November 24, 2014

Commentary | October 17, 2013
What defines a medical transition?
The despotism of Standards of Care for trans* health
Written by | Visual by Alice Shen | The McGill Daily

When talking about trans* individuals and their transitions, there are many details one can get caught up in. Within transition itself, many complications are easily overlooked. One of the complicated issues that often comes up is the question of whether transition ought to be considered a social process or a medical one. It’s unclear why a medical process isn’t also social, and what the difference is between the two.

What is clear is that classifying transition as either social or medical has very profound effects on how we come to view transition, with positives and negatives in both categories. Viewing transition as a medical process is a very powerful thing; it allows us to legally offer benefits to those who can meet the criteria put forward. In order to make transition a medical process, however, these criteria must be clearly defined. Like all categories, this requires that we make some exclusions.

In order to make transition a medical process, however, these criteria must be clearly defined. Like all categories, this requires that we make some exclusions.

To get a clearer picture of transition as a medical process as well as the kinds of exclusions made, let’s take a look at the World Professional Association for Transgender Health Standards of Care (SoC). Specifically, I want to look at the requirements for genital surgery, a process that, in mainstream media, seems to define much of what it means for someone to transition. My hope is that these requirements will illustrate the kind of person one has to be in order to go through medical transition, as well as the assumptions made about that person. This will highlight what kinds of people or what aspects of individuals are left out of the discussion.

All of the requirements are interesting and say something about the kind of person the SoC assumes will want genital surgery. The first thing of note is how the SoC describe the surgeries themselves: “metoidioplasty or phalloplasty in FtM [Female-to-Male] patients,” and “vaginoplasty in MtF [Male-to-Female] patients.” What makes this problematic is that the surgeries are separated according to whether one is ‘FtM’ or ‘MtF’. Already, this flies in the face of many possible identities that someone might have. To classify someone as ‘female-to-male’ or vice versa is to assume that transition means starting as one gender and moving toward another.

The narrative is like that of travelling from one country to the next, except there are only two countries and you’re solely responsible for that travel. This ‘travelling’ assumption is based on the idea that there are only two genders: male and female. To categorize one genital surgery as belonging to a group of people who are ‘targeting’ one gender is to make an essential connection between certain forms of genitalia and certain forms of expression and life. This insidious connection is a persistent issue in the SoC. Suffice it to say that the categorization of surgeries into ‘FtM’ or ‘MtF’ undermines many possible identities. Being genderqueer, two-spirited, or even simply wanting to have a body that is not the specific collection of penis-testosterone-pecs or vagina-estrogen-breasts are just a few of the possibilities that the phrasing in the SoC undermines.

One might want to make a distinction between being transgender, genderqueer, or nonconforming, and being transsexual, in that being transsexual entails having the medical symptom of gender dysphoria. As such, many procedures are understood as belonging to transsexuals in that they attempt to remove the symptom. Distinguishing transsexuals from other forms of non-normative gender is not a solution. What usually happens is that the procedures that are deemed to belong to transsexuals are seen as unessential to folks who do not belong in this category, but would still benefit from such procedures. This is grounded in the very problematic pathologization of transsexual folk which stigmatizes them while simultaneously undermining the plight of those who do not meet the troublesome criteria.

People are not responsible for their own identities. Being a man or a woman is not something that everyone accidentally invents and yet […] one can’t help but feel that the whole point of the requirement is to ask the individual: are you sure?

More importantly, to make such a distinction is to encourage dissent among people who could have fruitful discussion and could share experiences as people who do not conform to assumptions about gender. Being misnamed, having difficulty using public restrooms, and having trouble coming out to important people in one’s life are just a few examples of experiences that genderqueer, nonconforming, transgender, and transsexual folk can share and might discuss for the betterment of each other’s lives personally and politically. Making that distinction also gives the impression that one cannot be more than one of these categories, and it shuts off discussion between people who are constantly reminded that their being different is problematic.

Let us conclude with a look at the last requirement for genital surgery: “12 continuous months of living in a gender role that is congruent with the patient’s identity.” Setting aside the arbitrariness of 12 months, the language points to yet another problematic assumption about trans* folk and gender in general. The individual has to live in congruence with their identity – note the possessive. An identity is understood to be something one has, instead of something one is. There are two assumptions here: that someone’s identity is fixed or permanent, and that they are somehow responsible for their identity. Both of these are myths that are problematic for anyone who does not conform to them, because the language one must speak in, in order to be heard, is usually a language that implies this conception of identity.

I will not argue here that gender identity is something that cannot be permanent by definition. What I will argue against is the second part: people are not responsible for their own identities. Being a man or a woman is not something that everyone accidentally invents and yet, reading the SoC’s justification for its 12 month requirement, one can’t help but feel that the whole point of the requirement is to ask the individual: are you sure? To say that living in a gender role for a year allows for “a range of experience” or helps people “adjust” to their new role is to view them as the cause of the problem.

If you decide to set strict barriers for procedures that are helpful to a wide range of people, you ignore the years of experience that led them to seek help in the first place, in favour of controlling those certain products and services. This does two things. It gives the impression that if someone does not complete those 12 months, or get the referrals, or jump through the right hoops, then they didn’t want it enough. This also allows you to be the final arbiter of whether or not they succeed. This despotism is the paradox that is essential for the gate-keeper model to work the way it does in enforcing certain conceptions of what a gendered human being is.


Quotes are from the SoC’s seventh edition as it appears in the International Journal of Transgenderism, vol. 13, 2011.

Gabrielle Polce is a U4 Philosophy Honours student. To get in touch, email commentary@mcgilldaily.com.

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