Understanding Trans Health

Discourse, Power and Possibility

Pearce, Ruth

• Publisher: Policy Press
• Year: 2018
• ISBN:
  9781447342366
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

What does it mean for someone to be 'trans'? What are the implications of this for healthcare provision? Drawing on the findings of an extensive research project, this book addresses urgent challenges and debates in trans health. It interweaves patient voices with social theory and autobiography, offering an innovative look at how shifting language, patient mistrust, waiting lists and professional power shape clinical encounters, and exploring what a better future might look like for trans patients.

Part One
The context of care

ONE

Introduction: coming to terms with trans health

No social study that does not come back to the problems of biography, of history and of their intersections within a society has completed its intellectual journey. (C. Wright Mills, 1959)

Trans health … who cares?

The origins of this book lie in the emergence of sexology in the late 19th century as learned doctors sought to describe and categorise the deviant behaviour of those who failed to conform to norms of sex and gender.

The origins of this book lie in the emergence of transsexualism in the 20th century as a means by which individuals desiring social and physical transitions from one gender to ‘the other’ could be identified and managed.

The origins of this book lie in the emergence of the trans movement in the 1990s, which sought to redefine and recognise a great range of gender-variant identities and experiences as an aspect of human diversity, rather than as conditions requiring treatment.

The origins of this book lie in the emergence of my own trans identity in the early years of the 21st century, as a lonely teenager reaching out for solace, support, understanding and community on the internet.

The origins of this book lie … in a warm Birmingham meeting room gently devoid of character, in which I sat listening to a talk in March 2009. Spring was (in theory) just around the corner, but that wasn’t apparent on this overcast day, with its blustery wind and occasional showers of rain. I was attending a seminar entitled ‘LGBT Health … Who Cares?’ as a representative of internet-based advocacy and support group Trans Youth Network.1 The short walk to the seminar venue from the train station had been somewhat challenging; I was in the latter months of a gruelling recovery from surgery undertaken the previous summer, in what I imagined at the time to be the final stage of my long transition from ‘male’ to ‘female’.

I sat through numerous fascinating presentations on LGBT (lesbian, gay, bisexual and trans) health that day, delivered variously by practitioners, social researchers and community activists. What played on my mind after the event, however, was not any particular item of information I had picked up. Rather, it was the expressed lack of information on trans experiences of healthcare in the UK, as exemplified in a report launched by Catherine Meads and colleagues during the day.

[T]rans health research was originally going to be included in this systematic review. Unfortunately, having trawled through all of the literature, no peer-reviewed and published UK-specific information was found on the general health of trans people. (Meads et al, 2009: 81)

Meads and colleagues used trans as an umbrella term, incorporating a range of identities and experiences such as ‘transsexual’, ‘transgender’, ‘transvestite’ and ‘crossgender’. This approach links ‘trans’ to both medical accounts and collective social movement, with connections forged on the grounds of shared marginalisation. The Trans Youth Network conceptualisation of ‘trans’ was wider still, reflecting a move towards open-ended accounts of gender-variant possibility within the connected worlds of trans activism and academia. Similarly, Stephen Whittle (2006: xi) describes trans identities as accessible ‘to anyone who does not feel comfortable in the gender role they were attributed with at birth, or has a gender identity at odds with the labels “man” or “woman” credited to them by formal authorities’.

It is this ‘open’ definition of trans possibility that informs my own use of the term throughout this book. I use it to refer to a wide repertoire of identities, experiences and modes of gender presentation. The trans possibilities found within this repertoire are frequently – but not always – linked to a notion of social and/or physical transition. Transition refers to a move away from the gender that was assigned to a person at birth and towards to an alternative preferred, desired or felt state of gendered (or non-gendered) being.

I learned from Meads and colleagues that studies on trans health typically focus only on the transition process; indeed, the authors’ extensive review of UK literature failed to uncover a single peer-reviewed article looking at trans health more widely. Moreover, I would soon discover that research on the UK’s gender identity services, which facilitate physical transition through the provision of hormones, surgeries, hair removal and voice therapy, is also rare outside of medical journals. This is because the intellectual field of trans health has historically been shaped by the health professionals who oversee gender identity services. However, in recent years a range of alternative academic approaches to understanding categorisation, diagnosis and treatment have begun to emerge from the trans rights movement, reflecting and drawing upon similar contestations in the realms of queer and feminist health (Hanssmann, 2016). It is within this tradition that this book is located.

I left ‘LGBT Health … Who Cares?’ feeling inspired and motivated to address some of the gaps that exist in our knowledge. As both a trans patient and an active member of trans community groups, I felt intimately connected to the challenges faced by trans people in accessing healthcare services. My transition had been a lengthy process, mediated by multiple appointments, assessments and waits. Having first approached my general practitioner (GP) for help with feelings of severe dysphoria at the age of 16, I eventually attended a first appointment at London’s Charing Cross Gender Identity Clinic over three years later. I received approval for hormone therapy around the time of my 20th birthday, and acquired my first hormone prescription after a further wait of around four months. I was nearly 22 by the time I underwent an operation to surgically reconfigure my genitals. In the meantime, I found my GP to be indifferent at best and obstructive at worst; he was dismissive in appointments, denied me access to the regular blood tests required by the gender clinic and continued to refer to me as male in my medical records.

This book is written from a sociological perspective. Like many sociologists, I am interested in the connection between ‘personal troubles’ and wider ‘public issues’ (Mills, 1959: 8). Back in 2009, I had yet to embark on my training as a researcher, but was already aware that my own frustrating experience of long waits, extensive assessment procedures, ignorance and rudeness within healthcare settings paled in comparison to challenges faced by many of my peers. I felt that my transition, long and difficult as it was, had been a relatively straightforward process. This was facilitated by my luck in the ‘postcode lottery’ of local public health commissioning bodies, and the manner in which my relatively normative (white, middle-class, abled, English) female gender identity happened to ‘fit’ the existing diagnostic models and modes of assessment. By contrast, I knew trans people who had spent years fighting for access to specialist care, and others – particularly those whose gender identities could not be categorised straightforwardly into a male/female binary – who had trouble meeting the clinical criteria for treatment even as they experienced severe dysphoria. Within the wider realm of healthcare beyond the gender identity services, an enormous number of trans people I knew had been insulted or harassed (sometimes sexually) by health professionals, and denied routine treatments for all kinds of ailments due to their trans status.

I therefore realised there was a vital need to better understand why and how this happened, in order to address the issues reported by trans patients. I embarked on a research project that came to define my life for many years. I immersed myself in trans people’s stories and experiences, their (our) hopes, fears and dreams. I followed passionate arguments and heated debates within online activist groups and carefully read health practitioners’ accounts of working with trans patients. This book is the culmination of that project. It offers an insight into some of the narratives and contentions that characterise conversations around trans health, and I hope that it will be useful to patients as well as practitioners, activists as well as academics.

While my research focused primarily on trans healthcare services in a UK setting, many of the ideas and debates I draw upon and discuss in this book have a wider relevance. In addressing issues of power, identity, language and contestation with regard to health, I draw upon and contribute to international conversations about trans rights and access to services. This book will be particularly relevant to readers in countries with a strong tradition of public health and institutionalised gender identity services, but also speaks to ideas and concerns identified by scholars and activists in other contexts, particularly the United States. I also draw upon insights from wider critical health literatures, having noted parallels between patient activism in trans health and in other arenas, such as AIDS and cancer care. In turn, this book will be useful to social scholars of health working outside of the specific arena of transgender studies.

This book is not concerned with establishing what gender ‘is’ (or, for that matter, what sex ‘is’), or how this relates to trans identities, experiences and bodies. I regard both gender and sex as socially constructed categories with a complex relationship to biological difference, following theorists such as Judith Butler (1999) and Julia Serano (2007). My deeper thoughts on the matter of gender, sex and trans discourse would form the basis of an entirely separate book! However, this work is based on an acknowledgement that trans people are real, valid and deserving of affirmation, and the observation that trans people experience health inequalities that require specific attention.2

Discourse, power and possibility

I soon came to realise that it is insufficient to merely fill a perceived ‘gap’ in academic knowledge on social experiences of trans health. If it was enough simply to note that trans people face widespread discrimination and ignorance in public life, then many of the troubles trans people face might have been tackled decisively some time ago. Instead, I began to seek a deeper understanding of how and why the troubles that trans people face have emerged.

Many such troubles are not rooted in malice on the part of health professionals, but can instead by linked to different understandings of what it means to be trans and/or gendered. For example, the broad scope of trans possibility as understood by writers such as Whittle and grassroots organisations such as Trans Youth Network contrasted with more rigid forms of categorisation employed by the health professionals who assessed me for gender dysphoria at the gender clinic. Similarly, my understanding of myself as a woman contrasts with my former GP’s view that I was ‘really’ a man, as evidenced by his use of male pronouns to refer to me in my medical notes.

This book therefore goes beyond simply chronicling the challenges faced by trans patients. I ask why differences of perspective occur, how they might be characterised and in what ways they might be linked to the complex interaction of ‘medical’ and ‘trans’ ideas both historic and contemporary.

The main concept I use to make sense of this is discourse. Discourse refers to the authoritative ways in which we talk about ideas within and as a society. This concept can be linked to the operation of power, and the manner in which some ways of living might seem possible while others do not. Discourses do not simply describe the world: they also work to reproduce how the world is seen and experienced (Foucault, 1978). This does not necessarily mean that discourses come from a place of power. While some discourses are ‘hegemonic’ – meaning that they hold sway as the predominant way of seeing the world within a particular social context – counter-discourses may also emerge from the social margins. For example, the hegemonic discourse around gender within Western society holds that there are two and only two genders – female and male – and that everyone ‘fits’ into only one of these categories. This is not simply an idea that describes how the world works: it is an idea with power, shaping how the world works. By contrast, trans, feminist and decolonial counter-discourses of non-binary gender draw attention to the diversity and complexity of both biology and social life, enabling us to recognise a world that is not divided simplistically between two overarching ideals of sex and gender (Kessler and McKenna, 1978; Bornstein, 1994; Patel, 2017). As I shall show in this book, such ideas have come to challenge the hegemony of binary gender discourse.

Through analysing discourse, I seek to centre the importance of narrative in generating possibility and mediating relations of power. In doing so, I employ a poststructuralist framework. Poststructuralism ‘asks us to consider the ways in which subjects are constituted in and through social institutions and the language employed by these … bodies’, thereby enabling scholars to ‘examine the constitution of subjectivity in social life’ (Namaste, 2000: 16–17). However, I also follow poststructuralist transgender studies scholars such as Surya Monro (2005), Sally Hines (2007) and Zowie Davy (2011) in looking beyond language in and of itself, linking my discussion of discourse to an acknowledgement of the material conditions of trans health.3

Condition and movement

In this book, I ask two key questions about discourses of trans health:

1. How are ‘trans’ possibilities produced, reified and legitimated through health discourses and practices?

2. How are discourses of trans health negotiated within and between trans community groups, trans activists and health professionals? How are they disseminated, and how are they contested?

These questions aim to uncover how trans identities and experiences, along with conceptualisations of trans health, are understood in multiple contexts. My purpose is to grasp the social processes at play in encounters where trans patients feel marginalised, misunderstood and/or discriminated against. With these questions I also recognise that (like this book) the term ‘trans’ and concepts of ‘trans health’ have multiple points of origin and definition.

The first question asks how trans meanings and possibilities are produced, reified and legitimated through health discourses and practices. In unpacking and responding to this question, I describe ‘trans’ in terms of two intersecting discursive repertoires: ‘trans as condition’, and ‘trans as movement’.

Discourses of trans as condition frame ‘trans’ as fixed and fixable. ‘Trans’ in this sense is also resolvable: whether as medical condition or social condition, it can be clearly defined and delineated, while the problems it raises can be addressed and managed in a particular way. Fixing or resolving ‘trans’ typically entails a certain level of expertise: in this context, ‘trans’ can be understood as conditional, in that it requires identification from a qualified expert such as a health professional, with reference to a set of quite static criteria that are usually rooted in binary conceptions of gender.

Discourses of trans as movement recognise the potentiality and actuality of changes to theory, subjectivity, embodiment, space and time taking place through continual creation, fluidity and world-building. Rather than being a categorical matter, ‘trans’ in this context describes an open-ended ‘movement across a socially imposed boundary away from an unchosen starting place’ (Stryker, 2008: 1). Trans as movement can hence refer to collective social movements – that is, ‘politicised communities of identity’ (Stryker, 2006: 5) – but I also use the phrase to describe queer discourses of individual identity and experience. Expertise on ‘trans’ possibility is in this context typically loca...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• List of abbreviations
• Acknowledgements
• Part One: The context of care
• Part Two: Navigating health services
• Part Three: Changing trans health
• Appendix: notes on fieldwork, methods and ethics
• List of key terms
• References