Abstract
Although medical providers rely on similar tools to “treat” intersex and trans individuals, their enactment of medicalization practices varies. To deconstruct these complexities, we employ a comparative analysis of providers who specialize in intersex and trans medicine. While both sets of providers tend to hold essentialist ideologies about sex, gender, and sexuality, we argue they medicalize intersex and trans embodiments in different ways. Providers for intersex people are inclined to approach intersex as an emergency that necessitates medical attention, whereas providers for trans people attempt to slow down their patients’ urgent requests for transitioning services. Building on conceptualizations of “giving gender,” we contend both sets of providers “give gender” by “giving sex.” In both cases too, providers shift their own responsibility for their medicalization practices onto others: parents in the case of intersex, or adult recipients of care in the case of trans. According to the accounts of most providers, successful medical interventions are achieved when a person adheres to heteronormative gender practices.
Medicine is a powerful institution in countless ways, but it holds particular sway in producing and obscuring ideologies about sex, gender, and sexuality. When providers define bodies that defy sex, gender, and sexuality binaries as morbidities in need of corrective treatments (see Foucault [1973] 1994), they not only perpetuate but produce the notion that a healthy body is identifiably male or female, masculine or feminine, and heterosexual. Sociologist Catherine Connell argues that every setting has a “particular constellation of interactive practices and consequences” that interpret and reinterpret embodiment (2010, 50). This article compares how providers approach intersex and trans bodies in order to show how the “practices and consequences” of the medical profession actively work to align embodiment with binary constructions of sex, gender, and sexuality.
Public and intellectual discourse often conflates intersex and trans terminologies, experiences, and embodiments, but the two have important differences as well as similarities. 1 Intersex generally describes the presence of both male and female sex traits (genital, gonadal, and/or chromosomal). Trans is commonly used as “an abbreviated term” for “transgender” (individuals “whose gender identity or expression, or both, does not normatively align with their assigned sex”) and “transsexual” (individuals who align their physical bodies with their gender identities via medical intervention) (Pfeffer 2010, 167). While intersex and trans people disrupt binary understandings about sex and experience some of the same struggles with some identifying as both intersex and trans, our research suggests that they have significantly different experiences with medical providers, especially when it comes to surgery. 2
Even after years of criticism from intersex people, many providers are quick to perform surgery on bodies of babies and young children that they consider abnormal (Davis 2014b; Davis and Murphy 2013; Holmes 2008; Karkazis 2008; Preves 2003). At the same time, they hesitate to act in cases where trans individuals request surgery (Dewey 2013; Lev 2009; Speer 2006), instead requiring them to undergo lengthy diagnostic processes according to codes in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association 2013), and guidelines outlined in the World Professional Association of Transgender Healthcare’s Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC-7) (Coleman et al. 2012). This difference generates our discussion here, in which we ask why and how providers respond quickly to intersex but slowly to trans, and, in turn, is a crucial step in better understanding how intersex and trans embodiments are medicalized as problematic bodies. Specifically, we compare two qualitative datasets—one of medical providers who treat intersex people, and the other of medical providers who serve trans people—to explore how both kinds of providers articulate and address these issues.
Our fundamental claim is that providers often approach intersex and trans bodies through essentialist ideologies about sex, gender, and sexuality, which hold that sex is a binary biological phenomenon correlated with gender identity and sexuality. The majority of providers we spoke with base their medical recommendations on what they believe a patient’s gender identity to be. This applies equally to situations in which they are determining whether an intersex individual needs intervention and situations in which they are responding to a trans individual’s request for intervention. In 2010, sociologist Jane Ward theorized the process of “giving gender” as a way to understand how femmes in sexual relationships with transmen perform “gender labor” through various “emotional, physical, and sexual caretaking” acts that serve to authenticate their partner’s gender (2010, 236). In 2011, sociologist Tey Meadow deployed the notion of “giving gender” to illustrate how parents of gender-variant children “engage in affective, intellectual and bodily projects to assist their children in securing their desired gender identities” by simultaneously drawing on “scientific and social knowledge in their accounts of their children’s identities” (2011, 730). We join this conversation by arguing that medical providers for both intersex and trans people also engage in this process of “giving gender,” but they do so by “giving sex.” We theorize giving sex as the process where providers validate (the construction of) heteronormative bodies and invalidate intersex and trans embodiments according to their interpretations of appropriate gender expectations. In this circular struggle over gendered embodiments and identities, sex assignments become profoundly gendered markers, as the institution of medicine acts as a gatekeeping site, deploying normative ideologies of sex, gender, and sexuality to map sex onto gender for embodiments that do not fit existing sex, gender, and sexuality binaries.
The Medical Gaze and “Morbid” Bodies
Since the nineteenth century, medical thinking has been based on a “medical polarity of the normal and the pathological” which results in a “healthy/morbid opposition” (Foucault [1973] 1994, 35). In this context, intersex and trans bodies have been—and unfortunately still are, despite some changing beliefs—constructed as abnormal, which is to say, in Foucault’s terms, “pathological” and “morbid.” In the case of intersex, the medical profession precipitously medicalizes healthy bodies as pathological without conferring with the intersex person (or with their parents if they are too young for consultation); in the case of trans, this medical pathologization occurs slowly due to the numerous steps required by the current SOC guidelines that slow down any requested medical interventions, regardless of the desires of trans people. We believe that medicalization is “a fluid and mutable dynamic whose causes and effects must be analyzed rather than assumed” (Tone 2012, 319), that “medicalization and diagnosis represent sites of struggle,” and that the relationship between diagnosis and medicalization is rarely unidirectional but rather results in diverse and sometimes contradictory effects (Burke 2011, 188). Thus, we are determined to look closely at the connections providers make between normative sex embodiments and the possibilities for intersex and trans embodiments.
We are all, regardless of our genitalia, gonads, and chromosomes, subjected to the “medical gaze,” which is the process by which medical professionals approach, diagnose, and judge bodies with uncontested authority in ways that frame one’s body as either healthy or morbid (Foucault [1973] 1994). While providers could affirm intersex and trans as healthy differences on a continuum of normative sexed embodiments, instead, our data suggest, they often frame intersex and trans embodiments as pathologies on the basis of a belief that people are either male or female. Their judgments, in turn, can be a powerful incentive for intersex and trans folks—or their parents—to seek sexed embodiments via medicalized intervention so that normative sex, gender, and sexuality expectations do not disassociate them from their bodies. It is important to note here that regulation and normativity are not necessary outcomes of medicalization. Meadow (2011) uncovers moments when parents of gender variant youth use medical discourses to construct understandings of gender variance that resist the binary gender framework and create new spaces for their children; in essence, these parents use language and meanings derived from regulatory discourses in biomedicine and psychiatry to give gender to their children by affirming their gender variant identities. Similarly, Rahilly (2015, 358) finds parents of gender variant and transgender children disrupt the gender binary with their parenting styles, but “they do not refute presocial understandings of gender, which are often considered the converse of gender-progressive parenting.”
Providers may very well be unaware of their role in constructing normatively sexed embodiments as healthy. McGann (2011, 337) discusses the diagnostic imaginary as “a way of thinking which conceals the presence of the social in diagnosis, closing off critical analysis of the complex ways they are structured by history, culture, politics, and value judgments.” But conscious or not, this diagnostic imaginary and its privileging of normative sexed embodiments has powerful consequences. The construction of normative sexed embodiments has played a significant part in the history of medicalizing diverse sexed embodiments, to the point that we question whether the majority, rather than a minority, of medical providers can even imagine healthy gender identities for their gender variant intersex and trans patients. Moreover, pushing for and policing interventions that modify bodies to fit within gender expectations itself disparages intersex and trans embodiments (Sadjadi 2013), in essence culturally disciplining them through medical technologies. In these cases, there is no clear division between cultural expertise and medical expertise (Rose 2007): Providers treat intersex and trans people because society awards them authority to “fix” bodies that deviate from normative expectations (Foucault [1973] 1994).
Medical responses to intersex and trans reflect the bureaucratic and ideological work sparked by the categorical crisis these groups incite (Davis and Murphy 2013; Meadow 2010). Clearly, intersex and trans undermine the idea that biological sex is a fixed, unitary characteristic. When providers determine whether intersex and trans individuals need treatment, they exercise biopower (Foucault [1973] 1994), managing and regulating bodies to foster the normatively gendered and disallow the gender or sex variant (Mills 2007). The physician’s medicalized gaze determines a patient’s health and treatment solely on the basis of the presence of the intersex trait or the individual’s desire for a different sex to match their gender. This assessment begins when providers construct an intersex trait as an emergency that necessitates immediate attention (Davis and Murphy 2013) or an individual seeks medical services to address their trans embodiment (Dewey 2008; Winters 2006). A provider’s perception of the patient’s identity development plays a key, if often unstated, role in their interpretation of the best course of treatment. In the absence of a clear scientific test of sex, although they run many tests, providers often rely on an identity-based gender ideology and engage in a negotiated process of authenticating the patient’s gender to ensure that the body harmonizes with what is perceived as a stable, coherent identity (Meadow 2010; Westbrook and Schilt 2014). Providers thus tend to engage in “gender naturalization work” as they balance the “ideological collision” between identity- and biology-based ideologies of gender (Westbrook and Schilt 2014).
In this way, providers contribute to a proliferation of “advances” in biomedicine and psychiatry that provide ways we can “know” the appropriate binary embodiment of sex, through questionable scientific approaches. Drawing on Bourdieu and Wacquant’s (1992) discussion of “symbolic violence,” Bourgois and Schonberg (2009) theorize the symbolic violence embedded in public health policies by showing how medical practices and policies that are disguised as dissemination of medical information to better facilitate choice-making can further disempower marginalized recipients of care. Similarly, in our discussion of responsibility for treating intersex and trans people, we explore how providers enact symbolic violence by claiming that they only offer information to their patients (or patients’ families), while, consciously or not, pathologizing bodily variance.
Sociologist Raewyn Connell (2012) refers to the ontology of sex in relation to gender as “ontoformative”: We enter into an existing gender structure that shapes us at the individual level as others react to us and treat us at the interactional level in ways that are themselves shaped by historical gendered dynamics (see Risman 2004). Sexed embodiments, especially intersex and trans, can challenge the gender structure by disrupting ideas about sex and gender correlation, but only if non-normative sexed embodiments are allowed rather than pathologized. When providers instead pathologize intersex and trans embodiments, they establish the claim that they can surgically relieve societal anxieties associated with being differently bodied. Surgery thus functions as a tool for aligning sex with gender, where the ultimate success is the enactment of a gender normative heterosexual identity. In this way, providers not only give gender, but regulate sexed embodiments by giving sex.
Although the process we have just described applies to all kinds of non-normative sexed embodiments, differences between intersex and trans medicalization illuminate the social construction of sex, gender, and sexuality as arbitrary and correlated binaries (Butler 1993; Fausto-Sterling 2000; Foucault [1973] 1994; Kessler 1990). With these theoretical and empirical insights in hand, we compare the experiences of each group under the medical gaze.
Methods
We use a comparative case method with a “structured, focused comparison” (e.g., George and Bennett 2005, 67) to analyze how medical providers approach intersex and trans embodiments. Our comparative analysis sheds light on the similar yet different ways providers make accounts that articulate their views on gender for their patients, where they in effect give gender (Meadow 2011; Ward 2010), and articulate their views on sexed embodiments for their patients, where they give sex. These accounts from providers, who were interviewed for two separate studies and later brought together for this comparative analysis, provide their rationale for how they determine the appropriate treatment for the medicalization of intersex and trans embodiments. On a theoretical level, our analysis shows how the healthy/morbid distinction pointed to by Foucault ([1973] 1994) is channeled through essentialist ideologies about sex, gender, and sexuality. The healthy/morbid distinction drives these empirical differences, shaping how providers articulate their understandings of gender variation whereby they give gender through disciplining embodiments of sex, in essence, giving sex. While medical and mental health providers may differ in their approaches to non-normative embodiments, especially in the treatment of trans people where access to medical interventions is dependent upon a mental health evaluation, we bring these specialists together for the purpose of comparing intersex and trans medicalization processes, rather than analyze any variations that exist across specialization. 3 However, we note a provider’s specialty when it is pertinent to the analysis. Additionally, our findings cannot be generalized to all practicing medical providers, yet our data allow us to illustrate the conceptual comparison between intersex and trans medicalization.
Between 2008 and 2011, Davis interviewed 10 U.S. medical providers who treat intersex people as part of a larger qualitative study of intersex in the United States. Providers were recruited through current or past affiliation with the medical advisory boards of intersex organizations, including the Intersex Society of North America, Accord Alliance, and Androgen Insensitivity Syndrome Support Group-USA. Snowball sampling was employed to reach providers not affiliated with these organizations. Provider specialties included urology, endocrinology, and psychiatry, among others. Each expert received a random letter of the alphabet as a pseudonym, beginning with “A.” In this analysis, an “I” for intersex has been added before each letter. It is important to note that data collection was conducted from an informed standpoint: Davis has an intersex trait, and her lived familiarity with intersex both shaped data collection and continues to operate in analyses produced from the dataset.
In 2008, Dewey recorded 20 interviews with U.S. medical providers who treat trans people. The sample includes 10 physicians and surgeons and 10 psychiatrists, psychologists, and social workers. Participants were recruited from the World Professional Association for Transgender Health, previously known as the Harry Benjamin International Gender Dysphoria Association. As with the intersex sample, each participant was identified with a letter, and for this analysis, a “T” for trans has been added before each letter. At the time of the interviews, these professionals were operating under the Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, sixth version (SOC-6) (Meyer et al. 2002) and the fourth version of The Diagnostic and Statistical Manual [DSM] of Mental Disorders (DSM-IV-TR) (American Psychiatric Association 2000). Although the SOC and DSM have since been revised, 4 the data presented here are still relevant, for the medicalization processes they reveal are not based on medical categories but rather are embedded within “webs of practice” (McGann 2011).
Davis and Dewey first independently coded their interview data into general themes. On a shared panel at an academic conference, Davis and Dewey, along with Murphy, discovered that their work had several overarching themes in common. In light of this dialogue, they revisited their data collectively and found similarities and differences, which they present here in this comparative study.
Deconstructing Intersex and Trans Medicalization Practices
Our analysis revealed four key themes in the medicalization of intersex and trans embodiments as “problems.” These themes, which represent the thinking and work of the majority of providers interviewed, involve (1) defining the problem, (2) responding to the problem, (3) markers of successful treatment and perpetuation of the problem, and (4) responsibility for treating the problem.
Defining the Problem
When providers define intersex and trans embodiments as problems, they do so because they believe, consciously or unconsciously, in sex, gender, and sexuality as binary ideologies, which in turn underpin a problematic distinction between healthy and morbid bodies. In this binary framework, a healthy embodiment, to use Foucault’s term, neatly aligns sex, gender, and sexuality: A healthy woman has a vagina, a healthy man has a penis, and both engage in heterosexual relations, specifically penile-vaginal penetration. Any deviation from this alignment results in a morbid embodiment that is pathologized in providers’ accounts. While some intersex and trans people may also believe that sex, gender, and sexuality are binaries, their beliefs are less consequential for they reside outside the medical gaze. They do not, for example, self-perform surgeries on their bodies.
Armed with the medical authority to surgically modify intersex bodies, many of the providers who treat intersex people relied on a binary understanding of sex, gender, and sexuality, which disallows unaltered intersex bodies to be viewed as healthy. Their accounts articulated naturalized views of sex and gender that they believed demonstrated how sexed embodiments should be regulated. Dr. ID explained:
My experience with girls with CAH [congenital adrenal hyperplasia] suggests to me that [gender is] pretty hardwired. A lot of the CAH girls are significant tomboys. . . . I think some of those behaviors are absolutely hardwired.
If under the medical gaze gender is assumed to be a “hardwired” or inherent characteristic, the intersex body can never be considered healthy, for its natural sex ambiguity cannot be aligned with a singular gender. Some providers who treat intersex also correlate androgen exposure during gestational fetal development with sexual behaviors later in life. Dr. IA pointed to research on monkeys to suggest that “androgen levels during fetal development produce male-typical behavior later on . . . humping behaviors and things like that. . . how they engage in intercourse.” Here Dr. IA’s account correlates sex traits with gendered behaviors that seems as much based on ideology—“male-typical . . . humping behaviors”—as the biological predispositions he presumes.
It is an easy jump from these essentialist and correlated conceptions of sex, gender, and sexuality to the assumption that the uncorrelated intersex embodiment is a socially problematic morbidity. Dr. IC, for instance, insisted that life would be difficult for a child without a “normal” penis, who would not “see himself as most other males” and would not “be able to function as most other males.” Despite—or perhaps because of—years of experience with intersex, Dr. IC could not disentangle the body, especially the genitals, from gender identity and sexual practices, in essence insisting that a “normal” penis is essential to being a man. This accounting of intersex embodiment as a morbid sex variation justifies surgical intervention and establishes it as a reasonable response to intersex.
One major difference between intersex and trans treatment is the timing of diagnosis, which in turn makes a difference in how providers consider the identity development of their patients. Yet providers who treat trans adults, often interpret trans embodiments through a similar essentialist lens of male/female, masculine/feminine, gay/straight. Using the same language as Dr. ID, Dr. TM, a surgeon, articulated that gender identity is intertwined with biology: “First of all, it’s not psychological. . . . People are telling me that this is the way they’ve felt since they were three, four, and five years old . . . so it quickly became apparent to me that [gender is] something that is hard-wired in the individual.” Providers who serve trans people enact the medical gaze, establishing a narrative about patient identity grounded in biology to relieve the liability in providing treatments that are in opposition to binary views of sex, gender, and sexuality and to justify the interventions they employ.
Moreover, looking at childhood to construct a giving gender narrative serves as a necessary, yet problematic, proxy for proving that gender is biologically determined. At the same time, this framing explicitly aligns with what Judith Butler (2004, 76) labels the complicated “instrument of pathologization,” better known as the Gender Identity Disorder (GID) criteria in the DSM-IV-TR (American Psychiatric Association 2000), and which is also implied in the criteria for Gender Dysphoria in the DSM-5 (American Psychiatric Association 2013). Butler (2004, 76) reminds us that the diagnostic pathologization may offer access to insurance coverage for trans people requesting interventions, but it does so at the cost of constructing trans people as “ill, sick, wrong, out of order, abnormal, and to suffer a certain stigmatization as a consequence of the diagnosis.”
Providers for trans people tend to be sensitive to the fact that a giving gender narrative that medicalizes trans can help legitimate it in the eyes of families, insurance companies, and the like and validate giving sex. This is why Dr. TE sees value in the DSM: “I think we need it [in the DSM], otherwise how would you get insurance to pay for it? How could you explain it to family members?” In other words, medicalization becomes a tool for empowerment that can facilitate sex embodiment. But the irony is that when providers use medicalization in a progressive way to support their patients’ wishes, they do so by perpetuating the claim that sex, gender, and sexuality are natural, fixed phenomena whose pathological deviations can be medically corrected (see Butler 2004). Dr. TM, a surgeon, provided his giving sex account using intersex as a frame: “[Trans] . . . is basically an intersex condition. . . . It just happens to be brains that are intersexed, not genitalia that are intersexed . . . and it should not be in the DSM . . . because it’s certainly nothing psychological.” 5 Ironically again, while a diagnosis is required for insurance coverage, insurance companies often exclude psychiatric diagnoses related to gender from coverage, so providers who serve trans people often use alternative diagnoses, such as depression or anxiety, even as they continued to support GID’s place in the previous DSM-IV-TR, presumably because of their belief in diagnostic power.
Although providers for trans people attempt to depathologize trans embodiment through biomedical explanations, they still often view trans people as morbid, pathologizing their condition in order to offer treatment (see Butler 2004). Like providers who treat intersex people, providers who serve trans people leave little, if any, room for an understanding of trans embodiments as healthy. In this sense, providers intervene with embodiment processes by giving gender to their patients through the process of giving sex.
Responding to the Problem
Although many providers similarly define intersex and trans as morbid deviations from normative expectations of sex, gender, and sexuality, providers who treat intersex people often frame intersex as a medical emergency—a morbidity that needs to be fixed immediately. While trans people may feel they are in an emergency situation, their providers tend to do everything they can to avoid such framing. Because of the power of the medical gaze (Foucault [1973] 1994), how providers frame these conditions as problems matters in that these pathologizing frames produce “knowledge” with authority for treatment (Butler 2004). In other words, in both instances, providers maintain control and authority over the body with the power to assert the need for medical interventions.
Dr. ID accounts for the necessity of running emergency tests, explaining, “We try to find out as much biochemical and genetic data as we can, as fast as we can” [emphasis added] in order to predict “what is likely to happen to them at puberty.” Dr. II elaborated: “We let the family know that the emergency, which would have been a salt-wasting CAH, is or is not the concern. Once you say there’s no medical emergency here, then we say, let’s get some more data.” In this case, there is a possible “medical emergency”—“salt-wasting CAH,” which is potentially life-threatening—but ruling out that possibility does not end the medical investigation. Rather, the perception of an emergency situation is sustained by searching for “more data” in order to make questionable predictions about future gender (discussed in the next section). The sense of emergency is further heightened when a medical team treats intersex. In theory, the team model is in the best interest of the patient, but, as Dr. II explained, medical teams often meet to “help the family reach a decision as soon as possible” [emphasis added], thus perpetuating the creation of the emergency situation.
Similar to providers who treat intersex, providers who serve trans people often work within an emergency framework, but trans people are the ones who define their situation as urgent. In the trans case, providers try to minimize the emergency their patients created. Dr. TF explains: “If [trans patients] do not get what they want, surgery now, hormones now, they will go elsewhere” [emphasis added]. Therefore, he deflects the emergency by telling his patients that “this is not the way it works. . . . There are a lot of steps that you have to go through before we can say you need hormones [or other transitioning services].” Dr. TF references here the assessments with which many professionals begin the process of transitioning a patient. These assessments, under both the 6th and 7th versions of the SOC, include both physical examinations and mental health evaluations, an element of the decision-making process that is substantially different from that of intersex.
Providers who serve trans people report that the goal of assessment, which may last months or even years, is to ensure that the patient is mentally stable before undertaking irreversible treatments. Just as Dr. ID accounted for running tests on intersex patients which establishes an emergency situation, Dr. TO accounts for the screening process to assess the appropriateness of the patient’s sense of urgency for medical interventions, with another reference to the male penis as a fundamental part of a man’s identity:
Plastic surgeons don’t just do anything that anyone asks them to, they screen patients. . . . And it is very common when people have a vasectomy or an abortion that they have to have counseling first. So this is really a big myth that no one else has an evaluation. A total myth. If you have weight loss surgery, you have [a] psychological evaluation. And in most cultures, if you remove somebody’s penis it is the worst possible thing that could happen.
In comparing their treatment of trans patients to other medicalized groups, Dr. TF and Dr. TO fail to acknowledge a key difference, which is that “screening” for trans patients, often taking months or years, includes more than a medical or psychiatric diagnosis, but also a social one where patients’ lives, from their work to family relationships, are scrutinized to reduce what is perceived as a significant risk for providers in administering treatments for trans people. Whereas surgeries on intersex bodies continue despite a medical consensus advising otherwise (Lee et al. 2006), the considerations of the medical board become relevant for providers who serve trans people. Allowing sex and gender variants could be considered abuse on the otherwise healthy bodies of trans patients. Dr. TF shared the fear of giving sex upon the patient’s request:
I said [to my patient], “Every time I [administer hormones] my license takes a little walk onto the precipice because it is not in the mainstream. If I just put you on hormones . . . any medical board looking at this . . . would call me a nut. They could file child abuse charges against me.”
Although it hadn’t happened to any of them, providers for trans people were concerned that they could lose their medical licenses if they did not adhere to standards for providing treatment, especially administering the screening process that slowed the time between diagnosis and administering hormonal and surgical treatments. 6
When providers view medical guidelines as protection for themselves and benevolent assistance for their patients, they may frame patient impulsivity as noncompliance because of the power of the medical gaze to legitimately determine how to separate or incorporate one’s sex identity with one’s gender identity. According to Dr. TA, “[Usually] a person is being too impulsive and too pushy, not patient. . . .” Yet as providers slow down their patients’ requests, they ignore the fact that by the time trans individuals seek out medical services, they have likely been contemplating their decision for a long time (see Green 2004).
One additional important difference between intersex and trans medicalization is the role of psychosocial providers. Mental health professionals are less involved in intersex than trans medicalization. Current medical protocols for the treatment of intersex highlight the importance of psychosocial care (see Lee et al. 2006), yet mental health professionals are rarely meaningfully included in intersex medical decisions. In contrast, trans medicalization almost always begins with mental health professionals. One reason for this difference may be that while providers tend to pathologize intersex bodies as morbid because of ambiguous sex development, this is not an ethically viable view of trans bodies, so mental illness must be ruled out before proceeding with requested interventions, lest providers find themselves physically treating problems of the mind, which most would agree is unethical.
Though there are some differences between the framing of emergency in intersex and trans situations, both reflect the power of providers who control access to medical interventions. Although most intersex bodies are healthy, providers often respond to them as morbid emergencies that require intervention. Meanwhile, when trans patients seek medical treatment, providers with the power of the medical gaze slow the pace of treatment, redefining the situation from an emergency to a process designed to guarantee the persistence of their patient’s desire to transition. While providers in both cases might see themselves as guarantors of health, they tend to reinforce the pathologization of intersex and trans embodiments in their decisions to give sex.
Markers of Successful Treatment and Perpetuation of the Problem
In intersex and trans cases, providers view successful medical interventions as those that align sex, gender, and even sexuality, according to the binary ideology that upholds heteronormativity. This measurement of success perpetuates the assumption that intersex and trans embodiments are problems and fuels essentialist ideologies about sex, gender, and sexuality.
Providers for intersex people commonly referred to gender assignments as successful or unsuccessful—an outcome they could ensure if they had the right data. Dr. IC explained that achieving the correct gender assignment starts with figuring out “who the child [will] think they’re going to be later.” This prediction about gender identity that attempts to appropriately give gender reflects the belief that intersex is not a true sex, and thus that intersex individuals must, with the medical help to give sex, end up male or female. To figure out whether to give an intersex person a male or female sex, Dr. IC asks questions hunting for biological data: “Did the child have significant testosterone exposure? . . . And then once that’s been established, discuss [with the parents] the issues such as fertility, functional success of surgery,” especially as it pertains to future penile-vaginal penetration. According to Dr. IC’s accounting for surgery, which pathologizes intersex, “Nature . . . just about got it right,” but armed with more “knowledge” the surgeon “can complete . . . the last few steps or last step [of development]” in the operating room.
Many providers who treat intersex people feel their giving sex interventions are successful when the intersex person lives in the gender they were assigned at birth. Of course, their assessment of gender presentation is deeply rooted in cultural understandings of femininity and masculinity. When Dr. ID was asked whether incorrect gender assignment was possible, she answered:
Yes. When an individual who’s been raised as a female gender assignment comes to the office having totally cut off all her hair, wearing army combat boots and fatigues—it sounds very stereotypical, but it really happens—wearing combat boots and fatigues, saying, “Oh God, I hate having periods, it doesn’t make any sense for my life, I don’t like this.” Or they threaten to commit suicide or they’re institutionalized with substance abuse, and part of what comes out of their therapy through that substance abuse is that they don’t know who they are or they think they weren’t assigned to the way they feel now. And those are not always permanent, by the way . . . one of my fatigue-wearing persons came in a couple weeks later wearing a miniskirt, makeup, and having dyed her hair.
Although Dr. ID unwittingly acknowledged that gender presentation is fluid, she still tied a patient’s gender presentation to her assessment of whether a correct gender assignment had been made at birth. She could have said it is impossible to evaluate the success of gender assignment or tied success in a more central way to gender self-identification rather than gender presentation, but she instead focused on gender presentation.
Among providers who serve trans people, criteria for the successful treatment of giving sex vary, especially among most physical and mental health providers. Many mental health workers define success as therapeutic progress. For Dr. TG, a mental health therapist, successful treatment involves patients being “engaged in the process” of the therapy, in which they “try to understand [themselves], feel better, and make changes.” This self-understanding and change also entails moving into the gender the trans person wishes to express. Dr. TG offered an example of a patient still in the process of achieving this goal:
Sometimes he feels like he really is a woman and would like to transition into more of being a woman. Sometimes he talks about pursuing it medically in terms of hormone therapy, looking at surgery, but hasn’t gotten that far, but has, from time to time, varying degrees of cross-dressing, body hair removal, makeup, and haircuts. So he sort of plays with it. He dabbles.
Reducing the patient’s identity to a playful, childlike confusion, Dr. TG reinforces the idea that a successful adult ready to physically transition would embrace a steady stereotypical display of gender.
For surgeons, and some therapists, the success of giving sex is based on how well the medically altered body functions and allows the patient to have a “normal” life, defined as living in a gender aligned with physiological sex and a heterosexual identity. This is demonstrated in Dr. TJ’s account of “beautiful” success:
I have [a] patient who I met when she was 16. I thought she was a natural female. She was a male to female. When she turned 18 she came to me for surgery, male to female surgery. I saw her again about three weeks ago at the age of 23. [She] had signed [up] for a modeling job in Los Angeles, a very lucrative modeling career, and she’s getting married, has a modeling career, and is perfectly female in every way. No complications, a beautiful thing.
A modeling career and marriage to a man confirm her social acceptance, and even excellence, as a woman whose sexuality maps appropriately onto gender.
One central marker of success is the engagement of heterosexual intercourse, specifically penile-vaginal penetration. Socially, heterosexuality marks success in giving sex through medicalization because it reflects socially acceptable relationships with the “opposite” sex. Physically, it is additional evidence of successful compliance with medical directives, which is addressed in Dr. TE’s account: “Vaginoplasty is not always good because [patients who underwent vaginoplasty] don’t use dilators enough, don’t have sex enough. Many are not in a sexual relationship with a man. They need to get dilators out or there is a chance [the] canal can close. They cannot find a partner. Major problem.” When sex, gender, and sexuality align properly, with the achievement of a boyfriend who serves any number of purposes including keeping the vaginal canal open, patients succeed not only at being “normal,” healthy individuals, but also at being good, compliant patients under the authority of the medical gaze. When the heteronormative alignment between sex, gender, and sexuality fails to emerge, providers who serve trans people were inclined to shift the blame to trans patients for failing to comply with their requests—by not using “dilators enough,” for instance.
Defining success for giving sex by shaping patient-sexed embodiments to fit into binary categories further pathologizes intersex and trans embodiments, while leaving the medical system, its agents, and the cultural investment in those binaries unchallenged (Sadjadi 2013). Medical decisions reflect the bureaucratic and ideological work of a medical gaze that makes gender recognizable while perpetuating essentialist ideologies about sex differences, allowing some, but not all, intersex and trans bodies to exist by giving sex in order to give gender.
Responsibility for Treating the Problem
Despite the power providers for intersex and trans people clearly hold, neither group tends to accept responsibility for their authority in shaping intersex and trans medical experiences or responsibility in giving gender by giving sex. Instead, providers often see themselves as facilitators, rather than decision makers, and describe their role as educating patients (or their parents). This description may sound empowering, but in fact what is missing is an acknowledgement of providers’ powerful role to frame the appropriate “knowledge” of each condition, “knowledge” focused through the medical gaze that encourages self-regulated decisions. Ignoring this dynamic, providers shift decision-making responsibility onto patients and families without owning their active role in the decision-making process. Providers tend to argue that medicalized discourse educates, with the “knowledge” they create and frame, and empowers their patients, but this argument masks the symbolic violence inherent in aligning patient decision making to existing medical and cultural standards (see Bourgois and Schonberg 2009). When patients and families lean toward options that providers consider unacceptable, they find themselves pushed to make the “right” decision, as providers promote “disciplined subjectivities that self-impose responsible behavior” (Bourgois and Schonberg 2009, 106).
Although providers for intersex people enact interventions, they tend to frame their actions as a response to parental desires. Dr. IA’s account articulates this rhetoric: “[S]ome families, for cultural, religious, or psychological reasons, may feel very strongly about the importance of trying to have their child look more typically male or female.” Because intersex is often diagnosed in infancy or childhood, it makes sense that providers look to parents to grant medical consent. But in focusing primarily on consent, they evade responsibility for their role in framing medically unnecessary interventions as the best response to intersex, which can have a powerful and authoritative effect on the parental decision-making process. When providers define intersex to parents as a medical problem, providing medical discourses to interpret and recommendations on potentially life-altering courses of treatment, they essentially script parental response. When Dr. IB explained that providers “do the initial education with families . . . and get parents pretty actively involved . . .’cause they make the decision,” she is occluding a powerful set of influences that shape that decision.
Some parents do question medical recommendations, but they often are met with resistance from providers who hold tight to their medical authority. Dr. IC illustrated this resistance in an account of a consultation:
The father said . . . “Why should we do anything?” And I acted physically surprised, I’m sure I did. . . . [The father went on to say], “Well, in our family we like to celebrate our differences and not try to all be the same and feel the social pressure to do everything like everyone else does.” . . . I said, “I do have to say one thing, and I think it’s of key importance, that you both see a psychiatrist.”
If parents challenge providers, they may find themselves referred to a psychiatrist not for psychosocial care but because they have been pathologized for not adhering to medical recommendations. Such incidents paint providers in our analysis as far more than the mere facilitators of health care that they claim to be, further undermining the claim that providers are presenting parents with objective choices. When providers respond to intersex as an emergency, they frame it as a medical abnormality that must be treated, thus upholding essentialist understandings about sex, gender, and sexuality. Without medical expertise and in the face of these powerful imperatives, parents have little, if any, room to slow down irreversible, medically unnecessary surgical decisions designed to give their children sex.
Providers who serve trans people similarly assume little responsibility for their role in giving gender by giving sex. Since trans embodiments are more likely to be diagnosed in adulthood than childhood, 7 providers shift responsibility for decisions to patients themselves, on the basis of their ability to formulate coherent gender identities. They also accounted for themselves as facilitators and educators. Dr. TJ explains their role in “education”: “If you look in the Oxford English Dictionary for the word doctor, it’s Latin for teacher. My job is to provide enough education that people can make good choices based on sound understanding of the variable.” Dr. TA elaborated, “My role is really a consultant to the patient. . . . I view my role now not as gatekeeper but helping them understand what their options are and making a careful, thoughtful decision.” By highlighting patient desire, however, providers obscure their power in regulating the transition process and keep gender coherence as the standard criterion for moving transition forward. They tend to be skeptical of trans people who do not adhere to stereotypical displays of their chosen gender, and are more wary of providing them with transitioning services. Dr. TB explained the notion of responsibility: “[I] want to make sure that [I] appropriately identify individuals in my mind that would benefit from surgery. It’s still a matter of making an accurate diagnosis and formulating an appropriate treatment plan.”
Not wanting to appear as gatekeepers, providers who serve trans people point to DSM criteria and SOC guidelines to defend slowing down patient requests for gender transitioning services. They also not so subtly blame their patients for forcing them to slow things down. Dr. TH explained that when her patients have what she considers a reasonable “timeline in mind,” she doesn’t “feel any pressure, like oh my God, I am going to have to be a gatekeeper here,” but when a patient’s timeline differs from hers, she pushes back and has a more difficult time offering medical services. While providers may feel they are giving their trans patients agency and embracing the widespread belief that medicine ought to move away from paternalistic care in favor of more patient-centered care, they award full agency only to those who make decisions that align with their own treatment preferences, thus keeping pronounced barriers to agency in place in the process of giving sex.
While ostensibly transferring responsibility for giving sex to parents (intersex) or patients (trans), providers continue to frame the discussion and control the pace of intervention, pulling strings by controlling where and how to give sex, and thereby evading accountability for the symbolic violence they enact (see Bourgois and Schonberg 2009). Providers may speak to their deference to the decisions of parents and patients, but in doing so they obscure their own power in constructing possible treatments for intersex and trans that maintain the binaries of sex, gender, and sexuality.
Conclusion
Medical providers in our comparative analysis are often quick to respond to intersex with medically unnecessary and often irreversible interventions, but they are slow to approve and provide similar practices when trans people request them. This noticeable difference can be explained through Foucault’s ([1973] 1994) theorization of the medical gaze. More specifically, Foucault allows us to understand that providers, like all of us, are members of society who operate under the widespread heteronormative institutionalization of sex and gender binaries. However, providers have a unique power to either perpetuate or challenge prevailing assumptions about sex, gender, and sexuality. Unfortunately, the accounts providers gave in our interviews lead us to conclude that those who are positioned (because of their intersex and trans expertise) to disrupt stereotypical binary understandings of sex, gender, and sexuality by not approaching intersex and trans embodiments as abnormal in fact often perpetuate the binary rhetoric that pathologizes variance. They do so unreflexively and uncritically through their control and regulation of the interventions by which they give gender by giving sex, creating what they consider to be heterosexual and healthy male men and female women.
We have reached this conclusion by deconstructing intersex and trans medicalization practices. First, we argued that providers for intersex people and those for trans people similarly define intersex and trans embodiments as problems to be solved, rather than as healthy human variations. To put it another way, providers’ medicalization practices often construct intersex and trans embodiments as morbidities by viewing them through a lens that maintains normatively correlated sex, gender, and, although perhaps to a lesser extent, sexuality as indicators of ideal health. We then turned to the construction of intersex and trans as emergency situations, the one by providers eager to embark on medical intervention, purportedly to assuage parental anxiety, the other by patients eager for transition, who are slowed down by anxious providers. In other words, providers for intersex and trans people differ on whether and when to frame the situation of giving sex in order to give gender, but in both cases they tend to enact and maintain their authority over the body and the medical tools they use to irreversibly shape it.
Both sets of providers determine the success of their medicalization efforts on the basis of signs that their patients are living heteronormatively gendered lives. These markers of success further reify socially constructed binaries, perpetuating binary ideologies and impediments to better care for intersex and trans people. Yet providers for both intersex and trans people commonly evade responsibility for their roles in perpetuating these problems, presenting themselves as facilitators, not decision makers, for patients (or parents) who have responsibility for their own decisions about medicalization. This false perception of medical autonomy obscures the ways in which the health care system is not just unreflexive and uncritical but also creates self-discipline in parents and patients through medicalized scripts that enacts a symbolic form of violence (see Bourgois and Schonberg 2009).
While our deconstruction of intersex and trans medicalization has revealed the medical and social power providers hold, it has also identified spaces where they could make very different choices. In light of this analysis, we suggest that providers need to be more self-critical and aware of their powerful influence. They can do this by creating a welcoming and supportive institutionalized space for those who want to enact sex, gender, and sexuality as multifaceted rather than binary phenomena. In doing so, providers could approach their intersex and trans patients as healthy people who have the right to make autonomous decisions about their bodies.
One step in this direction may be the new Medical College Admission Test (MCAT), approved in 2012. According to the Association of American Medical Colleges (AAMC), the new MCAT will “require aspiring doctors to have an understanding of the social and behavioral sciences, in addition to a solid background in the natural sciences” (Mann 2012). AAMC President and CEO Darrell G. Kirch, M.D. said, “We all know America is becoming much more diverse. . . . These changes to the exam have been done with a very clear eye toward the changes that are occurring in health care and the kinds of physicians we will need” (Mann 2012). We are hopeful this change to the MCAT will affect intersex and trans medical care. Future generations of providers will hopefully have, and rely more on, knowledge from the social and behavioral sciences when they see intersex and trans patients. However, we fear providers may instead still cling to the power to give sex to their patients in a binary way, given the inertia of medicalization and the medical gaze.
Footnotes
Acknowledgements
The authors wish to thank Joya Misra and Maxine Craig for their editorial direction and the insightful reviews they secured. We also wish to thank Rachel Allison, Pallavi Banerjee, and Amy Brainer for their helpful comments on earlier iterations of this paper. And, lastly, we’d like to thank Ranita Ray for lending us her breadth of knowledge during the revision process.
Notes
Georgiann Davis is assistant professor of sociology at the University of Nevada, Las Vegas. She has written numerous articles on intersex in various venues ranging from Ms. Magazine to the American Journal of Bioethics. Her book, Contesting Intersex: The Dubious Diagnosis, is available from NYU Press.
Jodie M. Dewey is associate professor of sociology and director of the criminal justice program at Concordia University-Chicago. She has published several articles on trans-identified patients’ impact on the health care process. Her work focuses on medicalization and psycho-pathologization in transgender health.
Erin L. Murphy is an independent scholar and graduate of the Sociology Doctoral Program at the University of Illinois at Urbana-Champaign. Her work has previously appeared in Gender & Society, Feminist Formations, Critical Sociology, and the Journal of Historical Sociology. She is working on a book tentatively titled Exceptions of Empire: Anti-Imperialist Protests during the Philippine-American War.