnes 1985, Collins 1992). Recent work in the sociology of
standardization suggests that scientists may engage in boundary work that erodes their authority
over certain domains so that they can function more efficiently in others and divert moral
scrutiny to standards documents and standards-making bodies rather than to themselves or their
profession (Timmermans and Epstein 2010). Producing scientific knowledge about transgender
persons required cooperation across multiple professional fields, including psychology,
endocrinology, urology, plastic surgery, and others. As I will show, standardizing the optimal
character of that cooperation was a central discursive pattern at this time.
vi
Finally, in the social worlds approach, boundaries are understood as creating cooperative
and interdependent relationship by facilitating communication across social worlds. In the case
of scientific knowledge production, “fields” emerge out of interactions between multiple social
worlds, or “groups with shared commitments to certain activities sharing resources of many
kinds to achieve their goals” (Clarke 1990: 18, original emphasis; see also Gerson 1983;
Fujimura 1988; Star and Griesemer 1989, Epstein 1996).
vii
Susan Leigh Star and her colleagues
have shown that boundaries are essential for making coordinated action possible and connecting
different social groups.
viii
Star and Griesemer (1989) propose the concept “boundary objects” as
interfaces that permit coherence across social worlds. Boundary objects can be material objects,
organizational forms, conceptual spaces, or procedures; they are simultaneously material and
23
symbolic, as their “materiality derives from action, not from a sense of prefabricated stuff or
‘thing’-ness” (Star 2010: 603). Interpretive flexibility is central to the concept: “a road map may
point the way to a campground for one group, a place for recreation. For another group, this
‘same’ map may follow a series of geological sites of importance, or animal habitats, for
scientists” (Star 2010: 602).
ix
That is, boundary objects are made useful and meaningful in
different ways through action in particular settings. By reconstructing “boundary infrastructures”
(Bowker and Star 1999), or the system of boundary objects, we can better understand important
processes of boundary work that facilitate diffusion, collaboration, and collective action.
Despite the diversity of approaches available for thinking about how boundary work
operates to shape research agendas, studies utilizing the concept, like much of the research in
political sociology, are focused most often on strategic action and rational interests. This chapter
advances the literature on “undone science” by bringing insights from cultural sociology that
move the analysis beyond strategic action to thinking about how calls for the production of
scientific evidence are shaped by cultural context.
Cultural sociologists have shown that cultural symbols “shape the terms of public debate
and constrain our way of knowing about social problems” (Fetner 2005: 73).
x
In his influential
work on collective action to eliminate drinking and driving, Gusfield (1989) argues, “social
movements and institutions affect and are affected by the interpretations, the language, and the
symbols that constitute seeing a situation as a social problem.” And in his study of the
emergence of public concern over “child-victims,” Joel Best (1990) argues that although social
problems emerge through rhetorical contests that might well be captured in a strategic action
perspective, to be fully understood, these contests must be located within their cultural and
historical context. “Claims-making about the issues we customarily call social problems almost
24
always spills well beyond the boundaries of a particular face-to-face encounter” (186). In other
words, to fully understand processes of boundary work, we need more studies that emphasize the
cultural meanings that scaffold strategic action.
xi
As Steinberg (1999) points out, studies in political sociology often underappreciate the
significance of dominant discourses in shaping a movement. That is, the meaning of the
signifiers that might make up strategic action are not themselves stable nor are the relationships
of that signifier to other possible signifiers. Crucial processes of meaning making are at work
“behind the scenes” of any clear mobilization processes.
xii
Similarly, Taylor and Van Willigen
(1996) demonstrate how broad “cultural and political repertoires” shaped movement action in
their study of the breast cancer movement of the nineties, while Klawiter (1999) deconstructs the
notion of a single breast cancer movement, demonstrating how different “cultures of action”
drive collective efforts in specific settings.
xiii
In this chapter, I advance the literature on “undone
science” by situating the discursive patterns seen in each historical time period not in a logic of
strategic action, but within a “discursive repertoire” shaped by the broader historical and cultural
context. “Discursive repertoires” can be understood as sets of discourse that emerge through
interaction when actors make use of larger systems of meaning. Actors selectively draw from
available systems of meaning in interaction in order to drive collective action, and in the process
they actually impose order upon that system of meaning (Steinberg 1998). Discursive repertoires
allow us to see action oriented by broader cultural symbols rather than as purely based on
rationally understood interests.
25
Methods
To rebuild the history of transgender advocacy and organizing in the West, it was
necessary to visit several archival sites, as transgender materials are only now starting to
aggregate into significant collections. Between 2015 and 2016, I spent over 1,500 hours
reviewing the records of relevant health organizations, personal collections of historically
significant healthcare providers, and transgender advocacy groups. I visited collections the
Archives of the Gay, Lesbian, Bisexual, Transgender Historical Society in San Francisco,
California; the James C. Hormel Gay and Lesbian Center, San Francisco Public Library; the
Medical History Center at Stanford University; Special Collections at the University of
California, Los Angeles; the Kinsey Institute in Bloomington, Indiana; the Transgender Archives
at the University of Victoria, British Columbia; the Canadian Lesbian and Gay Archives in
Toronto, Ontario; and the extensive personal collection of Ms. Bob Davis in Alameda Island,
California.
Following Rojas (2007), I approach archival data not with the assumption that I can or
should completely bracket out my own political and theoretical commitments, but with a
willingness to learn, an openness to finding the unexpected, a sense of humility and patience. To
the greatest extent possible, I try to let the data and interview informants guide my investigation
and analysis. At the same time, I maintain some tools as checks on the reliability and validity of
the data that I use on a use on a case-by-case basis in the archives. For example, rather than
understand personal biographies, letters, meeting minutes, and ephemera as depicting some
“objective reality” of transgender health organizing, I follow literary scholars in analyzing these
documents as writings that reflect meanings and vocabularies of motive the authors that
26
underwrote their work, and simultaneously as productive of meanings that are retroactively
assigned.
xiv
I reviewed a wide variety of archival materials including published documents, meeting
minutes, personal notes, patient charts, pamphlets, flyers, audio and video recordings, and much
more. The two time periods compared herein emerged out of this broad and indiscriminate
approach to data collection. Once the evidence became clear that this period was unusual, I
began intentionally sampling for more data to better understand its significance. I also discussed
my findings during formal and informal interviews that were conducted as part of the broader
research project of which this chapter is part.
In the following section, I begin with a discussion of the historical context leading up to
the emergence of the clinic at JHH. Then, I describe patterns that I identified in the way that calls
for the production, interpretation, and application of scientific evidence were made during this
unusual surge of interest in transsexual science. Finally, I conclude with a discussion of the
findings and their implications for research and practice.
Transsexualism: An emergent science, an emergent self
When "Ex-GI Becomes Blond Bombshell" newspaper headlines made Christine
Jorgensen an overnight sensation in 1952, it marked the first time in the contemporary era that
there was significant public interest in what today we would call transgender persons. Christine,
with the help of medical providers in Denmark, had undergone a complete physical and social
transformation from male to female. Her story helped solidify in the popular imagination what
had been gelling in mostly fringe (or frontier depending upon one's perspective) medical circles
for at least two decades: that there is a distinct group of “sexual deviants,” “gender
27
transgressors,” or “transsexuals” as they were variously called, for whom affirming a gender
other than that which had been assigned at birth, based on morphological characteristics, is a
deep and persistent desire.
xv
Through her public visibility, Christine signaled to the world that
medical technology in the West had (presumably) advanced to the point that a complete
transformation of one’s sex was possible. This revelation opened up, for a while at least, a slew
of moral, political, and economic questions among the public and medical professionals alike
concerning whether one should perform such operations given that one could.
xvi
Endocrinologists, psychiatrists, sexologists, plastic surgeons, and other medical providers
were among the earliest actors to make authoritative – albeit mostly speculative – claims about
the “true nature” and etiology of transsexualism in the 1950s and 1960s. Transsexual persons
were an unusual case in that those who wished to change their external reproductive organs
and/or secondary sex characteristics were inescapably dependent upon science and medicine. A
handful of medical providers who encountered patients expressing a desire to change their sex
came to play a pivotal role in figuring out what to do about transsexualism, that is, in defining
what the “proper” relationship should be between medicine, health policy, and transsexual
subjects. Even more fundamentally, these providers would also help to constitute the very
subjects they sought to understand and treat, by developing a new language for expressing
gender transgression.
xvii
That is, as transsexual increasingly became something one could be
labeled as, it also became something one could claim and communicate quickly to others.
The work of these early scientists and medical providers culminated in the opening of the
first American gender identity clinic at Johns Hopkins Hospital (JHH) in 1966. The clinic was
the first model of a specialized center for studying transsexual persons, a small number of which
would be deemed eligible for sex reassignment surgery, which would be performed on-site. The
28
clinic was also a place where scientists and medical providers could come to learn about
transsexualism and gender transition technologies. As word of the clinic at JHH spread, medical
providers across the West began to see an increasing number of patients who arrived equipped
with a nascent language to communicate their gender experience in a way that was legible to
medicine; these patients also increasingly had prior knowledge of the medical technologies that
could support their desire for gender transition. Other medical centers responded by erecting
their own gender identity clinics; a gender identity clinic pilot project, run by Dr. Betsy Steiner,
began at the Clarke Institute of Psychiatry in Toronto in 1969; in the same year, under the
direction of Dr. Donald R. Laub, Stanford University in Palo Alto, California began performing
sex reassignment surgeries following the JHH clinic model.
This flurry of interest in transsexualism surrounding the emergence of the JHH clinic
serves as the starting point for this analysis. In this section, drawing from examples in a variety
of mediums and settings, I show that throughout this time period there was a consistent
imperative to produce scientific evidence and to base transgender health policy upon that
evidence. Specifically, actors consistently called for the production, interpretation, and
application of evidence to specify a diagnosis and to regulate and standardize gender transition-
related care.
The birth of the gender identity clinic: Johns Hopkins Hospital and the search for a cause
Specifying a diagnosis
At the Fifth Annual Conference of the Mental Health Center Development Program in
Phoenix, Arizona, in 1966, Johns Hopkins Psychiatrist Dr. Richard Green gave the following
introduction:
29
In the twenty-five minutes you will hear me talk, two Americans will be born with birth
defects, two will commit suicide, three will be killed in auto accidents, and thirty will
contract a venereal disease. The shocking thing about the statistics of sex deviancy is the
lack of them. During the same twenty-five minutes that I talk, no one knows how many
young boys being called 'sissy' by their schoolmates are destined to develop into adult
homosexuals; how many grown men will be tormented by a compulsion to dress in
women's clothing and perhaps a desire for a sex-change operation; how many husbands
will be seducing another male; how many women will be making dinner, not for a family
but for a female lover; nor how many marriages will be prevented or destroyed by
impotence, frigidity, or some other sexual anomaly.
Dr. Green’s remarks encapsulated the impetus of the era that gave rise to the gender identity
clinic at JHH – gender and sexuality, or what he terms “sex deviancy,” ought, many agreed, to
come fully under the purview of modern science. Comparing evidence of suicide, birth defects,
car accidents, and infectious disease to sex deviance, Dr. Green suggests that the enigmas of
gender and sexuality ought to be as clearly defined and quantified at the population level. He
associates adult male homosexuality with childhood femininity, and an affinity for women’s
clothing among adult men with transsexuality. He calls the lack of statistics – presumably
prevalence and incidence rates based on his other cited statistics – regarding sex deviancy
“shocking,” implying that the existence of such evidence is as important as the other kinds of
evidence he sites.
30
While Dr. Green’s career studying sex deviance – particular childhood femininity among
boys – suggests that he had an unusually strong passion for this subject matter, his urgent calls to
produce evidence were echoed by providers, policymakers, patients, and the press across the
West. One article in the Stanford Daily on January 27 1969 read, “Somewhere between male and
female lies the transsexual, a deeply troubled ‘twilight personality’ who possesses the body of
one sex but the mind of the other. To help this individual, the Stanford Medical Center is
considering complete sex-change operations, but so little is known about transsexuals that
doctors in this controversial field are regarded as saviors by some and quacks by others”
(emphasis added). While medical providers working with transsexual patients often expressed
empathy for their patients and a true desire to help them, reducing the perception that they are
“quacks,” as this article put it, or that they are working in a morally questionable field was also a
clear objective. More clearly specifying the diagnosis was one route to achieving that objective.
To improve the perception of transsexualism a specific and legitimate diagnosis,
providers at this time emphasized the importance of finding a cause. For example, in 1964 Dr.
John Money, considered to be one of the founders of Sexology, wrote the following:
Much of the psychoanalytic thinking that has dominated medical understandings of
transsexualism… [have] relied heavily on a social-environmental determinism, but many
of the pioneering healthcare providers resisted this not only because they rejected the
logical step to causality but also because they, as many of their patients did as well,
favored a genetic/endocrinal cause…. Attributing causality to these dynamics is an
additional step in logic and, of course, an inference. In many ways it shows what a long
way psychoanalysis still has to go in research sophistication.
31
Identifying genetic or endocrinal determinants of transsexualism were favored by patients and
providers alike because their causal link was easier to identify than social-environmental factors,
but also because genetic disease and endocrine disorders carried a greater degree of perceived
scientific legitimacy (what Dr. Money calls “research sophistication”), particularly among the
public, than psychoanalysis. Identification of a clearly defined biological basis for
transsexualism would be the most authoritative form of evidence to specify the diagnosis. Dr.
Harry Benjamin, one of the most influential figures at the time, wrote in his communications
with patients and other providers repeatedly that he was almost certain of an endocrinal cause; he
spent much of his professional life working under the assumption that eventually that cause
would be found.
While many called for a greater emphasis on a biological cause, social-environmental
determinants remained important, as many hypothesized they might “trigger” a latent biological
“propensity” for transsexualism. Family members, childhood peers, spouses, and friends were all
potential suspects. One study presented by Ellen Hale, Chester Schmidt, and Jon Meyer at the
annual meeting of the American Psychiatric Association in Atlanta in 1978 suggested
grandmothers played a causal role in the development of adult transsexualism. In presenting their
study, the authors stated that one-third of their sample over the one-year study were reared in a
family setting in which maternal grandmothers were important parental figures during childhood.
They concluded:
The data suggest that the behavior and attitudes of these particular grandmothers (e.g.
encouraging cross-dressing) played a role in the development of the disorder. It is also
32
interesting to speculate on the influence the grandmothers had on the psychosexual
development of the patients through their role in the psychosexual development of their
daughters (the patients' mothers).
While no genetic/endocrinal or any other scientific evidence of a cause for transsexualism
was ever found, some evidence about transsexualism was available at this time; figuring out
what to do with it was a consistent topic of discussion. That evidence consistently showed a
frequent occurrence of behavioral health problems (personality disorders, depression, anxiety,
etc.) and substance abuse. Additionally, the evidence showed that even after gender transition,
these issues often only lessened in severity; they were rarely eliminated. The New York State
Department of Health, for example, released a report in February of 1974 that stated among
transsexuals “there is a high suicide rate, often other dangerous behavioral aberration, non-
employment and drug addiction.” As I show in the section to follow, the primary response to this
evidence was to call for the production of more evidence to determine the best screening tools
for identifying “true” or “confirmed” transsexuals, and weed out those who were deemed as
merely homosexual or psychotic.
Regulating and standardizing gender transition-related care
“DOCTORS CAUTIOUS: FEW QUALIFY FOR SEX CHANGE OPERATION” read
the headline of an LA Times Article on the 26
th
of February 1979. The title was referring to the
elaborate screening practices developed to identify candidates for sex reassignment surgery.
“Levine and others have tried to develop techniques for distinguishing ‘the true transsexual’
from troubled individuals who latch on to sex change as a solution to their deep, emotional
33
problems.” The fact that the only consistent available evidence showed a high association
between those who identified as transsexual and behavioral health problems and substance abuse
was potentially threatening to the perceived legitimacy of transsexual science. Providers
expressed concern that patients with either or both of these associated issues would be less likely
to adjust well into society following sex reassignment surgery, and they also expressed that these
patients would be more likely to regret having had sex reassignment surgery and accuse the
doctors of malpractice. For transsexual science, which had only recently begun to be accepted as
a potentially legitimate field of research and area of medical practice, these sorts of negative
outcomes could be very detrimental. As Dr. Norman Fisk of Stanford University wrote to Dr.
Harry Benjamin in August of 1970, “we are very invested in the concept of initially being able to
demonstrate a group of patients who have had successful and hopefully exemplary results from
gender change surgery treatment. In keeping with this, we are at this point being extremely
selective in those patients whom we accept for treatment.”
But these concerns also reflected patterns in medical practice at the time; many doctors
working at this time had been educated in the context of the 1950s when scientists had access to
nearly unlimited research funds and were increasingly sought as advisors. But also a time in
which scientists work and political views were highly scrutinized, resulting in the arrest and
prosecution of hundreds of scientists. These events produced a culture of medicine in which
doctors maintained largely unscrutinized authority, but their authority was limited to the
“technical.” As Thorpe (2002) writes “the freedom of expert scientific opinion was to be
respected, but the scientific opinion was to be regarded as ‘free’ and ‘expert’ only so long as it
was separate from moral and political concerns.” Developing elaborate screening tools conveyed
a heightened level of technical sophistication and in the absence of clear evidence of a cause,
34
became the route through which providers could claim to be able to affirm that their patients
were “true” or “confirmed” transsexuals.
Patients also actively participated in trying to regulate access to gender transition-related
care. In a letter dated January 13, 1976, “R.R.” writes to Dr. F. H. Lowy, Professor and
Chairman of the department of Psychiatry at the Clarke Institute of Psychiatry regarding its
gender identity clinic: “I must draw your attention to the fact that although many people consider
themselves ‘transsexual,’ this is no way implies that this is their actual diagnosis, and in many
cases surgical sex reassignment would be very detrimental to the individual.” Extensive records
document the persistence and tenacity of those seeking gender transition technology. “We are, in
a sense, besieged with requests for gender change surgery” one provider wrote, and the San Jose
Mercury reported “…publicity often results in hundreds of ‘patients’ pounding the hospital
doors, besieging surgeons to change their sex.”
xviii
But the records also show that for many patients in this period, scientific confirmation of
one’s long-standing conviction that they are transsexual was very important and validating. Dr.
Harry Benjamin’s archival collection is filled with letters from former patients showering him
with praise for helping them understand and name the discomfort they had felt for many years, if
not their entire lives. At the same time, providers also expressed that their patients were
extremely savvy at identifying the diagnostic criteria that would be used to evaluate them and
entering the clinic ready to present themselves in a way that they would be identified as a good
candidate for sex reassignment. For example, a Harry Benjamin Foundation research project in
1971 based on 80 intake interviews concluded "it's rare to find a patient these days who is
unaware that his disturbance is transsexual in nature, that treatment is available,” and the
requirements to access that treatment. This finding was interpreted as further support for the need
35
to produce evidence that could properly regulate access to treatment, regardless of patient
knowledge.
In developing screening tools, the problem of the known evidence of high rates of
behavioral health problems among transsexual patients was a regular point of contention. "In
response to this question as to whether the presence of psychosis should be an absolute
contraindication to surgery,” Dr. Richard Green commented during a meeting of the Harry
Benjamin Foundation, “a distinction could, perhaps, be made between a psychosis secondary to
the great stress of being a non-operated transsexual or the transsexual syndrome could merely be
one component of a large number of psychotic symptoms. In the latter case surgery would be
contraindicated, while in the former, the question would be more fully evaluated." The Harry
Benjamin Foundation, however, was more accommodating of evidence of “psychosis” than most
organizations at the time. For most providers, any indication of serious behavioral health
problems would likely be used as evidence to deny access to treatment.
As the calls for scientific evidence of a cause for transsexualism remained unanswered,
and clear evidence on which to base screening procedures to regulate access to gender transition-
related care also proved elusive, providers proceeded as cautiously as possible. While a truly
standardized process was never quite achieved, long wait times for surgery, multiple layers of
diagnostic evaluation from different providers, and highly elaborated application processes
became par for the course. While the length and content of these application forms varied
considerably across clinical sites, the following application table of contents dated from 1982
offers an illustrative example:
36
GENDER DYSPHORIA PROGRAM, INC. APPLICATION FORM (16 pages)
Personal Photograph (required)
Personal Information (15 questions)
One-page Personal Biography (required)
Family and Personal History (26 questions)
Employment and Education History (21 questions)
Social and Psychological History (38 questions)
Sexual and Gender History (45 questions)
As this table of contents shows, application forms generated extensive data about prospective
candidates for sex reassignment; nearly 150 questions were included in this application. If one’s
application was approved, a series of evaluations with psychologists, general practitioners, and
other providers would follow. By design, these stringent and complex screening procedures
produced very few viable candidates for surgery. By 1974, for example, over 1500 applications
had been received by the clinic at JHH, yet only 35 patients had completed sex reassignment
surgery. As Drs. Lawrence E. Newman and Robert J. Stoller explain in a 1973 article in the
Advocate, "Although transsexuals do want to change their bodies, the diagnosis, in our view,
also requires evidence of life-long femininity, inability to live in ones assigned (biological)
gender role, and the capacity to pass in society as member of the desired cross-gender role."
Declaring transsexual science “done”
The cultural context that enabled this surge of interest in transsexualism in the 1960s and
1970s made possible the emergence of the gender identity clinic, first at Johns Hopkins Hospital
and then at many sites across North America. The cultural and epistemic authority of science and
medicine at the time made possible a discursive repertoire among scientists, providers, and
37
health policymakers that provided a vocabulary of motive for advancing the knowledge about
this highly marginalized and only vaguely conceptualized population. As Dr. Ira B. Pauly stated
at the Fourth World Congress of Psychiatry in Madrid, Spain in 1964, "The medical profession
has become heir to its own technological advances and must now face the responsibility of its
own scientific progress." Given that medicine could use seemingly transform one’s sex, many
scientists and providers felt it was incumbent upon them to decide if they should. As I have
shown, that determination hinged upon the production, interpretation, and application of
scientific evidence. Yet despite repeated calls for this evidence and unprecedented data
collection efforts across the West, very little definitive evidence was produced. And the evidence
that was available – that transsexuals were much more likely to experience behavioral health
problems and substance abuse than the general population, and these issues were often only
lessened, rather than eliminated by gender transition – threatened to undermine this burgeoning
field of research.
In the case of the clinic at JHH, it did just that. After just ten years the clinic was abruptly
closed following a report in 1979 by psychiatrist John Meyers. “Surgery can’t cure transsexuals,”
the report stated. “They never forget that they’re only impersonating the other sex. What you’re
dealing with are deeply disturbed people whose problems won’t vanish overnight. We now have
objective evidence that there is no real difference… in adjustment to life in terms of jobs,
educational attainment, marital adjustment and social stability between operated and non-
operated groups” (emphasis added). The irony of this claim is that it draws such a dramatically
different conclusion from the same available evidence that had led to the founding of the clinic in
the first place. If anything had changed in terms of the available evidence from the founding to
the closing of the clinic, it was that despite the elaborate efforts of scientists and providers to
38
specify a diagnosis and to regulate and standardize treatment, outcomes for transsexual patients
remain largely unchanged. A select few experienced significant improvements in terms of
behavioral health, substance use, and social integration following sex reassignment surgery, but
more often patients continued to experience significant hardships following sex reassignment. In
this cultural context, the discursive repertoire of scientists and providers provided limited
language to explain this problem, leading many, like Dr. John Meyers, to identify transsexuals as
the reason transsexual science seemed to fail to meet their expectations.
In the next section, I discuss the implications of these findings and how these insights can
provide a helpful reference point for understanding the shifts happening in transgender health
policy in the contemporary moment.
Conclusion
The emergence of the gender identity clinic at Johns Hopkins Hospital marked a rather
sudden surge of interest in transgender health policy. As I have shown, throughout this period
there was a consistent imperative to produce scientific evidence and to base transgender health
policy upon that evidence. Actors called for the production, interpretation, and application of
scientific evidence to specify a diagnosis and to regulate and standardize gender transition-
related care. Nearly 50 years later, scientists, providers, and health policymakers across the West
have once again rather suddenly became interested in defining the “proper” relationship between
science, medicine, and transgender subjects. Only this time, the cultural context would shape
dramatically different conclusions, including overturning policies and practices perceived as
unduly limiting access
xix
to general and gender transition-specific health care for transgender
39
persons, as well as creating new policies and practices aimed at reducing negative health care
experiences.
xx
For scholars of health movements, this chapter shows that a cultural lens capable of
identifying the symbolic contexts in which scientific evidence is deployed, are crucial for
understanding how that evidence is informing the interpretation and application of that evidence.
For transgender health advocates and their allies working in policy and medicine, this chapter
offers reason to be cautious about the recent shift toward transgender-affirmative policies,
showing that such policies are vulnerable to reinterpretations that might once again reorganize
scientific consensus regarding the “proper’ relationship between transgender subjects, medicine,
and health policy.
40
Notes
i
Stockholm Administrative Court ruled that the nation’s 40-year-old policy of sterilization as a prerequisite for
state-sanctioned medical and legal gender transition was unconstitutional (Nelson 2013). Then, in May of 2014 the
U.S. Department of Health and Human Services Departmental Appeals Board overturned a 25-year-old national
policy preventing the use of public funds for gender transition (see http://www.transequality.org/know-your-
rights/medicare).
ii
For the purposes of this paper, transgender persons refers to those for whom correcting the misalignment between
the sex category assigned to them at birth and their gender identity is a major life project. This definition is drawn
from Stryker 2017.
iii
In 2007, UNAIDS announced that transgender persons were an urgent priority in its new global HIV/AIDS
prevention strategy. Prior to 2007, transgender does not appear in official strategy documents of UNAIDS. In a
sharp reversal of programming and policy, then Executive Director Dr. Peter Piot announced that year “empowering
MSM [men who have sex with men] and other marginalized groups to protect themselves from HIV is one of the
world’s most urgent health priorities” (UNAIDS 2007). Related research publications and subsequent official
strategy documents indicate that transgender (almost exclusively transgender women) was one of the key
marginalized groups Director Piot was intimating (see UNAIDS 2007, 2009). Simultaneously the Global Fund
developed a Sexual Orientation and Gender Identity committee charged with increasing the distribution of grant
funds to transgender-focused HIV/AIDS programming. For a thorough analysis of this major policy and
programming shift, see McKay 2013.
iv
See, for example, Hessen 1971, Blume 1974, Cummings 1984.
v
Here I do not want to characterize these doctors as purely benevolent do-gooders. Sociologists have long been
skeptical of the “helping professions” and studies have shown that misguided and nefarious motivations can be at
the root of seemingly benevolent and even well-intended action (see, for example, Augustín 2007 and Parreñas
2011). Certainly the lack of scientific knowledge about transgender patients created an opportunity for these doctors
to carve out a name for themselves in their professional field. And even in critiquing their own profession, doctors
might understand themselves to be working in their own interests to advance their professional status and autonomy.
No doubt some doctors simply saw transgender patients as dehumanized lab rats that could lead to them to fame-
generating breakthroughs in scientific knowledge of psychosexual development (as Stryker (1994, 2008) argues, it
has been difficult historically for the general population to see gender transgressors and cross-gender identified
persons especially as humans, thus making it quite likely that some doctors working with transgender patients also
internalized this dehumanization). But still, the important insight here is that in order to understand the front-stage
boundary work engaged by these doctors, we must view them as complex actors with multiple interests and
commitments.
vi
While several organizations tried to distinguish themselves as the main producers of such standards, the Harry
Benjamin Standards of Care became the most influential of such documents and remains widely circulated to this
day by the World Professional Association for Transgender Health. Although I do not engage this issue here,
standards-making as an incentive to build organizations and as a route to organizational prestige and influence is an
important topic that deserves further analysis in this case.
vii
The adaptation of Bourdieu’s concept of “fields” to this school of thought is credited to Epstein 1996: 18, but see
also Crossley 2006.
viii
See Star 1988, 2010; Star and Griesemer 1989; Bowker and Star 1999; and Thévenot 1984.
ix
See also Star and Griesemer 1989.
x
See also McKay (2012) and Pettinicchio (2013)
xi
This insight also emerged organically in the field. I found that I could not arrive at satisfactory explanations for my
ethnographic and archival observations without understanding the broader cultural and historical context in which
the observation occurred.
xii
See also Donati 1992, Kane 1997.
xiii
See also Moore 2008.
xiv
For example, Sidone Smith (1987) writes that autobiography should be understood as “the process and the
product of assigning meaning to a series of experiences, after they have taken place, by means of emphasis,
juxtaposition, commentary, [and] omission” (45).
xv
For a thorough accounting of this history, see Meyerowitz 2002.
xvi
For more on the life and impact of Christine Jorgenson, see Docter 2007.
xvii
See Meyerowitz 2002.
41
xviii
Certainly these accounts are likely sensationalized; however, across the West gender identity clinics during this
time consistently reported receiving more applications and requests for surgery than they could possibly accept.
xix
Access has historically been limited in myriad ways, by explicit policy language, implicit provider biases, lack of
transgender-inclusive protocols in health care settings, patient fear of discrimination due to past experiences of
discrimination, and others. See, for example Stroumsa 2014.
xx
For a recent update on the state of transgender subjects in health policy; see Stroumsa 2014.
42
Chapter 3
Hybrid styling:
How culture shapes the relationship between
transgender subjects, medicine, and health policy
Introduction
In just under two decades, a series of court cases, policy determinations, and professional
convenings
i
of medical care providers (hereafter referred to as “providers”) have resulted in
significant shifts in health policies
ii
about or affecting transgender
iii
persons across the West.
iv
These shifts have included overturning policies and practices perceived as unduly limiting
access
v
to general and gender transition-specific health care for transgender persons, as well as
creating new policies and practices aimed at reducing negative health care experiences.
vi
A small
but growing body of research investigates these shifts, showing how they have been driven by
strategic claims-making by transgender advocates and allies. However, these studies do not
address the formative role culture – understood here as a set of constraining and enabling
contexts – has played in shaping these strategic claims. This paper addresses this gap by
analyzing claims that were made during one professional convening of providers dedicated
entirely to transgender health, the Transgender Health National Conference (THNC).
vii
THNC was held over a three-day period in a major city in the U.S. in 2015.
viii
Data were
collected at THNC as part of an international, multi-method study carried out from 2013-2017 of
how transgender health gets constructed as a public problem and how that construction shapes
clinical decision making, health policy, and transgender self-making. In this paper, evidence
from participant observation at THNC, contextualized with archival data drawn from the broader
43
research project, show that one symbolic maneuver was central to claims-making; in this
maneuver, participants mixed together symbolic categories reflecting commitments as both
activists and objective scientists. Specifically, when the content of a particular claim was not
based on scientific evidence, the claim was articulated in a way that reflected a primary
obligation to objective science. Conversely, claims that emphasized objective scientific evidence
reflected an obligation, not to objective scientists, but to transgender communities or social
justice. This symbolic maneuver allowed participants to make claims that were understood as
both transgender-affirming and scientifically objective. This blending of categories and
obligations is conceptualized here as “hybrid styling” and implications of this concept for future
research are discussed.
These findings demonstrate that while strategic action is indeed an important part of
claims-making, cultural context shapes the kinds of claims that actors imagine are possible to
make in advance of strategic action. In this way, culture plays an important role in the ongoing
organization of scientific consensus regarding the “proper” relationship between transgender
subjects, medicine, and health policy.
Seeing culture in claims-making
In this paper, THNC serves as an analytical case for understanding how claims about
transgender health are constructed. “Claims” are demands, criticisms, or declarative statements
about something deemed to be a public concern (Koopmans and Statham 1999). Claims-making
links together certain ways of knowing from a wide range of conceptual associations. To
understand processes of claims-making is to understand a critical component of how “larger”
processes, like policy change, happen (Gusfield 1984; Best 1987, 1993).
44
A large body of literature analyzes how health, as a prism through which to make rights
claims, has been mobilized strategically by civil rights (Nelson 2003; Nelson 2011; Dittmer
2017), women’s rights (Boston Women’s Health Book Collective 1976; Murphy 2012; Moore
2010), gay and lesbian rights (D’Emilio 1983; Epstein 1996; Conrad 2007; Hurewitz 2008) and
other advocates (Heaney and Rojas 2014). Professional convenings like THNC have sometimes
served as sites of analysis in these studies (e.g., Epstein 1996).
These studies draw from a foundational insight of science studies that all scientific
knowledge claims are inherently political and contested (Kuhn 1962; Shapin 1995; Gieryn 1999)
to demonstrate how movement actors manage to effect change in health policy. When analyzing
rhetorical work by movement actors to affect this change, previous studies typically borrow from
the “framing”
ix
approach in social movements studies. Framing shows how health advocates
make specific, strategic claims in a self-conscious attempt to organize understanding of an issue
in a particular way or to build constituencies by strategically aligning ideological orientations
(McAdam et al. 1996; Snow and Benford 1988; Snow et al. 1986). This approach provides an
important and necessary piece of the story of how health movements effect change, and are
particularly important for analyzing moments of confrontation between medical care providers,
policymakers, and health advocates.
Far less attention, however, has been paid to how culture enables and constrains
possibilities for reflective discussions and for recognizing available frames before they can be
strategically deployed (Williams 2004; Polletta and Ho 2006; Snow 2008; Dasgupta and
Lichterman 2016). This paper contributes to this gap in the literature, providing an up-close
conceptualization of how health claims are constructed in action; that is, how culture shapes
what people can say and do together in order to make claims about health. To build a framework
45
for analyzing claims-making at THNC, I borrow two related concepts in the civic action
approach in cultural sociology: scene styles and scene-switching.
Scene styles and scene-switching
As the framing approach mentioned above helpfully points out, actors are certainly, in
part, acting strategically when they make claims. However, a central insight of cultural sociology
is cultural symbols provide the very contexts in which actors are able to act strategically.
Cultural symbols or representations shape actors’ ability to make sense of their experiences;
those representations take on different meanings in different contexts, and in specific settings
actors have to filter cultural symbols to create a shared ground for interaction (Ricoeur 1974;
Swidler 1986; Goffman 1974; Schudson 1989; Kane 1997). The cultural symbols associated with
specific settings are culturally patterned, such that actors most often move through settings quite
smoothly, filtering a small number of possible cultural symbols that might define the situation
(Becker 1999; Hallett and Ventresca 2006). The cultural symbols that shape what actors can say
and do together in particular settings make up the cultural contexts that enable and constrain
strategic action.
Lichterman and Eliasoph (2014) conceptualize these contexts as “scene styles.”
x
Scene
styles are patterned ways of filtering and using cultural symbols in interaction; they provide a
frame of reference for actors to define the situation they are in and who they are in relation to
imagined others in that situation. This information helps actors recognize what is appropriate for
them to say and do in that situation. Scene styles emerge in specific settings, but they are not
determined by settings; actors can enter the same setting and yet be oriented by different scene
styles. Actors may enter a setting and define the situation in the same way, but may recognize a
46
very different sense of who they are in the situation. However, in many settings a particular
scene style tends to be dominant, allowing actors to operate in that setting with relative ease.
xi
The scene styles concept provides an up-close understanding of how cultural contexts shape the
kinds of claims actors imagine are possible to make, in advance of their ability to act
strategically.
To identify scene styles operating at THNC, this paper focuses on two components of
identifying scene styles: maps and bonds. As mentioned above, scene styles contribute to
orienting actors with a sense of who they are relative to imagined others. Maps are collectively
shared reference points actors use implicitly and explicitly to orient themselves in the wider
world. These reference points make a sense of who we are possible by identifying boundaries of
what is included in, and what is excluded from, a collective sense of identity. Reference points
may include other groups, actors, or categories. While actors do not enter a setting by
announcing the boundaries and reference points, by listening closely and over long periods of
time to interactions in particular settings, researchers can identify many reference points that
work toward mapping a particular scene style. Bonds are collectively shared assumptions about
particular reference points with which actors share an obligation. Bonds can exist between actors
and other groups, actors, or categories. Maps and bonds tend to appear together in patterned
ways. In particular settings, actors most often rather seamlessly recognize an implicit sense of
who they are (their collectively shared map) and how to act in relation to others who may or may
not fit within that map (bonds).
Additionally, this paper also borrows a related concept, scene-switching. Scene-switching
occurs when participants within a scene shift their implicitly shared understanding of the
situation; that is, they switch between the meanings and assumptions orientating the action taking
47
place in that scene (Goffman 1979). Although actors typically are able to recognize these shifts
rapidly such that the switch occurs smoothly – and perhaps imperceptibly – some settings may
require more frequent scene-switching than others. Scene changes like these can be helpful for
identifying the maps and bonds at play in any given moment. In settings where frequent scene
changes occur regularly, it may be more likely to observe actors in a setting failing to recognize
the change. That is, actors saying and doing things that other actors recognize as out of step with
their expectations about what is acceptable to say and do in that scene. In these moments, the
unspoken and implicit may become explicit, helping to strengthen interpretive validity.
Methods
Health movements studies have often used a logic of inquiry that starts with identifying a
site where claims-making is expected to take place. However, insights from cultural sociology
and recent studies of hybridity in health movements suggest that assuming a priori what
important sites are for observing collective action may hinder or distort research findings.
xii
Additionally, transgender studies demonstrates that organizing around transgender subjects has
historically occurred across diverse, and perhaps atypical, spaces.
xiii
Following these insights,
data collection for this study began with actors and archives rather than sites. I reviewed
thousands of documents – meeting minutes, personal communications, conference programs, and
other records – kept by transgender advocates and provider-allies. I spent over five hundred
hours participating with transgender health advocates and providers as they moved – sometimes
separately, sometimes together – across multiple settings. Professional convenings of providers,
like the one discussed in this paper, were just one type of setting where the actors I followed
regularly congregated.
48
Studying the contours of claims-making in specific settings requires spending long
stretches of time participating in – but mostly actively listening to – discussions, debates,
presentations, hallway conversations, and any other kinds of interactions taking place in that
setting. While helpful conceptual tools can be gleaned from the literature on claims-making,
contextual information about the specific topic provides a sense of the kinds of claims that might
be made in those settings to help organize data collection. For this paper, limited literature was
available to draw from. As a result, I leaned heavily upon the primary data – archival research
and participant observation at other convenings – gathered as part of the broader project.
Additionally, a recent review of the published literature provided an inventory of scene styles
observed across a range of studies.
xiv
These resources were used to create a coding scheme to
interpret the data.
Data collection, including note-taking and note-coding, was informed by the “extended
case method” (Burawoy 1998), the “constant comparative method” (Glaser 1965), and a recent
re-articulation of “abductive methods” (Timmermans and Tavory 2012). These methods
emphasize balancing one’s own theoretical commitments and backgrounds with attention to the
unexpected. Moments where actors seem to “mess up,” or violate, the taken for granted
assumptions of communication in that setting are particularly telling. Data collection, therefore,
is theory-driven but also very open to unexpected findings as well as not finding what I expected
to find; data collection and analysis are kept constantly in dialogue. This approach is critical to
empirically-grounded theory-building, but should not be confused with “grounded theory”
(Glaser 1967).
Throughout each day of the convening, I took notes whenever possible without disrupting
the scene. At the end of each day I reviewed these notes and added in additional detail from
49
memory whenever possible. Then, using the categories of claims I generated from the contextual
data described above, I passed through the notes looking for examples that fit the code. I then
made a second pass through the notes looking for patterns that did not fit any of the codes I had
predetermined. If a similar example not included in the original list of codes emerged at least
five times, I gave it a category name and included it in the master list of categories used to code
the notes in the first pass. When all coding was complete, I looked for patterns across codes, such
as when codes frequently occurred together or when they never occurred together. These patterns
were summarized in coding memos that were later synthesized in preparation for the final
analysis.
Organizing for transgender health: The case of THNC
THNC brought together a diversity of participants, including providers, community
members, advocates, academic researchers, private industry, public officials, and others.
Programming included a dizzying range of medical topics as well as sessions that were topically
related to the subject matter but not principally about health or medical care. For example,
THNC offered job placement and job training sessions, responding to the high rates of financial
instability in transgender communities compared to the general public (Grant et al., 2011; James
et al., 2016). Although these sessions were not explicitly about health, conference materials
indicated that they were an important part of a “broad approach” to improving transgender health
outcomes.
THNC is an example of a common event in contemporary medicine: the formal
conference. At these events, providers give case presentations, pharmaceutical companies
providing sponsorship give presentations on medical innovations for which they have a financial
50
stake, ethical and legal considerations are discussed, public officials and community members
give presentations that bring a sense of humanity and public impact to the science, and in
exchange for participation, providers acquire continuing education credits that support their
continued professional licensure. These conferences are an important part of the
professionalization of providers (Anspach 1988). Although formal scientific conferences like
THNC have regularly been targets of political demonstrations (Epstein 1996), the evidence
discussed here came from the planned programming.
While conversations about transgender health in community-based organizations with an
explicit political orientation would typically be sites where we would expect to see claims-
making, formal scientific conferences are primarily limited to the technical. As expected,
communications soliciting participation at THNC did not indicate it would be a fertile site for
studying claims-making. The convening beckoned professionals to come learn about the latest
“evidence-based practices”
xv
and to attend “interdisciplinary educational training” opportunities.
Session titles typically seemed unlikely to arouse political or moral debate, ranging from
“introduction to transgender care” to “advanced case discussions for surgical procedures in
transgender men.” Even when session titles contained phrases like “transgender rights,” or
“transgender politics,” they were typically dedicated to updating participants on the latest
transgender-relevant changes in health care law and laws related to gender transition. Moreover,
when I spoke with participants at THNC, none of them described motivations for attending
THNC that included an explicit desire to debate the politics of transgender health. Rather, they
most often emphasized that transgender persons simply have specific health care needs and
conferences like THNC are important opportunities for providers to learn the about the latest
scientific evidence and best practices to meet their transgender patients’ needs.
51
Ambiguity and uncertainties beneath seemingly straightforward topics, however,
regularly emerged; this sometimes led participants to conflicting conclusions. “Best practices”
for transgender health care, for example, was understood differently by different participants at
different times. Participants in one setting said the use of any formal diagnostic or health
screening criteria to regulate access to transition-related medical care was merely “gatekeeping;”
others advocated strongly that doctors are responsible for ensuring their clients are healthy
enough to medically transition. A presenter at one session, a middle-aged transfeminine
xviii
xvi
general practitioner, said, “what counts as transition-related medical care must be narrowly
tailored to those things directly related to top- and bottom-surgery.”
xvii
An audience member
rebutted that facial feminization surgery was essential for transgender women’s physical
safety and mental health, and should therefore count as transition-related care. In these moments
where participants discussed the “boundaries” of what transgender health should include, and the
uncertainties beneath scientific knowledge claims about transgender care became more salient,
participants engaged in claims-making.
In the sections that follow, I describe two patterns of claims-making that emerged
consistently throughout the convening. Then, I draw from the theoretical work discussed above
to conceptualize these patterns as a symbolic process I term “hybrid styling.” I conclude with
implications for future research.
Styles of THNC
“This is a remarkable time when people are unbelievably interested in transgender
health,” said Dr. Roberta Silva,
xix
the opening plenary speaker at THNC. “Who here does not
identify as transgender, but identifies as an ally” she asked. Hundreds of arms went up
52
enthusiastically and in almost perfect synchronicity; several more followed, rising with subtle
hesitation. Dr. Silva paused for a moment as she surveyed the expansive banquet hall. I caught
the glances of several participants as our eyes moved across the room; a sense of satisfaction
could be read on the smiling faces that filled the room as we collectively noted that the vast
majority of the roughly 700 participants had raised their hands. “There’s a great opportunity that
we all face,” she continued as participants began lowering their hands; “to create a reality where
regardless of race, socioeconomic status, gender identity, or sexuality, people can receive the
health care they need.” Roaring applause filled the packed room.
This opening scene at THNC felt to me more like a political rally than a scientific
convening. Dr. Silva spoke authoritatively and charismatically. Her use of “we” reflected a
perception of unity among the diverse participants. By first asking all transgender allies to raise
their hands, Dr. Silva implied that she understood everyone with their hand raised as loosely
oriented by certain commitments and obligations to a broad social justice mission. That mission
might have been limited to the boundaries of the transgender community, wherever one might
erect those. But Dr. Silva situated their commitment to a much broader project of social
transformation. The “great opportunity” she referenced required systematically identifying and
eradicating what she understood as inequities in health care based on race, socioeconomic status,
gender identity, and sexuality.
xx
Inequities that overlap with but are not limited to transgender
communities.
In this moment, Dr. Silva seemed to put forth a “social critic” scene style.
xxi
In settings
with this style, actors coordinate interaction around broad principles, fitting action into an
expansive vision of social transformation. Actors expect each other to link up everyday action to
broader social commitments; bonds are created between actors through meeting these shared
53
expectations and through identifying real or imagined others who either fail to connect their
action up to something broader, or who foster different principles that are understood as
conflicting with their own. But, importantly, Dr. Silva did not erect high barriers limiting who
might collaborate in this vision; anyone who raised their hand was a worthy collaborator; and Dr.
Silva did not put forth a singular issue on which attendees should focus intently; the opportunity
to “create a reality” certainly entailed myriad and intersectional issues that would all need to be
addressed. Expansiveness was key. Either of these boundaries – limiting who should participate
or what issue they should focus on – would have suggested a different scene style was at play.
Selectively collaborating only with those who share a mutual sense of common identification, for
example, would suggest a “community of identity” style, while focusing a broad constituency
intensely on a single issue would suggest “community of interest” was the style orienting the
scene.
xxii
That Dr. Silva’s claims were met by such an eager and receptive audience suggested
participants readily recognized the style at play and understood it as appropriate for the moment.
Over the next few days, many discussions also linked the everyday work of providing medical
care for transgender clients up to broader social transformation. Take the following exchange
during a panel on access to care. Throughout the panel it was clear there was a baseline
consensus among participants that increasing access for transgender persons to gender transition-
related care, especially hormone replacement therapy, was inherently good for transgender
communities. But quickly, participants connected care access up to a broader social justice
mission.
Allen: Behavioral modeling has really helped to show people what's appropriate
54
behavior; it has hugely changed the culture of hospitals in my area. Hormone
access is not asthma care, it's not diabetes, it's super easy. The important things
are the psychological and social issues; building a bridge of trust is key. More and
more people are accessing care in appropriate ways as a result [of that trust].
Rikki: The more we talk the more I hear that the biggest issues come up in the waiting
area; that's why we need appropriate ways to get people's names and information.
Culture change has to involve the entire frontline staff.
Claire: But, the reality of trans folks transitioning is that there is a tremendous amount of
gatekeeping, even despite the informed consent model. [Access] is still contingent
upon a small number of [transgender-friendly] providers.
Xavier: Trans people have to interface in this way with the medical profession in ways
that other groups simply don't have to.
Amy: Yes, but, it's not easy for “lgb”
xxiii
people either. When lgb people go to doctors
they
are often treated terribly… so the key is creating systems that are supportive of all
people. And we need online resources for training to make it available to all
providers no matter where they live.
Allen: Yes, [providers] need this training for all patients not just trans. I try to get at their
55
social support for any kind of mental health medication; it’s about recognizing
and respecting all patients’ agency.
The discussion started with a narrowly focused technical conversation about specific models for
increasing access to general and gender transition-specific care for transgender patients.
“Behavioral modeling” with frontline staff was offered as a way to get at “culture change” to
foster a more transgender-affirming clinical environment. But then, the speakers expand the need
for culture change in medicine beyond creating a better clinical environment for transgender
patients specifically. Amy politely responds to Xavier’s contention that only transgender patients
have to interface with medicine in a way that makes them vulnerable to negative experiences.
“When lgb people go to the doctor they are often treated terribly,” she states. The other
providers, including Xavier, immediately gestured support for Amy, nodding and passing
confirming glances at one another. By the end of the interaction the conversation had expanded
to “creating systems supportive of all people,” and “recognizing and respecting” patient agency.
The panelists mapped themselves as in conflict with institutionalized practices of medicine and
in solidarity with their patients; they bonded over the shared struggle of working from within to
change an institution understood as contributing to poor health outcomes by creating negative
care experiences.
When analyzed separately from the rest of the convening, this access to care discussion
and Dr. Silva’s opening remarks suggest claims-making at the convening was oriented by the
social critic style. However, situated in the context of the entire convening, this interpretation
becomes doubtful for two reasons. First, other scene styles operated simultaneously at THNC. At
times it was important participants linked up the immediate topic at hand to broad principles that
went beyond transgender-specific issues; other times participants needed to demonstrate a
56
narrower commitment to transgender communities. Importantly, sometimes making claims that
reflected commitments to either transgender communities or broad social transformation projects
actually undermined participants’ perceived credibility. One interpretation of these observations
might be that no single scene style dominated the convening; instead, participants engaged in
scene-switching to navigate convening smoothly. Another might be that there were “style
digressions” during which a scene at the convening called for a different style, but one style still
remained dominant.
However, these interpretations are complicated by a second pattern observed throughout
the convening. Participants’ comments “backstage” regarding specific scenes at the convening
suggest different participants recognized different styles as orienting the same scene. To explain,
let me return to Dr. Silva’s words above; the fact that her words were not bounded by a high bar
for who could participate or what the specific issues they might work on should be suggested the
scene style at play was the social critic style. For some participants, certainly it was. Others
expressed a significantly different orientation to the same scene. One participant, a social worker
who looked to be in her mid-30s, told me casually in regard to Dr. Silva’s speech, “You know,
Dr. Silva’s right. Science was really corrupt before; one by one new evidence is proving we were
wrong about a lot of things.” Another participant, a medical officer working for a government
agency, leaned over during the speech to tell me, “That’s right! It’s all about equality baby!”
These participants were in the same scene, yet they were mapping it differently. For the social
worker, Dr. Silva’s obligation was to objective science; the medical officer on the other hand
mapped herself and Dr. Silva as bound by social justice, not by objectivity.
This flexibility was the central pattern that tied together the many scenes at the
convening. These scenes created room for provider-allies committed to deeply understanding and
57
responding to the wishes of transgender patients, without a need for supporting evidence; they
created room for providers committed to providing the latest evidence-based care but with no
particular commitment to or knowledge of transgender communities or politics. At the same
time, they accommodated overtly political participants who were interested in advancing the
needs of their community, as they understand them, regardless of any connection to scientific
evidence or “objective” logics of justification. This flexibility was achieved by a symbolic
maneuver in which multiple symbolic contexts are allowed to operate simultaneously.
Mixing symbolic categories: Community affirmation and scientific objectivity
Scene flexibility at the convening was made possible by a particular symbolic context. In
a peculiar form of scene-switching participants mixed together symbolic categories reflecting
commitments as both activists and objective scientists. Specifically, when the content of a
particular claim was not based on scientific evidence, the claim was articulated in a way that
reflected a primary obligation to objective science. Conversely, claims that emphasized objective
scientific evidence reflected an obligation, not to objective scientists, but to transgender
communities or social justice. This symbolic context allowed participants to make claims that
were understood as both transgender-affirming and scientifically objective.
This pairing of symbols is seemingly counter-intuitive. The logic of scientific objectivity
requires disinterestedness (Haraway 1988), while coordinating action on behalf of a broad social
justice mission or on affirming the interests of a specific community requires interestedness. A
commitment to scientific objectivity would suggest actors in a setting were driven by
objectively-produced evidence. In a scene oriented by this map, a commitment to affirming
transgender communities would only make sense insofar as that affirmation emerged out of an
58
objective interpretation of scientific evidence. But in the case of transgender health, scientific
evidence that meets traditional criteria of strength and reliability is most often absent. Where
extensive evidence does exist, the validity of that evidence has largely been identified as suspect
given that transgender health advocates and allies have argued persuasively that the evidence
was produced in questionable or biased circumstances. Thus, in a scene oriented by a
commitment to objective scientists, it is reasonable to expect actors would conclude that action
should not be taken until sufficient evidence was produced. And if sufficient evidence does exist,
actors would emphasize the importance of providing care in accordance with that evidence.
However, in the following examples from the convening, we see that rather than reaching this
conclusion, scenes oriented by a commitment to scientific objectivity became opportunities to
make claims affirming transgender communities.
A central discussion point throughout THNC regarded the need for psychosocial
assessments and other protocols to ensure clients received standardized, evidence-based
transgender-specific care. In the following exchange, the validity of psychosocial assessments is
discussed:
Dr. Brown: The department of public health does letters to figure out how to
psychosocially capture [transgender patients] for good outcomes. Their
importance is more than just a referral.
Dr. Lu: Yes, I see the value of assessment, especially given that mental health is the
largest known health disparity for trans people. But, I mean the idea that I need
one letter for this and two letters for that… it's not about the letters, it's about
good access to care. Consulting with care providers about the best sequence of
59
transition, etc. is valuable, but it has been reduced to letters. That reinforces that
it's about gate keeping rather than opportunities to consult people so you can
make informed decisions about your own care. [In an informed consent model] a
person would come and say ‘I want hormones’ and there would then be an
educational session. Then, after taking that in, the patient would sign a consent
form…. The Standards of Care required a more particular evaluation by a mental
health professional. But this should not be a requirement.
Dr. Lu affirms the value of assessments in regulating and standardizing care. She affirms that
psychosocial assessment is critical in trans patients given that they experience significant
disparities in mental health compared to the general population. These statements map Dr. Lu as
committed to objective scientists. At the same time, Dr. Lu pairs her commitment to objective
scientists in a commitment to affirming transgender community interests. While upholding the
need of transgender patients to be “consulted” by providers, she affirms the value of an informed
consent model in which transgender patients would use those consultations to make informed
decisions about their own care. Thus, Dr. Lu’s support for this informed consent model reflects a
dual commitment to objective scientists and affirming transgender community interests.
In a different panel at THNC, Trevor, a transmasculine provider discussed the protocols
most transgender men have to go through in the United States in order to have complete bottom
surgery including phalloplasty and scrotoplasty. After explaining the protocols, drawing from his
own personal journey through transition, Trevor states, “the science doesn’t show that at all!
There’s nothing in the scientific literature that supports these requirements.” Trevor critiques the
protocols governing bottom surgery for men in the United States by stating they should be based
60
in scientific evidence. Through this claim, Trevor maps himself as committed to objective
scientists. However, in the absence of evidence, Trevor does not conclude that action should be
stalled or that great caution should be taken. Rather, Trevor concludes “trans men are finding a
way to get what they want one way or another. It’s best that we just inform them about risks.”
Through this conclusion, Trevor’s also affirms a commitment to transgender communities.
“We're living in a different time now,” a different provider told me after this session. “Providers
are no longer gatekeepers, people can go online and get anything, we have to form alliances with
our patients, we have to form trust and focus on education, because people who feel like they
have no options will take things into their own hands.”
In the following exchange a middle-aged pediatric endocrinologist, Dr. Rosalin,
discussed her approach to screening youth for access to exogenous hormone therapy. Other
providers in the room expressed concerns that especially when dealing with clients who are
under 18, they needed clear evidence-based guidance for identifying appropriate candidates for
hormone replacement therapy (“HRT”). Dr. Rosalin made the following statement:
Yeah I could go off of all these criteria to determine if someone should be put on HRT,
but honestly, I don’t use that anymore. Now I diagnose based on my feelings from the
encounter. That’s enough of a positive predictive value. Like if I leave an interaction and
feel like this person is ready for hormones, then I recommend them. That may seem like
it’s not evidence-based, but it still takes into account the evidence, but it also takes into
subjective factors and recommendations of the transgender community.
61
Dr. Rosalin’s statement takes seriously the commitment to objective scientists and evidence-
based clinical practice. However, she uses the language of scientific objectivity, such as “positive
predictive value,” in order to make a claim that affirms the interests of transgender communities.
Her statement “now I diagnose based on my feelings” does not resonate with a commitment to
scientific objectivity and disinterestedness. On the contrary, it speaks from the position of
affirming the interests of clients and using subjective emotions as a basis for clinical decision-
making.
Following this discussion, I spoke with a participant who was in the audience during the
discussion, a primary care doctor from Colorado. I asked how he felt about Dr. Rosalin’s
perspective. “As physicians,” he said, “we take an oath to do no harm. I think increasingly
people are saying, ‘hey, this kid knows who they are… if I can reduce their suffering with a little
T, then that’s what I need to do.’” As this was a scientific conference, claims could not be purely
transgender affirming without regard to the additional commitment providers held to objective
scientists. A social critique was acceptable when it was able to expose prejudices and injustices
that ran counter to that community’s commitment to being objective actors. Claims-makers held
the commitment to objectivity together with an affirmation of transgender community interests.
In the case of this primary care doctor, these symbolic categories are held together in tension
through an invoking of the Hippocratic Oath providers take to “do no harm.” Other providers I
spoke with mentioned various specific kinds of harm that could be committed by denying access
to HRT, including psychological discomfort, social isolation, and economic marginalization.
“Barriers are now manageable” another presenter stated during a different session. "The idea of
letters
xxiv
is an idea of yesterday. We should let go of these old ways of thinking.” All of these
62
responses maintained a commitment to objective scientists while denying a need for objective,
rigorous scientific criteria in favor of affirming transgender community interests.
Style violations at THNC
As discussed in the methods section, moments where actors “mess up” in a setting can be
particularly insightful for identifying how symbolic contexts are shaping the action in a scene.
The following are two examples of times where actors messed up and what their perceived
violation said about the symbolic context orienting scenes at THNC.
In the following exchange, a presenter briefly switched out of the style dominating the
scene to provide a candid response; the reaction of several audience members indicated this was
inappropriate. The setting was a session dedicated to “improving access to care” for transgender
persons by “eliminating barriers” to care. Session presenters consistently depicted these barriers
as rooted in “paternalistic” and “discriminatory” protocols, repeating the refrain that these
protocols were not rooted in scientific evidence or that the evidence was suspect. Two scene
styles were orienting the session: community of identity. Participants were expected to orient
their claims to a commitment to doing what the best scientific evidence dictates, and in the
absence of relevant or definitive evidence to do what transgender community members felt was
best. The presenter’s candid responses diverged from both of these styles. The exchange went
like this:
Presenter: [To gain access to hormones] patients had to get a letter from a mental health
provider. If they didn't have one, they would go through a hormone readiness
assessment, which lasted about an hour, to get a strong psychosocial
63
assessment…. This model became hard to sustain. Back then we had a couple
hundred patients; we have now just over 1400 trans patients. So the improvement
in access has been tremendous! But patients were having to wait [a long time]
until the program could ok them for hormones. Meanwhile patients were telling
us ‘I can manage my own mental health.’ So our new protocols are: no readiness
session and no letters from mental health providers.
Audience member: Under your old system, if a client who had already been on hormones
for 10 years came to you, you would make them do all the same protocols?
Presenter: Yes! And that wasn't so bad when we would see two patents per month
(laughs). But now we can't sustain that, so we changed it.
Grumbling among the audience immediately followed the presenter’s response; his facial
expression shifted from a smile to a frown and his eyes darted back and forth across the room as
if they were looking for clues to explain the audience’s negative response. Another panelist
quickly intervened stating, “when providers are no longer gatekeepers… we have to form trust
and focus on education, because people who feel like they have no options will take things into
their own hands.” The audience, satisfied with this response, moved on to the next presenter.
What “mistake” had the presenter made? How did the other panelists’ responses correct
it? Like other panelists, the presenter described a “tremendous” increase in the number of
patients receiving hormones at his clinic after removing barriers to access. However, unlike other
panelists, this presenter situated the decision to remove the “hormone readiness session” and
64
“letter from a mental health provider” protocols on the need for expediency and lack of resources
to support the number of patients requesting access. Without explicitly denouncing these
protocols as either discriminatory or scientifically invalid, the presenter had deviated from the
styles orienting this scene. As discussed above, scenes were oriented by a commitment to
objective scientists and transgender community affirmation. But here, the audience member’s
question gave the presenter the opportunity to appropriately map his remarks within this style.
Instead, his response indicated that the protocols were important – or at least necessary – but he
wasn’t firmly committed to enforcing them (which would have reflected a commitment to
objective scientists). At the same time, the elimination of them had nothing to do with affirming
transgender communities. Rather, he simply couldn’t sustain them given the purely pragmatic
concern of patient volume. The other panelist came to his rescue by switching the focus of
eliminating screening protocols to a transgender-affirmative move, which fit within the scene
style operating at THNC. Regardless of scientific validity, they stated, if patients were going to
seek hormones using any means necessary, providing them was the right thing to do.
In the following example, a different kind of mistake was made in which presenters’
claims began to reflect a narrower commitment to affirming transgender communities rather than
the dual commitment to transgender community affirmation and objective scientists. The
exchange took place during a session that promised to provide an update on the legal status of
various components of social gender transition (e.g. sex marker changes on birth certificates) and
insurance coverage updates for surgical and hormonal sex reassignment procedures. The topic
was dry and technical but inspired regular applause and cheering from the attendees as the vast
majority of updates included significant increases in insurance coverage amid what was
understood as transgender-affirming legal decisions. The enthusiasm for such technical details
65
suggested that the dominant scene style in this moment was either social critique or community
of identity. That is, attendees were not merely discussing technical updates, but rather, they were
celebrating social justice victories and validations of a shared cause for what they understood to
be transgender equality under the law. The enthusiasm became untenable as the session
presenters began veering off script during the question and answer session that followed.
Attendees and panelists began participating in what seemed to be a shared sense of
disdain for any lawmaker, insurer, or provider who did not support transgender equality. A
medical doctor who apparently testified in court against expanding public health insurance
coverage in her state for surgical and hormonal sex reassignment procedures was mentioned by
an attendee. The panel speakers responded with nods and eye-rolls of shared disdain. One
panelist responded that “unfortunately, there are still many transphobic and uninformed
providers working with transgender patients.” An attendee sitting immediately to my left seemed
increasingly agitated during this exchange. The steel frame of his padded fabric seat squeaked as
he repeatedly shifted his hips, and the tapping of his pen on a crinkled hotel room notepad
seemed deafening. Suddenly, he broke his silence. “Isn’t the real issue here the [public
insurance] reimbursement rates? I can’t survive on that! I don’t know any doctors who would
refuse to see a transgender patient, they really don’t care. I don’t care who you are, if you have
good insurance or you can pay for my time, I am happy to help you. So I don’t think it really
matters how the doctor feels about being transgender. The real issue here is reimbursement rates;
if you want to fight for something, fight for that!”
The issue of inadequate reimbursement rates was certainly on the radar of the panelists
and the other attendees in the room. In fact, a not insignificant amount of conference
programming was dedicated to just this subject. But the agitation expressed by this attendee and
66
the painfully long period of silence and averted eye contact throughout the room that followed
suggested something had been violated. The collision exposed that as much as participants were
committed to affirming transgender community interests, they needed to do so while maintaining
their commitment to objective scientists. Failure to link technical knowledge up to a broader
sense of social justice either for transgender persons specifically and/or for affirming diversity
and challenging social structures generally violated the shared ground for participating at THNC.
But here we see that equally so, failure to link affirmation of transgender community interests or
a broad social justice mission to a commitment to objective scientists was also a violation.
Hybrid styling
This chapter demonstrates that while strategic action is indeed an important part of
claims-making, cultural context shapes the kinds of claims that actors imagine are possible to
make in advance of strategic action. Critical to claims-making at THNC was allowing two
symbolic contexts to operate simultaneously without crowding the other one out. Holding
multiple symbolic categories together in the same scene created a flexible context for claims-
making in which participants oriented by different maps to that scene could hear the same claim
without a sense that their shared ground for interaction had been violated. Certainly every scene
style is composed of at least some variability in terms of maps orienting individual participants.
Although scene styles are collectively shared, even members of a tightly knit community may
understand their bond to that community somewhat differently. In these ways, flexibility and
ambiguity are persistent features of social and organizational life.
However, at THNC this specific form of symbolic flexibility was the foundation for
interaction. More importantly, this hybridization of scene styles, or “hybrid styling,” was the
67
basis for claims-making at THNC. Future research should advance this line of inquiry – whether
settings are dominated consistently by a singular scene style, or actors are regularly scene-
switching within a setting, carefully analyzing the hybridity of styling within a scene can be
fruitful for two reasons. First, for providers in the case of medicine, and organizational actors
more broadly, analyzing this hybridity can provide helpful insights for understanding why
sometimes interactions fail and other times succeed. In medicine, improving the likelihood of
successful interactions is not just important for organizational stability, it also has profound
public health implications.
Second, hybrid styling has symbolic consequences, potentially reshaping the very
categories that drive action. As we saw in chapter two, discursive repertoires patterned the way
the dominant discourse shaped the production, interpretation, and application of scientific
evidence. Similarly, scene styles at THNC patterned the way that symbolic categories shaped the
kinds of claims made by participants. By mixing or blending styles, hybrid styling shifts the way
that symbolic categories shape action; in the process, it can also work toward reshaping the
categories themselves. In this case, blending categories may not only (re)shape the way we
understand transgender health, but health itself. Carefully analyzing instances of hybrid styling,
therefore, provides a lens through which we can see structural change happening.
Finally, given that claims-making is increasingly happening across diverse organizational
settings,
xxv
including those like THNC that were not constructed for the purpose of claims-
making, various forms of hybrid styling may be shaping action in ways that have profound
implications for collective action. Future research should pay close attention to instances of
claims-making happening in other sites that were not constructed for making claims. On one
hand, these settings might offer novel or unexpected opportunities for collective action, engage
68
actors in politically-minded discussion. On the other hand, claims-making in these settings might
prove threatening to politically-minded discussion that leads to collective action if it engages
actors in what appears like collective action without actually coalescing around any specific
political stance or social issue. If the same scenes are flexible enough to permit multiple,
seemingly conflicting orientations, it may prevent participants from needing to engage in
difficult conversation or needing to come to explicit agreements about how best to understand a
particular social issue. If this is the case, it could mean that claims emerging out of these settings
are less solidly grounded and therefore more amenable to sudden or significant change. In the
case of transgender health, I caution that building bonds by allowing the moral and political
bases of transgender health claims to remain tacitly understood, yet not explicitly discussed or
agreed upon, may leave greater room for a backlash. That is, for a reorganization of scientific
consensus regarding the “proper” relationship between transgender subjects, medicine, and
health policy.
69
Notes
i
Professional convenings include scientific conferences, trainings, certifications, continuing education programs,
and other gatherings of medical care providers to enhance or sustain medical knowledge and in some cases to
establish “best practice” guidelines that inform clinical decision-making. Participants include providers of medical
care, federal, state, and local policymakers, allied health professionals, and other professionals connected to
transgender medical care.
ii
For the purposes of this paper, the World Health Organization’s definition of health policy shall suffice: “Health
policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a
society.” See http://www.who.int/topics/health_policy/en/
iii
For the purposes of this paper, transgender persons refers to those for whom correcting the misalignment between
the sex category assigned to them at birth and their gender identity is a major life project. This definition is drawn
from Stryker 2017.
iv
The larger, international research project of which this study is part, has also shown similar patterns in
programming beyond the United States and increasingly across the Global South.
v
Access has historically been limited in myriad ways, by explicit policy language, implicit provider biases, lack of
transgender-inclusive protocols in health care settings, patient fear of discrimination due to past experiences of
discrimination, and others. See, for example Stroumsa 2014.
vi
For a recent update on the state of transgender subjects in health policy; see Stroumsa 2014.
vii
Pseudonym.
viii
Although it is often customary and permissible to indicate the region of research sites, I have opted against that
here for two reasons. First, to create greater protection for the anonymity of participants discussed in this paper.
Second, transgender health meetings I attended over many years typically drew professionals from across the
country and beyond. Different meetings often had slightly different approaches to the programming, but these
approaches rarely reflected anything particular about the geographic region in which the meeting took place.
ix
Note that much of this literature does not explicitly name the framing concept as its guiding framework. However,
for the purposes of this paper, those studies that analyze actors’ self-conscious, strategic work of articulating certain
ways of understanding an issue are grouped as examples of framing. These studies replicate the spirit, if not the
name, of the framing concept.
x
In their original formulation, the concept was termed “group style” as it pertained to patterns within groups (see
Eliasoph and Lichterman 2003). However, the authors later drew from the work of Erving Goffman to refine the
concept as “scene style.” The use of “scene” makes the concept more flexible for analyzing interactions across
diverse and hybrid settings.
xi
To say that actors are able to operate in a setting with ease is not to say that conflicts are absent. Conflicts are not
necessarily more or less likely to occur in settings where a particular scene style is dominant.
xii
Scholars in the civic action approach in cultural sociology caution researchers about assuming where claims-
making and other kinds of coordinated action will take place, or assuming certain kinds of action take place within
well-defined “spheres” of social life. Lichterman and Eliasoph (2014) emphasize that actors coordinate action “to
improve some aspect of common life in society, as they imagine society,” in myriad, multi-institutional spaces.
Further, recent studies of health movements also suggest that actors are increasingly coordinating action in “hybrid”
organizational spaces; that is, in spaces where organizational actors engage and partner with actors in a variety of
institutions often with different principal foci that may or may not include health (Epstein 2010; Banaszak-Holl et
al., 2010; Dasgupta and Lichterman, 2016).
xiii
Previous research in transgender studies has shown that transgender communities and persons have historically
been quite geographically dispersed relative to other marginalized groups and often had very limited resources
(Grant et al., 2011; James et al., 2016). Out of necessity, much of the work of transgender advocacy since the 1990s
has occurred online (Wilchins, 2004; Rosser et al., 2007; Psihopaidas, 2016) and at professional convenings such as
THNC that provide precious opportunities for advocates to congregate in person (Meyerowitz, 2002; Psihopaidas
2016; Stryker, 2017).
xiv
See Lichterman and Eliasoph 2014.
xv
There is a growing body of literature that analyzes the emergence of “evidence-based everything” (Fowler 1997)
and how the language and logic of “evidence-based medicine” works to mask the uncertainties – including moral
and political debates – that underlie claims to scientific knowledge (see Timmermans and Angell 2001). The way in
which this operates in transgender health is alluded to in this study, but warrants further investigation.
xvi
Throughout this paper I use the term “transgender” in order to reach the widest possible audience, as many
readers may not be familiar with the extensive number of gender categories that all might be considered “housed”
70
within the umbrella of transgender. However, out of respect for the participants, whenever a particular person is
described, quoted, or paraphrased, I substitute their preferred terminology whenever possible.
xvii
“Top surgery” and “bottom surgery” are short-hand terms used widely in transgender communities to refer to
what are often considered to be classic gender-affirming surgical procedures for transgender clients. “Top surgery”
typically refers to bilateral mastectomy (removal of the breasts), although it often also includes a follow-up
reconstructive chest surgery (or “male chest contouring”). “Bottom surgery” may include phalloplasty, vaginoplasty,
hysterectomy, gonadectomy, vaginectomy, scrotoplasty, testicular prostheses, and others. Note that one experiences
difficulty in enumerating a list of procedures that would be widely understood as falling within the scope of gender-
affirmation surgeries. Additionally, note the significance of language in describing these procedures and how that
might affect perceived status as necessary or elective procedures for transgender clients: “chest reconstructive
surgery” might suggest a necessary, corrective procedure that would be covered by medical insurance, while “male
chest contouring” might mean something a person with means might elect to purchase in order to obtain a more
desirable physique. Both names, of course, refer to the same procedure.
xviii
Facial feminization surgery refers to a constellation of procedures typically performed by a plastic surgeon to
conform the facial structure and appearance to be more in line with contemporary cultural standards of feminine
beauty. In the West, and often beyond, these might include: mandible reduction/contouring, rhinoplasty, tracheal
shave, and reduction mentoplasty, among many others.
xix
All names used in this paper are pseudonyms. The selected names balance confidentiality with an attempt to
convey a sense of racial/ethnic and gender diversity that reflects the diversity observed at THNC.
xx
These conceptual linkages are not inevitable. Racial disparities, for example, may not be attributed to social
structures. One might draw from an individualist theory of “cultural habits” to identify individuals rather than social
structures as the cause of inequities.
xxi
See Lichterman and Eliasoph 2014.
xxii
Ibid.
xxiii
Lesbian, gay, and bisexual.
xxiv
“Letters” refers to the need for formal written letters from various providers supporting one’s claim to
transgender identification as a requirement for access to transgender-specific medical care. Such letters have been a
critical requirement for access to care for over half a century in the West.
xxv
See footnote xii.
71
Chapter 4
Intimate standards: Medical knowledge and
self-making in digital transgender groups
Introduction
On April 19, 2012, Pheenx,
i
a popular trans user on YouTube, published a video to
announce that after much deliberation he had decided to seek testosterone replacement therapy,
or “T” as he and most other users referred to it. “My biggest fear,” he shared, “is [the doctor] is
going to say ‘no, sorry, you don’t qualify, you’re not trans enough…’ She will be like [switches
to a sophisticated sounding, vaguely-British accent] ‘oh, sorry, you’re actually not trans, you’re
just a crossdresser!’” Through a series of video logs (or vlogs), Pheenx had documented an
exciting and sometimes tumultuous process of self-discovery, in which he wrestled over his
gender embodiment and gender identity. In the April 19
th
vlog, he declared that he was finally
confident that the right way forward was to affirm a male gender identity publicly and begin
taking T. Yet at this very moment of clarity, Pheenx’s hard-won self-knowledge ran up against
the medical authority that could deny him this path. Fortunately for Pheenx, we learn in a later
post, he ended up having a positive clinical experience, and after a few blood tests, he began his
journey on T.
Thousands
ii
of trans
iii
persons, like Pheenx, login daily to groups on Facebook, reddit,
Tumblr, Yahoo, YouTube, and other sites. A dizzying array of topics emerge within these digital
groups, yet a major theme uniting them involves sharing affective and embodied experiences of
participants’ gendered self. Most users express that at least some degree of medical gender
72
transition (such as hormone replacement therapy) is necessary to achieve a reasonable level of
comfort with their gender embodiment. Legal access to transition-related care has historically
hinged on whether medical professionals identify one as “truly” trans according to a standardized
model of the transsexual subject.
iv
This standard, developed largely by sexologists and
psychiatrists, draws from a long tradition in Western thought by conceiving of transsexualism in
an inner (mind) versus outer (body) frame that Bettcher (2014) calls the “wrong-body” model. In
this frame, one either becomes a man or a woman through the medical realignment of their mind
and body, or simply is a man or a woman based on their inner gender, regardless of their outer
body (Bettcher 2014: 383; see also Meyerowitz 2002; Rubin 2003: 150). In both versions, the
body is the site of error/conflict, while the mind is the site of deep, abiding truth; patients are
expected to convincingly demonstrate to clinicians that they are, and have always been, the
gender they claim to be (inside). Although procedures set by the Diagnostic and Statistical
Manual (DSM) and the Standards of Care
v
to evaluate the “authenticity” of trans patients have
become less stringent over time, the wrong-body model’s legacy is such that it remains the
dominant reference point for understanding and communicating trans experience, both inside and
outside of the clinic (Bettcher 2014).
In this chapter I use the medical standardization of transsexuality as a case for
understanding how processes of standardization impact intimate life, and how intimate standards
are made meaningful through everyday interaction. Specifically, I examine how this intimate
standard impacts processes of self-making in digital groups. I use the term intimacy, following
Wilson (2004), in order to point to the deeply felt orientations and entrenched practices that
make up what we imagine to be our most personal or private lives, even our very sense of self
(11). Self-making in this article refers to the intimate labor that goes into producing and
73
maintaining our sense of self (Boris and Parreñas 2010). Drawing from participant observation,
interviews, and survey data involving group participants, I show how users regularly invoke the
wrong-body model to understand and communicate their gendered self. Yet the presence of this
standard – that is, its language and logic emerging in everyday interaction – does not alone
predict how users make it useful or meaningful. In what follows, I show how rather than simply
adopting the wrong-body model, users draw from it in ironic and playful ways that actually carve
out space for ways of knowing the self that feel authentically their own. I argue that in these
interactions, the wrong-body model becomes both useful as an explanatory frame and
simultaneously the basis for disrupting its privileged status and the logic of justification that
scaffolds it. These findings show that it is through the standard, as opposed to in spite of it, that
users encourage alternative conceptions of trans selfhood that are less bound to the standard.
Through this, we begin to see how standards and processes of standardization can impact the
intimate labor of self-making in ways that may be unexpected. I conclude with brief suggestions
for future research on trans self-making and further integration of the literatures on intimate life
and standardization.
Standardization, medicalization and intimate life
I begin with an overview of recent advances in the literature on standardization, drawing
attention to the promising, yet underdeveloped insights this literature has for studying intimate
life. This growing body of work has demonstrated that standards are often the crucial links (or
barriers) to making possible many of the political and economic processes scholars attribute to
contemporary social life, such as commodification and globalization. Standards emerge from
processes of standardization, or the “process of constructing uniformities across time and space,
74
through the generation of agreed-upon rules” (Timmermans and Epstein 2010: 71; see also
Bowker and Star (1999)). Governments, courts, national and international NGOs, activist groups,
and charismatic leaders all drive the production and implementation of standards (Epstein 2009;
Olshan 1993; Shenhav 1999), and while processes of standardization are ubiquitous in human
societies, they occur at varying rates across fields (Noble 1984), and have become particularly
significant engines of globalization (Lakoff 2005). Once in place, standards often become taken-
for-granted, naturalized, or seemingly inevitable despite their fundamentally social origins,
making them very difficult to change (Bowker and Star 1999:14; Thevenot 2009).
While more often this literature focuses on structural and institutional levels of analysis,
standards have also been shown to heavily inform intimate labors, including self-making. These
intimate standards of the self tell us who and what we are, will be, and have been. Igo (2007), for
example, shows how modern surveys in the US, developed as a tool of population
administration, underwrote the emergence of widely held and intimate categories of common-
sense knowledge, from “the average American” to the sexual self. Czerniawski (2007) shows
how height and weight tables, originally designed to standardize selection processes for life
insurance companies trying to assess risk, facilitated the notion of “ideal” body weight in the US.
As these studies show, qualities that we understand as inherent aspects of human life in the
contemporary world were once simply tools designed by standards regimes for industrial and
government pursuits. While standards are often understood as politically neutral metrics for
gauging existing realities, they are also productive of reality (Timmermans and Epstein 2010).
As a result, they are part of the moral economy of the modern world, having considerable impact
on fundamental questions about who we should be and how we should live (Busch 2000).
75
Medicalization, or the process by which a particular human experience comes to be
defined, treated, and experienced as a medical condition (Conrad and Schneider 1980), is a
particularly influential concept for analyzing the productive power of standards of the self.
Literature on medicalization has shown how standardizing a set of biophysiological phenomena
under a specific medical diagnosis can have a profound impact on one’s sense of self (Rosich
and Hankin 2010). Recent research has pointed to the Internet and social media as increasingly
significant culprits in an ever-widening scope of medicalized ways of knowing the self. These
studies have shown that digital groups are not merely places to reflect upon health and illness,
but play a key productive role by turning lay persons into lay experts of their condition (Broom
2005; Fox et al. 2005b), facilitating patient-driven medicalization (Barker 2008), resisting the
normalization of treatment (Richardson and Cherry 2011), and influencing identity-formation
(Fox and Ward, 2008). These studies point to an ever-widening scope of medicalized ways of
knowing the self, which at least implicitly suggests the foreclosure of other ontological and
epistemological possibilities.
Medicalization and standardization, however, do not simply render the world
standardized (Timmermans and Epstein 2010). Modification and negotiation are central to
making standards meaningful in the real world (Lampland and Star 2009: 4), and sometimes
those processes can have unexpected outcomes, potentially undermining the standard’s original
purpose. Everyday interaction is a crucial site where this negotiation takes place. By looking
carefully at the way standards percolate up into everyday interactions, we can build a better
understanding of their relationship to intimate life.
76
(De)medicalizing transgender
Like all standards of the self, the medical standardization of transsexuality under the
wrong-body model has profound implications for how gender-variant persons understand and
communicate their gendered self. As a result, the model has long been a contentious issue for
transgender politics. Feinberg (1993) and Bornstein (1994) identified this standard as the medical
regulation of non-binary bodies aimed at the erasure of gender-variant persons. In order to
liberate non-binary bodies, these foundational theorists advocated for a new way of knowing and
a consciously political identity under a new term “transgender.” This term was meant to loosely
encompass a broad array of gender-variant persons under a new model of personhood that was
distinctly “beyond-the-binary.” This new model called upon transgender persons to remain
visibly outside of the categories of woman/man, rendering suspect attempts to medically
transition the body from one binary position to another (Bettcher 2014).
However, some scholars have argued that this beyond-the-binary model is not an
adequate alternative to the wrong-body model. Namaste (2005) argues that taken to its logical
extreme, this beyond-the-binary model suggests that any gender-variant person who does not
identify outside of the categories of man or woman is the victim of a sort of false consciousness
and represents a threat to a formidable transgender rights movement. Prosser (1998) argues that
this model reduces gender to nothing more than an oppressive cultural construct, while most
transgender persons identify as transgender precisely because their gender identity seems so
visceral, so resistant to being (re)shaped by cultural expectations.
Finally, the beyond-the-binary model has also proven problematic in recent years as
transgender health advocates have found great success in leveraging the legitimating authority of
the wrong-body model to demand competent, legal, and respectfully-provided medical services,
77
as well as rights and protections against discrimination more broadly (Meyerowitz 2002; Stryker
2008; Wilchins 2004). Bettcher (2014) and Connell (2012) argue that in order to move beyond
the limitations of both of these dominant paradigms for understanding trans personhood and
trans politics, we need more research that actually accounts for the lived realities of trans
populations. By examining how trans persons actually make use of the language and logic of the
wrong-body in everyday interactions, this study works toward filling that gap.
Methods
I first discovered these groups years ago through my own desire to connect with and learn
from the experiences of other cross-gender identified and gender non-conforming persons.
vi
Between March 2013 and March 2014, I engaged in intensive participant observation within
trans groups and among trans users on Facebook, YouTube, and web forums. Throughout this
time, I participated in forum discussions like any other user – reading recent posts, engaging in
commentary, and occasionally continuing the conversation in private, one-on-one messages with
group users and administrators. On YouTube I followed the video log (vlog) entries of several
active users, many getting tens of thousands of views per video upload. At least once per week I
spent several hours watching videos and response videos, reading and participating in the
comments section discussions that emerged from the videos, and through Facebook following
the posts and comment streams in several trans groups. All of these groups influenced my
analysis, but the examples shown here come almost entirely from YouTube and two web forum
groups where I was able to participate most thoroughly.
I treat these groups as “digital field sites” where I can observe everyday interactions.
Digital field sites offer unique opportunities and challenges for social science research (Lazer et
78
al. 2009). Digital ethnography, in particular, has very rich, undervalued potential; however, it
also presents challenges, particularly through the lack of temporal and spatial boundaries that
characterize typical field sites (Constable 2003). Indeed, the immense wealth of information
available through the Internet and new media forced me to make decisions about how to limit
and direct my ethnographic gaze. For example, I decided that I needed to pay close attention to
the conversations that emerged from original posts in comments or reply sections. These sections
carved out a form of “digital backstage”
vii
where meanings of original posts were interactively
constructed, contested, affirmed, and contradicted, providing invaluable clues for my analysis.
Despite the unique challenges and considerations one must make in conducting digital
ethnography, in conducting this research I have treated digital groups as merely particular, if
somewhat strange, settings for everyday life interactions. Zhou (2005) argues that it is important
not to imagine the Internet as somehow an independent entity from the “real world.” Both the
“real” and “virtual” worlds are always comprised of interactions.
Another challenge for online research is the lack of context and demographic data often
used by social scientists to identify their sample and population composition (Golder and Macy
2014: 141). Other important distinctions that are meaningful for the setting may also be masked
to the researcher (Lewis 2014). To address these challenges, I also collected questionnaire and
interview data that serve as a check on ethnographic findings and maximize interpretive validity.
I conducted a total of 10 semi-structured interviews with users, medical providers working with
trans populations, and trans health activists. Interview questions focused the discussion loosely
on the significance of digital groups for trans patients and lasted for approximately one hour
each. Interviews were transcribed and coded in conjunction with the coding of field notes in
order to compare emergent themes. Additionally, I distributed an open-ended questionnaire to
79
users in the groups in which I participated, and the questionnaire was also distributed by users to
other digital trans groups. The questionnaire consisted of 25 questions and responses continued
to be collected through October 2014, reaching a total of 138 respondents.
Virtual intimacies
In the following sections, I outline the key findings. I begin by situating the virtual spaces
these digital groups occupy in the lives of the users. The Internet and social media, collapsed
here as digital groups, are particularly important for trans communities. Trans persons (as we
would call them today) were “early and enthusiastic adopters” of the Internet as an infrastructure
for building communities of support (Wilchins 2004; Rosser et al. 2007). Digital groups provide
crucial linkages between trans persons and trans communities often separated by social and
geographic divides. As a result, these groups provide a particularly unique opportunity to witness
the intersection of self-making and standardization in action.
Dallas Denny, a prolific writer, speaker, and activist in the trans community, started the
first transgender newsfeed in 1995 through the website Yahoo.com. In an interview, Dallas
shared that she sort of “ended up” an activist in her efforts to find cheap and convenient ways to
acquire and disseminate information about trans identities and transitioning. “I realized that to
survive we were going to have to accept that the whole service delivery system of sending [paper
pamphlets] was too costly and slow; through the Internet you could provide unlimited
information to potentially unlimited numbers of people and they would get it instantly.” Nearly
two decades later, the Internet is as important as ever for trans populations. Based on
questionnaire responses (see Table 1), the Internet and social media are users’ most significant
sources of medical information about gender transition, followed closely by peer networks.
80
While 50% of respondents indicated that the Internet was a primary or secondary source of
information about transition-related care, less than 15% indicated that medical professionals
were primary or secondary sources. These findings are not meant to be generalizable, but they
are well-supported by a recent national survey that found fully 50% of transgender patients have
to teach their medical providers about transgender care (Grant et al. 2011).
Table 1. Significant Sources for Transition-Related Information (n=138)
Source
Primary
Secondary
Total
Internet/Social Media
98 22 120
Peer Networks
31 14 45
Medical Professionals
16 6 22
Medical Literature
2 7 9
Trans-authored Literature 4 7 11
Other (e.g. conferences, nonprofits) 5 7 12
Unspecified Literature 4 5 9
NOTE. –This table represents the frequencies with which particular sources were identified as primary or
secondary sources. Several users listed more than one source in each category. Finally, the list of sources was
populated retroactively through analysis of the data; in the original questionnaire it was an open question.
Far more than simply downloading information, users actively generate much of the
information they seek. The knowledge users generate is simultaneously local/affective and
scientific/objective, covering everything from types of hormone-replacement therapies, methods
of administration, drug regimens, and side effects, to neurological and psychological changes,
and impacts on libido. Tipper writes, “it wasn’t until I joined a number of online groups that I
knew a surgery option that was suitable for me was actually possible… I’ve also heard a lot
about anecdotal experiences and side effects of taking T, a lot of which is barely documented
anywhere else.”
81
Yet users aren’t only supportive and affirming as they were for Tipper, they also censor
and police each other. Some users express that extensive transition seems expected, and that
users should desire to, and seek whatever means available to them, to "pass," or appear
cisgender.
viii
In a YouTube video where a popular trans user posted a vlog about her recent
breast augmentation, a user commented, "being transgender doesn't mean you have to get 3423
surgeries, starting to look ridiculous." In response, Jaynee replied: "actually it does mean that.
Especially trans women who had very masculine looking faces. They need multiple surgeries to
get their face as feminine as possible." While the first user critiques what they see as excessive
measures to pass, for Jaynee, transition is understood as a corrective measure whose efficacy is
demonstrated when one is able to pass. Some users supported Jaynee’s comment, noting that
being able to pass in public is important to reduce the risk of violence.
These debates about passing highlight that transition is more than a desire to be pretty in
a conventional sense, or an internalization of the wrong-body model’s expected trajectory that
the body should be “corrected.” Rather, it is also a practical consideration in ensuring one’s
health and wellbeing and reducing potential exposure to transphobic violence. Despite the
complex circumstances surrounding transition, one might conclude that these interactions are
nonetheless promoting a medicalized way of knowing the trans self. However, in the next
section, I will show that when users explicitly discuss their gendered self and their reasons for
transitioning, they actually carve out space for ways of knowing the self that feel authentically
their own, using the language and logic of the wrong-body model.
82
A self authentically their own
In contrast to other spaces – medical, occupational, educational, and legal spaces – where
users are expected to affirm a deep and abiding sense of a binary gendered self, in these digital
groups users were able to explore their gendered self and embodiment. Users excitedly and
curiously discuss physical, sexual, and affective changes that transition technologies are bringing
to them and what these changes mean for the self they are becoming. These discussions
repeatedly invoke the language and logic of the wrong-body model; however, through ironic and
playful uses of the standard, I argue that users actually disrupt the standard’s privileged status
and the logic of justification that scaffolds it. In so doing, they carve out space for alternative
ways of knowing the self that feel authentically their own.
De-privileging the wrong-body
Users regularly draw upon the notion of an inner/outer self that is central to the wrong-
body model. For many users, these groups are the first places where they express to another
person that they might “actually” be a woman/man “inside” despite having been assigned a
different gender at birth and having presented a gendered self that matched that assignment. The
wrong-body model carries an air of legitimacy having been developed by medical professionals,
and users often expressed comfort in its authoritative language. However, while users did not
reject the model outright, they regularly disrupted its privileged status as the only legitimate
route to self-making, creating room for alternative ways of knowing. Take for example Leona, a
new user who made the “mistake” of assuming that users would apply some explicit criteria to
determine what their experience of their gender and sexuality meant. Leona posts the following
thread:
83
I am confused. All I know for sure is that I don’t want to take the clothes off, and I don’t
want my chest hair to grow back. I am tired of shaving my face. I am tired of pretending
to be tough. I feel like putting down my weights and picking up some nail polish. I think I
would make a pretty, smart, fun woman. But am I a woman on the inside, or just a giant
pervert? Or both? I don’t know.
In this post, Leona expresses affinity for a few female gender markers – nail polish, lack of facial
and body hair, being pretty – and contrasts those to opposing male gender markers – chest and
face hair, lifting weights, and toughness. Unsure if this is confirmation of an inner/outer gender
misalignment or simply the mark of a “pervert,” Leona longed for some concrete way to separate
the two, a longing that might be easily satisfied by the wrong-body model.
However, the following examples from TransBoards
ix
demonstrate how, in response to
posts like Leona’s, users actually used the language of the wrong-body model to complicate and
expand rather than standardize or medicalize Leona’s self-making:
Mallie: Here's the way I see myself. I am female, the inner me is. I don’t think that I’m
trapped in a male body although I don’t particularly care for the construct of my
body as it was given to me. I feel more compelled to step out of my physical body
and extend my feminine spirit wherever and whenever I can. I know that I cannot
change the inner me nor do I want to. I’m very happy as a woman. I can change
the outer shell that carries this woman about her daily life and I am doing so now.
Occasionally I feel frustrated that my transition cannot happen faster yet I do take
84
time to enjoy every minute of progress and celebrate each new step toward a
unified body and mind. Just writing this response has made me feel better about
myself.
Miraj: Trapped in the wrong body? I dunno. When I first started transition, I did relate to
that thought... but... I simply felt wrong. Now, 2.5 years later on hormones and
now fulltime... I look in the mirror and see a pretty girl (when I have makeup on).
The problem is... when I see the reflection, it’s almost as if I’m looking through
the eyes of a stranger. So explain THAT one?!
These responses provide affective and embodied accounts of users’ own sense of what it means
to be trans. Although they use the language of the wrong-body model, they complicate the
explanatory power of its inner/outer dichotomy. As Bettcher (2007) helpfully points out, in the
wrong-body model “gender presentation (attire in particular) constitutes a gendered appearance,
whereas the sexed body constitutes the hidden, sexual reality” (48). But here, Mallie indicates
that although she is certainly on a path toward a “unified body and mind,” she does not
necessarily see her body as male and her mind as female, she simply “doesn’t care for the
construct” of her body. Similarly, Miraj claims that although the idea of being “trapped in the
wrong body” resonated with her early on in her transition, now that her body is allegedly much
closer to her “inner self,” when she looks in the mirror she feels she is looking through “the eyes
of a stranger.” By gliding back and forth between the inner and outer as sites of dysphoria,
deception, and truth, users disrupt the privileged status of the wrong-body standard. In this way,
they actually complicate the notion of medically aligning inner/outer selves even while they are
85
medically transitioning. This self might seem less satisfying than a neat, standard case of a
wrong-body “corrected” by medical technology, but for these users, it is authentically their own.
Of course some users regularly indicate that the best course of action is to seek
“professional [medical] help,” where a diagnosis can provide scientific legitimacy and clarity for
users who are unsure what they are experiencing. However, these responses are notably in the
minority. More often users emphasize the importance of trusting and valuing self-knowledge
over medical diagnostic criteria, even when self-knowledge is complicated and confusing. At the
same time, many of these users indicate that for trans persons, seeking medical technologies to
feel more comfortable in their own body is often a necessary, perhaps life-saving, course of
action. As Nelly put it: “Surgery is only necessary if you think it is. The only wrong way to do
transition is to not do what is right for you.” In this way, users navigate an understanding of trans
selves that draws from both beyond-the-binary and wrong-body models, asserting the
epistemological supremacy of embodied and affective self-knowledge.
These examples emerged during particularly existential moments when users discussed
questions of who they are. But as I will show in the next section, users also complicated the
wrong-body model when discussing more practical questions, such as what am I using this
transition technology for, and what is it accomplishing?
Avoiding the logic of justification
The language of the wrong-body model describes transition technologies as corrective
measures – bringing the sexed body in line with the “inner truth” of the gendered self. However,
through ironic and playful uses of the standard, users avoided the logic of justification that
86
scaffolds it when describing what these technologies are accomplishing and why they are using
them.
For example, on YouTube there is a deluge of vlog posts where users document yearly,
monthly, weekly, and even daily changes that they experience after beginning hormone
replacement. Among these posts, a particular playfulness emerges. Users openly mock their own
interest in documenting the changes that hormone replacement therapy is bringing to their
bodies:
Beekmng: [in a highly exaggerated low, monotonous voice] This is my voice two
hours into T...
Made&Born: [having developed a significant increase in muscularity after a little
over two years on testosterone] With the camera resting on the ground, a shirtless
Made&Born appears horizontally in the frame. One, he forces out as he struggles
to press himself back up from the floor. Two. Thr-e-e, he barely manages to
verbalize. I can do three pushups...
Beekmg mocks his own interest in lowering the tone of his voice and the power of testosterone
therapy by pretending that within two hours of his first injection, he has achieved a
hypermasculine, deep tone. Similarly, Made&Born’s vlog history indicates that he quite enjoys
the increased muscle-building capacity of his body thanks to testosterone, but in this video he
responds to other users’ request for a post-T pushup video by pretending that it is very difficult
for him to do even three pushups after two years on T. For these users, medical transition is
87
clearly very important for achieving a reasonable level of comfort with their gender embodiment.
But by being playful with or mocking the effects of the transition, users avoid reproducing the
binary and essentialist expectations that are associated with the wrong-body model, where
“properly aligning” the body can often be reduced to very superficial and stereotypical gender
markers such as muscularity and deep vocal tone for men, as well as delicate beauty and
exaggerated femininity for women.
Many users emphasized that despite transitioning they would “always be trans” as
opposed to erasing their trans identity post-transition by finally “becoming” a man or a woman
as the logic of the wrong-body standard goes. Some users made a point to make sure others knew
that they were trans, even if it felt good to “pass” as cisgender. Leanne states:
In the beginning I felt kinda weird going in public and stuff... but now that I have been
full time for six months and I have been on hormones for a year… I’m definitely not
ashamed of it. I’m proud of it. I wear it on my sleeve. I talk about it when I meet people.
I’m not afraid to say ‘yep, I’m trans!’
Leanne’s affirmation that she is not ashamed of being trans and proudly shares that with people
she meets fits well with the logic of the beyond-the-binary model. However, Leanne has also
taken significant steps to socially and medically transition. In this way Leanne constructs a self
that feels authentically her own, one in which she embraces her trans identification, and makes a
point to publicly identify as trans, but also follows the logic of the wrong-body model by
medically correcting her gender embodiment to better match her sense of her gendered self.
88
In the logical trajectory of the wrong-body model, through medical gender transition the
body is understood as having been healed or corrected, where that healing is experienced through
the normalized desires of the “healthy,” gendered body (Heyes 2007). For example, when a
transman appears rough, rugged, and muscular, or the “opposite” of feminine, their body has
been healed. But even while Made&Born clearly gained muscularity and Beekmng’s voice did
lower as a result of getting on T, in these digital groups, users create space to display those
changes while rejecting that they reflect a corrected body. For these users, they reflect a changed
body. A changed body did not necessarily have a normalized trajectory, but was ambiguous, or
was open to new possibilities. Matilda makes this point explicit:
People… have often claimed that our bodies are normal and healthy, so
being trans isn’t something that should be treated, physically. But what if we could be
more than just normal? Why should we settle for what is supposed to be good enough
when we have the option to become something even better? Others may see this as
choosing to reject what’s normal, and in doing so relegating ourselves to being abnormal.
But I don’t see this as a choice between normal and abnormal. I see this as a choice
between average and awesome! Over the past two months, HRT has improved me in
ways that I didn’t even know needed improvement!
Here Matilda carefully filters both the wrong-body model as well as the beyond-the-binary
model. For Matilda, both models seem to hinge on a sense of what is “normal.” In the wrong-
body model, normal is a congruence between inner gender identity and outer sexed body,
compelling trans bodies to seek medical intervention. In the beyond-the-binary model, normal is
89
accepting the body you have, or seeing it as having no bearing on the self you can present to the
world. But for Matilda, this model also invalidates those who seek transition technologies. To
preserve space for a self that feels authentically her own, Matilda draws from the language of
consumption, where users have the right as consumers to access the services they desire, and on
their terms. This construction of transition technologies as merely commodities allows Matilda to
avoid the logics of justification that support the wrong-body and beyond-the-binary models.
Intimate standards
In this article, we can begin to see how standards can impact the intimate labor of self-
making. As I’ve shown, in digital trans groups the wrong-body model, a standardized medical
explanatory frame for understanding gender-variance, is repeatedly drawn upon to communicate
and understand user’s experiences of their gendered self. This might be interpreted as evidence
that these groups drive medicalized ways of knowing the self, inculcating the adoption of the
wrong-body model. But, by paying close attention to the way participants actually make use of
the standard in everyday interactions, we can see that they use its language and logic in ways that
actively carve out room for alternative ways of knowing, for becoming something authentically
their own. That is, it is not in spite of but through the wrong-body model that users construct an
authentic sense of self. The wrong-body model becomes both a shared framework for
communicating and understanding one’s experience, and simultaneously the basis for its own
critique. This finding suggests that standards of the self become part of, or a grammatical
element within, a broader language of the self. Certainly, then, standards can profoundly impact
one’s sense of self; but, importantly, this process can have unexpected or unintended outcomes.
In this case, everyday use of the wrong-body model does not wholly displace or affirm it, but
90
complicates and manipulates it in ways that create room for ways of knowing that exceed or even
challenge it. Thus, this finding shows that standards and intimate life can intersect in unexpected
ways, urging further research on intimate standards.
Scholars of intimate life would benefit from paying greater attention to the
interrelationship between standards and intimacy, or what I call intimate standards. This
emphasis on standards focuses our analytical lens more firmly on the everyday processes that
make possible broader shifts in contemporary social life. For scholars of intimacy, an explicit
focus on standards promises to advance studies of domestic, erotic, reproductive, and care work,
as standards regimes increasingly come to define the limits and norms of these formerly private
spheres. For scholars of standardization, greater research is needed that highlights the
relationship between these processes and our most private or personal lives. I echo Timmermans
and Epstein (2010) in urging scholars to pay close attention to the creative or unexpected
outcomes of intimate standards. In particular scholars should examine the ways in which
standards are made meaningful for everyday life in interaction, as I have begun to do here.
This chapter contributes to the need for more research on the lived realities of trans lives.
However, further research is needed that addresses how axes of difference – race, class, gender –
might impact individual’s ability to “opt in” or “opt out” of the wrong-body and beyond-the-
binary models. While the users in these groups shared trans-identification, they varied widely in
terms of other identity markers, including age, race, gender, time of transition, degree of
transition, and many more. Future research should advance and complicate the findings of this
article by bringing these differences to the center of the analysis.
91
Notes
i
Following Raun (2014), I made the users discussed in this paper anonymous, unless they specifically asked me to
name them. Although all of these sites are public, users at most sites retain the possibility of removing content they
no longer wish to be public. I honor that control by making user data anonymous.
ii
One forum group alone had over 15,000 active users at the time of the research.
iii
I follow Stryker (1994) in my use “trans” as a broad umbrella term to denote the many diverse forms of sex and
gender crossing that users undergo as significant life projects. I use transgender in the abstract and title of this paper
so that it might reach the broadest audience. I use “transsexual” only when referring to medical models that were
specifically developed under this term. In this paper, users embody and cross multiple gendered positions (Female to
Male, Male to Female, etc.). While I fully appreciate that these positions have material consequences for transition,
in a spirit of trans and trans-feminist solidarity, I have intentionally avoided drawing attention to which positions
users occupy unless it seems relevant to the discussion.
iv
In using the phrase standardized transgender subject, I do not wish to imply that the institutions of medicine have
but one static model of transgender. What I am pointing to is simply the ossification of a variety of possible
understandings and meanings into a single dominant standard. Standards are always in flux. Still, dominant
standards percolate up into everyday life in important and meaningful ways.
v
Published by the World Professional Association for Transgender Health.
vi
Although I consider myself to be within the broad trans umbrella, following other feminist scholars (Heyes 2003),
I have attempted to stay true to the important directives laid out in Hale 1997.
vii
I use the term “digital backstage” as an extension of Goffman’s (1959) formulation. Goffman states that backstage
language “consists of reciprocal first-naming, co-operative decision-making, profanity, open sexual remarks… use
of dialectic or sub-standard speech, mumbling and shouting, playful aggression and ‘kidding,’ inconsiderateness for
the other in minor but potentially symbolic acts…” (128). While both original posts and comments sections are
“public” in the sense that they are accessible to visitors to the page, I found that there seemed to be similar
differences in the language between the “digital frontstage” – or the original post – and the “digital backstage” – or
the comments/reply sections. Digital frontstage language was often aimed at more carefully crafted impressions,
while digital backstage language was more off-the-cuff and offered intriguing insights into the meanings that users
gleaned from frontstage content (see also Eliasoph 1998).
viii
Cisgender is the term used to denote non-trans identified persons who feel a congruence between their socially
assigned gender and their gender-identity.
ix
Pseudonym.
92
Chapter 5
Mapping the cultures of transgender health policy
To reflect upon the contribution of the chapters in this dissertation, in this conclusion I
first elaborate on the historical and conceptual contexts in which this study emerges. Then, I
discuss how mapping the cultures of transgender health, as the chapters herein have done,
contributes both to an improved historical understanding of the contemporary shift in transgender
health policy and to theoretical approaches to the study of health movements.
In her discussion of transgender health policy, Susan Stryker (2008) writes, the “status of
GID and the rationale for transgender access to healthcare raise important questions about the US
healthcare industry more generally, and about the increasingly powerful ways that medicine and
science define our bodies and lives.” In this passage, Stryker makes an important point that
studying transgender health provides insight into how science and medicine shape the bodies and
lives of everyone, regardless of gender identity. In sociology, this way of thinking about the
importance of critically analyzing science and medicine is perhaps most epitomized by the
“medicalization” concept popularized by Peter Conrad and Joseph Schneider. Medicalization
(Zola 1972, 1991), or the extension of medical jurisdiction, authority, and practices into an
increasingly greater number of areas of social life, is one of the most striking features of the last
half of the twentieth century in the West (Clarke et al. 2003; Clarke and Olesen 1999; Conrad
1992, 2000). Conrad and Schneider (1980) argue that medicalization steps in to replace explicitly
racist, sexist, or homophobic legal statutes as a new, more covert form of social control. Feminist
scholars Ehrenreich and Ehrenreich (1978) added that medicalization also supports the capitalist
93
interests of an ever-expanding “medical industrial complex.”
i
According to Moore (2010), health activism arose out of a growing recognition that
otherwise routine aspects of everyday life were becoming medicalized (97). For feminists and
civil rights activists, “health” emerged in the 1960s as a powerful tool through which many
ideals could be signified (Nelson 2011). In an historical moment when explicitly racist and sexist
legal statutes were being overturned, health “was a site where the stakes of injustice could be
exposed and a prism through which struggles for equality could be refracted” (Nelson 2011).
Radical feminists began organizing around the banner of health as a route to illuminating
and subverting the increasingly diffuse operation of patriarchy. In The Dialectic of Sex (1970),
Shulamith Firestone argued that the uneven labor of reproduction was central to the operation of
patriarchy, and that seizing control of it should be prioritized above any efforts to dismantle the
sexist division of labor under capitalism. Following this insight, women’s health projects
emerged in nearly every major city in the US in the 1970s (Murphy 2012). Feminist health
activists were unified in their view that bodily experiences specific to women had come under
the authority and jurisdiction of medicine as a form of social control over “the most intimate
dimension of woman’s personhood, her body” (Moore 2010: 97). Undermining the authority of
medical experts and affirming women’s self-knowledge, self-help manuals such as the iconic
Our Bodies Our Selves (Boston Women’s Health Book Collective 1976) politicized reproductive
medicine, encouraging women to seize control over their bodies by “looking together” in small,
empowering communities of women who would build intimate knowledge and expertise of each
other’s bodies (Murphy 2012).
During that same period, Black Panther community health projects mirrored women’s
health activism by offering not just nonprofit alternatives to mainstream institutions of medicine,
94
but also by providing services seemingly specific to “African American health” such as sickle
cell anemia screenings (Nelson 2003). These projects emerged out of a longer history of African
American organizing around health beginning in the early 1960s. Standing before the Medical
Committee for Human Rights in 1966, Dr. Martin Luther King, Jr. proclaimed that “of all forms
of inequality, injustice in healthcare is the most shocking and inhumane” (see Dittmer 2009). By
the time of his speech, civil rights leaders were actively involved in establishing alternative
health institutions, desegregation of (or inclusion in) the health care system, and critical analysis
and reinterpretation of scientific research, which posed epistemological challenges to biomedical
claims about race (Nelson 2011).
The social climate that produced health activism during this time also buttressed efforts
of homophile and later gay liberationist efforts to demedicalize homosexuality, long categorized
as a mental health disorder in the DSM (Conrad 2007; D’Emilio 1983; Hurewitz 2007). In the
1980s when the “plague years” of the AIDS epidemic were devastating gay communities and
undoing decades of work to improve relations with mainstream society, a somewhat different
approach to health activism took shape. Entangled with a series of rapid transformations that
Starr (1984) calls the “social transformation of American medicine,” lesbian and gay
communities and many of their allies in the health professions demanded access to unapproved,
experimental treatments, contested and reinterpreted scientific research on AIDS, refused to
accept traditional clinical trial procedures (most notably the use of a placebo group), and even set
up illegal distribution clinics to disseminate drugs not yet approved in the US to their
communities (Epstein 1995, 1996; Fetner 2008: 51; Monett 1988). Although AIDS activism
extended and benefitted from earlier health activism, it was unique in its alignment with the
institutions of medicine. Returning to an integrationist approach like that advocated by WEB Du
95
Bois, AIDS activists demanded inclusion, not separate institutions. Inclusion, Epstein (2008)
argues, has since become the dominant paradigm that governs the biopolitics of medical
research. The work of AIDS and other advocacy groups, health professionals, and Congressional
Acts have forced the diversification of medicine and to some extent created opportunities for
underserved groups to gain access to adequate care.
Contemporary transgender health advocacy has drawn from the rights discourse that
underwrites this inclusion paradigm in order to demand transgender-inclusive reforms to
established science and healthcare policy as well as access to and insurance coverage for
transgender-specific medical care. Unlike the feminist and civil rights health activists discussed
above, transgender health advocates have not sought the demedicalization of transgender
identity; maintaining the diagnosis has been important strategically in achieving these objectives.
Demands have been made for reducing the stigma associated with the diagnosis and making the
diagnostic process different for children than adults. For example, DSM-5 (published May 18,
2013), included many changes that were driven, in part, by transgender health advocates.
Primarily these changes include a terminology change from “Gender Identity Disorder” to
“Gender Dysphoria” and a removal of this diagnosis from the “Sexual Disorders” category.
The successes of transgender health advocacy have emerged through a complex interplay
of individual patient actions, community organizing, media campaigns, and others. But one
particularly important factor has been the increasing deference that policymakers give to
international and nongovernmental organizations in providing policy guidance. Organizations
such as the World Professional Association for Transgender Health and the University of
California, San Francisco’s Center For Excellence in Transgender Health have played a critically
important role in creating institutional change through continuing education conferences for
96
medical professionals, training health providers in transgender-sensitivity, and publishing the
Standards of Care for Transgender Health.
ii
Alternative health clinics have also been a priority
for transgender health advocates, with a growing number emerging in major cities in the US,
largely through community centers.
Contemporary shifts in transgender health policy emerge within this complex historical
context, entangled in major shifts both in the practice of medicine and the way that movement
actors interface with healthcare institutions. As Stryker points out in the quote above, studying
this shift can provide us with helpful insights about how science and medicine shape our bodies
and lives. But what I have attempted to show through the previous chapters is that the rather than
imagining science and medicine as increasingly shaping our lives, as Stryker and others have put
it, it may be more helpful to think in terms of the increasing complexity of the relationship
between culture, medicine, and health policy. The interactions detailed in these chapters
demonstrate a relationship between medical providers and their patients that is much less “top-
down” story than standard accounts in the medicalization literature. Chapter four showed
medical models for transgender identity shaping the way transgender individuals experience and
communicate a sense of self, but in ways that were highly unpredictable, underscoring patient
agency. Chapter two showed a highly dialectical relationship between gender nonconforming
and gender transgressive persons and healthcare providers in different historical moments of
transgender policymaking. We saw patients patterning their stories intentionally to fit narratives
that would allow them access care. We saw doctors limiting through diagnostic criteria the
boundaries of transgender as it became more and more legitimized in professional circles in an
effort to convey credibility. By focusing on interactions – derived through ethnography and
primarily archival research – the chapters in this dissertation captured a much more nuanced and
97
complicated relationship between transgender persons and the institutions of medicine, both in
the contemporary moment (as seen in chapter three) and in historical periods (as seen in chapter
two).
These more nuanced accounts of the role of medicine in shaping the lives of transgender
persons also help to clarify independent effect of culture, that is, how culture shapes action.
Chapter two showed that doctors and patients aren’t passively reproducing an overarching and
clearly defined cultural “ethos;” rather, they are, in specific interactional settings, drawing from
discursive repertoires to (re)produce, a particular way of thinking about the proper relationship
between transgender subjects, medicine, and health policy. In chapter three we saw how shared
assumptions about “who we are” further shape the kinds of things actors were able to say in
specific settings. As the relationship between science, medicine, and policy becomes increasingly
complex, the greater becomes the need to fully understand how these cultural contexts shape
action. In these ways, the cultural-in-action approach advanced in this dissertation permits a far
more nuanced analysis of the role of science and medicine in contemporary social life.
Future research
The particular cultural and historical formation of transgender health that I have outlined
in this project has not occurred in isolation. Non-western actors and cultural contexts have also
shaped the contemporary shifts in transgender health policy. Moreover, the policy changes that
have been taking place in Western states have mirrored (sometimes preceding, sometimes
following) policy changes in international organizations, including UNAIDS, the Global Fund,
the European Court of Human Rights, and the World Health Organization. While the policies of
these international organizations certainly do not dictate individual state policies, states
98
increasingly defer to international organizations to inform policymaking and to regulate industry,
superficially depoliticizing policy decisions and regulatory efforts.
iii
Thus, contemporary
transgender health policymaking is a globally significant topic. Future research should examine
how transgender health policies get negotiated and translated at the local healthcare level in
different national, cultural, and economic contexts. Additionally, particularly fruitful analyses
would likely be achieved through a comparative analysis with a different health policy topic or
research on transgender health politics in the Global South.
99
Notes
i
This term is an adaptation of “military industrial complex” coined by President Dwight D. Eisenhower in the
1950s to describe the dangers of astronomical military expenditures following the end of World War II.
ii
For the latest version of these standards of care, visit:
http://www.wpath.org/uploaded_files/140/files/IJT%20SOC,%20V7.pdf
iii
Frickel and Moore 2007; Frickel and Moore 2011; McKay 2013; Timmermans and Epstein 2010.
100
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Appendix I
108
A note on terminology
I follow Stryker (1994, 2008) in my use of the term “transgender” here to mean persons
who move away from the gender they were assigned at birth; that is, persons for whom crossing
boundaries imposed by their culture to define and contain their gender is a significant life
project. It is precisely this insistence upon, and possibility of, moving across cultural boundaries
i
of gender that has recently drawn significant attention from policymakers.
ii
I am acutely aware
that the term is already somewhat dated, rapidly falling out of favor relative to more fluid and
perhaps less constraining possibilities, such as trans*, trans/gender, or simply trans. I use the
term transgender, a term that has only been in significant use since the 1990s,
iii
because it is the
term used most often in policy debates and institutions of medicine. Additionally, it is popularly
recognizable in the contemporary moment and it is more readable for a broad audience (or at
least, as broad as academic writing can hope for).
I will also use the term transsexualism, popularized by Harry Benjamin in the 1950s,
when referring to the early development of a science of cross-gender identification. However,
readers should be sensitive to the fact that this term is understood in many transgender
communities today as pejorative and pathologizing. Both terms have a history and a politics that
inexorably orient them in some way to medical technologies that emerged in the West in the
early twentieth century and to an identity politics that is also rooted in a Western context.
Because using the term calls upon this scaffolding of meaning, I use descriptive terms like
“gender transgressive behavior,” “gender transgression,” or “gender boundary-crossing,” when I
wish to discuss behaviors rather than identities. Use of all of these terms will be necessary to
illuminate processes by which behaviors came to be known in the stabilized category
transgender, and how the social and cultural organization of that knowledge shaped the historical
trajectory of transgender health policy.
Lastly, although I am interested in analyzing transgender broadly, it will become
necessary at times to separate transgender women and transgender men. Early on, especially in
medical institutions, it was common practice when using these terms to refer to the assigned
gender marker; that is, “transgender woman” referred to an individual who was assigned female
at birth, but who did not identify as a woman. Although it comes at the cost of historical
inaccuracy, I follow the accepted contemporary practice of referring to one’s self-attributed
gender marker. Hence, “transgender woman” refers to someone who self-identifies as a woman.
109
i
One might object it is not, in fact, cultural but physical boundaries of gender that one is crossing. But certainly it is
a cultural distinction that breast augmentation in adult persons assigned as female at birth is seen as a common,
normal, even desirable elective procedure, while a double mastectomy with masculine chest reconstruction in the
same individuals is seen as an unusual, perhaps shocking act of gender boundary-crossing. Moreover, even hormone
replacement therapy in the absence of any surgical interventions constitutes an act of boundary-crossing, as the
visible effects of the hormones operate as “cultural genitalia” (Kessler and McKenna 1978; see also Schilt 2010).
ii
Regulating movement, after all, is a primary objective of the (post)modern state (Torpey 2000; Brown 2010).
iii
The term “gender transgressive identities” was popularized by the once widely circulated magazine Chrysalis
Quarterly when transsexualism was predominantly used but falling out of favor. Transgender was developed as a
shorter, more simplified way of conveying a similar meaning.
Appendix II
110
Archival Sites/Collections Reviewed
Site/Collections
Dates Visited
Organizational records, Los Angeles Gender Center
ONE National Archives
Digital records, International Organizations
WHO; UNAIDS; GLOBAL FUND
Kinsey Institute
HBIGDA Collection
Harry Benjamin Collection
UCLA Special Collections
Robert Stoller Collection
San Francisco Public Library
Lou Sullivan Papers
GLBT Historical Society, San Francisco
David Kessler Papers
Bay Area Physicians for Human Rights Records
Tamara Ching Papers, 1993-1997
Jordy Jones papers, 1977-2002
FTM International Records, 1986-2005
Lou Sullivan papers, 1955-1991
TransGender San Francisco collection, 1950-2001
Lane Medical Library, Stanford Medical History Center
Donald R. Laub Collection
Personal collection, Ms. Bob Davis
Kinsey Institute
Charles Ihlenfeld Collection
John Money Collection
National Transgender Archives, University of Victoria
Ari Kane/Fantasia Fair Collection
barbara findlay, Q.C./Kimberly Nixon Collection
Betty Ann Lind Collection
Internal Foundation for Gender Education Records
Reed Erickson Collection
Rikki Swin Institute Records
University of Ulster TGA Collection, 1986-2010
Canadian Lesbian and Gay Archives, Toronto
Clark Institute of Psychiatry GID Clinic Collection
10-12/2014
1-2/2015
6-8/2015
10/2015
12/2015
01/2016
01/2016
01/2016
01/2016
02/2016
03/2016
04/2016
Abstract (if available)
Abstract
In a curiously sudden and remarkably consistent shift since the turn of the century, health policymakers on a global scale have, with some urgency, devoted increasing amounts of time and energy to reconsidering established policies about or affecting transgender persons – those for whom moving away from the sex/gender assigned to them at birth is a significant life project. Since medical technologies may be used to adjust one’s body to be more in line with one’s gender identity, the medical, legal, and political implications of cross-gender identification, referred to variously as transsexualism, transgenderism, trans*, and others in different eras, have periodically emerged in local health policy debates since the early 1900s. Yet the degree of attention to transgender related policies is unprecedented. “We can barely keep up with all of the new improvements in access to [health]care,” declared the director of the National Center for Transgender Equality in the summer of 2014. Importantly, this shift has occurred in the absence of any significant changes to transgender population size, health, or the quality, availability, and cost of technologies of gender transition. ❧ To understand this peculiar shift, this dissertation examines the broader historical and cultural contexts in which transgender gets constructed as a public problem. One might take for granted that one is entitled to a “right to health,” that transgender persons necessarily need access to medical technologies governed by health institutions in order to be their “authentic selves,” and that it is quite inevitable, therefore, that “transgender rights” organizing would entail health advocacy as a central component. A classic “medicalization” perspective would suggest that the category transgender only exists because of medical science and through medical technology, thereby making it inevitable that health institutions would have to grapple with the proper way to regulate access to medical interventions for a newly politically powerful transgender community. But none of these associations are inevitable
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Asset Metadata
Creator
Psihopaidas, Demetrios
(author)
Core Title
Unsettled lives: Medicine, culture, and transgender subjects
School
College of Letters, Arts and Sciences
Degree
Doctor of Philosophy
Degree Program
Sociology
Publication Date
02/01/2019
Defense Date
03/30/2018
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
culture,Health policy,Medicine,OAI-PMH Harvest,transgender
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Eliasoph, Nina (
committee chair
), Casper, Lynne (
committee member
), Crimmins, Eileen (
committee member
), Parreñas, Rhacel (
committee member
)
Creator Email
dpsihopa@gmail.com,psihopai@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-41243
Unique identifier
UC11669365
Identifier
etd-Psihopaida-6575.pdf (filename),usctheses-c89-41243 (legacy record id)
Legacy Identifier
etd-Psihopaida-6575.pdf
Dmrecord
41243
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Psihopaidas, Demetrios
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
transgender