Letter from Ohio — From the February 2018 issue

Within Reach

The transgender community fights for health care

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Last May, I climbed into a cherry-red Honda Fit that belonged to Ramona Peel. A forty-two-year-old with bright-blue hair, two children, and an obsessive love for the Seattle Seahawks, Peel was charged with connecting Equitas to the local trans community. She shot out her hand and then stopped herself. “Let’s model good behavior,” she said. “I’m Ramona; my pronouns are she, her, hers.” I told her my pronouns were she, her, hers, and we shook.

Ohio is a largely conservative state — Columbus is one of its few solidly progressive cities. Its annual gay pride celebration rivals Chicago’s, and Ohio State nurtures a vibrant queer community. But outside the I-270 loop, the city’s unofficial boundary, attitudes lean traditional, and Peel was heading seventy miles north, to lead a training session for a group of caseworkers at an Equitas facility in Mansfield.

The office was located in a one-story brick building that housed a hair salon and a Methodist church. In the sunny conference room, Peel unpacked her projector and took a selfie as a small group filed in and loaded plates with fruit and cookies. Many had been hired before ARC became Equitas. After the changeover, all the employees were required to undergo LGBT-cultural-competency training.

Peel wanted them to understand why the relationship between trans people and the medical community was so fraught.1 Not all trans people wish to medically transition, she explained, but those who do depend on doctors for surgery or HRT or both. In most cases in the United States, this requires a diagnosis of gender dysphoria, a mental health condition characterized by distress arising from the conflict between the gender one was assigned at birth and the gender with which they identify.2

1 For centuries, gender-variant people have been called many names, several of them derogatory, but today “transgender” is the most widely recognized descriptor. The meaning is constantly evolving but can include people who physically transition, people who are intersex, people who consider themselves nonbinary, and people who do not physically transition but do not identify with the gender assigned to them at birth.
2 Many gender nonconforming people use they, their, them as preferred pronouns.

Even routine visits can reveal how little doctors know about this population, a lack of awareness that advocates say has caused a health crisis. In 2015, when the National Center for Transgender Equality surveyed more than 27,000 trans adults, one third reported a negative experience with a doctor; one quarter avoided going to a doctor altogether because they were afraid of having one. Liam Gallagher, a twenty-five-year-old who used to work as a trans-outreach coordinator at Stonewall Columbus, an LGBT community center, told me that several years ago he had gone to the emergency room with abdominal pain. Because he knew he would have to explain his “entire life story,” he delayed going until he became seriously ill. The doctor insisted that his pain was a side effect of HRT, though there is little in medical literature to support such a claim. After several hours, Gallagher was diagnosed with pancreatitis. “Discrimination damages people’s health and makes them afraid to seek health care,” said Harper Jean Tobin, the director of policy for the National Center for Transgender Equality.

This kind of discrimination and stigma in medicine has been widespread and enduring. For most of the twentieth century, doctors considered sex a fixed state. Expression of gender variance was seen as criminal behavior or a sign of mental illness requiring psychological treatment, which sometimes involved electroshock therapy and institutionalization. From 1848 to 1974, it was illegal in Columbus for a person to appear publicly in “dress not belonging to his or her sex.”

Yet advances in endocrinology were making it possible to control the development of breasts and facial and body hair, and in the Twenties and Thirties, some patients underwent “sex change” procedures. One of the first was Lili Elbe, a Danish woman who had her penis removed and had ovaries transplanted into her abdomen in Germany.

Though Elbe died after a uterus transplant, her story galvanized people seeking similar procedures. Physicians largely turned them away. One exception was Harry Benjamin, a German-born endocrinologist and sexologist who began treating trans patients in the United States in the Forties and played a major role in bringing these advances to America. According to How Sex Changed, a deeply researched account of this medical legacy by the historian Joanne Meyerowitz, hundreds of gender nonconforming people approached Benjamin. “I would rather die than be a man all my life. It is a life of torture,” wrote one. Benjamin began treating his patients with hormones and X-rays to suppress sexual function and stop hair growth.

In the Fifties, psychologists developed the concept of gender — a sense of oneself that was distinct from sex. This allowed relatively progressive doctors and more conservative psychologists to compromise when treating someone who wouldn’t or couldn’t live as the sex assigned to them at birth. If a psychological evaluation demonstrated both long-standing feelings of being the opposite sex and an absence of mental illness, a patient would be eligible for “sex reassignment.”

The surgeries were expensive and hard to obtain. The Johns Hopkins Gender Identity Clinic, which started doing the procedures in 1966, received two thousand requests in its first two years. The vast demand allowed physicians to be aggressive gatekeepers. They were disrespectful and often mistrusting. In a letter to a colleague, one doctor wrote, “These patients are simply awful liars.” Only twenty-four of those requests were approved.

Around the same time, trans and gender nonconforming people were beginning to demand political rights and recognition. They built communities and identities around acceptance and pride. People with fluid lives, sexual practices, and gender expressions started to self-identify as drag queens, hair fairies, hormone queens, butches, FTMs, MTFs, shunning the notion that their identities were a problem to be fixed. After decades of looking to the medical establishment for help, they began to see that doctors were only “one instrument or resource to be deployed,” in the words of Angela Douglas, who founded the radical Transsexual Action Organization in 1970. Those seeking treatment learned the script: they dressed conservatively for appointments, professed a desire to lead quiet, heterosexual lives away from their queer communities, and claimed to be “trapped in the wrong body,” a common and overly simplistic stereotype that persists today.

By 1980, advocates and sympathetic doctors had gained some public approval and legitimacy; “transsexualism” became an official gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders III. The Harry Benjamin International Gender Dysphoria Association had formed to develop standards of care for trans patients, which recommended medical treatment but advised that surgery be available only to patients with two letters of support from psychologists or psychiatrists. This conservative model remains in use: typically, therapists determine who is “ready” or “qualified” for treatment. One thirty-five-year-old told me that his counselor made him fill out a six-hundred-question survey, which asked what kind of magazines he read. Another man had a therapist who insisted that he was a lesbian, not transgender.

Ramona Peel knows that the dialogue about trans issues can make some uneasy. Now as in the past, objections to procedures reflect cultural anxiety about gender nonconformity and diversity rather than concerns over body modification. Moving away from a gatekeeping model also requires abandoning the belief that some gender presentations or identities are more acceptable than others and that there is a right and a wrong way to be trans. This would mean any and all gender presentations are valid, a prospect that is upsetting for some and thrilling for others.

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lives in Philadelphia. This article was reported in collaboration with the Investigative Fund at the Nation Institute.

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