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The book has posed several questions about how self-determination is conceived, achieved, contested and materially lived through in (some) historical realities of sex/gender. My intention was not to answer all the questions posed, because we cannot securely retrieve them due to the productively fleeing, eluding, flowing, leaking and disappearing nature of sex/gender self-determination in complex assemblages developed vis-à-vis legal statutes, healthcare protocols and pedagogical cultures. I have instead tried to pose dilemmas, paradoxes and look at power games that assert forces within debates about sex/gender self-determination. Nonetheless, I have tried to draw out the singularities of trans, sex/gender expansive and intersex people and show how, in our examples, they connect to bioethics (in the form of research relations), biopolitics (in the forms of sex/gender assignments and the connected citizenship and policy frameworks), and the wider population (in their singularities). The one clear force that I wanted to highlight, even though this force is affected and affective differently in all these nomadic connections, is the birth designation made by physicians and recorded by parents. This led me to the questions: Is sex/gender assignment at birth fit for purpose? Do sex/gender assignments have a medical purpose? and What challenges can be levelled at the practice in light of human rights declarations surrounding the rights of people to their bodily integrity, autonomy and ‘self-determination’? I demonstrated that sex/gender assignment at birth is only ever a clumsy representation that cannot cope with those bodies that do not, will not, or indeed cannot be constrained within the parameters of those vague designations in use across the world.
The concept of ‘self-determination’ in social work, medicine, education, human rights and political theory functions on both molecular and molar planes of immanence. The term, however, is often treated as a transcendental phenomenon unconnected to the physical matter of the human drives (desire) to become. Deleuze and Guattari (2004) understand the molecular as the micro affective intensities, which can be produced in relation to macro communities and beyond, but this is complicated with the idea that communities can also become the molecular when talking about, for example, larger bureaucratic agencies, such as government, the United Nations or the NHS, technology, the environment and so on. DeleuzoGuattarian thinking provides an ontological basis for the analysis of multiple governance networks and allows for imaginative modes of non-representative democratic governance because of its refusal to homogenize the affective intensities into binary structure/agency arguments without denying either. DeLanda (2006, 2016) proposes that social complexity connected to governance networks can be thought through assemblage theory and is a valuable basis to conceptualize the heterogeneity of key affect, affecting and being affected by humans.
Each assemblage consists of molecular and molar configurations and exists as a collection of bodies, communities, organizations, technologies and de jure states. As I have argued elsewhere (Davy, 2019), the notion of an assemblage is helpful to understand human connections and relations with other humans, animals, objects, institutions and cultural artefacts. Moreover, an assemblage does not privilege the human (body) as the site where sex/gender and sexual desire is always located. Desire is produced at the interstices beyond the human body. The assemblage disrupts the notion of a unified sex/gender.
The concept of self-determination has a lengthy scholarly history. The concept has motivated a range of bioethical concerns; as such, the interpretations and thus the effects that result from utilizing the concept vary. This book considers key personal, political and pedagogical approaches to trans, sex/gender expansive and intersex people in various policy fields such as sex/gender recognition legislation, medical diagnoses, medical interventions and educational policies. This book also contemplates how self-determination relates to sex/gender productions, transitions and expressions, and how they correspond to current debates around binary sex/gender embodiment. I will consider throughout how diverse cultural practices and systems may still be (de)limiting trans, sex/gender expansive and intersex trajectories to self-determination. These are not dead ends though but produce new virtualities. This is because trans people are always becoming-trans, sex/gender expansive people are always becoming-sex/gender expansive and intersex people are always becoming intersex-people. This is the same for cis people too, who are always becoming-cis people. The relevant qualities that everybody has are not inherent, archetypal or phylogenetic but are desired in specific assemblages of becoming-human and/or becoming-social (Deleuze and Guattari, 2004).
We will ask if (self-)determining sex/gender is an effect of desire connected to coercive effects, and what this looks like. We will explore how legal, medical and pedagogical policies have more in common with each other than we may think and ask does each of these policy areas co-produce and affect human and non-human bodies? The basic response from a new materialist perspective, which I draw on throughout, must be ‘of course’.
In the last chapter I suggested that self-determination theory is a widely researched and an empirically evidenced theory of human needs fulfilment and motivation and offers a potentially valuable conceptual framework for understanding why the current policy environment has not led to the anticipated improvement in equity, quality and safety of clinical care with trans, sex/gender expansive and intersex people. I also looked towards a more sustained move towards patient-centred self-determination models of healthcare provision, regardless of whether that provision is privately or state funded.
In this chapter, I will look at how self-determination is affected by and affects medical self-governed institutions, the elevated professional and social position of physicians, and the UK’s development of a patient-centred approach to healthcare. This will not be an extensive genealogy of the UK system as that is too vast a subject to do justice to in a single chapter. Margaret Stacey (1992) has written an excellent detailed analysis of the importance of the role of the GMC in the UK in relation to the protection of both physicians and patients. Although Stacey’s book is almost thirty years old, it still holds much relevance in the ways that medical registering and physicians’ appraisals and revalidations have been and continue to be evaluated, and to some extent how the role of the patient/consumer functions (see also Quick, 2018; Gladstone, 2000). I will draw on some areas of contention that allow us to see some of the biopolitical assemblages that generate key forces in everyone’s self-determination efforts related to health (Irving, 2008).
The term ‘sex/gender self-determination’ will be important throughout the book. Scholars have been exploring self-determination in relation to individuals’ minority and majority identities, colonial and postcolonial nation building, citizenship, healthcare, pedagogy and more. These fields of literature are not impervious to theoretical changes. One stark omission in earlier debates has been in relation to sex/gender self-determination. It is as if this is an impossibility and that sex/gender is an inherent given. However, the concept increasingly crops up in the literature about intersex bodies, and also in relation to sexed/gendered bodies, in medicine more generally. When intensities of power shift through human and non-human bodies, that are either supportive of, or a challenge to, (a) people’s self-determination, we begin to see nuanced conceptual changes in the literature. We can use these analytical conceptualizations as ‘types’ within a particularly Deleuzian form of empiricism and ethics to talk about differing levels of ‘self-determination’ as ‘desire’ if, indeed, we believe that there is such a thing in the first place. The ‘types’ of literature help us attend to an examination of the principle of self-determination on micro and macro planes of immanence and at all the levels between.
This chapter takes as its starting point the ways in which our bodies are produced and are sites of production. The dimensions of ‘sexual difference’ have been key cornerstones in how we produce, and how particular people are given, the power to sex/gender bodies, resulting in a context that has come to be understood as essential to life itself.
In this chapter I will look at different assemblages that affect and are affected by trans and sex/gender expansive children and their parents.1 In the school-education assemblage there are forces that intensify, affecting trans and sex/gender expansive children and their parents. This is the same for cis people too. The relevant qualities that everybody has are not inherent, but are gripped in specific assemblages. The qualities are not archetypal or phylogenetic, but are grasped/desired in assemblages, becoming-human and/or becoming-social (Deleuze and Guattari, 2004). There is a growing evidence base that promoting self-determination has positive effects on students (Wehmeyer, 2014). Generally, students with various physiological and psychological differences have been the focus in building self-determination theory in schools (Eisenman and Chamberlin, 2001; Wehmeyer et al, 2003; Wehmeyer, 2014). Educationalists have developed what they refer to as self-determination interventions in order to support and motivate students by developing strategies that may help them succeed through school. These interventions are meant to be worked out with the students and through considering the goals that are meaningful to the student. This enhances students’ engagement with the curricula and strengthens their chances of completing school (Abery et al, 1995; Eisenman, 2007). Whether these strategies, motivations and self-determination opportunities can be implemented rests on the chances that educators and the curriculum allow (Eisenman and Chamberlin, 2001) alongside other systemic forces, such as policy incentivizations and wider public pressures.
Is diagnosis a useful frame within which to conceptualise trans experience? We submit that it is not. Diagnosis is still necessary for funding and sundry bureaucratic matters, but it is a poor method of understanding the complex interplay of biology, psychology, personal and social influences which form this complex topic; and especially the complex interplay of such elements in any given trans person. Our clinical experience is that understanding and assisting with these elements and the interplay within them is of far more use than the rather procrustean approach of ‘fitting’ a given trans person within a diagnostic box and potentially dismissing the elements which do not comfortably fit … We will, of course use diagnosis for pragmatic ends to assist the trans people who see us, but, to help, not to label, and given the long history of pathologisation, and longer history of diversity, never as a de facto understanding that trans people are disordered. (Richards et al, 2015: 311)
At a time when gender diversity is gaining increasing public attention, this book presents a poignant account of the current policy approaches to self-determining sex and gender in the UK and beyond.
Davy shows how legal, medical and pedagogical policy developments are interconnected, while unique interviews with parents of sex/gender expansive children reveal how policy affects and is affected by experiences and advocacy.
Written by an internationally renowned scholar, this book sparks new debate on the challenges and opportunities surrounding sex/gender self-determination.
