Undoing Gender (16 page)

Ironically, it is these very structures that support normalcy that compel the need for the diagnosis to begin with, including its benefits for those who need it in order to effect a transition.

It is with some irony, then, that those who suffer under the diagnosis also find that there is not much hope for doing without it. The fact is that under current conditions a number of people have reason to worry about the consequences of having their diagnosis taken away or failing to establish eligibility for the diagnosis. Perhaps the rich will be able to shell out the tens of thousands of dollars that an FTM transformation entails, including double mastectomy and a very good phalloplasty, but most people, especially poor and working-class transsexuals, will not be able to foot the bill. At least in the United States where socialized medicine is largely understood as a communist plot, it won’t be an option to have the state or insurance companies pay for these procedures without first establishing that there are serious and enduring medical and psychiatric reasons for doing so. A conflict has to be established; there has to be enormous suffering; there has to be persistent ideation of oneself in the other gender; there has to be a trial period of cross-dressing throughout the day to see if adaptation can be predicted; and there have to be therapy sessions and letters attesting to the balanced state of the person’s mind. In other words, one must be subjected to a regulatory apparatus, as Foucault would have called it, in order to get to the point where something like an exercise in freedom becomes possible. One has to submit to labels and names, to incursions, to invasions; one has to be gauged against measures of normalcy; and one has to pass the test. Sometimes what this means is that one needs to become very savvy about these standards, and know how to present oneself in such a way that one comes across as a plausible candidate. Sometimes therapists find themselves in a bind, being asked to supply a letter for someone they want to help but abhorring the very fact that they have to write this letter, in the language of diagnosis, in order to help produce the life that their client wants to have.

In a sense, the regulatory discourse surrounding the diagnosis takes on a life of its own: it may not actually describe the patient who uses the language to get what he or she wants; it may not reflect the beliefs of the therapist who nevertheless signs her name to the diagnosis and passes it along. Approaching the diagnosis strategically involves a series of individuals not quite believing what they say, signing on to language that does not represent what the reality is or should be. The price of using the diagnosis to get what one wants is that one cannot use language to say what one really thinks is true. One pays for one’s freedom, as it were, by sacrificing one’s claim to use language truthfully. In other words, one purchases one sort of freedom only by giving up another.

Perhaps this brings us closer to understanding the quandary of autonomy that the diagnosis introduces and the specific problem of how freedom is to be understood as conditioned and articulated through specific social means. The only way to secure the means by which to start this transformation is by learning how to present yourself in a discourse that is not yours, a discourse that effaces you in the act of representing you, a discourse that denies the language you might want to use to describe who you are, how you got here, and what you want from this life. Such a discourse denies all this at the same time that it holds out the promise, if not the blackmail, that you stand a chance of getting your life, the body and the gender you want, if you agree to falsify yourself, and in so doing support and ratify the power of this diagnosis over many more people in the future. If one comes out in favor of choice, and against diagnosis, it would seem that one has to deal with the enormous financial consequences of this decision for those who cannot pay for the resources at hand, and whose insurance, if there is insurance, will not honor this choice as one that is to be included as a covered elective treatment. And even when local laws are passed, offering insurance to city workers who seek such treatments, as is the case now in San Francisco, there are still diagnostic tests to pass, so choice is clearly bought at a price, sometimes at the price of truth itself.

The way things are set up, if we want to support the poor and the uninsured in this area, it would seem that we have to support efforts to extend insurance coverage and to work within the diagnostic categories accepted by the AMA and the APA, codified in the
DSM-IV
.

The call to have matters of gender identity depathologized and for elective surgery and hormone treatment to be covered as a legitimate set of elective procedures seems bound to fail, only because most medical, insurance, and legal practitioners are only committed to supporting access to sex change technologies if we are talking about a disorder.

Arguments to the effect that there is an overwhelming and legitimate human demand here are bound to prove inadequate. 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 to 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. However, some gender identity clinics, like the one at the University of Minnesota run by Dr. Walter Bockting, do make such arguments and do provide supportive therapeutic contexts for people disposed to make a choice on this issue, whether it be to live as transgendered or transsexual, whether to be third sex, whether to consider the process as one of a becoming whose end is not in sight, and may never be.
¹³
But even that clinic has to supply materials to insurance companies that comply with
DSM-IV
.
¹⁴

The exercise of freedom that is performed through a strategic approach to the diagnosis involves one in a measure of unfreedom, since the diagnosis itself demeans the self-determining capacities of those it diagnoses, but whose self-determination, paradoxically, it sometimes furthers. When the diagnosis can be used strategically, and when it undermines its own presumption that the individual diagnosed is afflicted with a condition over which no choice can be exercised, the use of the diagnosis can subvert the aims of the diagnosis. On the other hand, in order to pass the test, one must submit to the language of the diagnosis. Although the stated aim of the diagnosis is that it wants to know whether an individual can successfully conform to living according to the norms of another gender, it seems that the real test that the GID poses is whether one can conform to the language of the diagnosis. In other words, it may not be a matter of whether you can conform to the norms that govern life as another gender, but whether you can conform to the
psychological discourse
that stipulates what these norms are.

Let’s take a look at that language. The GID section of the
DSM
starts by making clear that there are two parts of this diagnosis. The first is that “there must be strong and persistent cross-gender identification.” This would be difficult to ascertain, I would think, since identifications do not always appear as such: they can remain aspects of hidden fantasy, or parts of dreams, or inchoate structures of behavior.

But the
DSM
asks us to be a bit more positivist in our approach to identification, assuming that we can read from behavior what identifications are at work in any given person’s psychic life. Cross-gender identification is defined as “the desire to be” the other sex, “or the insistence that one is.” The “or” in this phrase is significant, since it implies that one might desire to be the other sex—we have to suspend for the moment what “the other sex” is and, by the way, in my mind, it is not quite clear—without necessarily insisting upon it. These are two separate criteria. They do not have to emerge in tandem. So if there is a way to determine that someone has this “desire to be” even though he or she does not insist upon it, that would seem to be satisfactory grounds for concluding that cross-gender identification is happening. And if there is “an insistence that one is” the other sex, then that would function as a separate criterion which, if fulfilled, would warrant the conclusion that cross-gender identification is happening. In the second instance, an act of speech is required in which someone insists that one
is
the other sex; this insistence is understood as a way of laying claim to the other sex in one’s own speech and of attributing that other sex to oneself. So certain expressions of this “desire to be” and “insistence that I am” are precluded as viable evidence for the claim. “This must not merely be a desire for any perceived cultural advantages of being the other sex.” Now, this is a moment for pause, since the diagnosis assumes that we can have an experience of sex without considering what the cultural advantages of being a given sex are. Is this, in fact, possible? If sex is experienced by us within a cultural matrix of meanings, if it comes to have its significance and meaning in reference to a wider social world, then can we separate the experience of “sex” from its social meanings, including the way in which power functions throughout those meanings? “Sex” is a term that applies to people across the board, so that it is difficult to refer to my “sex” as if it were radically singular. If it is, generally speaking, then, never only “my sex” or “your sex” that is at issue but a way in which the category of “sex” exceeds the personal appropriations of it, then it would seem to be impossible to perceive sex outside of this cultural matrix and to understand this cultural matrix outside of the possible advantages it may afford. Indeed, when we think about cultural advantages, whether we are doing something—anything—for the cultural advantage it affords, we have to ask whether what we do is advantageous for me, that is, whether it furthers or satisfies my desires and my aspirations.

There are crude analyses that suggest that FTM happens only because it is easier to be a man in society than a woman. But those analyses don’t ask whether it is easier to be
trans
than to be in a perceived bio-gender, that is, a gender that seems to “follow” from natal sex. If social advantage were ruling all these decisions unilaterally, then the forces in favor of social conformity would probably win the day.

On the other hand, there are arguments that could be made that it is more advantageous to be a woman if you want to wear fabulous red scarves and tight skirts on the street at night. In some places in the world, that is obviously true, although bio-women, those in drag, transgendered, and transwomen, all share certain risks on the street, especially if any of them are perceived as prostitutes. Similarly, one might say, it is generally more culturally advantageous to be a man if you want to be taken seriously in a philosophy seminar. But some men are at no advantage at all, if they cannot talk the talk; being a man is not a sufficient condition for being able to talk that talk. So I wonder whether it is possible to consider becoming one sex or the other without considering the cultural advantage it might afford, since the cultural advantage it might afford will be the advantage it affords to someone who has certain kinds of desires and who wants to be in a position to take advantage of certain cultural opportunities.

If the GID insists that the desire to be another sex or the insistence that one is the other sex has to be evaluated without reference to cultural advantage, it may be that the GID misunderstands some of the cultural forces that go into making and sustaining certain desires of this sort. And then the GID would also have to respond to the epistemological question of whether sex can be perceived
at all
outside the cultural matrix of power relations in which relative advantage and disadvantage would be part and parcel of that matrix.

The diagnosis also requires that there be “persistent discomfort” about one’s assigned sex or “inappropriateness,” and here is where the discourse of “not getting it right” comes in. The assumption is that there is an appropriate sense that people can and do have, a sense that this gender is appropriate for me, to me. And that there is a comfort that I would have, could have, and that it could be had if it were the right norm. In an important sense, the diagnosis assumes that gender norms are relatively fixed, and that the problem is making sure that you find the right one, the one that will allow you to feel appropriate where you are, comfortable in the gender that you are. There must be evidence of “distress”—yes, certainly, distress. And if there is not “distress,” then there should be “impairment.” Here it makes sense to ask where all this comes from: the distress and the impairment, the not being able to function well at the workplace or in handling certain daily chores. The diagnosis presumes that one feels distress and discomfort and inappropriateness because one is in the wrong gender, and that conforming to a different gender norm, if viable for the person in question, will make one feel much better. But the diagnosis does not ask whether there is a problem with the gender norms that it takes as fixed and intransigent, whether these norms produce distress and discomfort, whether they impede one’s ability to function, or whether they generate sources of suffering for some people or for many people. Nor do they ask what the conditions are in which they provide a sense of comfort, or belonging, or even become the site for the realization for certain human possibilities that let a person feel futurity, life, and well-being.

The diagnosis seeks to establish criteria by which a cross-gendered person might be identified, but the diagnosis, in articulating criteria, articulates a very rigid version of gender norms. It offers the following account of gender norms (the emphases are mine) in the language of simple description: “In boys, cross-gendered identification is manifested by a marked preoccupation with traditionally feminine activities. They may have a preference for dressing in girls’ or women’s clothes
or may
improvise such items from available materials
when genuine materials are unavailable. Towels, aprons, and scarves are often used to represent long hair or skirts.” The description seems to be based on a history of collected and summarized observations; someone has seen boys doing this, and reported it, and others have done the same, and those reports are collected, and generalizations are derived from the observable data. But who is observing, and through what grid of observation?