The Corrective Model of Trans Healthcare

In order to think about the logical limits of the informed consent model (IC) we need to imagine if it was practically feasible to do same-day bottom surgery on trans folks and someone woke up one day wanting gender confirmation surgery (GCS) after spending the entire morning making themselves informed on the risks and benefits. Furthermore, assume they are of sound mind and not having a psychotic episode. Would it be permissible for surgeons to perform GCS on this patient? The case seems absurd because under reasonable assumptions about how IC works there is an implicit assumption that the desire for GCS must not be a whim but rather a deeply held desire. Thus it seems reasonable there needs to be some persistence criterion built into informed consent (IC), and some diagnostic factor to ensure the persistence is there in order to prevent people from making rash decisions that they will later regret.

Furthermore, imagine the case isn’t about trans surgery. Suppose someone walks in same day to get a hysterectomy because they decided that morning they didn’t want kids. Or they have Bodily Integrity Identity Disorder and want to amputate a leg. We can multiply the examples endlessly to show that an extreme informed consent model does not work – some amount of gatekeeping needs to be in place to ensure that the decision is rational and in the best-interest of the patient.

Although the IC model represents a significant advantage over the traditional gatekeeping model, I do not think it goes far enough in addressing the needs of all people who seek out either HRT or GCS. Instead of the medical system, I propose that access to HRT and GCS should be modeled on the basis of the cosmetic surgery industry, where people seek treatment intervention in order to change their bodies to better align with their desired body image, or what I am calling one’s fundamental self-conception. I call this the “Corrective Model”, in the sense that cosmetic surgery is sometimes called “corrective surgery”. But the phrase “corrective” should not imply the Corrective Model assumes the desire for HRT/GCS is necessarily derived from an underlying medical condition or pathology. If I order a laptop off the internet and they send me a perfectly good but wrong model, I can request that they send me the “correct” laptop without assuming the laptop they sent me is in anyway defective. That is, one can desire to “correct” their body to better conform to an ideal image without believing they have a medical condition or underlying pathology. This ideal image I call someone’s “fundamental self-conception”. Not all self-conceptions are fundamental though. Making the distinction between fundamental and non-fundamental self-conceptions will be crucial for my project in carving out the uniqueness of transgender corrective surgery as opposed to traditional cisgender plastic cosmetic surgery.

Intuitively, the Corrective Model seems like a poor fit for the treatment of people seeking HRT and/or GCS. First, many trans people see themselves as having a medical condition, not a cosmetic condition. That is, they claim they want to change their bodies not for vain or superficial reasons but because they have a gender dysphoria, what they see as a medical condition that is characterized by significant distress over their sexed body and/or social role. Furthermore, the Corrective Model seems like a poor fit because of the need of trans people to have their treatments covered by insurance. If we model transgender healthcare after the cosmetic industry then it seems like this would limit access to HRT/GCS because cosmetic surgeries are typically not covered by insurance. The Corrective Model also seems like a poor fit because it treats gender dysphoria individuals on par with so-called “freaks” who want to radically modify their bodies through extreme cosmetic surgery, e.g., the Lizard Man. This invites further stigmatization to a marginalized group of people who just want to be seen as normal.

So the Corrective Model faces steep challenges. But none of these are fatal to the Corrective Model. All these concerns can be adequately addressed. First I will outline several distinct advantages the Corrective Model has over both the gatekeeping model and the IC model. Then I will address several worries about the Corrective Model.

Advantages of the Corrective Model

Lack of Gatekeeping

By modeling transgender healthcare on the Corrective Model, it necessarily removes the paternalistic gatekeeping based on the WPATH SOC that sets up strict requirements for access such as an in-depth documentation of gender dysphoria through a licensed therapist or medical professional. 

Allows for Non-Classical Treatment

There exist men who self-identity as men yet nevertheless desire to have breasts. These men do not want to live as women. They want to keep their male name, wear masculine clothing, and otherwise present themselves as normal cisgender men. Yet they sincerely desire breasts. For many of these men, their desire is sexual in nature. Having breasts would significantly improve their sex life and bring them psychosexual satisfaction. These men are rational and generally have no other mental health problems.

The traditional gatekeeping model would not recommend that these men get access to breast augmentation procedures or HRT. The IC model would also not recommend that these men get access to intervention because it is not a medical issue and there is not enough significant distress to warrant surgical/hormonal intervention.

The Corrective Model would make it permissible for surgeons to treat these men provided they have signed the appropriate waivers recognizing the physical and social risks involved. Crucially, the Corrective Model would not recommend that these treatments are covered by insurance because the desire for treatment is not rooted in dysphoria but rather euphoria at the thought of having breasts. These men are not suicidal because they do not have breasts nor is their psychosocial functioning significantly compromised from not having breasts. Rather, their psychosexual lives would be significantly improved if they had the treatment. I see no principled distinction between a cisgender man seeking breast augmentation and a cisgender woman seeking breast augmentation in order to make her feel better about her appearance. Both people are (1) rational and of sound mind, (2) have a strong desire to change their body, and (3) would not be hurting anyone else in virtue of getting their treatment.

On my view, the principle of autonomy makes it permissible for surgeons to treat these men who want breasts. These men have a fundamental conception of how they want their bodies to look and a vision for how they want their lives to go. They are not hurting anyone and they would be much happier if they had corrective treatment. There would of course be social risks for these men, risking social ostracization. But it should be part of their autonomous decision making process to decide whether the benefits outweigh the social risks.

Removes the stigma of pathologization

Increasingly trans people have started pushing back against the pathologization of their identities. Trans activists were responsible for removing “gender identity disorder” from the DSM, where, for decades, it was considered a mental disorder to have a gender that was different from the gender you were assigned at birth. GID was replaced simply by “gender dysphoria” such that it’s no longer a disorder to be trans in and of itself but dysphoria can be so bad as to warrant a mental diagnosis. Trans activists pushed for the non-pathologization of trans identities because of the societal stigmas that comes with being diagnosed as having a mental health disorder. Trans people were seen as not being rational enough to make autonomous healthcare decisions when it came to access to hormones or surgery.

Although this is a contentious issue in trans communities, I am going to follow the DSM in arguing that being trans in and of itself is not a medical disorder but rather simply a natural variant with the spectrum of human difference, like being tall, or being gay. This has important ramifications for how we think of access to HRT/surgery. If I am right that the correct model is the cosmetic surgery industry, then it’s important that we fully appreciate how surgeons will sign off on giving someone a face lift without needing any kind of well-documented diagnostic referral stating they are in psychological distress over their face lift. Rather, the patient simply consults with the doctor about their desires in accordance with their self-conception about how they want their body to look.
Thus, the advantage of the Corrective Model is that it moves away from the psychiatric conception of people who seek HRT or GCS. The psychiatric conception sees the desire for HRT/GCS as pathological, as a medical condition to be fixed, cured, or managed. While it is true that many trans people do in fact see their transness as a medical condition and many trans people experience gender dysphoria to the point of it being incredibly psychosocially distressing, this is not necessarily the case for all people seeking access to HRT, GCS, or top surgery. Some trans people claim to experience no significant gender dysphoria at all. Rather, their desire for HRT/GCS is rooted in gender euphoria, the palpable sense of relief and joy that comes from having their desired body and/or being treated as their identified gender. The Corrective Model is maximally inclusive because it enables these gender euphorics to actualize their autonomy by giving them a means to change their bodies in accordance with their fundamental desires without having to distort their narratives to fit into the classical transsexual model of gender dysphoria.

A bio-political argument for the corrective model

In his ground-breaking book Testo Junkie (2013) Paul Preciado writes:

I refuse the medico-political dose, its regime, its regularity, its direction. I demand virtuosity of gender; to each one, its dose; for each context, its exact requirement. Here, there is no norm, merely a diversity of viable monstrosities. I take testosterone like Walter Benjamin took hashish, Freud took cocaine, or Michaux mescaline. And that is not an autobiographical excuse but a radicalization (in the chemical sense of the term) of my theoretical writing. My gender does not belong to my family or to the state or to the pharmaceutical industry. My gender does not belong to feminism or to the lesbian community or to queer theory. Gender must be torn from the macrodiscourse and diluated with a good dose of micropolitical hedonist psychedlics. (p. 397)

Preciado’s call for “micropolitical hedonist psychedelics” represents a push towards a “radical” informed consent model that is in line with the Corrective Model. The decision to experiment with hormones, and yes it is nothing but an experiment, must be allowed by the medical profession to create “viable montrosities” of gender and sex through techno-medical treatment. Notice that Preciado is not merely meekly asking for access to HRT but “demanding” it. But where does this demand derive its moral-political authority? The authority derives from the “micropolitical” authority inside all of us, the autonomous center of decision making that helps constitute our personhood. We all have a vision for how we want our lives to go. We are the best authorities on what this vision in – only we can place the valuations upon what hormonal treatment means to us.

An upshot of the Corrective Model and Preciado’s call for virtuosity is that trans people should have the right to experiment with hormones without losing access to legal pharmaceutical drugs. If a doctor values maximizing cardiovascular health during healthcare treatment, but the patient values maximizing the relief of dysphoria through masculinization or feminization, then it should be up to the patient which pathway they choose. The job of the doctor is to provide information that is relevant to the decision making procedure but doctors should not have dictatorial power in influencing what treatment option is pursued. If a trans woman wants to be on 8mg a day of estradiol based on a careful consideration of the risks and benefits but the doctor thinks a conservative 4mg a day is less risky and thus preferable, the trans woman should be able to get access to the extra dosage so long as she signs off on the increased risks. If we are free to cause our own death by smoking excess cigarettes and eating cheeseburgers then presumably we should be able to take on a higher risk in our medical treatment. 

One might think this argument falls apart upon considering a parallel case in healthcare. Suppose a patient on opiates demands a higher dosage but the doctor is worried about the health effects and possibility of addiction. It seems preposterous that the doctor should be obligated to assent to the demands from the opiate patient. So why should patients demanding a higher HRT dose be allowed to get access to that dosage level? The problem with this opiate analogy is that it begs the question against the corrective model because it implicitly assumes we are working in a medical-pharmaceutical model instead of a model that is based on the cosmetic surgery industry. If a patient is demanding more botox, but the doctor thinks that they don’t need it or that they are already attractive enough, it is usually the patient demand that wins out. There are limits to this, however, no doctor would inject more botox than is medically safe in terms of causing immediate dangerous physical consequences. The corrective model does not advocate direct suicidal overdose by doctor prescription though it does advocate for informed risk taking. But the relevant analogical parallel is in terms of evaluating the risk with respect to the psychological effects of changing one’s face with botox. If a patient places enough value on a smoother face then it doesn’t matter if the doctor thinks it risks making them less attractive. It is the prerogative of the patient to get bigger lips or bigger breasts even if the doctor does not place the same aesthetic valuation on the change. The plastic surgeon is essentially a techno-surgical mercenary, willing to perform a procedure so long as the patient can pay for it.

So who pays for Preciado’s micropolitical hedonism? According to the corrective model, it is not the insurance companies unless there is a documented case of gender dysphoria. But Preciado explicitly devows the label “gender dysphoric” to describe himself. He calls himself a gender rebel, a biopolitical gender terrorist, performing a hormonal experiment to make a philosophical point. So gender dysphoria should not be the criterion used for getting a prescription of HRT. But if you want to get it paid for, then you must go through the medical-pharmaceutical-insurance system in order to get a diagnosis. This model is designed explicitly for the United States. In a country with universal healthcase, the question of who pays for micropolitical hedonism is trickier. Following the model of Basic Income, one could argue the government has a responsibility to provide the basic means for citizens to pursue their vision of healthiness and happiness.

Now, onto the objections:

Objection: Cosmetic Surgery is shallow

Reply: Cosmetic surgery is not necessarily shallow

There is a common assumption that when we are talking about cosmetic surgery we are necessarily talking about something that is “shallow” and superficial, that hovers on the surface and is largely inconsequential, that it doesn’t do anything but deal with someone’s vanity or desire to fit into today’s beauty culture. When we think of cosmetic surgery we think of someone unhappy with the size of their breasts, or someone who does not like the fat accumulation in their stomach. When we think of cosmetic surgery we think of treatments that are not medically necessary, that do not save lives or prolong life. Sure, cosmetic surgery might make you happy but you could have just learned to accept your appearance for a lot cheaper.

I believe this conception of cosmetic surgery is deeply flawed. I believe that cosmetic surgery can be both shallow and deep. It can address surface issues such as age-related wrinkles but it can also deal with deep psychological problems. All that “cosmetic” means is that it deals with appearances. But how your body appears is inseparable from how your body is and how your body is is deeply connected to psychological well-being. If a person with severe burn scars on their body wants to change their appearance, is that “superficial” or “shallow”? When we think of cosmetic appearances we think of a superficial focus on beauty, such as wearing makeup. But sometimes appearances can involve fundamental psychosocial issues such as when people with severe facial disfigurement seek out face transplants. Part of the reason these transplants are done is to deal with functional issues such as blinking or sensation, but the primary reason they are done is to deal with the “superficial” issue of how their face looks. But it would be insensitive to dismiss the psychosocial needs of these disfigured people as being superficial or shallow even though they are “cosmetic” i.e. dealing with appearances and not an underlying medical or biophysical problem.   

Feminist Critiques of the Cosmetic Surgery Industry

Studies have shown that cosmetic surgery is on the rise. Feminist scholars and historians argue that the rise of the plastic surgery business is directly a result of the increasing objectification of female bodies in the media, the way that the media judges the validity of a woman based on her appearance rather than her intelligence. With this critique in mind, some have argued that the entire Western obsession with unattainable feminine beauty ideals is an negative influence on young girls and women that has led to an unhealthy obsession with plastic surgery. Thus, if the cosmetic surgery industry is morally suspect then it would be bad to model trans healthcare on such a morally corrupt institution.

Along these lines, one might say to a trans woman seeking Facial Feminization Surgery (FFS) that she is just influenced unduly by society’s beauty norms and should seek self-acceptance instead of surgery in order to deal with the dysphoria she feels about her facial structure. But there is a key difference between “unhealthy” unattainable beauty ideals and the ideal body image of most trans women seeking FFS or other “elective” cosmetic surgeries. Trans women have been stereotyped as wanting to be nothing but Kim Kardashian-esque beauty models but in reality most trans women would be content with being perceived as an “average woman” rather than the most beautiful woman in the room. Feminist critiques of modern beauty culture focus on the cattiness and competitiveness of woman seeking to be the most beautiful in order to seek validation from society and to impress men. But most trans women seeking FFS are doing it fundamentally for themselves, in order to be happy just seeing a woman instead of a man in the mirror. Similarly, trans men seeking top surgery are not seeking approval of society – they are seeking corrective surgery in order to make their bodies line up with a fundamental self-conception of what their body should look like.

Insurance Coverage
One worry about the Corrective Model is that it would potentially take away the insurance coverage that so many trans people need in order to pay for their HRT and surgeries.But thinking about transgender treatment as being analogous to cosmetic surgery does not necessitate that no insurance company could cover the treatments.

When most people think of cosmetic surgery they think of “beauty” enhancing treatments such as botox or face lifts. Surely, goes the argument, the desire for HRT or GCS is different than the desire to have less wrinkles on your face. Imagine April was born without a nose. April’s condition in no way affects her physical health. Yet she suffers extreme psychosocial distress about her appearance. Would plastic surgery on her nose be considered “cosmetic” or “medically necessary”? Arguably it would not be considered medically necessary because her lack of nose does not affect her physical health in any way. But I would argue that it would be ethically obligatory for her nose surgery to be covered by insurance and that even if her treatment is not medically necessary it is psychologically necessary.

In the DSM-V there is no diagnostic category for “nose dysphoria”. Yet April’s lack of a nose is psychologically stressful to the point of causing problems in her life, both at work, socially, and with her family. Why not think of gender dysphoria in the same way as April’s lack of a nose? Gender dysphoria individuals are born with a body that causes them tremendous psychological distress which often leads to a host of psychosocial problems including depression, anxiety, and high risk of suicide. Some trans men believe they should have been born with a penis. This belief causes them an incredible amount of stress and often leads to psychosocial dysfunction. Calling the treatment of their condition “cosmetic” in no way necessitates a lack of appropriate insurance coverage.
The key advantage of the Corrective Model is that it puts the autonomy of treatment decision making into the hands of the patient. The patient gets to decide if they want a procedure to change their bodies in order to relieve their distress.

As we can see there is a fuzzy line between what counts as cosmetic treatment and what counts as medically necessary treatment. The line is so fuzzy that the distinction itself breaks down, especially if the worry is about the distinction between cosmetic treatment and necessary treatment, not just medically necessary. Not all treatments that are necessary are necessarily medical in nature. A treatment can be necessary to the proper psychosocial functioning of an individual without that treatment being necessary in the sense of being life-saving or life-prolonging.

Let us think this through with an example. A cisgender woman who desires breast augmentation in order to make her feel marginally better about herself should not be covered by insurance because it is a “shallow” cosmetic treatment. But now considered Jane, a cisgender woman. Jane has a flat chest. Ever since she was young she has agonized over her flat chest. Her flat chest has caused her endless psychosocial stress and the stress is so great that it prevents her from going out of the house or working. Due to her flat chest, Jane has been contemplating suicide. Although breast augmentation for Jane would be considered “cosmetic” because it is not medically necessary I believe it is ethically obligatory for insurance companies to cover her breast augmentation procedure. We can even imagine an entry in the DSM-V for “cisgender breast dysphoria” and it would parallel the entry for “gender dysphoria”. I see no principled reason for insurance companies to treat transgender breast dysphoria differently from cisgender breast dysphoria so long as the underlying psychosocial distress is equivalent.

Furthermore, the Corrective Model does not assume that the only valid reason for insurance coverage is psychosocial distress. As Judith Butler writes,

Examples of the kinds of justifications that ideally would make sense and should have a claim on insurance companies include: this transition will allow someone to realize certain human possibilities that will help this life to flourish, or this will allow someone to emerge from fear and shame and paralysis into a situation of enhanced self-esteem and the ability to form close ties with others, or that this transition will help alleviate a source of enormous suffering, or give reality to a fundamental human desire to assume a bodily form that expresses a fundamental sense of selfhood. [Butler 2004 92 Undoing Gender ]

The Corrective Model is pluralistic in terms of the justifications for insurance coverage. Arguably a cisgender woman’s desire for liposuction does not conform to a fundamental sense of selfhood in the same way that a trans woman’s desire for breast augmentation does and so the Corrective Model would therefore not endorse all forms of beauty-enhancement for insurance coverage. However, the line here between justifiably “enhanced self-esteem” and unjustified self-esteem enhancement is difficult to draw sharply. The attempt of therapists to demarcate cases of cosmetic enhancement that truly lead to better flourish from those that are vain, shallow, and derived from beauty culture will likely lead to the same gatekeeping problems that plagued the traditional model of trans healthcare. Instead of sharpening up our criteria to separate out moral from immoral cosmetic surgery perhaps it would be more ethical to change the nature of the insurance system to better enable human flourish on a wide scale.

Objection: The CM is Unfair to Cisgender Women

The idea is that if insurance companies cover Facial Feminization Surgery for trans women why shouldn’t they also cover facelifts or rhinoplasties on cisgender women? What’s the philosophical difference?

I believe the difference comes back to the issue of fundamental self-conceptions that don’t have an undue or unhealthy casual history that traces back to unhealthy displays of objectification in the media. For most trans people, it is not a desire for an unattainable beauty ideal they see in the media. It is simply a desire to blend into society, to be perceived a normal functioning member of society who is not a “freak” because of their gender ambiguity. The 55 year old woman who wants a facelift to look 10 years younger might “see herself” as being “really” 45 at heart but she is not exposed to violence, insults, discrimination, etc. in the face of being seen as a normal 55 year old woman. She is not prevented from using public bathrooms because of her wrinkles. Thus, another factor in separating trans cosmetic surgery from cis cosmetic surgery is the issue of justice. Trans people have historically faced injustice at the hands of a system that makes their very identity subject to attack and ridicule. The cisgender 55 year old woman might feel depressed and might be harmed by being exposed to the unhealthy societal beauty ideals but the harms are not directed at her in such a way that expose her to legitimate violence and harassment on the street whereas a trans female who is gender ambiguous faces real violence and trans man without top surgery has to bind their chest daily which can introduce many complications and difficulties that a ciswoman seeking breast augmentation simply doesn’t face.  

Who Ultimately Decides To Change Trans Bodies?

One potential objection to the Corrective Model is that it should ultimately be the doctor who decides whether to go ahead with the treatment, not the patient. Although Hale (2007) agrees with me that the WPATH SOC should be done away with, he still prescribes to the view that transgender treatment should be modeled after the standard medical model, albeit with more emphasis on autonomy than proponents of gatekeeping. He writes:

“[Getting rid of the SOC] 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, 2007, 503)

Although Hale disavows any kind of gatekeeping through the SOC 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 medical 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 of 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.

We can think of standard cosmetic surgery in the same way. A woman goes into the surgeon’s office seeking a face lift. The doctor checks for medical contraindications and then decides whether to go ahead with the treatment. As I see it, it is not the doctor who “ultimately” decides whether to change the woman’s face. The woman decides. It is her autonomous decision to do so. The surgeon is merely a technical expert that assists her and makes sure her desires are satisfied in a safe and effective manner.

Cosmetic surgery might be described as “surgery on demand”. But why is that problematic? It is not like you can walk into a plastic surgeon’s office and demand a surgery that will lead to immediately dangerous medical complications that will cause death the next day. The plastic surgeon still has to check for medical contraindications. So the “surgery on demand” is a red herring. What the Corrective Model really amounts to is “surgery on demand provided the surgery is medically safe”, which sounds decidedly less ominous than the way Hale describes it. Similarly, I believe we should adopt “HRT on demand provided there are no medical contraindications”. If someone just had a heart attack last week they should not be able to walk into a clinic, demand HRT, and then receive them. There are checks and balances in place that prevent such scenarios. But assuming the patient is healthy and of sound mind then it is ultimately the patient who decides what happens to their bodies.

Sexual Reasons for Wanting HRT or GCS

One might argue that treating transgenderism as a medical condition is appropriate because it weeds out “genuine” trans people who seek HRT/GCS from people who seek out HRT/GCS for “sexual” reasons. But this is no reason to abandon the Corrective Model.

Suppose Bob is a cisgender man who wants HRT and GCS because it would lead to a more satisfying sex life. Bob’s lack of HRT and GCS does not cause him any significant psychosocial distress. In my view, it is permissible for doctors to give Bob HRT and surgery on the basis of informed consent but I do not think his treatment should be covered by insurance.

The key difference between Bob and gender dysphoric people is that Bob does not experience significant psychosocial stress from not having HRT/GCS. Bob is not at increased risk of depression and suicide because he cannot have the body he desires.

Obviously it is a fuzzy line between “how much” distress is necessary in order to warrant insurance coverage. But presumably the professional class of doctors/therapists/psychiatrists would be able to determine if the gender dysphoria was significantly affecting the psychosocial functioning of the patient. On the Corrective Model, seeing a therapist is not a requirement for getting access to HRT/GCS but it is recommended. However, on the Corrective Model, if you plan on getting your insurance to cover your treatments then it would be necessary to seek out a professional therapist or psychiatrist to get a diagnosis of gender dysphoria showing that your gender incongruence is significantly causing psychosocial problems in your life.

Body Dysmorphia

Someone might object to the example of April wanting a nose by saying we already have a category in the DSM for people who are unhealthily obsessed with their physical appearance: Body Dysmorphia. People with body dysphoria, e.g., might think that their head is incredibly large and ugly and strongly desire to change their physical appearance. Isn’t this just the same as April, who is obsessed with her nose? Or perhaps this is akin to the anorexic who is obsessed with how their body looks. Treating these issues is not just a cosmetic issue – it is a medical issue. Shouldn’t we think of April’s case similarly as well as gender dysphoria?

The problem with this objection is that body dysmorphia and anorexia are both characterized by misperceptions of reality. The person who hates their head because they have a huge head actually has a normal size head – everyone in their life, doctors, friends, family, all ensure them that they have a normal size head. But no amount of external observation will change the belief that their head is too big. With April and her nose she is not making a perceptual mistake. Her nose really is gone.

Someone might object to my “distress” criterion by saying that the anorexic distress would be alleviated if we helped them achieve their desired thinness. But obviously we should not encourage or help the anorexic to become thinner. So the argument goes, the distress that Jane, the cisgender breast dysphoric, feels should also not be indulged as well. It would be better to put her in therapy in order to get rid of her chest dysphoria. But of course this never happens. If Jane walked into a plastic surgeon’s office seeking breast augmentation the surgeon would not deny her request and refer her to psychiatrist or therapist. He would listen to her desires and recommend the best course of action to satisfy her desires and relieve her chest dysphoria. If Jane’s dysphoria over her chest was so debilitating that she was unable to go out of her house or work a job then her treatment should be covered by insurance in the same way transgender surgery is covered by insurance.  

The Insurance Objection Redux

Someone might object that my distinction between who gets insurance is too fuzzy and reintroduces gatekeeping all over again. If who gets insurance coverage is determined by the amount of psychosocial distress, who gets to decide what amount of psychosocial distress is acceptable? The line seems so fuzzy that doctors and therapists would just be re-introducting their own biases and we have the same gatekeeping system the Corrective Model is meant to replace. Someone might instead argue that we should just have insurance cover all forms of cosmetic surgery rather than trying to argue the cisgender woman wanting breasts is “less deserving” of breast augmentation than the trans woman who wants breast augmentation. I am open to this objection.

Perhaps instead of trying to draw a line between acceptable and non-acceptable cosmetic surgery on the basis of diagnosed levels of psychosocial distress we should just be lobbying local and federal governmental systems to increase funding money for educational programs that seek to correct the fundamental problems of why cisgender women (and some men) seek out what many proclaim to be unnecessary cosmetic surgery. Feminists have long argued that media representations of women objectify and cast them as sex objects as well as give young girls and women unattainable beauty ideals. If we as a society spent more time and money on correcting this problematic media representation, then perhaps the issue of women wanting a face lift would not cripple the insurance system if that system did cover cosmetic surgery. Likewise, insurance companies would then have no basis to distinguish cis and trans desires for cosmetic surgery and everyone would be on equal footing in regards to using medical technology to make us feel more at home in our own bodies.

But this might just been as laughably naive. Cosmetic industry is a booming industry and if health insurance covered it willy-nilly then already rising premiums would increase dramatically. Which brings me back to my original claim: get rid of gatekeeping for cosmetic eligibility but have a system of therapists and professionals in place to assure that the people seeking corrective surgery have levels of distress that significantly affect their well-being. If psychiatrists and therapists can distinguish between sadness and clinical depression then surely they can distinguish between low levels of distress and significant distress when it comes to non-dysphoric individuals seeking cosmetic surgery. If the transgender woman seeking Facial Feminization Surgery is experiencing suicidal thoughts or is depressed by how she “doesn’t pass” because of her masculine facial features then a professional psychiatrist or therapist should be able to offer a diagnosis of dysphoria that enables insurance coverage. The cisgender woman who simply wants a face-lift because she feels “ugly” in contrast to beauty models likely will not receive a diagnosis of any kind unless she suffers from body dysmorphia in which the appropriate treatment would be covered by insurance.

Conclusion

There are two types of gatekeeping: minimal gatekeeping and transphobic gatekeeping. Minimal gatekeeping is about checking for medical contraindications such as heart disease or brain damage or psychosis and it’s about establishing whether someone is of sound mind to understand the risks and benefits of HRT. But I contend that in most cases it does not take 6 months of therapy to assess whether someone is of sound mind to start HRT. Transphobic gatekeeping is the type of gatekeeping whereby trans people are made to jump through many various hoops in order to get access. Transphobic gatekeeping is when trans women get turned down for HRT because they should up to the doctor’s office in jeans and a t-shirt (yes I have heard of such cases in the 21st century). Transphobic gatekeeping is the erasure of non-binary narratives and denying non-binary people access to HRT because they don’t fit into the standard narrative. Minimal gatekeeping is necessary and a part of the doctor’s duty. Transphobic gatekeeping is a much more pernicious idea insofar so it is the product of all the collective social biases we have against trans people and the very idea of transitioning. As a trans person I am highly aware that transphobia is alive and well. Doctors and therapist are not immune to that and thus have their own biases. This manifests in transphobic gatekeeping.

Gatekeeping Is Transphobia

Gatekeeping is a direct product of transphobia. Transphobia manifests in the ideology that being trans is a malady that needs to be prevented at all costs – that a child or adult transitioning represents a failure of character, a sickness, a failure or breakdown of what is right and proper for normal development of gender identity. Gatekeepers seek to limit the amount of people transitioning to it’s lowest possible number. The more cis people created, the better, since trans is a disease, a negative outcome that must be stopped. Gatekeepers are ultimately worried about cis people transitioning and then regretting their transition because they weren’t “truly trans”. This is why gatekeepers go out of their way to find reasons to discourage people from transitioning. Maybe you’re just a crossdresser. Maybe you’re too masculine/feminine to be trans. Maybe your hobbies do not align with the stereotypes that dwell within a therapist/doctor’s mind. Maybe your childhood doesn’t conform to classical “true trans” transsexual narratives.Maybe you walked into your doctor’s office wearing the wrong item of gendered clothing, making them doubt you are “really” trans. These acts of gatekeeping are direct products of transphobia.

Gatekeepers universally believe that trans people who pass better are more valid or real in their gender identity than trans people who pass less well. The is the basic function through which gatekeeping occurs. 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 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)

Hamburger represents the essential gatekeeping mindset. Passing equals validity in the mind of the gatekeeper. Non-passing means you are a deluded freak, a pervert, a confused cis person, and faker, a trans-trender. Strangely, gatekeepers think they are helping us – preventing us from making a mistake that we will later regret because of not having a “harmonious result” where harmonious means replicating the cis body to perfection such that society does not torment you to suicide or detransition. Notice how gatekeeping feeds off the larger transphobia of society. Because society shits all over trans people gatekeepers want to prevent “weak” trans people from transitioning because they will be chewed up and spit out by the transphobes of society, unable to find employment, housing, or love. If there was no transphobia, there would be no gatekeeping except for the minimal kind used to make sure the patient is rational and of sound mind in their desire for medical treatment.

The anti-thesis to gatekeeping is radical informed consent. Radical IC insists that trans people themselves are the best authorities on deciding whether medical transition is a rational decision. IC is fundamentally about respecting the autonomy of persons to decide which gendered body they want to live in: male, female, or something in between. It is the right of every rational person to have access to treatments that rectify fundamental incongruities of the mind-body that lead to psychosocial dysfunction. The difference between gender dysphoria and diseases like anorexia is that if anorexics had their way, their condition would lead to severe physical dysfunction. But if gender dysphorics had their way, their resulting condition post-HRT/GCS is not physically unhealthy when done under the supervision of doctors. If anorexics had their ideal body they would be physically unhealthy. If gender dysphorics had their ideal body, they would be perfectly normal functioning humans, aligned in their gender and their sexed body.

Gatekeeping is not compatible in a society that respects the autonomy of trans people. Some minimal gatekeeping is necessary to prevent medical contraindications, obviously. But that kind of gatekeeping is not pernicious. What’s pernicious is the Hamburger-style assumption that non-passing trans people are better off not transitioning at all. Pernicious gatekeeping is reflected in the idea that gender ambiguity is an “unharmonious result” and that the only acceptable result of gender transition is cis-passing. While many trans people of course also aspire to cis-passing, it should not be a hidden criterion implicitly used by therapists and doctors to discourage people from transitioning. At the heart of it all is cis-sexism, the pernicious idea that everything about the cisgender identity and body is superior to the transgender identity and body. It represents a metaphysical hierarchy of gender that places cis-ness at the top and trans-ness at the bottom.

In contrast, radical informed consent assumes that trans identities and bodies are just as real and just as valid as their cisgender counterparts. It accepts that people choosing to medically transition is not a bad thing, that hormonal and surgical treatments should be available to all those seek them with a sound mind and rational assessment of the risks and benefits.   Gatekeeping strips the autonomy of the patient and installs a false authority onto the doctor, a false sense that it is up to the doctor to decide whether transition is a beneficial decision. Informed consent puts the nexus of decision making back where it belongs: in trans patients.

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.

Transition, Hormones, Informed Consent, and Gatekeeping

So I have been on the fence about going on hormone replacement therapy (HRT) since I realized I am trans about 2-3 months ago. One of the big reasons that I didn’t necessarily want HRT was because I had to decide whether I want biological children or not given that I cannot afford to bank sperm right now (being on a grad stipend). I eventually realized (1) I can adopt or use sperm donors and (2) going on HRT is more important now than my long-term desires for raising children. In other words Im doing some temporal discounting right now and placing my priorities on my short-term happiness with the understanding that my long-term desires might change as I make further progress in my transition. I know that HRT will make me happier. How can I not choose that?

Another reason why I didn’t want to just ASSUME that because I’m trans I MUST go on HRT is that I have always liked forging my own path. I’m not going to do something just because everyone else is doing it. I think it’s perfectly possible to fully transition without HRT. It’s harder but it’s doable. I thought seriously about taking that route. But ultimately I realized that I want the secondary sex characteristics that come with HRT (mainly breasts).

So having decided that I want to go on HRT I talked to my psychiatrist yesterday and asked her for a letter. She said yes! And I booked an appointment for an endocrinologist on Sep 1st! So hopefully that means I will have a prescription for estradiol in a little less than a month from now. I am so excited! Besides doing laser for my facial hair this is the most significant step in my transition. I could hardly sleep last night.

For those that don’t know, many endocrinologists will not prescribe HRT to trans people without a letter of recommendation from a psychiatrist or therapist. Traditionally this requirement has led to many trans people not being able to get the treatment they need to feel comfortable in their own bodies and to ease their gender dysphoria. Such requirements have been criticized for being a method of “gatekeeping” that is biased towards trans people who have won the genetic lottery and have passing privilege. It was a lot harder for people without passing privilege to gain access to treatment because it was assumed that they would be “unsuccessful” in their transition and this would lead to suicide or self-harm.

But now the new model for HRT access is the “informed consent” model that doesn’t require a letter from a therapist in order to start HRT. So long as you are of sound mind and understand all the risks that HRT entails then an endo will prescribe you them and help you monitor your blood levels for safety reasons. For obvious reasons I think the informed consent model is superior to the traditional model. The biggest advantage is that the informed consent model respects the autonomy of the patient to make healthcare decisions for themselves. Since the principle of autonomy is one of the major foundations of biomedical ethics it’s pretty easy to make arguments that the informed consent model is ethically superior to other models.

Think about it. We respect the principle of autonomy enough for people to get FACE transplants, a hugely risky procedure that was entirely experimental until recently. Why did we allow this? Because the patients gave their informed consent. They knew the risks but decided it was worth the risk. And the risks of HRT are significantly less than the risks of face transplants. So the only reason why HRT has not traditionally been on an informed consent model is because of transphobia, which translates to the idea that transitioning is so radical as to require some kind of paternalistic oversight from the medical profession. But paternalism does not respect the autonomy of the patient. The underlying assumption of paternalism for HRT is that trans people are not of sound enough mind to evaluate the risks of going on HRT so the medical professionals need to make this evaluation for them. But often the professionals end up projecting their own transphobia onto the patient and bias themselves against trans people who dont have passing privilege or fit into the “standard” trans narrative (“I’ve always been a girl/boy”).