Medical Authority in the Discourses of Disability and Transsexuality
Medical Authority in the Discourses of Disability and Transsexuality
Exile and Pride: Disability, Queerness and Liberation is an impossibly far-ranging book. Its author Eli Clare covers many topics that are entangled within his own life: tensions of class, sexuality, gender, abuse, disability, environmentalism and exile. Here I want to use his discussion of the medicalization of disability as a springboard to approach Rachel Ann Heath’s description of the pathologization of transsexuality in The Praeger Handbook of Transsexuality: Changing Gender to Match Mindset. Medicalization and pathologization are not precisely equivalent terms, but to me both represent a process of delegitimizing their subjects and placing this lost authority into the hands of medical professionals. Both produce negative or limiting effects that are not widely acknowledged. In addition, both are oriented towards “curing” or “normalizing” difference.
Exile and Pride: disability history
Clare opens part II of his book, bodies, with the section freaks and queers. In it he discusses the freak show, an American tradition from the 1850’s to the 1930’s, when “freaks were big entertainment and big business,” (85). Clare discusses the culturally constructed freakishness of the era, which conflated four different categories: disabled people, people of color from other countries, people of color from within the US, and nondisabled people with obvious physical differences (86). He points out the context that made these displays possible and profitable: the racism and ableism of the audience. This relates to the question of exploitation and partnership between managers, freaks and audience.
However, the freak show didn’t last forever. Its decline was accompanied and influenced with a wholesale change in the perception of disability. Clare notes that “During the freak show’s heyday, today’s dominant model of disability—the medical model—did not yet exist. This model defines disability as a personal problem, curable and/or treatable by the medical establishment, which in turn has led to the wholesale medicalization of disabled people,” (96). This is the shift that caught my attention, and that I want to explore in relation to The Praeger Handbook of Transsexuality. It’s a change so widespread and complete that it’s hard to think of disability as it was once seen, as a religious or supernatural (or subnatural) matter, when the disabled were imagined to be “extraordinary creatures, not entirely human,” (97). The medicalization of disability shifted the disabled from freak shows to hospitals—surely a positive move? Clare points out some of the negatives.
What function does the medicalization of disability serve?
The medicalization of disability occurred in the US after WWII, as doctors were gaining authority in the eyes of the public. I would argue that their status has only grown since then. The medicalization of disability both relies on and feeds the authority of the medical establishment. It separates one type of freak—the disabled—out of a broader category. It also provides subcategories that delineate the various types of disability. And, in the opinion of Eli Clare “[t]he end of the freak show didn’t mean the end of public voyeurism. We simply traded one kind of freakdom for another,” (103). He cites public stripping, a teaching practice used in hospitals through to the 1960’s in which disabled patients (often children) are stripped in front of a large group of doctors and students and evaluated (103). This new type of freakdom is unpaid and everywhere.
There is another effect of medicalization visible in Clare’s narrative, though not one he states outright. Reading about his life I see the extension of the medical sphere into his social life, in terms of the way that able-bodied strangers interact with him. He writes “[t]oday’s freakdom happens every time some well-meaning stranger or acquaintance suggests a certain combination of vitamins, crystals, or New Age visualization techniques that she knows will cure my CP,” (111). Medicalization defines disability as an individual flaw that can be treated or cured—therefore, Clare must be looking for a cure. He also admits that he never quite manages to retort as he wants to. This type of interaction shows that medicalization isn’t simply something disabled people face when they go to the doctor for treatment. It’s part of the social discourse. It’s part of the way they are understood by the wider world.
So, the medicalization of disability reinforces the authority of the medical establishment and provides categorization for those who fall too far outside the norm. It continues public voyeurism in a different form, in the name of education and cure. And it extends into the social realm, in that the nondisabled learn to understand disability—and, by extension, disabled people—in medical terms.
Later Clare notes explicitly that “Queer identity has [also] been pathologized and medicalized… today transsexuality and transgenderism, under the names of gender dysphoria and gender identity disorder, are classified as psychiatric conditions,” (112). It is this pathologization, and the way it functions, that I want to understand.
The Praeger Handbook: a medical view of transsexuality
The Praeger Handbook of Transsexuality: Changing Gender to Match Mindset, by Rachel Ann Heath, is a valuable resource for understanding the medicalized discourse of transsexuality. Published in 2006, it aims to “provide… an up-to-date account of current knowledge about gender and sex and their relationships when people transition from one gender role into another, and ultimately into their affirmed sex following surgery,” (xii). I would add that it seeks to provide mainly medical knowledge, with some social context. As broad as Heath’s purpose is, she doesn’t attempt to cover transsexual politics or legal struggles, though she mentions them in passing. Instead, the focus is on the relationship between transsexed individuals and the medical community, and on physical transition. Heath’s hoped for audience includes a combination of curious laypeople, medical professionals and policymakers (196). She is not writing solely for a transsexual or transgender audience.
Like Clare, Heath is interested in the issue of terminology. She briefly acknowledges the emotional weight terms can have (xiii) but seems most interested in the practical matter of reader understanding. To understand her writing it is necessary to know how she defines her terms. Throughout her text, she uses transsexed to mean “people transitioning from their natal sex to their affirmed sex, that is, the sex they know they have always been,” (xiii). Additionally, she “prefer[s] the term transsexuality to the more common term transsexualism, simply because the later refers to a purported medical condition (now superseded by the even more prejudicial term gender identity disorder) to describe the pathologization of gender variance… Transsexuality is a much more neutral collective term,” (xiii, emphasis in original). This distinction is not merely semantic; it becomes very important later in her argument.
Heath mentions in passing that “An assumption, especially among the medical establishment, is that transsexed people will want to have GRS, pass as a man or woman, and thereafter live their lives by being as indistinguishable as possible from natal people of their affirmed sex,” (171). Although she provides some examples of different, “radical” ideas about gender (171-172) the information Heath presents on transsexuality is largely centered on this narrative. Though Heath aims to provide social context at both the beginning and end of the book, her focus remains medical rather than social. She also frames the information in her book firmly within a Modernist discourse of progress. Discussing the history of transsexuality from the first successful genital surgeries, Heath asserts that “there have been considerable advances in assistance to transsexed people, as well as in the recognition of transsexed people as productive members of society. The situation continues to improve in the new century with an increase in social tolerance accompanied by improvements in surgical and other medical procedures,” (8). Within this framework, social and technical progress go hand in hand, with prejudice and surgical difficulties forming barriers to overcome.
However, this book does not espouse or accept the medical status quo. Heath denounces in several places what she terms the pathologization of transsexuality, the classification of transsexuality as transsexualism or gender identity disorder, a mental illness. Instead she argues for a reimagining of the transsexed’s role in seeking treatment and of the relationship between doctor and patient. She declares that “”A shift in focus to transsexuality being considered a normal variant of gendered behavior rather than a pathological condition is required,” (15). As a model, she compares transsexuality to pregnancy-- a state of being that is considered completely natural and also routinely medicalized (80). As part of this change, a therapist would be seen as a facilitator rather than an evaluator or authority figure.
Why is Heath so against pathologization? Firstly, it leads to a paradox in which mentally stable patients must allow themselves to be categorized as “unwell” to receive the treatment they want. She points out that it leads to gatekeeping, in which medical professionals are allowed to judge their patients and make decisions on when and how they transition. Additionally, it fosters distrust between transsexed patients and their doctors, where patients will lie to gain treatment, giving the answers their therapists want to hear (87). Additionally, she argues that the reason behind this gatekeeping—keeping doctors free of blame in potential cases of “postoperative regret” when patients regret the physical changes they have made to their bodies—is insufficient to merit such distress.
What function does the pathologization of transsexuality serve?
When discussing gatekeeping, the exercise of excessive authority by medical professionals over transsexed patients, Heath states only one reason: “With so much pressure placed on gender clinic personnel by eager aspirants for GRS [genital reconstruction surgery], responsibility is required to minimize the regret following GRS. This is undoubtedly the reason for gatekeeping,” (81). However, this conclusion makes no sense. Heath writes later that there are many similar cases—surgeries performed on patients with breast cancer, for example—which are of equal or greater risk, and which simply require informed consent from the patient. Additionally, she asks “why must transsexed people be labeled as “mentally ill” in order to begin their medically supervised transition when we know that the incidence of postoperative regret is so low, even lower than regret rates for breast removal for breast cancer patients?” (190).This question may be rhetorical, but I want to try to answer it.
Transsexuality is, in our society, transgressive. Medical professionals are figures with wide-ranging authority over different types of “abnormal” bodies—the sick, the injured, the disabled. It makes sense that in a society in which transsexed bodies are seen as abnormal, doctors are trusted to oversee the process of transition--- a process continually framed in this book and in general medical discourse as bringing a transsexed person in line with “normality.” In other words, in the pathologized model therapists and doctors work together to “cure” transsexuals by guiding them to a new, nontransgressive way of looking and being, which lines up with their gender identity. The subtitle of Heath's book, “Changing Gender to Match Mindset,” summarizes this process, though “Changing Sex to Match Gender” might be more accurate.
Throughout this book, a huge emphasis is placed on “passing.” Some of the emphasis comes from collected responses of transsexed patients, but much, interestingly, comes from medical figures and guidelines. Heath describes in detail the current standards of care for transsexed patients. These include certain steps, first counseling, then hormone treatment, then at least “a year's real-life experience in the opposite-gender role” (91). Only after this time has been successfully completed and evaluated by two independent professionals can a client recceive GRS. This is the normalized path: counseling, hormones, living in a gender role, then surgery. In other words, a client is required to pass (or at least, do their best) for a year before obtaining surgery.
Heath does mention that not everyone follows this path, but also reinforces it as the norm: when certain clients do not wish to pass, and are not interested in surgery, “[t]his situation complicates the evaluation process as many gender clinics assume that, except for medical complications, all accepted clients will eventually progress to GRS,” (92). This narrative of progress, from sex-gender misalignment to sex-gender alightment, mirrors the medical narrative of disability treatment and search for a cure.
In the next section Heath brings up treatment for children and adolescents: in some cases, young patients have been approved for “reversible puberty-delaying agents” (94) although they are not considered old enough to be legally responsible for transition. Heath notes that this “has the desirable effect of enhancing passability should these young people proceed to GRS as adults,” (95). Again the narrative of progress towards GRS and “passibility” is invoked.
Describing the specific case of one such young person who delayed the onset of puberty and transitioned after the age of 18, Heath notes that “[a]s confirmation of the effectiveness of his medical treatment, no one considered him to be, or have been, female owing to his convincing male presentation,” (99). Again medical success, social success, and passing are linked. This remains true even though Heath later discusses some of the drawbacks of passing: the need to live in “stealth” and the fragmentation of the trans community between those who wish to pass and those who don't, or those who can't and those who can (171-172).
Heath’s alternative model of transsexuality, as a normal condition requiring some medical assistance, challenges the medical status quo. However, it never engages with the practice that the status quo facilitates: the guiding of individuals into a new socially acceptable role, in which sex aligns with gender so seamlessly that an observer cannot guess at the history, therapy and surgery which are part of the individual he or she sees. Even so, by taking away medical authority to decide who can transition when, she may be opening the door to new paths. In her sincere, well-researched plea to open up a space for marginalized voices to speak, she may be setting professionals and policymakers up to hear answers which no one expected.
Heath, Rachel Ann. The Praeger Handbook of Transsexuality: Changing Gender to Match Mindset. Westport: Praeger, 2006.
Clare, Eli. Exile & Pride: Disability, Queerness and Liberation. Cambridge, MA: South End Press, 2009.