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Goldsmiths, University of London

SO71089A - Gender, Media & Culture Student Number 33304956

‘Are you a girl or a boy?’ A study into the reinforcement of gender binary through medical transition and the NHS.

Word count: 14,540 August 2014


An in-depth critique and discussion into the medicalization of the transgendered person in both historical and current contexts, and the ‘normalization’ of transsexuality through the implementation of the gender binary model in terms of language and medical interven- tion.






  • 1 Introduction


  • 2 Background


  • 2.1 Clarifying ‘Trans’ Terminology .























  • 2.2 The Issue with ‘corrective’ and Intersex surgery




  • 2.3 Assigning gender – The case of David Reimer



  • 3 Medicalizing Trans: The Problem with Medicalizing bodies and Medical Terminologies


  • 4 Legitimizing Trans Identities



  • 4.1 Gender Recognition Act and Acceptable vs. Unacceptable Trans































  • 4.2 Medical Treatment Narratives and Gendered Citizenship






  • 5 Citizenship


  • 6 Issues with the ‘De-Medicalization’ Of Transgendered People



  • 7 Independent Study



  • 7.1 .































  • 7.2 Ethics




































Online Survey

  • 7.3 .


























  • 7.4 Online Survey Results




























  • 7.5 Skype Interviews






























  • 7.6 Skype Interview Results


























  • 8 Conclusion


A Appendix


B Bibliography



Chapter 1


This dissertation will be looking into the ways trans people must conform to

specific gender binaries in order to be legitimized as a Transgender person and to receive and gain access to surgery and hormone treatments, specifically through the national healthcare system.

  • I wish to explore the way stereotypical gender roles are encouraged in order to legitimize medical transition, and how access to gender reassignment serves as a

reward for fulfilling the quota of ‘masculine male’ and ‘feminine female.’

  • I will look into the eect this has on non-binary identified trans people and the extent to which medical conceptions of sexed identity associated medical practice

have a detrimental eect to the encompassing of all trans people with varying gender identities within society and with access to medical care.

  • I will do this by firstly looking into the history of medicalization of trans and gen- der variant people in both historic and current contexts. This will include a look

into ‘corrective’ surgery on Intersex people and the way ambiguous gender is per- ceived as ‘abnormal’ within medical practice. I will also be looking into the initial conception of ‘trans’ into medical discourse and the changes and progression made over time with replacement of terms such as ‘gender identity disorder’ to ‘gender dysphoria’ within the DSM-V manual. Do these changes in medical terminology reflect a change in attitude and a new understanding of gender identity?

  • I will address issues of Gender binary as a system of oppression by looking at texts such as; Kate Bornstein’s ‘Gender Outlaw’ (1994) and Alison Rooke’s ‘Telling

Trans Stories,’ (2010) which focuses on a project involving debates between young


Chapter 1. Introduction


Trans people and medical professionals involved in their care as well as Oral History taken from literature by Zowie Davy. (2010)

In the final part of this dissertation I will be drawing upon my small scale research study of non-binary identified trans interview participants, and an online survey that asked questions relating to the medical interactions and care they had received as a non-binary person. With this approach and by drawing upon each individuals’ experience, I hope to illustrate the ways in which the healthcare system is failing non-binary trans people.

Chapter 2


2014 has been a good year in regards to raising visibility of Trans people and putting issues of Transgender rights into the spotlight. From Laverne Cox making history as both the first transgender actor to be nominated for an Emmy (Cullen, 2014) and for being the first Trans person to feature on the front cover of Time Magazine. (Hach´e, 2014) However, increased visibility has meant that mainstream media and society have constructed their own ideas and ideals of what ‘trans’ signifies to them based on potentially outdated ideologies and definitions of ‘transgender.’ BBC Online for example, defines a transgender person as, “Someone who has a conviction that they’re trapped in the wrong body.” (

There have been many criticisms of the ‘wrong-body’ model such as Talia Bettcher’s ‘Trapped in the Wrong Theory,’ in which she states,

“. . .

The wrong-body narrative is deeply connected to genital recon-

struction technologies, the narrative, just as the technologies, is open to worries about class and race-dierentiated access. The wrong-body narrative outlines a standard genital reconstruction surgery, and any identity that fails to desire that is ruled ineligible. It thereby attempts

to restrict access to womanhood or manhood itself through hegemonic class-, race-, and culture-inflected modalities.” (Bettcher, 2014:402)

Bettcher outlines how limiting Trans identity to a wrong-body narrative dictates the ‘authenticity’ of a trans person’s identity that must follow the guidelines of an


Chapter 2. Background


oppressive medical definition, such as: the desire for ‘corrective’ genital surgery which I will discuss further, in the section ‘The problem with Corrective surgery.’

  • 2.1 Clarifying ‘Trans’ Terminology

To ensure clarity of the subject, I feel it necessary to define what I mean by ‘trans people’ throughout the context of this essay. The term ‘trans’ can usually be incorporated within many levels of gender ambiguity. In fact one of the first problems I encountered was giving it a narrow definition as it is utilized as such an extensive umbrella term.

This notion of a term that encompasses gender variance on such a huge scale is emphasized in Vanessa Sheridan’s ‘Complete Guide To Transgender In The Workplace.’ As Sheridan explains:

“Transgender is a very big tent that covers a lot of territory, with much of it di cult to categorize. A useful understanding of the term is this: transgender includes everything not covered by our culture’s narrow terms for ‘man’ and ‘woman.’”(Sheridan 2009:1)

In this dissertation, I will use the term ‘trans’ to describe those who do not identify with the biological gender they were assigned at birth. One important factor that Sheridan (2009) fails to mention is that the medicalization of trans people does not seemingly acknowledge this vast spectrum of alternative gender identities that the term ‘trans’ covers. This way of viewing gender has been debated by many queer theorists (Whittle, 2000; 2006) who argue that gender is very complex, is a social construct (Phillips, 2006; Kessler and McKenna, 2006) and even a performance, which is not based on your genitalia or your internal organs (Butler, 1999; 2004).

A good example on the issue of defining gender on the distinction of ones physical anatomy is illustrated in an article by Geertje Mak appropriately entitled, ‘So we must go beyond what the microscope can reveal.’ Mak focuses her attention on late 19th century studies into genitalia and gender identity, critiquing the work of Alice Dreger’s ‘Hermaphrodites,’

Chapter 2. Background


“. . .

Most physicians agreed that the true sex had to be defined by

the structure of his/her gonadal tissue. Dreger labeled this period ‘The age of gonads.’ Arguing that no matter how an individual lived in a

gender role- they would be labeled male or female by their anatomical gonads.” (Mak 2005:69)

As Mak (2005) explains, the belief was held that the construction and appearance of your genitalia ultimately defined ones gender identity. Whilst Mak argues there had been queries and disputes regarding the concept of sex/gender long before-

hand, Dreger argued that Blair Bell, a surgeon in Liverpool (1915), was one of the

first to publicly question this practice by asking “Whether we are

justified. . .


branding patients with a sex that is often foreign not only to their appearance but

also to their instincts and social happiness” (Mak, 2005: 69). We can conclude that Bell was advocating the idea that anatomy should not necessarily reflect gender identity, and by drawing upon the ‘social happiness’ of individuals, Bell recognizes the adverse aects that ‘branding patients’ can have on ones emotional wellbeing.

With this in mind, Mak (2005) states how a new understanding of ‘biological sex’ began to influence the language used to define gender. Mak writes, “Other kinds of biological sex were being discovered, e.g. hormonal sex and chromosomal sex. A shift in conceptualization also attributed a shift in name, from hermaphrodite to intersex.” (Mak, 2005:69)

  • 2.2 The Issue with ‘corrective’ and Intersex surgery

In this section I will look into the concept that Intersex surgery as ‘corrective’ is a Westernized cultural idea influenced by a belief system that considers gender ambiguity ‘abnormal’ and in need of medical intervention by way of surgical nor- malizing (in this case) sexual organs to make them appear more ‘male’ or ‘female.’ In other words; enforcing a binary gender identity on an otherwise gender-neutral individual. To illustrate this, I am going to focus on Nancy Ehrenreich’s essay ‘Intersex surgery, FGC and the selective condemnation of cultural practices’ (2005) In which she compares criticisms of African cultural practices of ‘Female circumcision’ more

Chapter 2. Background


commonly known as ‘Female Genital Mutilation (FGM),’ and looks into why these same criticisms are not applied to the practice of intersex surgery.

Ehrenreich states that much of the argument for Intersex surgery is based around the way it is represented as respected practice purely within a medical context, “The Western medical community has represented its genital cutting as modern, scientific and above reproach.” (Ehrenreich, 2005:71) By the same token, African genital cutting is presented as a ‘barbaric, irrational and harmful’ practice due to it being considered ‘uneccessary’ (Ehrenreich, 2005:71) due to there being no scientific or medical explanation for the practice. Ehrenreich argues that playing FGC under in the category of the ‘other’ means that Western feminist scholars (and medical practitioners alike) fail to acknowledge the similarities between the two practices.

One such procedure, she argues, that of surgical genital cutting once considered necessary to be performed on intersex infants carried far greater risks than African genital cutting, Eisenreich comments that these procedures are ‘medically unec- cessary’ (Eisenreich, 2005:74) which is one factor upheld in arguments against African FGC. The important point is made over the use of ‘medical terminology’ and acceptable language that harbor positive and harmless connotations such as ‘circumcision over the use of terminology used to describe FGC such as ‘mutila- tion’ and ‘cutting.’ (Eisenreich, 2005:72) The dierence in how these surgeries are referred shows how one type of genital surgery is considered acceptable over the other due to the belief that one is ‘neces- sary’ and scientifically justified because the medical professional sees the surgery as corrective, even if the procedure itself holds more health risk and is more in- vasive than FGC. Eisenreich argues that it is the construction of African societies and practices being presented as ‘primitive, patriarchal and barbaric’ (Eisenreich, 2005:75) essentially implying that African understandings of the body are merely ‘cultural’ that serves as justification to condemn such practices.

Considering the similarities between to the two surgeries in that they both run the risk of infection, are medically unnecessary, can aect sexual function and can cause problems later in life, how is surgery on Intersex infants justified? One explanation as illustrated in an article from The Independent argues that it is due to the medical professional’s refusal to allow for the existence of those babies who ‘do not fall neatly into the category of male or female.’ (Morrison, 2013)

Chapter 2. Background


Sarah Morrison reports that,

“[Intersex people] argue that their very existence has been ‘erad- icated’ by British society. Generations of children have been oper-

ated upon to ‘normalize’ their

genitals. . .

while o cial documentation

from birth certificates to passports requires a male or female box to be ticked.” (Morrison, 2013, my emphasis)

Morrison not only highlights the fact that Intersex people are being forced into a gender binary by way of having their genitals ‘normalised’ and their intersex identity subsequently eradicated, but also introduces the concept of being forced into a gender binary by default due to lack of appropriate documentation such as:

having to tick a male or female box on a passport.

“In the 1960s it became the norm to operate on children with atypical sexual anatomy at a young age. Doctors assigned the child’s gender and operated to reinforce it.” (Morrison, 2013) This concept of surgical intervention on sex organ- s/anatomy enforces the idea that genitalia/sex equates to gender identity and the two become indistinct from one another.

  • 2.3 Assigning gender – The case of David Reimer

This section will be looking into the issues of medical professionals assigning gender markers and gender identity. One of the earliest and well-known cases ever recorded involving a doctor assigning a child’s gender was that of David Reimer, whose penis had been ‘burned beyond surgical repair’ during a circumcision attempt. (Woo, LA Times, 2004)

In an LA Times article Elaine Woo reports that ‘At 8 months of age Reimer became

the unwitting subject of ‘sex reassignment’

The American doctor whose advice

. . . they sought recommended that their son be castrated, given hormone treatments and raised as a girl.’ (Woo, 2004) The prospect of a child without a penis was

immediately equated with the idea that he could be raised a ‘girl’ regardless of the child’s gender presentation and gender identity. Dr Money – the Doctor involved in the experiment and acclaimed sex researcher argued that sex roles were largely the product of social conditioning, essentially gender was nurture over nature.

Chapter 2. Background


Money argued that ‘through surgeries and hormone treatments’ he could turn a

child into whichever sex seemed most appropriate. (Woo, 2004) In the case of

Reimer however, the sex that was ‘deemed appropriate’ was purely based on the

failed circumcision attempt as opposed to the child’s gender identity and expres-


Importantly, Money is also quoted as stating he had experienced success changing

the sex of babies born with ‘incomplete or ambiguous genitalia.’ (Woo, 2004)

‘Ambiguous genitalia’ implies that it does not correspond what would medically

be considered normative, i.e. male or female genitalia.

We can subsequently presume that Dr Money performed what would thus be

considered ‘corrective’ surgery on intersex infants.

Dr Money’s experiment was unsuccessful as David ‘was rejecting his feminized


“. . .

David had steadily rejected (his) assignment from male to female, at 15

he refused to continue living as a girl.” (Woo, 2004, my emphasis) David eventu-

ally committed suicide due to bouts of depression namely brought about by his

traumatic childhood. (Daily mail reporter, 2010) This shows how gender is intrin-

sic to the individual. Surgery cannot be performed to dictate whether a child is

one binary gender or the other.

In Judith Butler’s ‘Undoing Gender,’ she illustrates how the failure of Dr Money’s

experiment gained him many critics within the medical field including sex re-

searcher Milton Diamond, who according to Butler believes in the hormonal basis

of gender identity. (Butler, 2004:60) Butler states that those critical of Dr Money’s

theories believed that David’s failure to be accept his socialized role as a girl shows

us that there “was some deep-seated sense of

gender. . .

one that is linked to his

original set of genitals as an internal truth and necessity, which no amount of


socialization could reverse.” (Butler, 2004:62)

Butler comments that the Brenda/David case was now being used in order to

provide evidence for the reversal of Money’s thesis.

As such, these new arguments were,

“. . .

supporting the notion of essential gender

core, one that is tied in some irreversible way to anatomy and to a deterministic

sense of biology.” (Butler, 2004:62)

Butler draws upon Gender studies professor Anne Fausto-Sterling to question this

ideology stating,

Chapter 2. Background


“Her (Anne’s)

view. . .

is that although a child should be given a

sex assignment for the purposes of establishing a stable social identity,

it does not follow that society should engage in coercive surgery to

remake the body in the social imagine of that gender. Such eorts

at ‘correction’ not only violate the child, but lend support to the idea

that gender has to be borne out in singular and normative ways at the

level of anatomy.” (Butler, 2004:63, my emphasis)

It could be argued that by suggesting a child should be assigned a sex, this puts

the focus back onto the biological and medicalized aspect of sex rather than the

child’s own gender identity. Although Anne strongly criticizes the idea of corrective

surgery and ‘normative’ ideas of gender and the anatomy, it seems hypocritical to

critique social norms of gender while implying the necessity of ‘sex assignment,’

especially on a child whose gender identity may not fit into a male/female binary.

Alice Dreger illustrates the problems of Dr Money’ ‘Concealment-centred’ ap-

proach of intersex patients in her paper ‘Shifting The Paradigm of Intersex Treat-

ment,’ which directly compares the concealment-centred model (such as the one

utilized on David) with a patient-centred approach.

The paper was prepared for the Intersex society of North America (ISNA). Dreger’s

comparisons drew attention to the way being Intersex was interpreted within med-

ical discourse within concealment centered model as being ‘a rare abnormality

which is highly likely to lead to great distress,’ to the patient-centered model of

Intersex which states that it is merely ‘an anatomical variation from the ‘standard’

male and female types; just as skin and hair color vary along a wide spectrum.’

(Dreger, ISNA, 2014) The Concealment approach regards Intersex as an abnor-

mality whereas the Patient approach rightfully understands gender ambiguity as

merely a variation of what is considered the norm.

In the section ‘Are Intersexed genitals a medical problem?’ The concealment ap-

proach argues that if untreated, it is highly likely to ‘result in depression and

suicide.’ Intersexed genitals must be ‘normalized’ to whatever extent possible if

these problems are to be avoided.’ (Dreger, 2014) There is a direct connotation

with Intersex and abnormality as well as an implication of mental health issues

in the Concealment approach. The Patient-centered approach argues that ‘Inter-

sexed genitals are not a medical problems’ and that there are no evidence for the

Chapter 2. Background


concealment paradigm.’ (Dreger, 2014) Arguably the belief that an Intersex per-

son will grow up to be ‘depressed’ or ‘suicidal’ due to not having ‘normal’ genitalia

are merely preconceived ideas of the medical professionals as opposed to the lived

reality of the Intersex person.

Chapter 3

Medicalizing Trans: The Problem with Medicalizing bodies and Medical Terminologies

In the book Transgender Nation (1994), Gordene Mackenzie discusses this notion

of the damaging eects of medicalization,

“Often we lose sight of the individual with clinical categorizations

and rigid

definition. . .

As Foucault and Planner suggest, they have

stigmatized, dehumanized, condemned and justified the barbaric tor-

ture of whole groups of people as ‘sick and deviant,’ simply because

they did not conform to the status quo.” (Mackenzie 1994:55)

Mackenzie (1994) continues: “Much of the medical and legal pressure for sex

reassignment surgery is based on the persistent American belief that somehow,

gender emanates from the genitals” (Mackenzie, 1994: 56). Similar to the critique

of the Age Of Gonads, it is apparent that there is a lack of separation between

gender identity and biological sex. Mackenzie (1994) notes;

“This idea of trans people ‘born in the wrong body.’ Common sense

dictates that the idea of wrong bodies assumes the existence of right

bodies. Right bodies, according to transsexual ideology must match


Chapter 3. Medicalizing Trans


the gender of the individual accordingly. Masculine-male, feminine-

female, thereby reinforcing sex and gender congruence demanded by

contemporary American society.” (Mackenzie, 1994:61, 62)

Here we can argue that trans people’s gender identities are dictated by societal

presumptions on gender binaries; male and female. This, once again, shows the

reinforcement of gender dialectics and binaries.

In Kate Bornstein’s ‘Gender Outlaw’ (1994) she discusses how these binary ide-

ologies on gender influenced her decision to have surgery,

“I never hated my penis; I hated that it made me a man – in my

own eyes and in the eyes of others. For my comfort, I needed a vagina –

I was convinced that the only way I could live out what I thought to be

my true gender was to have genital surgery to construct a

vagina. . .

(Bornstein, 1994:47)

Bornstein’s desire for surgery was born out of her desire to conform to what she

believed at the time – would make her more of a ‘woman,’ and this was directly

equating genitals (sex) to gender.

This next section will be focusing on the Parliamentary Guidelines for the commis-

sioning of healthcare treatment services for trans people, and some of the issues

this brings up in regards to the language used and the definitions put forward

within the guidelines.

The guidelines define gender dysphoria as,

“(The) experience of oneself as male or female that is a gender

identity which is incongruent with the phenotype (the external sexual

characteristics of the body). The personal experience of this incongru-

ence is termed gender dysphoria.” (GIRES, 2009:3, my emphasis)

From the outset, gender dysphoria is defined as experiencing oneself as ‘male’ or

‘female’ outside the biological sex. It immediately presumes the dysphoria will be

experienced as one binary gender or the other as opposed to merely an experience

of incongruence which deviates from the normative gender role.

Chapter 3. Medicalizing Trans


The guidelines go on to state,

“. . .

The individual may need medical assistance to

facilitate a transition of status to live in accordance with his or her gender identity

rather than with the phenotype.” (GIRES, 2009:3) Again, the guidelines presume

the trans person to be identifying as male or female and that they would also

require medical assistance to live adequately in this ‘role.’ What then of gender

ambiguous trans people requiring or desiring surgery and/or hormones to facilitate

their feelings of gender dysphoria? The guidelines fail to take non-binary trans

people into consideration and presume all dysphoria must equate to a desire of

transitioning to male or female.

The next section in the guidelines become confusing as it states, “The services

should be flexible and patient-led, taking into account their particular needs and

circumstances. . .

the aim of the treatment services is to achieve lasting personal

comfort with the gender role.” (GIRES, 2009:3) How can a service be flexible when

it denotes how one must feel to legitimately be experiencing ‘gender dysphoria?’

On the one hand it emphasizes the fact that treatment should be ‘patient-led’

implying it must accommodate to a patient-centred treatment approach to ensure

each individuals personal needs. This gives a sense that there is some acknowl-

edgement that each case will be dierent to each trans person, but again, failing

to acknowledge how each trans person’s dysphoria and gender identity may not

reflect the rigid definition of what gender dysphoria encompasses since there is no

mention of anything outside of the ‘male’ ‘female’ binary.

In the section marked ‘terminology’ the guidelines illustrate the extent to which

the definition of gender dysphoria and ‘transsexualism’ still utilize gender binaries

to dictate how the trans person will identify. Interestingly, they also acknowledge

the ways in which many of the terms are evolving. “The language used in the fields

of gender dysphoria is constantly evolving as understandings and perceptions of

these conditions change.” (GIRES, 2009:4) If it is understood that perceptions are

changing, why is it not necessarily reflected within the medical terminology?

“A person who is

transitioning. . .

should be addressed according to the name

and title (Mr, Mrs, Miss or Ms).” (GIRES, 2009:4) The guidelines once again only

foresee binary gender titles as applicable to the trans individual. The gender-

neutral title ‘Mx’ of example, has not been included within the guidelines. The

reason why this is important is due to the fact ‘Mx’ has been implemented by

many major organisations and corporations as a legitimate title choice, reflecting

Chapter 3. Medicalizing Trans


a change in attitude regarding gender identity and the freedom and right to express

oneself outside of the binary.

An article taken from polyinpictures online magazine entitled ‘The Growing Use

of ‘Mx’ as a Gender-Inclusive Title in the UK’ (2014) illustrates this by listing

various companies and organizations of which Mx is an accepted or oered title

form. These include the ‘DVLA, DWP, NHS, HMRC, Post O ce Ltd, and most

of the major banks including Barclays, HSBC, RBS Santander, Halifax and Co-

Op.’ (polyinpictures, 2014, online article) It is puzzling therefore, that in-depth

guidelines set about to educate and inform medical professionals and organizations

regarding treatment of trans people do not encompass this. If the guidelines state

that the terminology is evolving, then this should be reflected within the literature.

Other aspects of terminology evolving in regards to understandings of Trans and

gender identities is in the teachings of Transgender issues, as illustrated in Laurel

Westbrook’s ‘Becoming Knowably Gendered.’ Westbrook comments, “In challeng-

ing dominant understandings of gender, teaching transgender articles promote an

idea of gender as a ‘continuum’ as ‘diverse’ and as ‘fluid.’ These understandings

explicitly argue against a belief that the world is comprised of two mutually ex-

clusive genders.” (Westbrook, 2008:49) It is interesting to see that in teaching

transgender articles, it promotes the ideology that there are more than two binary

genders, since much of the information based on medical knowledge of transgen-

dered people does the opposite.

“Besides challenging current gender norms. These teaching trans-

gender articles dispute dominant understandings of gender by arguing

that all people should be allowed to choose their gender and that gen-

der should not be determined by sex.” (Westbrook, 2008:49)

Westbrook argues that it is the individual who should choose their gender identity,

directly opposing the idea that medical professionals are the ones who get to

dictate an individuals gender identity or a Transgender person’s status by way of

legitimizing the Trans status based on a diagnosis of ‘gender dysphoria.’

In Holly Boswell’s ‘The Transgender Alternative’ she states,

“Many confuse sex with gender. Sex is biological, gender is psy-

cho/social. If biology does not truly dictate gender or personality,

Chapter 3. Medicalizing Trans


then dichotomies of masculinity and feminity may only serve to coerce

or restrict the potential variety of ways of being human.” (Boswell,


Boswell is essentially implying that masculinity and femininity do not represent

or coincide with either gender identity, and are in fact social constructs that work

against a notion of gender fluidity.

The guidelines go on to state, “It is important to note that many people. After

receiving the appropriate medical care do not identify as trans, but simply as ‘men’

and ‘women.’” (GIRES, 2009:4) The concept of trans people ‘simply’ identifying

as men or women give a notion of normalization, and the implementation of the

word ‘simply’ implies that identifying in this way is a far less complex identity

than it is to identify as transgender. Remove the ‘trans’ status and underneath

they are just regular men and women like everyone else. By stating that Trans

people identify in this way ‘after receiving the appropriate medical care’ suggests

that trans people could only really identify as ‘men’ or ‘women’ post surgery or


When a trans person discounts their trans identity, this is what is known within

literature and trans communities as living in ‘stealth.’ Opinions on ‘stealth’ vary

drastically with some advocates of trans people denouncing it as having negative

consequences on the community. An article in The Transadvocate for example,

stated how it is only when transpeople are out and open about their gender iden-

tity, that change within societal opinion and policy happen.

“. . .

Only being out

and proud of being trans has led to the major gains we’ve made in the public

policy realm the last few years.” (Roberts, 2013)

Roberts argues that being stealth perpetuates the narrative of trans people being

forced to hide their trans identity, arguably associating being transgender with an

innate sense of shame.

“How are they helping the trans community by NOT being out at

the two large gay inclusive organisations? They will be more concerned

about hiding their trans status at all costs than being fierce advocates

for our community alongside these organisations.” (Roberts, 2013)

Chapter 3. Medicalizing Trans


This statement is in regards to the 6 alleged stealth trans people working at

HRC and GLAAD. It could be argued that social and medical reinforcements

on acceptable gender identities have an impact on a trans person’s willingness to

disclose certain information about themselves.

Another way of interpreting this is by looking at it from a perspective of ‘Nat-

uralizing’ Transgendered people, and instead of considering being transgendered

outside of the normative, understanding it as something that has merely been

considered as such by years of social conditioning. Laurel Westbrook discusses

this idea by looking into Transgender articles that address issues of ‘Naturalising’


“Through their tone and formatting, as well as explicit claims that

transgender practices come from nature, these teaching transgender

articles naturalise the concept of

‘transgender’. . .

Authors frequently

argue that transgender is natural and biological. For example, Holly

Boswell writes ‘It is our culture that has brainwashed us and our fam-

ilies and friends, who might otherwise be able to love us and embrace

our diversity as desirable and natural – something to be celebrated.’

(Westbrook, 1991:31)”

For Boswell, it is culture and society that has made transgender identity or gender

ambiguity ‘abnormal’ as opposed to the identity itself, which she states is ‘natu-

ral.’ It could be argued, that medical diagnosis of ‘Gender Dysphoria’ and medical

literature have also contributed to an ideology of Transgendered people not nec-

essarily fitting in with the norm. It is also important to note, that for those Trans

people who do not identify into either binary gender, fail to have the opportunity

to be granted ‘normalisation’ due to the fact that their identity is not considered


Chapter 4

Legitimizing Trans Identities

  • 4.1 Gender Recognition Act and Acceptable vs. Unacceptable Trans Identities

This section will be focusing on what kinds of trans people qualify for legal citi-

zenship and are recognized within the legal system and society and importantly-

those who don’t. It will also look into legislative changes such as the Gender

Recognition Act (2005) and whether this has been beneficial for trans people and

if not, why, and if it has been beneficial- for who? To aid the discussion I will

be focusing on Sally Hines ‘Transforming Gender: Social change and Transgender

Citizenship.’ (2006)

The Gender Recognition Act came into force in April 2005 allowing trans people

to ‘become the acquired gender’ by way of applying for a Gender Recognition Cer-

tificate that had to be approved by a Gender Recognition Panel. The Certificate

would allow the trans person to have their birth certificate and passport altered

so that the gender would match their ‘lived’ gender. In Sheila McLean’s ‘First Do

No Harm’ (2013) she comments that the acquiring of a GRC is:

“. . .

Subject to certain expectations.” (Mclean, 2013:563) “The ap-

plicant (must have) have gender dysphoria, has lived in the acquired

gender for at least two years, and intends to continue to do so for the

rest of his or her life. As such, the Panel’s decision is one of fact rather

than judgment.” (McLean, 2013:563)


Chapter 4. Legitimizing Trans Identities


McLean highlights the fact that the GRC can only be obtained by fulfilling certain

quotas such as the diagnosis of gender dysphoria, and ‘living in role’ for two years.

As previously established, the quota needed to fulfill a diagnosis of gender dyspho-

ria rests quite firmly on a notion of identifying oneself ‘male’ or ‘female’ that diers

from biological sex. This would make it increasingly di cult for a trans person

who does not identify within a binary to be eligible for a Gender Recognition Cer-

tificate. But why does this matter? It matters because the GRA was considered a

shift in changing attitudes towards transgender people and in encompassing them

as legal citizens as illustrated by Sally Hines. (2013)

Hines commented that the Gender Recognition Act ‘represented the civil recogni-

tion of gender transition’ and marked ‘an important change in attitudes towards

transgender people.’ (Hines. S, 2013:2)

This specific change in attitudes was in reference to the fact the legislation no

longer required surgical intervention as a requirement to obtain a GRC. Hines

states that this

“. . .

brings a new framework for understand sex and gender, and

the relationship between these concepts.” (Hines, 2013:2)

Whilst it is positive that shifts in understandings of gender and sex have progressed

so far as to not dictate gender via genitalia, in her paper ‘Transforming Gender,’

Hines argues that the GRA is still rooted in medicalised ways of thinking that

marginalize practices of gender diversity. (Hines. S, 2007:1) In other words- the

GRA still limits what is acceptable and legitimized gender diversity and what isn’t.

“Normative binary understandings of gender underpin recent social and legislative

shifts.” (Hines, 2007:1)

This is evident in the fact the GRA only accommodates those trans people looking

to change the gender on their birth certificate from M to F or vice versa, and the

right to marry in their ‘new’ gender.

One of Hines’ interviewees ‘Christie’ highlighted the fact that the rights the GRA

granted were not extended to non-gendered people commenting,

“I could only successfully apply for gender recognition if I were to

identify within the gendered societal

construct. . . .

The law does not

recognize human existence outside the gendered societal structure.”

(Hines, 2010:100)

Chapter 4. Legitimizing Trans Identities


The legislation only serves those trans people who have the desire to change from

one binary gender marker to the other.

In Stephen Whittle and Taryn Witten’s ‘The greying of Transgender and the

Law,’ they discuss these exact issues in relation to the GRA commenting, “It is

both medically incorrect and ethically wrong to assume that trans people’s needs

only relate to gender reassignment therapies and surgeries.” (Whittle, Witten,

2004:511) This acknowledges the fact that the needs of Trans people go beyond

medical intervention. Whittle and Witten highlight the fact that the pathologising

of Trans bodies can be extremely damaging to individuals.

This is illustrated in the case of Trans man ‘James’ who at 71 and with early

stages of alzheima’s was placed within a local authority where every other client

was female. (Whittle, Witten, 2004:513)

“The staat the care home were very uncomfortable with meeting his bodily

needs and were very unhappy with his constant removal of his incontinence pads.”

(Whittle, Witten 2004:513) Incidentally, James had undergone chest reconstruc-

tion surgery, but not genital surgery. A local volunteer contacted a support group

after discovering James very distressed. A Trans man met up with James to dis-

cover he was very distressed with the use of incontinence pads used, and regarded

them as ‘women’s aids.’ (Whittle, Witten, 2004:513) After a threat to invoke Dis-

ability Discrimination James was eventually moved into a Men’s home and became

much happier. Whittle and Witten comment,

“The Western biomedical healthcare sustem, with few exceptions,

pathologises trans-behaviours and intersexed bodies – ‘right mind/right

body vs. wrong mind/right body or right mind/ambiguous

body. .


‘Trans’ is invisibilised as well as pathologised, through a classification

of mental pathology.” (Whittle, Witten, 2004:513-514)

The emphasis on ‘marriage’ highlights an idea of acceptability that is rooted in

heteronormative ideals, such as marriage and binary gender. Hines comments,

“. . .

Notions of citizenship are heterosexualised, such boundaries of tolerance de-

pend upon rights based claims (such as the right to marry) which fit with a het-

erosexual model of the ‘good citizen.’” (Hines, 2007:7) It could be argued that the

same can be applied to notions of ‘acceptable trans person’ vs. ‘unacceptable.’

For example; a binary identifying trans person vs. non-binary trans person. Hines

Chapter 4. Legitimizing Trans Identities


utilizes the fight for lesbian and gay rights as an example of the way articulating

the rights of lesbian and gays through the concept of ‘citizenship.’ (Hines, 2007:7)

In Michael Warner’s ‘The trouble with Normal,’ he comments that “Marriage, in

short, would make for good gays – the kind who would not challenge the norms

of straight culture, who would not flaunt sexuality, and who would not insist on

living dierently from ordinary folk.” (Warner, 2000:113)

Warner makes an important point; the concept of ‘not living dierently’ from

‘ordinary folk.’ This notion could definitely be applied to Transgender people in

the sense that those who comply with medical transition in order to present as a

binary gender are ‘ordinary folk’ compared to those who don’t.

Warner goes on to illustrate the fact that marriage is not just about two people

taking a vow; marriage is much more to do with having that relationship acknowl-

edged by the state. (On this occasion, those marriage privileges tied to marriage in

the United States.) “Let us begin with the menu of privileges directly tied by the

state to marriage. Marriage is nothing if not a program for privilege.” (Warner,


Warner mentions how marriage as a social institution is constructed and the stereo-

typical ideologies surrounding marriage are perpetuated,

“. . .

Advocates of gay marriage assume that marriage as a social

institution is, in the words of Bishop John Shelby Spong, ‘marked by

integrity and caring

and. . .

filled with grace and beauty’; that it will

modify ‘behaviour’ (that) is desperately in need of virtue.” (Warner,


Essentially, Warner implies that advocates of gay marriage believe aording mar-

riage to gay people will, in a sense – ‘normalize’ them and eradicate the idea of ‘bad

queers.’ Marriage will allow gays to be accepted within heteronormative society

by following the alleged sanctity of marriage.

The idea of acceptable vs. unacceptable in regards to alternative sexual identities

can also be noted in Kath Browne’s ‘Geographies of Sexualities,’ in which it is

argued that success if granted by the state always lead to negotiations and a

‘burden of compromise’ that results in an agreed to “acceptable’ mode of being a

sexual citizen.” (Browne K, 2007:162)

Chapter 4. Legitimizing Trans Identities


“State and gay and lesbian acceptance of certain forms of homo-

sexuality – forms of ‘homonormativity’ – reflect forms of discipline and

constraint that eectively close ospaces that support various forms

of alternative ‘erotic citizenship’ (Bell and Binnie 2000:19) Alternative

sexual practices and identities are pushed into the private and invisible

sphere, causing a division between ‘good gays’ and (disreputable) ‘bad

queers.’” (Browne. K, 2007:162)

If we can come to an understanding that those minority groups who follow the

heternormative ideal tend to fare better within state protection and acceptance,

then the same argument could be applied to transgender people. Specifically those

who do not fit in with social ‘normative’ gender roles.

  • 4.2 Medical Treatment Narratives and Gendered Citizenship

This section will look into the medical narratives a Trans person must usually fol-

low in order to be seen as a legitimate case for medical intervention and treatment.

I will also be looking into the ways Trans people are aorded Citizenship by look-

ing into the concept of what is seen as ‘acceptable’ and ‘unacceptable’ in regards

to identities that are situated outside the norm, and the pattern of acceptability

one must follow in order to attain citizenship.

Hines comments that,

“. .

.Whilst some new forms of trans femininities and mas-

culinities are benefitting from recent policy developments, other experiences and

practices of gender transformation remain marginalized.” (Hines, 2007:2)

It could be argued, that there is a real lack of research on the topic of marginalized

trans people due to a lack of representation and acknowledgement of these trans

people’s existence. In many cases, a non-binary trans person will follow a medical

narrative of a binary trans person purely in order to move through the healthcare

system. Providing these trans people identify as one binary gender or the other

and present themselves in a satisfactory way that proves they can conform to a

specific ‘gender role,’ they are able to fulfill the medical professionals expectations

and thus receive access to medical care and access to certain legislation and rights

to citizenship. Other trans people are excluded because they do not conform to

Chapter 4. Legitimizing Trans Identities


the rules set out by the heteronormative state.

This idea is illustrated in Zowie Davy’s ‘Transsexual Agents’ (2010) in which

she interviewed various self-defining Trans people and their experiences within

the health care system. One such participant named Benjamin responding when

asked about the positives from the NHS stated, “The positives are only that you

get what you need from. The negatives

were. . .

very generalized and out of date

questioning which resulted in standard answers.” (Benjamin, transman from Davy.

Z, 2010:115)

Davy states that this response follows a ‘standard narrative,’ (Davy, 2010:115)

and the responses are therefore not truthful accounts of the trans person’s iden-

tity per se, but rather obligatory responses rooted in preconceived knowledge of

what requirements are necessary to access medical care.

“As with the majority of participants in this

research. . .

Benjamin understood

that taxonomic legitimacy and a diagnosis are required to actualize transforma-

tion of (his) body.” (Davy, 2010:115, my emphasis) Davy highlights the fact that

Benjamin had prior knowledge that the ‘condition’ (in medical terms) of “Trans-

sexualism” (Davy, 2010) had to be legitimized by a medical professional, and

subsequently persuading the gatekeeper to allow for access to the treatment.

“Most participants demanded medical services even though some

were skeptical about the psychiatric process within the NHS. The pro-

cesses involved in persuading their psychiatrist (gatekeeper) that they

were legitimate candidates for hormonal and surgical intervention were

viewed as

ritualistic. . .

” (Davy, 2010:11)

The concept of medical Transition as ‘ritualistic’ is a notion suggested in Whitney

Barnes paper ‘The Medicalization of Transgenderism.’ Barnes states that Trans

people are fully aware of the procedures that need to be followed and are not

‘passive agents in the medicalization of their existence.’ (Barnes, 2001)

“The evidence that transgendered individuals find it necessary to

circumvent the rules governing their access to legitimate and adequate

health care, often through means of dishonesty and/or embellishments

brings one to question the very existence of those regulations they must

work within and against. Any institutional structure which causes

Chapter 4. Legitimizing Trans Identities


people to provide their health care providers with less than entirely

honest information is subject to scrutiny.” (Barnes, 2001)

Here, Barnes criticizes the medical institution by suggesting that the rules that

are put in place to decide who gets access to healthcare and who doesn’t forces

Trans people to lie and give dishonest accounts in order to receive the healthcare

they need. This is not a negative reflection on the Trans person, but a reflection

of the rigid regulations set out by the medical professionals.

This is a notion reflected by Scholars such as Califia and Namaste, who suggest

that, “Transgendered people read what psychiatrists write about

them. . .

so that

they can enter the clinical setting, present the ‘classic’ transsexual narrative, and

receive the health care and medical technology they desire.” (Califia, 1997:192)

And that “The gender community has at this point accumulated a lot of folk

wisdom about what you need to tell the doctors to get admitted to a gender-

reassignment program.” (Califa, 1997:224)

The idea of medical professionals acting as ‘Gatekeepers’ for treatment and the

pathologised treatment of Trans individuals is also reflected in Juliet Jacques ar-

ticle published in The Guardian (2010) in which she documents her experiences

as a Transgender patient of the NHS going through gender transition.

Jacques comments,

“’Charing Cross’ (London’s Gender Clinic) – struggles to shake a

reputation for being cold and overly demanding. This is not always di-

minished by the experiences posted online by patients, some of whom

have reservations about gender services being pathologised under men-

tal health.” (Jacques, my emphasis, 2010)

Jacques addresses the issue that the gender clinic has a ‘reputation,’ arguably fu-

elled by online discourse of people’s experiences at the clinic who are dissatisfied

with the pathologised approach of treatment and services.

Jacques comments, “If you arrive prepared to work with the clinicians, you shouldn’t

have many

problems. . .

I had plenty going for

me. . .

having changed my name

and begun living ‘in role.’” (Jacques, 2010) Here, Jacques illustrates the ways

in which it is possible to get through the system more e ciently providing you

work ‘with’ the clinicians. She mentions having changed her name and lived in

Chapter 4. Legitimizing Trans Identities


her desired gender role, implying these are factors taken into consideration by the

Gender Clinic.

What exactly is meant by ‘living in role?’ (Sometimes called Real Life Experi-

ence) In a document taken from Ontario Human Rights Comission (OHRC, 2014)

entitled ‘Medicalisation of Identity,’ it discusses the issue of ‘real life experience’

(or living ‘in role’) and the problems this can encompass.

“The real life experience requires the pre-operative individual to

‘live’ in their felt gender for a prolonged period of about one to two

years. . .

There is significant controversy within the transgendered

community about ‘RLE’ and its medical necessity. One individual

with a medical background stated that RLE does not provide useful

information to the

patient. . .

it is rather a period of compliance with

a rigid set of criteria.” (OHRC, 2014)

This is an important point, as it addresses the fact that ‘living in role’ does not

serve to inform the Transgendered person about what should be expected in ‘sex

reassignment’ or indeed any kind of medical intervention that Trans person may

choose to undertake, but instead is merely a medical requirement one must comply

with in order to gain medical services.

Concepts of ‘living in role’ and ‘real life experience’ also bring about the concept

of ‘Passing.’ According to Lori Girshick (2009)

“The word as it is used today generally refers to fitting into the

gender binary as a man or a woman. In order to pass in this sense

it is not enough to be who you are – you have to alter your gender

appearance and behaviors to fit notions of masculinity and femininity.”

(Girshick, 2009:108)

Girshick highlights the fact that to pass within society means living up to soci-

ety’s expectations of male and female. Leslie Feinberg stated that Passing was

a ‘product of oppression,’ (Feinberg, 1996:89) whilst Kate Bornstein comments

that “Passing becomes silence. Passing becomes invisibility. Passing becomes lies.

Passing becomes self-denial.” (Bornstein, 1994:125)

Chapter 4. Legitimizing Trans Identities


However, what is failing to be acknowledged is the way in which ‘Passing’ can

also prove extremely positive for the Trans person by way of having their gender

identity taken seriously within society, and also furthering their chances for medical


In Josephine Ho’s ‘Transgender body/subject formations in Taiwan’ (2006) she

explores the ways in which ‘passing’ often allows for easier integration within

society for the Trans person.

“. . .

The concept of ‘passing – along with its connotations of decep-

tion – entails profound knowledge/power maneuvers for Trans subjects.

For passing presupposes the unchallengeable ‘naturalness’ and ‘truth-

fulness’ or ‘evidentially’ of the physical body, and a rms the meaning

and status assigned to such a body by the social culture.” (Ho. J,


Ho suggests that passing as their chosen gender grants acceptability and status of

the Trans person within the society in which they move.

“The operation of such as truth regime thus serves to reduce/stig-

matize the trans subjects’ bodily self realization as nothing but scams

and deceit, not to mention creating a profound sense of shame and

insecurity in the subjects in regard to the clear discrepancy between

one’s body and one’s chosen identity.” (Ho, 2006:230)

Ho argues that the negative connotations and criticisms of ‘passing’ encourage the

idea that a Trans person’s body (post surgery) and the living in role of that gender

identity or ‘passing’ is nothing more than a ‘scam.’

Ho suggests that bodies are not given, fixed materials and instead comments that

they are physical embodiments of the self (Ho, 2006:230).

“Trans subjects dier from other subjects only in that they have formed a very

dierent feeling of ‘at-homeness’ as their endowed body completely fails to provide

that feeling.” (Ho, 2006:230-231)

It could be argued that a Trans person’s body post surgery or hormones is no

dierent from any other gendered individual and is not an attempt at ‘passing’ as

one specific gender or another. The need for medical intervention is separate from

Chapter 4. Legitimizing Trans Identities


the need to be ‘accepted’ within society,’ and is merely a way of feeling ‘at home’

within a body. However, Ho’s paper mainly focuses on those Trans people who

wish to ‘Pass’ within society and she fails to address issues of gender ambiguity

within the Trans community in which her paper is based.

Concepts of medical intervention and Trans Bodies have always been a topic of

debate and disagreement between medical professionals and Trans people them-


In Alison Rooke’s ‘Telling Trans Stories,’ (2008) she brings together a paper in

which both Medical Professionals and Transgendered people are able to put their

opinions on medical services and the treatment of Trans bodies together in the

same forum. Rooke focuses on the ‘Scidentity Project’ which was a workshop/-

panel discussion bringing together academics, arts practitioners, medical profes-

sionals and a group of 18 young transgendered and transsexual people between the

ages of 15-22 who were ‘living their sex and gender with a degree of complexity.’

(Rooke, 2008:65)

By bringing together both medical professionals and Transgender people and al-

lowing a dialogue to initiate between the two parties, it allows the Trans person

to voice their experiences. Rooke suggests that their trans identity may allow for

a more complex understanding of sex and gender that say – a medical professional

would not have. In light of this, it brings about the question, who has the right

to diagnose? If we separate gender dysphoria from a medical definition and un-

derstand it as more of an identity that is individual to each person as opposed to

a medical condition – who holds the right to give the go ahead for surgery over

someone else’s body?

Rooke comments,

“. . .

Young trans people could form their questions, explore, deepen

and express their understandings of gender and sex, interrogate scien-

tific discourses of sex, gender and transsexuality and respond to the

‘authority’ and apparent certainties of

science. . .

” (Rooke, 2008:65)

By using the term ‘interrogate’ Rooke suggests that the trans people in the project

may disagree or have issues with the scientific discourses of ‘Transsexuality’ –

subsequently utilizing their own experiences to directly challenge the medical dis-

course. Placing the word ‘authority’ in quotations also suggests that Rooke has

Chapter 4. Legitimizing Trans Identities


her own doubts on the authoritarian stance placed on medical discourses.

The two phases of the project featured a creative engagement, and outreach work-

shops aimed at a variety of audiences such as teachers, youth workers, activists

etc. The workshops served to inform and educate those who worked in the private

sector so they would be better equipped in dealing with trans youth.

“There was space where the participants could relate with other young trans peo-

ple and explore their own identities through the relations with others.” (Rooke,

2008:66) Rooke outlines the fact that the creative segment was made interactive

in the hope that non trans participants would be better able to understand gen-

der non conformity, by finding and relating to similarities through the stories and

experiences of trans people.

This implies that it is possible to educate and inform cis-gendered people (non

trans people) of gender ambiguity and gender variance through Trans narratives.

It also brings medical definitions of what it is to be Transgender/Transsexual un-

der scrutiny and medicalization of Trans people into question. How can one truly

comprehend and define what makes a legitimate trans person unless they have

experienced the feelings of ‘trans-ness’ themselves?

Group discussions allowed transpeople to discuss their experiences, worries and

feelings about their identity in a safe space. The presence of medical professionals

also gave them the opportunity to challenge the status quo.

“The participants own histories and experiences were transformed through chal-

lenging the authority of the science of sex and gender.” (Rooke, 2008:68)

They developed critiques of the scientific and medical practices that reproduce the

coherence of sex and gender in the figure of the ‘man’ or ‘woman.’

We could argue that the practice of telling trans stories and narrative means the

medical professional will hear the trans person’s individual experience and own

relationship with their gender identity as opposed to basing treatment of all trans

people on one specific protocol or structure according to medical guidelines.

If all trans people are not the same, then the treatment model to which they are

ascribed should not be the same for all trans people.

One Trans participant in the project named Shannon brings up quite an important

point regarding cosmetic surgery.

“To get your tits enlarged you need money, but to get them cut o

you need a gender shrink. That’s bloody weird!

. . .

.Why is one more

Chapter 4. Legitimizing Trans Identities


of a problem for society than the other? Why does society require that

we have an either/or gender?” (Rooke, 2008:69)

Shannon makes and extremely valid point. If one experiences body/gender dyspho-

ria, why does the desire for a specific body modification surgery require someone

to jump through medical and gender binary hoops in order to access one specific

type of surgery.

Chapter 5


“Bell and Binnie propose ‘queering’ citizenship to acknowledge and

celebrate the ways in which normative practices and arrangements (e.g.

non monogamy) challenge the institution of heterosexuality and tradi-

tional conceptualizations of citizenship.” (Hines, 2007:7)

It could be argued that if ‘queering’ citizenship can challenge normative ideology

of the regulations one must follow in order to be accepted as a legitimate citizen,

there is space to ‘queer’ gender in the same way, so that those who do not fulfill

the correct regulations of ‘gender ambiguity’ as set out by heteronormative ideals

and medical practitioners may too be accepted.

Can citizenship be Gender Neutral? This is a question posed by Mark Rix.

Rix looks into social citizenship and asks whether it’s possible to have gender-

neutral citizenship incorporated into the citizenship system when it has long been

‘burdened’ with the issues of gender inequality. (Rix, 2006:1)

Rix suggests that because legal citizenship focuses on the idea that ‘all citizens are

equal before the law’ it is able to escape the gender inequality embedded within

social citizenship. (Rix, 2006:1) This, Rix argues – is due to social citizenship’s

focus on ‘paid employment’ as an eligibility requirement to the public sphere and

the rights of cizenship. “This meant that womens traditional roles of child bearer,

caregiver and homemaker were usually regarded as being inconsistent with social

citizenship and full participation in the public sphere.” (Rix, 2006:1)

From the outset Rix paints a picture of citizenship being fully grounded in ide-

ologies of binary gender and traditional gender roles based around inequalities of


Chapter 5. Citizenship


citizenship through ‘gendered work.’

This is an important point, because it reinstates a notion of citizenship encom-

passing binary gender, reinforcing the fact that non-binary gendered people may

not be valid candidates for this specific citizenship model.

But it can be done. Germany is the first country in Europe to legally recognize a

third gender, while several other nations have already taken similar steps. (BBC

News, 2013) German passports now have a third designation ‘X’ for intersex hold-

ers. Allowing legal recognition of its intersex citizens is a huge first step. For

one, it acknowledges the existence of a third gender, and also indirectly acts as a

deterrent for any social and medical ideas revolving around ‘corrective’ surgeries

and the need to make an individual one gender or the other. It encompasses a

gender identity that it previously denied existed.

Silvan Agius of IGLA-Europe which campaigns for the rights of LGBTI people

said the law needed to go further. “While on the one hand it has provided a

lot of visibility about intersex

issues. . .

it does not address the surgeries and the

medicalization of intersex people and that’s not good. That has to change.” (BBC

News, 2013)

Silvan highlights the important issue that although a third gender option is avail-

able, the issues of medicalization still exist and are failing to be addressed. Could

it be argued that gender-variant bodies are so heavily associated with medical

interventions and surgeries, that it is hard to separate the two even when legal

recognition and citizenship is granted?

Another aspect of citizenship, specifically when we think of how it is associated

with binary gender is by looking at gender as a system of it’s own, in this case

‘Gender as a system of Oppression.’ (Bornstein, 1994:105) In Kate Bornstein’s

‘Gender Outlaw’ (1994) she looks at binary gender as a form of oppression ‘made

all the more dangerous by the belief that it is an entirely natural state of aairs.’

(Bornstein, 1994:105) By presenting the gender binary as ‘natural’ (I previously

discussed concepts of ‘naturalising trans’) non-binary gender becomes unnatural

and ‘the other.’

Bornstein looks into gender binaries as a system of class and power, and how one

cannot exist (or indeed, oppress) without the other. Bornstein comments,

“In the either/or gender class system that we call male and female,

the structure of one up, one down fulfills the requisite for a power

Chapter 5. Citizenship


imbalance. . .

It’s an arena in which roughly half the people in the

world can have power over the other half. Without the structure of the

bi-polar gender system, the power dynamic between men and women

shatters.” (Bornstein, 1994:107)

Bornstein is essentially stating that the gender binary exists purely to enforce the

oppression of women and ensure that men retain their position as the ‘dominant

class.’ Without gender binaries, there would be no division of power. And without

the division of power, ‘one half’ of the population would not be better othan the


Does the separation of medicalization and gender identity help to eliminate gender

binaries? In what ways, if any, is the move away from medicalization detrimental

to the rights and healthcare of Trans people?

Chapter 6

Issues with the ‘De-Medicalization’ Of Transgendered People

“The demedicalization of transsexualism is a dilemma. There is

a demand for genital surgery, largely as a result of the cultural gen-


imperative. . .

Transsexuals, especially middle-class pre-operative

transsexuals are heavily invested in maintaining their status as ‘dis-

eased’ people. The demedicalization of transsexuality would further

limit surgery in this culture, as it would remove the label of ‘illness’

and so prohibit insurance companies from footing the bill.” (Bornstein,


This section deals with the potential problems that arise from arguments that call

for the moving away from a medicalized view and treatment of Transgender people.

I believe it is important to address this issue as the bulk of this dissertation has

explored the negative aspects of medicalizing trans people without acknowledging

the ways in which Medicalization also protects and allows for the treatment of

Trans people.

Bornstein (1994) highlights the fact that maintaining ‘Transsexualism’ as a med-

ical issue or a ‘disease’ means that Trans people maintain an access to medical

intervention if they need it. They are protected in the sense that with a diagno-

sis comes medical assistance. “Transsexuality is a medicalized phenomenon. The


Chapter 6. Issues with the ‘De-Medicalization’ Of Transgendered People


term was invented by a doctor. The system is perpetuated by doctors.” (Bornstein,


If we are to acknowledge the Transsexual or Trans identity of an individual, we

must acknowledge the term and identity was constructed by medical professionals

utilizing medical terminologies. Subsequently, can it ever be possible to demedi-

calize the Trans person and Transgender identity? Barnes (2001) comments;

“Transgender identity is claimed by the psychiatric community as

a ‘disorder’ or ‘condition.’ These regulatory functions include the ne-

cessity for transsexuals to claim ‘illness’ before being considered for sex

re-assignment hormones and/or surgery. This ‘illness’ is itself trans-

sexuality, and unless one accepts transsexuality as an ‘illness’ and as a

component of their own personality, they will be excluded from most

sex-reassignment programmes.” (Barnes, 2001)

Barnes illustrates the way that a Trans person as a patient seeking medical help

has to conform to the rules and regulations laid out by (in this instance) the ‘psy-

chiatric community’ who have given Transgender identity the label of a disorder

or a condition. To qualify for medical attention and to have their Trans identity

legitimized the Trans individual must accept, whether they feel it is the case or

not – that they have the ‘illness’ of Transsexuality. They must ascribe to the

condition already set in place by the Medical professional which in turn enforces

Transgender identity as a medical ‘condition’ as there is no other choice for the

Trans person if they want to receive treatment.

It could be argued that de-medicalizing Transgender would run the risk of remov-

ing regulations that the medical professional deems ‘necessary’ in order to treat


However many theorists argue that Transsexualism’s place within medicine and

psychiatry will continue for a long time to come (Barnes, 2001) as Barnes com-

ments the two have grown together and become intertwined.

In Janice Raymond’s 1979 publication ‘The Transsexual Empire’ she controver-

sially argues that ‘transsexuals are created through medicine’ and that ‘psychiatric

evaluation as well as the availability of surgery function to produce transsexuals.’

(Namaste, 2000:33) This is a highly problematic statement since it presumes that

one cannot identify or be Transgender without being a post-operative Transper-

son. It implies that one becomes Transgender or ‘Transsexual’ through medical

Chapter 6. Issues with the ‘De-Medicalization’ Of Transgendered People


intervention. In essence, it claims Transgender is not a legitimate gender identity.

Raymond fails to recognize the distinction between biological sex and gender iden-


Barnes (2001) argues that the problem with this concept lies in the medical defini-

tion and terminology surrounding the Trans identity. This definition presupposes

the need for medical intervention.

“. . .

The term ‘transsexual’ mandates some desire to attain attributes

of the ‘opposite sex.’

. .

.Western medicine holds a firm monopoly over

the various possible means with which to achieve those ends.” (Barnes,


In essence, ‘Transsexual’ cannot exist without Medical intervention because Medicine

and Psychiatry created the term.

“It is di cult to imagine that people existing in cultures without

modern Western

medicine. . .

could have conceived of surgically and/or

hormonally altering their sex in the methods now practiced by modern

Western medicine.” (Barnes, 2001)

Arguably, the desire for these changes may have existed, but Barnes does not ad-

dress the fact that these desires and needs for surgical intervention presuppose the

existence of Western medicine. The fact Western medicine began to incorporate

such surgeries and medical options for Trans people must have been born out of a

need for it.

Leslie Feinberg (1998) addresses this point:

“It’s true that the development of anesthesia, and the commercial

synthesis of hormones, opened up new opportunities for sex reassign-

ment. However, the

argument. . .

doesn’t take into account ancient

surgical techniques of sex-change developed in communal societies that

oered more flexible sex and gender choices.” (Feinberg, 1998:105)

Feinberg agrees that advances and development within medical treatment meant

that ‘sex reassignment’ was made further possible by way of surgeries and hor-

mones. However, Feinberg makes the important point that these Western medical

Chapter 6. Issues with the ‘De-Medicalization’ Of Transgendered People


interventions are restrictive and limited since they perpetuate the notion of binary

gender by oering surgery and hormones in order to change ‘from one sex to the

other.’ Feinberg also states that surgical techniques to assist Trans people existed

prior to Western medicine, and in fact accommodated gender fluidity as opposed

to enforcing gender binaries.

“Descriptions of Native American’s fluid perceptions of sex and gender poignantly

illustrate that transgendered individuals accessed recognition of their gender iden-

tities without the aid of modern Western medicine or technology.” (Barnes, 2001)

It could be argued, that because perceptions of gender identity within these com-

munities embraced notions of gender ambiguity (or in the case of tribal communi-

ties within Native American societies - ‘Two-Spirit’ people) (Barnes, 2001) there

was less of a need for ‘sex reassignment’ surgery since fluid gender identities were

accepted without the Western social expectations of fulfilling a specific binary gen-

der quota.

Therefore, we could argue that modern Western social expectations of gender have

an influence on not only the kind of surgeries and medical services a Transgender

person is able to access, but also the kind of surgeries and medical services a Trans

person desires.

At what point does Medicalization of Trans people become beneficial? One major

argument in favour of medicalizing Trans identities is the fact that through medi-

cal terminology and the articulation of ‘Transsexuality’ through medical diagnosis,

comes legislation, rights, and medical implementation in order to accommodate

those who have been diagnosed with the ‘condition.’

One example of how medical diagnosis serves to protect and accommodate Trans

individuals are in cases such as; where a Transgendered person has been incarcer-


Alvin Lee (2008) recounts the incident of Donna Konitzer, a trans woman diag-

nosed with Gender Identity Disorder (GID) incarcerated in Wisconsis until 2026.

“Recognizing their Eighth Amendment obligation to provide in-

mates with

healthcare. . .

Wisconsis prison o cials enacted a policy in

2002 stating that those diagnosed with GID should be given access to

hormone therapy while incarcerated.” (Lee, 2008:448)

Chapter 6. Issues with the ‘De-Medicalization’ Of Transgendered People


In this instance, it is evident that the law ensures Transgender people are able

to access the medical services, in this case the hormones that they require. Iden-

tity is legitimized through the medical definition of Gender Identity Disorder, and

without that definition or diagnosis, there would be no foreseeable reason to allow

medical treatment for the Trans person.

Lee acknowledges the controversy with medicalization and asks, “Does the use of

medical evidence create or perpetuate an image of trans people as mentally dis-

eased. . .

does the use of medical evidence actually do more to harm than help the

trans community?” (Lee, 2008:448)

Whilst it has been established throughout the duration of this paper that medi-

calization retains focus on maintaining binary gender, it also brings about issues

of reinforcing Transgender identity. This is a notion discussed in Mary Burke’s

‘GID and the contested terrain of diagnosis’ (2011)

“Through medicalization and diagnosis in particular, patients are also able to form

collective identities, which foster the creation of support networks and advocacy

groups. . .

institutional recognition, access to services and resource allocation.”

(Burke, 2011:188)

However, as previously discussed in this paper, diagnosis of Gender Identity Dis-

order or Gender Dysphoria - whilst positive in the sense it subsequently opens

gateways to treatments and legislative measures for those successfully diagnosed;

reinstates notions of femininity and masculinity and denies Transgendered people

who ‘do not conform to a particular, narrowly defined set of standards.’ (Burke,


My data collection deals with Trans people’s perceptions and experiences within

the NHS and medical healthcare system, and oers a view of medicalization of

Transgender people from the Trans person’s perspective.

Chapter 7

Independent Study

  • 7.1 Methodology

My research draws upon 1) A qualitative study based on 77 participants who com-

pleted an online survey that asked Four main questions, these included multiple

choice, stating their agreement or disagreement with certain statements and also

the opportunity to add their own input and opinion on certain question topics.

2) Two Skype interviews. I had conducted many more interviews over Skype and

in person, but hadn’t specified that I needed non-binary Transgender people, thus

the majority of my interviewees experiences did not reflect the issues a non-binary

Transgender person faced and had to be omitted. I also had not left enough time

to transcribe the interviews conducted.

  • 7.2 Ethics

My ethics form was approved by Goldsmiths University Of London. The research

has been conducted in a way to prevent any harm to participants. This entails a

full briefing of the research, its purposes and the way in which it will be utilized

so the interviewees can provide fully informed consent to take part. No questions

required the participants to identify themselves and there was no way to trace

participants’ identity so the survey was automatically anonymous. The terms and

conditions are stated on the first page of the survey (see appendix 1) including

advising participants that they must be 18 or over.


Chapter 7. Independent Study


  • 7.3 Online Survey

The survey can be viewed in full at:

The only demographic that was asked was gender identity. I felt that this was the

only demographic relevant to the research since this dissertation focuses on the

complexities of binary gender and I wished to illustrate that in my results.

  • I promoted the survey via Internet links on my own personal Facebook page as well

as multiple Transgender/Gender variant Facebook group pages. I also attended

a Queer club night and made an announcement in regards to my survey to try

and encourage more people to take it. I focused on the Trans community since

the questions would be revolving around their own experiences as a Trans person

dealing with the NHS and medical healthcare professionals.

The survey was constructed online using a web-based survey creator called Sur-

vey Monkey, which was free of charge to use and allows the creator to analyze

the results online. I felt this was the best method of data collection due to it

being anonymous and online-based. I opted for a method I knew would be easily

accessible to people and reach a far higher number.

  • 7.4 Online Survey Results

    • I will firstly address the demographic result regarding the gender identity of par-

ticipants. Question 1 asked: ‘How would you describe your gender identity?’ I

gave a total of 18 dierent gender identities for participants to choose from and

importantly allowed them to tick as many of the options as they felt applied.

There was also the option to add a comment to state their own gender identity if

they felt it wasn’t one of the choices oered. (See appendix 2)

  • I will focus on the most relevant results. 52% of respondents identified with

Transgender, 50% identified with Genderqueer, 31% identified with Trans* and

24% identified as Androgynous. Importantly, only 9% identified as ‘Transsexual,’

which is a term heavily associated with medical terminology and practice.

  • I took into consideration the fact that many of these people may identify them-

selves as gender variant, the results indicate that this is the case. We could argue

that these people hold greater understanding of the issue due to their own per-

sonal experience of gender variant bodies. It also shows just how broad and varied

Transgender people’s gender identities can be.

Chapter 7. Independent Study


Question 2 asked, ‘When consulting a medical professional (GP or Gender Clinic)

about transition, did you have any prior knowledge of the process? (This can be

anything from researching online, to talking with Trans friends)’

Respondents were only able to tick ‘Yes’ ‘No’ or ‘Unsure.’ This question was

posed because I wanted to illustrate the way in which preconceived knowledge or

direct knowledge regarding medical practice has an impact on the way Transgender

people access medical services, specifically the NHS.

A massive 87% of respondents stated that they did have prior knowledge regarding

the process of Transitioning. (see appendix 3) This result is important as it goes

on to show how this knowledge perhaps had an impact on their experience with

the medical professional in later questions.

Question 3 asked respondents to look at statements and decide whether they

agreed or disagreed. Response options were on a sliding scale of ‘Strongly Agree’

to ‘Strongly Disagree.’ (see appendix 4)

The question posed was: ”During my appointments with the medical professional

  • I ” ...

followed by nine dierent statements applicable to experiences within the

NHS/medical care as a Trans person.

83% of respondents Strongly agreed or agreed that they ‘felt like they had to

present a certain way (i.e. binary gendered) to be taken seriously,’ and 80%

Agreed or Strongly Agreed that they ‘Knew that if they acted a certain way they

would get treated more promptly.’

These two finding are of key importance as it reflects a notion of having to le-

gitimize ones Transgender self in a binary gender in the presence of medical pro-

fessionals. It is also important to acknowledge the fact that the majority of the

Survey participants already had prior knowledge of the way the medical system

worked in order to treat Transgender people and that this must have been a factor

in the way they prepared for appointments.

80% of respondents Agreed or Strongly Agreed that they ‘Felt they had to prove

their Trans identity.’ It could be argued that this pressure to ‘prove their Trans

identity’ is a major factor in the way Trans patients approach and deal with their

appointments with the medical professional.

76% of respondents Agreed or Strongly Agreed that they ‘left out certain aspects

of their history/lifestyle when talking to the medical professional.’ It could be

argued that this supports Barnes (2001) comment that institutional structures

cause people to provide their health care providers with less than entirely honest

Chapter 7. Independent Study


information should be ‘subject to scrutiny.’ (2001)

78% Agreed or Strongly Agreed that there was a ‘specific Trans Narrative they

could follow in order to get treated more e ciently.’ This supports the notion

that Transgendered people have an understanding the medical healthcare system

and realize that by following a ‘narrative,’ it is easier to access treatment. A

majority of 54% Agreed or Strongly agreed that they ‘Acted in a more masculine or

feminine way during appointments,’ arguably reflecting the way gender stereotypes

and expectations of gender dysphoria by the medical professional perhaps enforce

binary gender presentation.

Question 4 asked: ‘How do you think the NHS/Healthcare could be more accom-

modating towards non-binary gendered Trans people?’ (See appendix 5)

This was another multiple-choice question where participants were advised to tick

as many answers they felt applied, there were 13 options as well as an ‘other’ box

where participants could add their own response.

I asked this question because I felt it was important to gain insight and feedback

from Trans people of whom had experienced being treated by the NHS.

Over 80% of respondents ticked the following options, ‘Encompassing non-binary

gender identities on the ”gender dysphoria” spectrum,’ ‘Providing Nurses/GP’s

/Doctors/Psychiatrists with updated information on gender identity and Trans

people,’ ‘Oering treatment to non-binary individuals,’ ‘Updating medical termi-

nologies/information on Transgender people to include non-binary individuals,’

and ‘Updating language used within medical establishments/databases to encom-

pass gender neutral pronouns and gender ambiguity.’ These were the most popular

response choices and interestingly, they all incorporate a notion of better medical

services and acknowledgement of non-binary Trans people.

This reflects that the majority of participants held an understanding that non-

binary Trans people are failing to be accommodated by the healthcare system,

and hold a desire to see more done in order to accommodate them.

Over 70% of participants agreed with: ‘Treating Trans patients on a case by case

basis,’ and ‘Moving away from the ’Trapped in wrong body’ medical narrative.’

This implies that Trans people wish to have less of a medicalized emphasis on

their treatment and desire a move away from the traditional ‘medical narratives.’

69% of participants agreed that ‘Surgery should be oered without having to be

on hormones.’ This too deviates from the medical requirement and treatment

narrative of having to be on hormones before surgery and would subsequently

Chapter 7. Independent Study


accommodate those Trans people who did not feel they needed or wanted to begin

hormone treatment.

A minority of 42% agreed with ‘Looking at treatment for Trans people as more of

a need for ‘comfort’ as opposed to medical intervention.’ In the ‘Other’ response,

one participant stated,

“While I agree with the de-pathologisation of Trans people, I think

it’s still important to recognize that care pathways are commissioned

on medical terms. If chest reconstruction doesn’t fall under a medical

pathway specific to the ’treatment’ of gender dysphoria, then it be-

comes perceived as a purely elective cosmetic surgery, and then there’s

a danger that that care could be taken away from people who really

need it and can’t aord private treatment.” (Anonymous, 2014, see

appendix 5.1)

This participant re-iterates the fact that whilst it is positive to resist the pathol-

ogization of Trans bodies – if surgery and medical intervention is reduced to ‘cos-

metic’ needs, then it will no longer be covered by health services. This would put

those Trans people who desire medical transition and cannot aord it, at risk.

The final question was another multiple choice where participants could tick as

many statements they agreed with and asked ‘How do you think the Governmen-

t/Society could accommodate non-gendered people?’ (See appendix 6)

Over 90% agreed that ‘there should be better education on non-binary gender iden-

tities and dierences between sex and gender identity in schools and the workplace.’

Over 90% also agreed that there ‘should be acknowledgement and the oering of

gender-neutral titles and pronouns in all application forms (such as ‘Mx’). This

shows that the vast majority of Trans people would like to see the option of gender-

neutral inclusivity in documentation. It also highlights the desire to have better

information within education system and the work place in regards to Trans and

non-binary gender identities, suggesting that the information out there already is

potentially inadequate and outdated. Or that it does not represent non-binary

gendered people.

Chapter 7. Independent Study


Over 80% of respondents agreed to ‘Allowing citizens to self-define as gender-

neutral/third gender without a medical diagnosis.’ This is important as it illus-

trates the belief that Gender Identity shouldn’t necessarily need a medical diagno-

sis in order to legitimize ones Trans status. It also reinstates the fact that people

should be able to self-define as third gender (not just ‘male’ or ‘female’)

  • 7.5 Skype Interviews

The Skype interviews were conducted via Skype text chat. The two interviews

utilized in my research were conducted utilizing the text chat method as this

made the transcribing far easier. The Skype interviewees were also informed of

the terms and conditions prior to the interview and had to state ‘I Agree’ to signify

they had understood the terms of the interview and that their responses would

be utilized in my dissertation. (see appendix 7) All names have been altered to

protect anonymity.

All quotes taken from the interviews have been directly cited from the Skype text

chat interviews. The full transcription from which the interviews are quoted can

be located in appendix part II.

In order for me to be reflexive it is important to recognize that my own gender

identity is similarly aligned with those whom I am studying; I am also a trans

person highly active within LGBT issues. This in itself enabled me to gain access

to a potentially hard to reach social network of people. By using my own identity

to gain participants in this research through social capital it has enabled me to

access my sample more easily and I acknowledge this fact.

  • 7.6 Skype Interview Results

My two interviews were conducted using Skype’s online Text Chat feature. The

interviews followed a very loose structure of 9 preset questions (See appendix 8)

based around the interviewee’s gender identity and experiences as a non-binary

Trans person with the healthcare system. However due to the nature of inter-

views, topics would occasionally branch ointo more personalized areas of the

participants life and experience and my questioning would subsequently reflect


Chapter 7. Independent Study


My first interviewee was a 27-year-old non-binary Trans identified person named

‘Edward.’ I will utilize male pronouns, as these are what Edward had requested.

Edward explained his understanding of the term ‘Transgender’ to me,

“I think transgender is a really complicated term that can mean

really dierent things to dierent people I found out about the term


pretty late, only really properly in my last year of my undergrad degree

from what I can remember. So it was through academic texts and

through a course on feminism.”(Edward, 2014)

Edward’s understanding of the term hadn’t been influenced by medical ideologies

of Transgender(ism) and had instead he had come to an understanding of Trans

identity through Trans literature and academia – and also through feminism.

It could be argued that learning about the term in this context may have helped

in understanding Trans identity in a more varied spectrum than if he had learnt

about Trans identities through medical discourse that tend to utilize more narrow

and binary definitions.

When asked about his experiences with the NHS, Edward emphasized that he

didn’t feel like what he was doing was Transitioning, “



away I don’t feel

like I fit what the NHS system would want me to say to them.” (Edward, 2014)

Edward noted that some of the things he had heard through other Trans friends of

whom had been through the NHS system that had made him apprehensive about

appointments at the (in this instance) Charing Cross Gender clinic,

“I had heard complete horror stories about gender policing, about

trans women who weren’t taken seriously because they turned up to

appointments wearing trousers. I knew about the requirement to take

T (testosterone) and the phrasing used such as ’living in role’. Basically

I knew a lot of people who were way more binary identified than me,

who already were getting a hard time from doctors.” (Edward, 2014,

my emphasis)

Here, Edward illustrates how more binary identified people had experienced neg-

ative issues with medical professionals, and this subsequently led him to believe

that he too would be given a hard time as a non-binary identifying individual.

Chapter 7. Independent Study


“I felt I had to lie because I didn’t trust them to be able to help

me if I was honest with them. I started to see it more as ’what do I

want and how can I get that’.’ (Edward, 2014)

The information Edward had access to enabled him to have a firm understanding

of the kind of Trans-Narrative he would have to follow in order to receive the

treatment he needed. Acknowledging that the medical professional could not ac-

commodate him due to his non-binary identity, he would have to ‘lie’ in order to

obtain the treatment he needed.

My next set of questions posed to Edward addressed issues of ‘proving trans iden-

tity,’ honesty with the medical professional and whether there were feelings of

having to give socially acceptable or normalized responses.

“I felt I had to present a certain way - as male/masculine as pos-

sible, so they would take me seriously. I definitely felt I was trying to

prove that I was trans, or that I was trying to convince them or make a

case for it. This aected the answers I gave (not necessarily lying, but

selecting what anecdotes to tell about my childhood and presenting

one particular narrative.” (Edward, 2014)

Edward connotes presenting in a binary gender and stereotypically masculine way

to being taken more seriously by the medical professional. He also emphasized

the need to prove his trans identity aected what he felt he could and couldn’t


My second interviewee was a 36-year-old non-gendered Trans person called ‘Aiden.’

(See appendix part II.2) I will use the gender-neutral pronoun ‘they’ since that is

the one Aiden utilized to describe themself.

Aiden emphasised the issues they had experienced with their GP in regards to

getting documents changed,

“I had a Statutory Declaration drawn up and signed by a solicitor

changing my title to MX and my GP refused to amend my records, he

also refused to do anything for me from that point unless as he put it

he had a ‘green light from CHX,”’ (Aiden, 2014)

Chapter 7. Independent Study


What is important to note is the refusal to amend Aiden’s records even though

they had provided the medical professional with legal documentation. By law, the

records should have been changed. It could be argued that the issue lay in the

fact the title was attempted to be changed to ‘Mx.’ As previously discussed in the

dissertation, many documents and applications fail to have or even acknowledge

this as a legitimate title – so the issue may lie more in the lack of accommodation

or acknowledgement for non-binary titles in legal documents.

Aiden also emphasizes the fact the GP would not help in any way until they had

received a ‘green light’ from Charing Cross (gender clinic.)

This implies the GP was waiting for Aiden’s Trans status to be confirmed and/or

diagnosed by the ‘Gender specialists’ – or subsequently have Aiden’s Trans Status

legitimized at Charing Cross before accepting Aiden as a treatable Trans patient.

“At my first GIC appointment I was told ‘We see a handful of people like you


every year and we never know what to do with them.’” (Aiden, 2014)

Arguably, this illustrates the way in which the NHS do not have the knowledge or

experience to treat non-binary Trans people as their service only caters to binary-

identified Trans patients.

“I did feel I needed to ’prove’ that my identity was legitimate in

some sense. My understanding of how trans healthcare services worked

was that they were set up to assist those people they could diagnose

as ’Transsexual’ according to their definition of that term. At my

third appointment at CHX GIC I was informed quite explicitly that

the clinician would not consider endorsing me for any treatment at all

unless I was living ”as a woman.’” (Aiden, 2014)

Aiden comments that due to not identifying in a way that meant they could receive

a medical diagnosis, the clinician openly stated that they would not be eligible for

treatment unless they were living ‘as a woman.’ This shows the way in which

non-binary Trans people are unable to access healthcare due to falling outside of

the conditions of treatment.

It could be argued that updating medical literature and diagnosis to include non-

binary Trans people would better allow and encompass a variety of dierent gender

identities and Trans people who are in need of medical treatment.

“I had to attend a panel meeting early last year, there were about 7-8 clinicians

present, the general consensus was that non-binary identity was not stable or

Chapter 7. Independent Study


permanent.” (Aiden, 2014) This illustrates the way in which clinicians do not

consider non-binary gender a stable or permanent gender identity, or even a legit-

imate identity.

Aiden also outlined the way in which it was impossible to follow through with the

clinicians guidelines due to their being no way to ‘live in role’ as a non-gendered


“They (medical professional) state in the letter that in order for

them to endorse me for surgery they require me to go ‘through the

usual Real Life Experience, including 1 year of substantial occuptation

of some sort as evidence of stable functioning in the desired gender


role (whether male, female or gender neutral)’ - despite me having re-

peatedly pointed out to them that there is no social or legal recognition

of non-gendered identity.” (Aiden, my emphasis, 2013)

Aiden points out the fact that even if a non-binary gendered person were to try

and abide by the Gender Clinic guidelines in order to receive treatment it would

currently be impossible. Requirements such as ‘living in role’ prevent a non-binary

gendered individual from qualifying or being eligible for treatment since there is

no way to legally live in their chosen ‘gender role.’

When I quizzed Aiden on what they thought needed to change in regards to

medical treatment for Trans people, they responded,

“Healthcare services for trans people should be designed in relation

to easing the symptoms of gender dysphoria rather than in relation to

notions of disordered identity They should drop the idea of transition


’pathways’ and instead oer a range of services they should oer a


patient centred approach to treatment based on informed consent.”

(Aiden, 2014)

Aiden emphasized the idea of treating Trans patients on a case by case basis, and

that treatment should be implemented in order to relieve symptoms as opposed

to ‘corrective’ treatments and surgeries which imply a more final and clear-cut

approach. The utilization of medical services to relieve gender dysphoria symptoms

would allow Gender Clinics and clinicians far more lee-way and broader options

in which to treat Trans patients, especially those who do not identify as a binary


Chapter 8


This paper has looked into the history of Medicalization of Trans people and the

way in which these ideologies and medical texts are still influencing the treatment

of Trans patients in 2014.

  • I have addressed the way Trans narratives such as the ‘Born in the wrong body’

ideology perpetuate the pathologisation of Trans bodies and an outdated focus

on corrective surgeries and ‘sex change’ that proves to reinstate notions of gender

binaries, roles and stereotypes.

  • I have addressed legislation such as the Parliamentary Guidelines for the commis-

sioning of healthcare treatment services for Trans people,’ and the way in which

the wording of such documents excludes non-binary Trans people by incorrectly re-

instating that Trans people identify as binary gendered. Also the issues associated

with the GRA and its failure to accommodate non-binary Trans people. These

normative binary understandings of gender have influenced social and legislative


This led me to look into the way certain ‘acceptable’ Trans bodies are legitimized

through medical, social and political movements, and others are not, drawing upon

arguments of acceptable homonormativity versus deviant Queer people who, like

non-binary gendered folk, do not reflect the status quo.

  • I have addressed issues of gendered citizenship, and the ways in which binary

gender is heavily indebted within the system, so much so it makes the concept of

gender-neutral identity hard to implement.

But I have also shown examples of certain countries and societies where a third-

gender has been successfully instated which prove it can be done.


Chapter 8. Conclusion


I have utilized actual experiences of Trans people through oral histories from Rooke

(2008), Davy (2011), and through my own research and interviews with Trans

participants to explore how the medical system is failing them.

Through these findings, I hope to have su ciently shown the way in which the

NHS and medical system are indirectly enforcing gender binaries through rigid

and exclusionary pathways in accessing Trans healthcare.

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