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In this chapter I expand upon the discussion of medical social control outlined in the previous chapter by analyzing some the mechanisms that are used to exert power over trans people. I start by looking at healthcare in the UK as a bureaucracy which illuminates the structure of gatekeeping and barriers that have been placed between research participants and accessing the healthcare they need. The elements of these bureaucracies that the participants helped illuminate, including cancelled appointments, ‘ticking boxes’, jumping through hoops, shifting responsibility, the structure of forms, and social networks (Varela, 2001), are all sites in which trans people come up against barriers they must navigate to access their healthcare. I also look at time as a key factor in these power structures, which particularly manifested for all participants as waiting. Finally, I look at the physical spaces in which research participants and trans people more broadly create and enact their gender, particularly waiting rooms and bathrooms, with the help of Lucas Crawford’s work on transgender architecture. This research has identified these spaces, time, and state and medical bureaucracies as simultaneously tools and loci of power which can keep trans people from maintaining or achieving health.
Throughout this book, I have shown what it is like to navigate cisnormative healthcare systems as a trans person. But what would it look like to navigate a healthcare system that presumed a trans patient? Even if it is just a healthcare system that acknowledges the possibility of a trans patient there would be some major differences. As a standard across health services titles would be written in just like names and would not be changed by admin staff upon seeing the patient’s gender marker. Names and titles would also be easily changed. In terms of gender markers, sex and gender history would be recorded with more detail or perhaps there would be no need to record a patient’s sex and/or gender at all. Relevant body parts (that is, cervix, prostate, breast tissue) would be included in forms to offer correct cancer screenings and other care and these records would be kept up to date following any surgeries. It would be common practice to ask for or consult notes to determine a patient’s pronouns before consultations. In general there would be less multiple choice and more open-ended questions on forms and in appointments. There would be flexible ward assignments in hospitals. Most importantly, however, transness would not be considered a disorder and transition related healthcare services would be provided on an informed consent basis. It is this idealistic but nevertheless easily imaginable scenario that I describe in this chapter.
This book analyzes trans health in the UK through two key questions. Firstly, what barriers are there between trans people and the ability to access quality healthcare? Secondly, when they are able to at all, how do trans people overcome those barriers? I have found that there are significant and unique obstacles that delay or prevent trans people from accessing both transition and non-transition related healthcare. However, I have also found that in many cases trans people are able to overcome or at least push back against these barriers in creative and effective ways. Understanding these barriers suggests demedicalization as a solution, which brings up a central tension that will be addressed in this book, one between demedicalizing transness and ensuring continued access to medical technologies for trans people who require them. Additionally, I outline a trans methodology which has developed throughout the course of this research. Overall this work paints a picture of a healthcare system struggling to meet the needs of a population and illuminates what we can learn from that population’s response to that struggle.
In this chapter I argue for the demedicalization of transness as a key way to remove existing barriers to health. The NHS uses a diagnosis of ‘gender dysphoria’, which can also be referred to as ‘gender identity disorder’. This diagnosis and the corresponding ‘treatments’ of psychotherapy, hormone replacement therapy, and assorted surgeries represent the contemporary medicalized model of transness in the UK. My research demonstrates how this model has failed trans people. To best understand how medicalization operates and therefore how to counter it I use the extensive work of Peter Conrad. In the second portion of the chapter, I look at possibilities for limiting or eliminating that medical social control, in other words I outline a proposal for demedicalization. Here I use the work of Georges Canguilhem and compare some of the problems with the demedicalization of homosexuality with the proposed demedicalization of transness. In spite of these challenges, I propose that a non-pathologizing model for transness is necessary and urgent to address the dire issues raised in this research.
In this chapter I argue for moving past an understanding of sex and gender as completely separate and unrelated phenomena and toward one that comes to terms with the ways in which they are intertwined. To do this I look at the work of Emily Martin and Anne Fausto-Sterling to lay out how our understanding of how ‘biological sex’ is influenced by cultural ideas of gender. This leads to the very problematic idea that there are ‘male’ and ‘female’ bodies and that the only possible explanation for trans existence is that trans people were ‘born in the wrong body’ (Bettcher, 2014). I unpack the problems associated with this model, and critically address some alternative models including the ‘beyond the binary’ model, and the blatantly harmful ‘trans women are really just men’ model. This chapter will serve as important background for understanding the challenges faced by the research population.
In this chapter I look at how research participants used an alternative form of pedagogy, one that is social and decentralized, to exchange unique and targeted knowledges, what I call TransLiteracy. I specifically highlight the ways in which trans people learn to strategically deploy personal narrative but I recognize a wide range of knowledges that are exchanged in this way. For research participants this included everything from how to get referred to a gender identity clinic (GIC) to what shirts would be flattering: basically anything and everything a trans person may need to know in order to navigate the world. These knowledges are dispersed in different ways, but this research focuses on social media as a key pedagogical tool. Being decentralized decreases gatekeeping by experts. Every participant in this information exchange can, at one point or another, act as both the teacher and the student, adding to or learning from the lived experience of these communities. Being social contextualizes and personalizes the information as well as providing a diverse range of voices, ensuring the person trying to learn has the best opportunity to get accurate and helpful answers to their questions. The social aspect of pedagogy along with specific trans knowledges such as understanding the trans dialect and identifying allies and fellow trans people further help to build community. In this way pedagogy and TransLiteracy has helped research participants overcome barriers to their health through becoming better able to access transition and non-transition related healthcare and building community which bolster good mental health.
With those existing models put to the side I then explore how sex and gender are actually attributed (Kessler and McKenna, 1978/2006; Blackless et al, 2000; Roughgarden, 2004/2013). I try, and fail, to concretely define male-bodiedness and female-bodiedness and so instead explore how sexes and genders are assigned, both in everyday and in healthcare settings. This relates to my research where participants described the barriers they faced in navigating a cisnormative healthcare system. I then challenge the need for attributing sex and gender to others in the first place and propose a model of sex and gender where these concepts are equally socially constructed and can only be determined and articulated by the individual. This model would improve access to care for people like my research participants.
Healthcare for transgender people is in crisis. Many of the problems stem from bureaucracies within the health system, limiting conceptualizations of sex and gender, and the requirement for a diagnosis of ‘gender dysphoria’.
This book presents a unique argument for full demedicalization of transness as a crucial step towards removing existing barriers to good healthcare. Resisting the current norm of separating sex and gender, it also argues for an understanding of them as necessarily interlinked and co-constructed.
By elevating trans voices and experiences, this book offers a new perspective on transness, medicalization and research methodologies to help trans people, practitioners and policy makers better understand the barriers faced by trans people when seeking healthcare.
Here I describe the first finding of this research, the development of a trans methodology model. I begin by laying out my formulation of an ethics of a specifically trans methodology. This methodology evolved throughout the research, so it is based on what worked successfully in this research while also expanding the ideas beyond just this research project. The methodology has four elements: the research is done entirely within the communities; if interviews are used they center the voices of trans people in their own words; the research is written up in a trans style (which I describe in more detail later in this chapter); and the research is disseminated back into the communities in an accessible way. Following trans scholars Paul B. Preciado, Lucas Crawford, and others, and inspired by scholars of color like Richard Delgado, I describe the highly community focused approach to research, analysis, and dissemination that I took while completing this work, as well as ways that I can move toward an even more community centered approach with future research.
In this short article, we call for policy makers, activists and academics to take account of food aesthetics of economically and racially marginalised people – especially women – when understanding and intervening in food distribution. Although it may seem that aesthetics and poverty are mutually exclusive, and somewhat provocative to suggest that food aesthetics, when understood more expansively, aesthetics is an important aspect of domestic food work, as our findings from our research with British Bangladeshi women from Tower Hamlets on low incomes and responsible for social reproductive labour in their families and communities attest. We draw inspiration from feminist philosophy of food and taste, and everyday domestic aesthetics. Reflecting on our data, we combine these philosophies with Krishnendu Ray’s critique of food sociologists who imagine that people on low incomes lack a sense of beauty because their lives are dominated by their life of suffering. To conclude, we propose that food aesthetics should become part of the politics of food distribution and rights.
