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Dysphoria as a Symptom of Modernity

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Dysphoria is everywhere we look in American society. Take for example the toxic beauty culture of the media promoting images of beautiful models representing unattainable beauty ideals. There are many young women wishing they were skinnier, with bigger breasts, and the right size ass. I would imagine many if not most girls and women in America wish they could change something about their bodies or appearance. Men and boys as well. We live in a fix-it society exemplified in reality tv shows depicting “ugly” people getting a smorgasbord of cosmetic surgeries and then showing the dramatic “before and after” reveal. The plastic surgery industry is a multi-billion growth bonanza – with surgeons making big bucks by not having to deal with insurance – straight up cash please.  But dysphoria is at the core of this phenomenon, a cultural dysphoria we have all internalized due to our exposure to unattainable beauty ideals and constant exposure to the digital altered world where a thick instagram filter hides our imperfections.

There are many flavors and varieties of dysphoria – and it is not just a transgender thing either. It literally just means discomfort about some aspect of your physical body. But dysphoria is probably more associated these days with gender dysphoria.

Gender dysphoria is a special kind of dysphoria that is felt when one is uncomfortable in your body because it either makes you feel like the wrong gender or makes you socially perceived as the wrong gender. Gender dysphoria has been a known phenomenon for decades. Many kinds of treatment are available to gender dysphoric people. Therapy. Hormones. Surgeries. These have all been shown effective life-affirming and life-saving treatments. I wouldn’t necessarily argue these treatments should be seen as “medical” in any way, like fixing a broken truck. They affirm gender. They relieve that pain of looking in the mirror and not seeing yourself as the right gender. People who have never experienced it generally have little ability to know what it’s like. But I don’t want to buy into any system of thought that sees all trans people as these broken creatures in need of fixing with the doctor’s help. Some trans people might think they are broken but I don’t want to generalize to ALL trans people.

Why is dysphoria a symptom of modern society? It’s because dysphoria is a symptom of the hyper-sexualizing/beauty obsessed modern media machine that is Hollywood and American media at large, either in video games or magazines, to the models we see on the walls of every department store. It’s everywhere. When you see perfection everyday it’s hard to not feel like well if I had the money to spare maybe I really would like to have perfect teeth, or bigger breasts, or less wrinkles in my face, or a flat stomach. I would look younger, better, newer, improved.

Non-trans dysphoria feels like a tempting analogy with trans women who get “facial feminization surgery” which is essentially just cosmetic surgery with the intent of reducing masculine features and emphasizing feminine features.  The analogy is that the dysphoria of a cis woman wanting plastic surgery to look presumably more feminine and beautiful is like that of a trans woman wanting plastic surgery to look more feminine. Metaphyscially they seem to be very similar.

But we must be careful with this analogy. Very careful. Because we can make a distinction between healthy and non-healthy kinds of dysphoria, strange as that sounds. What kind of dysphoria would be healthy? First and foremost the kind that can be treated. If the underlying cause is gender based then there are proven treatments that often lead to easing the burden of gender dysphoria, though it might be present at low background levels or intermittent bursts. Second, in cultures that have a recognized social role for gender expansive people the kind of dysphoria present in those populations is not necessarily unhealthy so long as society at large approves transition and has the mechanisms in place to ensure a healthy transition.

On the other hand, the kind of dysphoria that stems from trying to live up to the beauty ideals in media and culture is a lot harder to treat because it’s based on a flawed ideology, an ideology of the body. Of what the body is supposed to be. This is also the root of cis-normativity as well. This kind of dysphoria is hard to treat with technology because the problem actually lies in the culture at large not necessarily in the individual. The media machine that spreads unattainable beauty ideals into every aspect of society is unstoppable and getting worse as our appetite as consumers grows larger. I don’t see it going away anytime soon. This affects everyone but especially young women.

But men have their own unique kind of dysphoria surrounding things like balding and muscles. They see physically perfect super men in Marvel movies and feel inspired to get a super hero body but few ever get to that level, just like most women don’t look like Kim K.

But I think it is these media-driven kinds of dysphoria that are unhealthy and thus different from the healthiness of gender dysphoria, which is rooted in concept- gender – that is absolutely fundamental to our essence as people whereas the beauty ideals of society are not core essential features – we can do without them thank you very much.

Last, and this is important, I don’t want this post to indicate that I mean to judge any particular person for getting cosmetic surgery. I support the autonomy of rational people to make decisions about their bodies as they see fit. And who am I to judge. But surely there are some cosmetic surgeries that cannot be described as healthy. People get talked into more work being done by overly enthusiastic surgeons during consultation.

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Estrogen and breakups = a lot of tears

Yeah, my engagement is over. She fell in love with another woman, a friend of mine actually – I even introduced them to each other. It wasn’t cheating. There was honesty and openness throughout the whole process. We briefly tried to do the poly thing but my now-ex partner and her new love just can’t do poly and want to be exclusive, so that leaves me out of the picture. Shucks. I just moved in a few months ago so I’m stuck wondering what’s gonna happen. I’m not getting kicked out right away but it’s gonna be weird living with my now-ex. It’s been hard. It is hard.

I’m still processing things – crying a good deal. Oscillating between feeling crushed inside and sad vs being icy and cold, closing myself off emotionally to what’s happening before my eyes, literally watching a relationship die. But now I’m calculating future possibilities. A whole new horizon has opened before me as the past 9 months melt away behind me. Old possibilities have died and new ones have opened up. In a weird way I’m excited for the future – the breathless anxiety of not knowing where I’ll be in a year.

Once again after the break-up of a serious relationship (I’m divorced) I am left with a dark cynical view of relationships. I will not jump into things so quickly again. Or I will try not to – the logical side of my mind does not always win against the almighty force of emotion.

On the bright side, during our little poly experiment I met a girl who is quite awesome – I really hope things work out – I really like her. She’s giving me hope that the future won’t be so bleak after all. She’s poly. And kinky. And smart. And successful. And beautiful. And she’s also a huge metal head (like me). So yeah – I hope it works out *crosses fingers*

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Infighting in the Trans Community

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Selfie culture: vanity or self-expression?

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Anyone who knows me well knows I post a LOT of selfies. On the days where I do my makeup (which is almost everyday) I take at least one selfie and post it on either instagram, Facebook, or tumblr. I sometimes post more than one selfie a day.I love it. I’ve been doing this since I started transition back in May 2015. However, I am generally very self-conscious of the image this projects to people who follow my social media accounts. I think often of: what do they think of me for posting so many selfies? Do they think I’m vain? Narcissistic? Shallow? Full of myself? Prideful?

Perhaps I am all of those things. But perhaps I want to carve out space in which it’s ok to be a little vain. After all, it brings me pleasure to take and post all these selfies – and who am I harming? I increase my pleasure and no one is harmed – sounds like a win-win right? If a little bit of vanity causes one to engage in acts that make you happy without hurting others – why not? Vanity has been thrown at femmes as a derogatory label since forever and us femmes have had to fight to protect our self-expression.

And that’s how I see selfie-taking – as a form of self-expression. I see makeup as a form of self-expression. Combine the two together and you have the hashtag #fotd (face of the day), which is my favorite hashtag. It legitimizes and normalizes the practice of selfie-taking.

Some people might have noticed that trans people early in transition post a lot of selfies. I am a good example of this. Part of it is documentation so I can look back on this special time in my life where my facial features are literally changing before my eyes. And part of it is just allowing myself to express femininity in an unfettered way, something I wasn’t able to do prior to transition. It gives me an excuse to put on my face, something I take intrinsic joy in doing – I enjoy the artistry of it – the infinite ways to paint your face.

Some might say “Oh well Rachel just posts so many pictures because she is pretty and has passing privilege and thus she’s just being vain, shallow, and narcissistic in taking so many pictures”.

And to this I say: so what? Again: who are we harming by taking selfies? And this brings me to a larger social commentary: why aren’t women allowed to think they are pretty after being told they are pretty? Ever notice that? Pretty women are not supposed to acknowledge their own prettiness. But after awhile, after hearing the same compliments over and over, you tend to hone on such things. And why should we play the demure little girl who isn’t confident in herself? Is it because women are held to unrealistic beauty standards that the acknowledgement somehow hurts women who are not pretty? Is it because vanity is a multi-billion dollar industry of plastic surgery? Perhaps – but it irks me that women are expected to live up to these high standards but not acknowledge their own attractiveness when they do meet them. But I am pretty sure I am pretty. Unless hundreds of people have been lying to me this whole time. And not to mention that it does seem possible for humans to look in the mirror and determine fairly objectively their own level of attractiveness.

Don’t get me wrong. I don’t want to claim that pretty women are some kind of super-oppressed class of people who need special protection. I raise this issue because I’ve noticed that women, especially trans women, who have less self-confidence tend to post a lot less selfies. But on the other hand, some of the most popular beauty bloggers on the internet are not attractive by the standards of Western society, specifically Hollywood. Beauty is not just about your raw physical features. It’s also about your personality, your grooming standards, the way you carry yourself, etc.

So this post has been about defending the existence and validity of selfie-culture for all those selfie-takers who get shit from others for “taking too many selfies”. Take as many selfies as you want. Post ten selfies a day on Facebook. Or more. Post 20 a day. You do you. Don’t let the threat of social judgment deter you from the practice if it makes you even the tiniest bit happy. And usually that’s why I love selfies: You get to see a picture that makes the selfie-taker happy in some small way. I love seeing selfies of my friends. I wish my friends would post more selfies. Maybe the world would be a better place if we spent more time posting selfies.

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My Many Privileges

First, I have the privilege of being white. I’m not going to elaborate on this privilege because if you don’t understand how being born white in America is a privilege then you’re probably just a racist bigot who won’t be persuaded by what I write anyway. But I recommend listening to the voices of #blacklivesmatter activists and listening to their stories of discrimination and violence at the hand of the police state as well as the systematic discrimination of white supremacy in the good ole US of A.

Second, I have class privilege insofar as I was born into the working middle class. My parents were never “rich” per se but they worked hard and could always provide food on the table and a roof over our heads as well as enough money for amazing Chistmas’s, birthdays, etc. I had a nintendo and LEGO and bikes and they bought me a car at age 16.I was fortunate to inherit money from my grandmother on my dad’s side. My middle class privilege has provided me numerous opportunities in life. Although I worked hard in school and was “smart”, my socio-economic status helped me get into a decent university while also having my family support me in countless financial ways through my young adulthood.

Part of my socio-economic privilege was that I was able to build up a good credit score which has allowed me to finance my transition, including paying for 8 sessions of laser (~$1,700) as well as buying a whole new wardrobe for all four seasons of St Louis weather (granted, I do shop at goodwill a LOT), buying a shit-ton of makeup, etc. I live a comfortable life for the most part. I have a lot of credit card debt but I managed to spend 11 years in higher-education without racking up any student loan debt.

I feel privilege that I was able to get so much university/graduate education before starting my transition. Some trans people feel like they would have been better off transitioning before puberty or during their teen years. But personally, I am glad I was not out-as-trans during highschool or college. For one, I would literally be a different person. And two, I probably would have faced outright bullying and intolerance. And I was able to use my “male privilege” in order to power my way through grad school without ever having my intelligence second-guessed just because of my sex.

But I can only feel that last one (late transitioning)  as a privilege because my genetics have made it such that when I did start transition, at age 29, after only like 5-6 months of HRT and a few laser sessions under my belt I started passing pretty well and now, 9.5 months on HRT and 8 sessions of laser, I pass probably like 80-90% of the time which is a HUGE privilege. It allows me to blend into society relatively well. My passing privilege allows me to be gendered correctly. To avoid harassment. To avoid danger, violence, insults. I don’t pass perfectly, and I am still clockable – but my genetic luck (and the laser) has made it such that I can go outside the house to run an errand without spending two hours putting on makeup to downplay my masculine features. I am lucky in that I don’t have to perform femininity to the extreme in order to be accepted for the person I am (although I do LOVE makeup and all things feminine and generally identify as a very femme person). But it’s not necessary to my survival. I also started transition with long hair and that helps a lot for avoiding misgendering.

Most trans women are not as privileged as I am. They struggle with suicidal thoughts. With homelessness. Rejection from family and friends. Depression. Anxiety. I don’t deal with any of that.  I haven’t been forced to turn to survival sex work just to pay for my hormones. I managed to get my legal name change ($175 court cost) without too much hassle. I have a good credit score.

I managed to find love and acceptance in my partner. I am happy and engaged. I found true love within the first year of my transition. You know how rare that is? I never take it for granted and count my lucky stars every day.

Sometimes I feel guilty – like survivor’s guilt. I want to make a difference – but who cares what a “stuck up white bitch” like myself has to say? I’ve been told I’m the “epitome of white passing privilege” and that I’m “just like Caitlyn Jenner”. But I still feel like I have important things to say. Important things to write. I want to help my fellow trans folks who are not as fortunate as I am. I want to be a voice for those who don’t have a voice. I never want to talk over people though I’m afraid I do that all the time as part of my privilege.  Please correct me when I’m wrong. I will listen. I’m all ears. I identify as an intersectional feminist. I want to listen to the diverse narratives of trans folks of all stripes so that I can boost their voices.

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Who Ultimately Decides To Change Trans Bodies?

 

The bioethicist Jacob Hale writes:

“This is not an endorsement of ‘surgery on demand,’ not even the more moderate view that surgery is a right to be granted upon request. Nor do I support Susan Stryker’s (1997) suggestion that the transsexual, rather than the psychotherapist, should ultimately determine what will happen to the transsexual’s body. Ultimately, decisions about whether to prescribe hormones and perform operations must be made by physicians – not prospective patients or mental health professionals – after careful patient-physician consultation and a thorough informed consent process” (Hale, C. J. (2007). Ethical problems with the mental health evaluation standards of care for adult gender variant prospective patients. Perspectives in biology and medicine, 50(4), 491-505.)

 

Although Hale disavows any kind of gatekeeping through the WPATH Standards of Care and advocates for an informed consent process, he mischaracterizes the nature of the shared decision making process by claiming that “ultimately” it is the doctor who decides what will happen to the trans person’s body.

If a trans patient comes into an IC clinic asking for HRT, the doctor checks for contradictions, and then decides to prescribe hormones, is it really the case that the doctor is “ultimately” making the final decision about what happens to the trans patient’s body? I think Hale is failing to distinguish between two different senses of what counts as the “ultimate decision”. On the one hand, the “ultimate decision” can mean the final step of the causal process, meaning that it is the doctor writing down the Rx on his pad that is the “final” decision. But in the other sense, the “ultimate” decision has already been made by the patient seeking HRT because it is their decision at a more fundamental level – they are the ones who stepped forward and made the decision to walk into the IC clinic with the intent on getting HRT. They are the ones who have decided to change their body.

Consider an analogy with an auto mechanic. A customer walks into the auto shop and requests a replacement of their exhaust system in order for it to sound louder. In one sense, it is the mechanic who “ultimately” decides what happens to the car because they are the ones who make the final causal step in agreeing to work on the car. But in another sense, it is really the customer who made the “ultimate” decision about whether to get a new exhaust system because it was their original desire for a louder exhaust system that brought them to the auto shop in the first place.

 

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The Traditional Gatekeeping Model of Trans Healthcare

Starting in 1933 with endocrinologist Christian Hamburger’s treatment of Christine Jorgensen, the triadic combination of psychiatric evaluation, hormones, and surgery became the default protocol for dealing with trans people who desired treatment. Not to mention that transgenderism itself was viewed by the professional community as a medical disorder – an idea that is now losing ground in wake of better knowledge about gender variance across cultures. The most comprehensive contemporary guideline for transgender healthcare is the Standards of Care (SOC) that comes from the World Professional Association for Transgender Health or WPATH. The WPATH guidelines provide a uniform set of standards for treating transgender and gender nonconforming people and have been the definitive source for transition guidelines for decades. When I talk about the “traditional” model of transgender healthcare I am referring to an amalgam of the WPATH guidelines prior to the 7th version( the current version, which came out in 2011), which has changed significantly to conform more towards the Informed Consent model. I’m focusing on the traditional model rather than the 7th version SOC because many healthcare providers across the world are still following the traditional model and using gatekeeping mechanisms to limit access to HRT and Gender Confirmation Surgery (GCS).

The first step in the traditional model is months of psychotherapy to evaluate whether the patient is genuinely transgender – often called the “trans enough” question. After this evaluation the patient would be diagnosed with gender identity disorder (GID) or “transsexualism” by a mental health professional.  Until 1998 the Harry Benjamin International Gender Dysphoria Association standards of care stated that “any and all recommendations for sex reassignment surgery and hormone therapy should be made only by clinical behavioral scientists.” (4th ed, 1990, quoted in Whipping Girl)

After getting a diagnosis of GID and starting psychotherapy, the patient would have to begin their “real-life experience test” (RLE) in which they are required to live full-time in their identified sex to experience what it is like living as their identified gender. Only after this real-life test, which could last for up to 1-2 years, would the therapist recommend the patient for hormone replacement therapy or sexual reassignment surgery. The WPATH 6th version recommends 12 months of RLE before irreversible physical treatment is started. The 6th edition WPATH Standards of Care state

“the act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. The real-life experience tests the person’s resolve, the capacity to function in the preferred gender, and the adequacy of social, economic, and psychological supports. It assists both the patient and the MHP in their judgments about how to proceed”

The underlying justification for these strenuous requirements was that the clinicians felt they were only trying to protect the trans people from having an “unsuccessful transition”, losing everything, and having deep regrets. As Julia Serano writes,

“Whether unconscious or deliberate, the gatekeepers clearly sought to (1) minimize the number of transsexuals who transitioned, (2) ensure that most people who did transition would not be ‘gender-ambiguous’ in any way, and (3) make certain that those transsexuals who fully transitioned would remain silent about their trans status.” (Whipping Girl)

The effects of gatekeeping in these early days can be seen in the fact that so few people ever got GCS despite the thousands of requests. The John Hopkins program accepted only 24 of the first two thousands requests for GCS.

Passing was considered a prerequisite for transitioning and thus for HRT – this bias still operates today implicitly and explicitly. Furthermore trans people were required to abide by heteronormative ideals such that a trans women should only show attraction to males and trans men only show attraction to females. The same applied to adherence to traditional gender expressions and gender roles, such as a trans women being femme and wearing makeup, heels, skirts, etc., or showing an aversion to “traditional” male activities or interests. Trans women still get turned down for HRT if they show up in jeans and a tshirt because this is evidence they are not “trans enough” or serious enough to begin medical transition.

The Stanford Gender Dysphoria clinic “took on the additional role of ‘grooming clinic’ or ‘charm school’ because, according to the judgment of the staff, the men who presented as wanting to be women did not always ‘behave like’ women…As Norman Fisk remarked, ‘I now admit very candidly that…in the early phases we were avowedly seeking candidates who would have the best chance for success” (Stone, 2006,  p. 227-228)

One of the most historically prominent endocrinologists, Christian Hamburger, was explicit in his recommendation of HRT only for those trans women who were not overly masculine. In discussing recommendations for HRT in trans women he writes:

“The attempts at feminization have better chances of being successsful in patients having a neutral or not pronounced masculine appearance. If the patients have a neutral or not pronounced masculine appearance, if the patient presents a black and vigorous growth of beard, deep voice, excessive hairiness on trunk and limbs, strong muscles and prominent veins, it is unlikely that the estrogen treatment will give a harmonious result. In such extreme cases it may be possibly wise to try to persuade the patient to abstain from any endocrine treatment unless the psychologic disposition makes such persuasion out of the question” (Green & Money, 1969, p. 302)

If a trans woman transitions yet maintains an masculine or androgynous appearance (such as a deep voice) then this would be considered “unharmonious”. This is a highly normative claim and builds a certain stereotype of what is to count as a “successful” transition. Can you be successful if people still read you as trans after your transition? Hamburger’s notion of “harmony” does nothing to address the question of psychological harmony: would going on feminizing hormones relieve dysphoria at all? If so, would not that be beneficial even if the patient was not harmonious with respect to the norms of society? Yet the medical gatekeepers who sought to prevent non-passing trans women from getting on HRT thought they were acting in the best interest of these patients, preventing them from harmful effects in society, post-transition regret, and a feeling of dissatisfaction with the results of HRT, which the doctors thought would leave these patients in a middle-state of ambiguity, neither male nor female and thus not able to fit into society in a functionally adaptive manner.

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