Transitioning at the Clinic

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“It is good to have an end to journey toward; but it is the journey that matters, in the end.”
Ursula K. Le Guin, The Left Hand of Darkness

Transitioning can be wonderful, affirming, and lifesaving. But it can also be a deeply problematic process; unless you’re rich and have access to resources and services. And while access to hormones is becoming more available for those of us who reject the binary notions the trans healthcare system is based upon, accessing medical services is still mired in ideas of binary sex and cis/hetero normativities. And unfortunately, most of us can’t afford access to medical interventions that circumvent these systems — a beach hut in Thailand.

I’m going to use the system in Netherland’s — where I reside — to illustrate my points. And while most Western clinical systems come from a similar medical institutional genesis, they operate with some variance depending on region/country. The American system is viewed by outsiders as having more freedom, but it is not subsidized. While the Canadian, UK, and Australian systems are accessed through lengthily gatekeeping models, but with subsidization. The VUmc in Amsterdam, which is one of the older style university clinics, like its mid-century American equivalents, is the primary trans healthcare provider in the Netherlands. The VUmc has historically doggedly attempted to shut down any other service providers that try to rise to the occasion of alleviating the desperate wait times it has created (even in a country as small as the Netherlands there is a massive demand for trans healthcare services).

The centrality of the VUmc’s power and control mean that it can still adhere to older models of trans healthcare that reflect Harry Benjamin’s diagnostic criteria form the 60s. And while the VUmc may not directly look for “true transsexuals,” its aggressive gatekeeping, intentionally long wait times, real-life trial times, and biometric criteria, ensure that only the most normative bodies receive treatment expediently. Thus, trans people looking to access medical services are still subjected to a largely patriarchal medical science which seeks to admit and treat bodies that most align with cisgender standards.

I should mention that there is an informed consent clinic in Amsterdam which is run through a sex-worker health organization (Prostitution Information Center [PIC]). It provides critical access to hormones and legal services to people unable to access the VUmc, or unwilling to acquiesce their long wait times. However, if you want surgery, then the VUmc is still the main option. The VUmc will not honour treatment done in the PIC clinic and therefore demands that the same wait times are adhered to for all clients, even for trans people who have been on hormones under medical supervision for years. There is no fast-tracking. Unless you have money and can leave the country. And even though a recent clinical network has taken off, despite the VUmc’s efforts to the contrary, surgery is complicated for trans people using the alternative system. This is because the VUmc refuses to cooperate.

What I find most disturbing about this system is how it is predicated on allowing the most cisnormative bodies to survive, while being incredibly inflexible to other types of bodies and gender identities. The medical transition process described above is one that assumes that we can transit the gendered and sexed space between opposed gendered states ([M]→[F]) &([F]→[M]). This is a holdover from when only “true transsexuals” were allowed to receive surgery and hormones: i.e. transsexuals who will pass, disavow any sense of pre-surgery sexuality — because that would be problematic — and assumed to have heterosexual relationships in the future. In other words, typical boys and girls.

Additionally, this system propagates the myth that these clinical processes have the power to take the fractured gendered self and traverse it along a linear track to a sense of whole being — healed. Remember that this is a system that ascribes fixed normative roles for gender and sex. And yet, gendered subjectivity and corporeal sex are complicated and diverse. It is thus unlikely that such a system can accommodate the plethora of gendered and embodied experiences. And then there is the issue that the system also assumes that body/self before transitioning is wrong-bodied. The very idea, when framed this way, is little more than a thinly veiled pathologization. Defining the pretransition body as wrong makes the entire process of gender transition more palatable to cisnormative sensitivities (there is something wrong here). It suggests that medical and legal interventions can fix the body, bring it in line with norms. It also casts the intermediately sexed/gendered body as incorrect, thus upholding cis/heteronormativity. The clinical process replicates a modernist narrative of progress and technological triumphalism.

What is perhaps most disingenuous about this type of system is its promise of healing. Surely for many, this is a process that is worth taking and will bring some form of relief — maybe lots. However, because of the temporal and spatial nature of medical transition, i.e. that you are a body that is becoming through transiting medicolegal systems, sometimes on an international scale, you will eventually arrive at a gendered telos — an end. This may be cold comfort for those of us who do not experience a fixed sense of gender. But even to those of us who define ourselves within the binary of woman and man, there are myriad factors that may disrupt this march towards harmony. On one level, the system — if not directly asking to — encourages us to create a fissure or schism between the current (aspiring towards) gendered subjectivity and that which comes before. In this system, the trans body moves from male to female or vice versa. But what happens in the liminal space (the → between the M&F)? A gap is created, a disjunction, made invisible by the emerging new subjectivity, a new corporeal understanding of the body. This is hardly a form of healing, but rather a rupture between past, present, and future.

Not all of our gendered experiences can be reconciled by the simplicity of MtF or FtM. What about the self that comes before and in-between? There is a great deal of diversity in how trans people think about their pre-transition selves (if they even choose to transition medically). Surely most of us have some incongruent experiences which defy such straightforward and progressive movements as MtF. This was traditionally dealt with through diagnostic criteria that were meant to suss out the “fake transsexuals,” the paraphilic. And though current clinical guidelines are more accepting of gender nonconformity, they still look for these markers. We often, whether through the clinic or ourselves, create narratives that accommodate these incongruences — a self-narrative: “I was like this all along” (maybe you were). In fact, in previous decades, this was a clinical imperative (falsified past histories). But why should we have to do this retconning? The answer is it reinforces notions that gender is static when it is largely contextually constructed. With that construction in mind, why isn’t my childhood, an antecedent to womanhood, even with the gendered-warts, considered a girlhood 2.0 (if girlhood is what proceeds womanhood)? Why should I have to clean it up? I know the incongruent parts; they were extremely private and felt like a betrayal of the social gender fabric. By re-narrativizing these experiences, we only reinforce their negative associations.

Furthermore, if there is a normative gendered state we are to aspire towards, many of us will not get to recognize it. I generally pass — I think; no one bats an eye when I use the toilet which is a cis privilege. And yet, the societal pressure around female body image and pervasive transphobia coalesce in a way that makes it very hard for me to feel comfortable in all 189 cm of my body. SRS (GRS, whatever you want to call it) won’t fix this. Additionally, while I am privileged enough to have had the resources to go to grad school, after four years of transitioning in foreign countries without the ability, still, to change my identity documents, I am placed in a state of permanent precarity. This precarity is entropic and erodes my material and psychic wellbeing. I am not sure if it will end. And this brings up another problem with the futural temporality of the clinic. Far from returning trans people to a sense of chrononormativity, that is a life that is dominated by normative, white, middle-class capitalist aspirations of wealth accumulation, children, property, career progress, retirement, and then death, transitioning can create queer temporalities that render normative life goals/events impossible or undesirable.

There are other issues with the clinical model, and for many people, these aren’t deterrents. Trans people are resilient and used to hobbling together healthcare. However, looking at this process I find its legacy of mid-twentieth-century medicalization problematic: with its association to cis/heteronormativity and the assumption that the gender binary is natural — even scientific. Thus, I am forced to chart my course, as much as I can. And yet, for those of us who want/need medical services and interventions, this is not an easy task. Something as seemingly quotidian as mobility for a white middle-class body becomes incredibly fraught. And sometimes, after four years of this, I feel empty and finished. Far from the promise of being healed, I need to shore up incredible amounts of energy to go out and deal with another setback, another legal document, find another source of hormones, or a reference to another clinic. But perhaps these things feel visceral to me because I am doing them on my terms, against the grain — as much as I can. To be trans and mobile is to be a rebellious body (when that movement is systemically transgressive and not replicating mobility in a capitalist sense). But I think the issues I experience transitioning in a transnational context only help highlight similar forces we all have to deal with if we take up this course.

I am leery of creating a post like this because god knows that transphobe loves them; I am not criticizing being trans. I am criticizing how little control we have over our healthcare and the power dynamics behind the providers of said healthcare. I will end with an anecdote. I have not confirmed this, but I have heard it from several trans people. Apparently, the VUmc does not hire trans doctors at the gender clinic. Why? I suppose they believe they can’t be objective providers of trans healthcare. And if this story is true, then it captures the problems I am trying to point out here perfectly.

I’m trans, a grad student in gender studies, and a legal researcher.

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