all the doctors are friends (but not *our* friends)

this is just because i’ve been having some conversations about kids and gender and transition and puberty-blockers and so on. and having some feelings about that.

(to get a few things out of the way as a preamble)

what i want in the world is for folks (of all ages) to be able to make and put into effect any decision they want about what to do with their bodies – which means, practically, working for there to be more and more possibilities available to more and more people. in the realms of gender and sexuality that includes access to all kinds of body modifications, whether towards or away from any particular socially recognized gender position, and also access to all kinds of options for reproduction, from permanently or temporarily preventing it to actively facilitating it. what’s important to me is the possibility of real, meaningful choice, and the removal of restraints on that.

probably because of coming up right before and after the arrival of antiretrovirals, i think about most of the access-to-medical-transition stuff as a “drugs in bodies” question, through the analogy of AZT. in the absence of much actual decent research on HRT drugs (either to learn more about their longterm effects or towards making better ones), we already know they’re generally shitty, but bad drugs in living bodies is better than dead bodies.

(and here’s the meat of the post)

so: in the current conversations, mostly things are framed as a fight in which advocates for kids’ access to puberty blockers face off against advocates of “reparative/corrective therapy” to normalize kids to their assigned genders. that’s how, for instance, julia serano sets things up in her mostly useful piece on Medium last year.

and that’s generally how things play out among trans community activists, parents, TERFs, and other folks outside the medical institutions involved.

but here’s the thing: that’s not a divide that exists among the doctors.

the best-known puberty-blocker doctors and the best-known “reparative” therapists work together, publish together, and generally see each other as collaborators rather than opponents. kenneth zucker and peggy cohen-kettenis, for instance, co-wrote the chapter on “gender identity disorder in children and adolescents” for a 2012 “handbook of sexual and gender identity disorders”. and that’s not an anomaly: even a mild bit of googling finds the two of them as co-authors on papers all the way from the late 1990s to the past few years (with at least a few also including ray blanchard in the credits). and that collaboration isn’t just on the page: well-sourced gossip tells me that before zucker’s clinic was shut down (finally!), he was known to send so many kids who didn’t respond to his “conversion therapy” bullshit to puberty-blocker clinics that he was considered one of their biggest referrers.

whether or not you agree with the analysis i lay out in the rest of this, if you care about trans lives, you need to think long and hard about that. not just the fact of the collaboration and mutual support, but also the fact that it’s not part of the public conversation (even the parts of it that well-informed folks like serano help to shape), and the amount of work that has gone into keeping it out of the public conversation.

(and here’s the analysis)

so what’s up here? what is it that unites these doctors? i’ll get back to that shortly.

but first, i want to talk a little about what i think the unity behind this assumed divide means for us, as we continue the nearly-century-long fight for access to medical transition support on demand.

first of all, it means that folks who think, as serano wrote, that “our contemporary trans healthcare system … works in partnership with trans communities, and… increasingly has trans people’s best interests at heart,” are just plain wrong. if folks like cohen-kettenis feel comfortable collaborating with the likes of zucker or blanchard (to say nothing of agreeing with them enough to be able to write textbook chapters together), they’re untrustworthy partners at best, and at least some of the time actively opposed to trans folks’ best interests. and these are the ones we’re being encouraged to think of as the best of the lot! we certainly do need a healthcare system that fits serano’s description – but to the extent that the seeds of it exist at all, it’s sure as hell not in the clinics where these doctors work.

secondly, it means we need to put a lot more emphasis on getting detailed information about what goes on behind the scenes at the clinics and hospitals where we seek care. at this point, there’s not much. there’s some research i’m looking forward to seeing published based on a friend’s Ph.D research, using what she found out through extensive back-of-the-house access she managed to get to a number of the high-profile clinics – hopefully that’ll start coming out soon. and i’d love to see what someone with university database and journal access could turn up about the web of collaboration among supposedly trans-positive and actively anti-trans doctors. as sara ahmed has been saying: citation is accountability.

third, it means we need to be deeply skeptical about what’s being offered to us by “supportive” doctors who’re deeply entwined with anti-trans eliminationists like zucker and blanchard. not just skeptical about their rhetoric, but about the actual medical interventions they promote.

(okay, fine, here is the analysis)

and that takes us back to the doctors we’ve been falsely told to see as two different camps.

what they agree on is a vision of a world where there are as few trans folks as possible, and where the ones who do exist are as indistinguishable from cis people as possible.

it’s a revolving door. the “conversion therapy” quacks think they can make kids stay as assigned? the puberty-suppression doctors are fine with that, as long as they get to make sure the ones who can’t be tortured into changing their minds can be made to blend right in. and the conversionists are down with that plan, too: if they can’t torture someone into being a proper man, at least someone else can make sure the kid winds up a proper, indistinguishable-from-cis, woman (or vice versa).

it’s the same vision as back in christine jorgenson’s day: discourage everyone possible, and make the rest live stealth. and that’s where the shared focus on kids comes from. it depends on establishing, as soon as possible, a person’s True Nature. then, they can be molded to fit it properly, whether through “reparative” therapy to shore up a crumbling gender assignment, or puberty suppression to guarantee the possibility of a stealth life.

what that approach does today, just as it did then, is make it harder for different kinds of trans and gender-deviant folks to support each other. which has been, of course, a main project of the past fifty years of organizing, and why our movements have created umbrella terms like ‘transgender’ as tools for unity.

(in that spirit, here, as i usually do, i use “trans” in the umbrella sense: meaning including nonbinary folks, and centered on those of us, binary-oriented or not, who live our everyday lives outside the presentation usual to our originally assigned gender)

the doctors’ vision, on the other hand, strengthens the line between folks who seek and are given access to medical transition and those who can’t get access (i.e. poor folks; black and indigenous folks; immigrants and refugees; disabled folks; some nonbinary folks; many non-fancy sex workers; &c) or don’t want access (folks who live as trans women or men without medical support; some nonbinary folks; some folks with culturally-specific gender positions that aren’t men or women; &c).

and that in turn encourages folks who can get access to medical transition to see value for themselves and folks like them in making that line as visible as possible: if they can more easily be told apart from the rest of the transgender world – or made more indistinguishable from cis people – then perhaps they won’t have to deal with the ways that our society attacks us. it’s the same fantasy of escape from community and history that has driven well-off gay liberals and gay conservatives to prioritize a symbolic push for ‘marriage equality’ rather than fighting for protection from discrimination in employment and housing, and to throw trans folks and sex workers under the bus at every turn.

that last bit stems from the “as indistinguishable as possible” part. the “as few as possible” part is creepier, especially where it slides out of gatekeeping and into eugenics. that’s where reproductive justice arrives to ruin everybody’s party, especially those who want to celebrate greater access to puberty blockers.

the doctors admit that no one has found a biological basis for being trans. but they all still believe that it’s there – that all people have some kind of innate True Gender that makes them either Truly a Man or Truly a Woman according to european christian/roman gender norms. never mind that gender as a structuring system isn’t universal among human societies, or that where it exists its content varies wildly – they’re not gonna read oyèwùmí, boyarin, or even kessler & mckenna. for them, the question isn’t whether being trans is genetic, it’s how to prove it. for instance, one of those cohen-kettenis / zucker collaborations i mentioned was a 2008 article on finger-length ratios, a popular subject for scientists desperately seeking to prove genetic causation (phrenology would be simpler).

i don’t think that the fantasy of a genetic basis for trans-ness is separable from these doctors’ promotion of puberty blockers. this form of treatment is meant to be smoothly shifted to ‘adult’ HRT and accompanying surgeries, which sterilize folks who go through it. that’s an added bonus, not a problem, for anyone who believes that being trans is genetic (especially without a specific basis to look at) and wants there to be fewer trans folks. it’s also right in line with the eugenic aspect of almost every other phase of medical and legal engagement with trans folks, which have almost always, almost everywhere (until very recently) required sterilization even before allowing access to HRT, forms of surgery that have no effect on reproduction (chest/breast surgery, FFS, &c), or changes to identity documents. there is no health-based rationale whatsoever for these policies, whether imposed by governments or medical institutions. some have been explicitly about not allowing “inferior” folks to have kids; all of them are based on that logic, and that logic alone.

now, the fact that there’s no there there – that being trans is a social condition, not a genetic one – doesn’t make this eugenic approach any less fucked up. that just means the doctors’ approach isn’t going to accomplish their goal of making there be fewer trans folks.

what it can accomplish, however, is making there be fewer trans parents, and in particular fewer trans parents of non-adopted kids (which doesn’t mean much: adoption agencies are massively bigoted in all kinds of ways, including being anti-trans). and that’s a reproductive justice issue, in a big way, and one that should shape our understanding of the place of puberty blockers in trans medicine.

the deal the doctors are offering us right now is, essentially, some trans folks turning out more indistinguishable from cis people, in exchange for sterilization. i don’t see that dealing at all with the things that make most trans folks’ lives hard in this society: employment and housing discrimination; the criminalization of sex work; lack of access to identity documents; lack of access to medical care, including medical transition for those who want it; state and social violence. as long as these conditions continue, even the most indistinguishable-from-cis trans person will live in fear of being outed and targeted, and the vast majority of us will continue to face them every day.

i think we owe it to young trans folks to not pretend the deal the doctors are offering them these days is some kind of wonderful liberatory advance. it’s not even particularly different from what was on offer decades ago – the gatekeepers have just expanded their scope to allow them to search for and decide about the True Genders of ever-younger folks. we need to continue to work for actual liberation, and to talk with young trans folks about what that can look like and how we can get there together. to me, liberation includes the medical research that can make it possible for us, regardless of age, to be who we want to be in the world without sacrificing their right to choose whether or not to have kids (as for me, i choose not, but ymmv). but even more so, it includes the social transformations that end the oppressive conditions i laid out above, and along with them, the structures of power that make them possible.


is anyone else done with the term “gender dysphoria”? one of the things the doctors and trans folks like serano agree on is the idea that dysphoria as an individual interior state that indicates someone’s True Gender, rather than a social product of oppression. can we just start saying “internalized transhatred” already?

just to make it clear how this connects to the rest of this piece: if dysphoria comes from within, as serano and the doctors agree, the answer to it can’t be changing a society that hates trans folks and our bodies and makes many of us internalize that hatred. instead, even in a fully transformed and affirming society, the only way to deal with it is individually – to make each trans body as much like a cis one as possible. which then depends on a smooth exchange of puberty-blockers for HRT and surgical interventions – and thus on sterilization.

and, because someone’s bound to have a snit about it unless i’m perfectly clear: internalized transhatred is real and material and fucks up people’s lives. just like any kind of internalized oppression. the fact that it’s induced from outside – that it’s a social product – doesn’t change that. we can (and do, and must) struggle against the different ways that it manifests in our various selves, as well as the social forces that create and feed it. which is a perfectly good reason to go for medicalized transition support (and a perfectly good reason not to); and access to that kind of support will be no less important after there isn’t much transhatred out there to internalize. but what we don’t have to do – what is destructive for us to do – is to accept the doctors’ fantasy that it is inherent to who we are as trans folks, or believe them when they tell us that so-called dysphoria is Our Lot In Life (a/k/a Our Fault), but it’s okay because they (and they alone) can fix it.

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