Transgender Issues & Health/Welfare Politics

This presentation is a combination of the opening address and a paper given at the Health In Difference conference by Jill Hooley.

(The Gender Centre advise that this article may not be current and as such certain content, including but not limited to persons, contact details and dates may not apply. Where legal authority or medical related matters are cited, responsibility lies with the reader to obtain the most current relevant legal authority and/or medical publication.)

Iam very pleased to offer the opening remarks at this historic conference for Gay, Lesbian, Bisexual and Transgender People. I speak as one who holds the interests of trannies dearly. We come to the end of a year which saw ground breaking legislation in N.S.W. for transgenders. The 1996 Transgender Amendment bill is, as the Attorney General said, the first of its kind in the world. It protects trannies from discrimination, without such protection being dependent upon "sex-change" surgery. The bill thus recognizes gender as a "doing" or behaviour, not determined by genitalia and the reality that most transgenders do not proceed to surgery. (Perkins 1994)

A view which individualizes trannies as "the problem" while failing to account for the marginalizing effects of social structures, institutions and the assumptions about sex/gender on which they are founded, makes us victims.

Another series of events this year requires comment. Conflict between a "service organization" (the Gender Centre) and a number of trany activists and academics. The conflict arose within two sets of power relationships; between trannies and social workers working "on behalf of" or "for" trannies and between trannies and the medical profession. I want to generate discussion of important practice issues in relation to these. It is part of social workers' role to protect "clients" from discrimination. It is part of professional development to expand and use new knowledge for practice and to base practice upon relevant knowledge. Also it is essential for workers to engage in vigorous criticism of their practice and theoretical base. (Social Work Code of Ethics 1990) It is also essential for workers to have a good understanding of gender and a multi-­disciplinary perspective, and I would argue that knowledge of sexuality theory, sociology and anthropology are extremely important.

"I noted some confusion, in the form of concerns about workers or researchers engaged professionally "with" or "for" trannies, who were accused of being "ideological" or "unobjective" in professional practice. It is clear to those of us who work in research, welfare, sociology and social work that workers who feel they can be "apolitical" neutral or "objective" are misled. I feel it is important to make one's own political ideologies clear, while not bringing one's own personal, emotional issues into professional relations with clients.

Social welfare is seen primarily as focusing on the amelioration of "oppressed people and communities". (Larbalestier 1996:20), Attendees at this conference, know that a holistic view of personal health means that health cannot be separated from social, political and cultural factors. We cannot avoid operating in fields of power. Health and welfare are embedded in politics, or caught up ineluctably with who gets what, when and how. Without activists and lobbyists there would be no Gender Centre, no legislation. We need to acknowledge that state agencies operate under contradictory forces.

The Perkins Report (1994), the document responsible for the legislation, informs us of high levels of systemic discrimination and violence, with accompanying levels of low self esteem, poverty and negative health outcomes. A view which individualizes trannies as "the problem" while failing to account for the marginalizing effects of social structures, institutions and the assumptions about sex/gender on which they are founded, makes us victims. The institutional power of sex/gender is apparent whenever we fill out a form. A historically produced set of gender relations, dominated by masculine heterosexuality, denies our legitimacy and "realness". The social terrain denying us full, equal economic and social participation as citizens is however, changeable, as the bill shows.

Vying for the allocation and distribution of resources, indeed the use of empowerment strategies with "clients", is indicative of welfare providing political skills. Health/welfare can't be "depoliticized" or made "neutral". The state's assistance of oppressed groups or communities is a paradox or contradiction of the welfare state apparatus, in which community organizations "serving" these groups are caught up. Some shared coherent understandings and negotiated boundaries concerning politics in such agencies is required, while respecting the delicacies of funding guidelines.

I feel we also need to acknowledge that our issues are never merely "gender issues." Gender is a part, the main part, of interconnecting structures of class, status, race, ethnicity, gender, sexuality, religion, able-bodiedness and so on, which impact varyingly upon every person with trans gender practices. "Gender issues" seems too singular as well as a tame and vague way of articulating the issues, since our small community is fragmented or cut across by different economic, racial, gender and sexual "identities". These differences, giving rise to possible inequality, tensions and resentment, may create hierarchy, or divisions we seek to avoid. The implications for welfare practice, policy and health, of the 50% of the sample In my recent report being welfare dependent or outside the "mainstream" workforce, need to be addressed. Training and employment Programmes now have the backup of recent Anti-Discrimination measures. A focus on opportunities for economic independence or mobility is paramount.

A crucial consideration is this. What factors create the circumstances for the generally poor health outcomes documented in Perkins? (1994). The main one? A social order of gender meanings, or taken for granted norms that be seen to be "natural". These norms are shaped in accordance with the social institution of gender, which many assume to be part of a natural order. However, when trannies pass as "real", they show the "real" to be a social construction, a mode of performance. The efforts of trany activists have been directed at challenging the power of "the real" to construct trannies as "false"; in this regard, current gender scholarship shows how material processes of gendering occur. The "sexed body" is not prior to or ever outside culture - it is never simply "nature". The view that gender is a social, historically developed institution is common. Judith Lorber notes, "Most people think that gender is bred into our genes. Most people find it hard to believe that gender is constantly created through human interaction, out of social life, and is he texture and order of that life." (Lorber 1994: 13) Or as Judith Butler says, " ... the social is the natural".

Roberta Perkins's work in this journal shows that crossing gender is a lived human experience with socially contingent meanings. It is practiced and interpreted differently in specific cultural, social, historical contexts. And since gender and sexuality are always caught up in relations of power, including the power of giving meaning and status to behaviour and groups, changing gender is an unavoidably political act, with social, economic and political consequences.

Such was the power of gendered institutions and medicine, that in cultures of the modern, "civilized", scientific West, trannies were seen as having "disorders of gender identity" - or an incurable mental illness. David King's work notes that trannies have been wedded to a "condition view" of ourselves. (King 1993) I feel that the medical condition view has exerted powerful control over how we live our lives - and our bodies. Identity is more realistically understood as constructed, as abundant, inexhaustible, changeable - a process of ongoing shaping of the self, subject to change. Indeed, the gender practices that attach to our notions of self are potentially mobile, fluid behaviours. Gender fluidity is constrained however, by forms of social discipline and punishment, by convention seen to be "nature", by coercion, by self regulation. The "common sense", taken for granted assumptions of gender, founded on the idea that there are two opposite sexes with corresponding "masculine" and "feminine" behaviour are easily troubled " why is so much emphasis placed on "proper" gender behaviour in child development, or why is "correct" socialisation even required, if gender is innate?

Ideas of a given, innate pattern of human sexuality arose from modern science. The privileged status of the "pure sciences" ensured respect for their claims to locate the "truth" of "sex differences" or gender as "inside" the body. This biologistic bias ignores the cultural realm entirely. A vast body of anthropological work shows the immense cultural variability of sexuality and gender. The notion of "pure nature" is as fraught as the notion of "pure science". The very concept of a male/female dichotomy is now shown to be quite problematic; to be part of 19th century political struggles over gender and power. Related to the rise of a bourgeoisie dominated by men, these battles produced a Western cultural imperative for two, and only two, clear cut, non-overlapping sex categories, and "science" was their handmaiden.

Anna Fausto-Sterling's paper about Intersexuality, titled "The Five Sexes" argues that sex is unstable, " ... sex is a vast infinitely malleable continuum that defies the constraints of even five categories ... " She shows how the medical fraternity completed what the legal profession had begun in the 18th century; the erasure of any form of embodied sex that did not comply with male/female heterosexuality. Part of this process was the, rise of sexology and psychiatry in labeling forms of gender that did not conform with sex as sickness and regulating sexual identity. These "sciences" created a cultural norm, demanding the consistency of "gender identity", "gender role" and "sexual preference" for a diagnosis of "normality". Trany activists responded to this arrogance by questioning it; we were rightfully engaged in struggles over naming, meaning and self-representation.

The power of self definition did not come historically for trannies, but from "experts supposed to know". Since Fiske's definition of "gender dysphoria" in 1974, Medical control escalated, with trannies having no control or ownership, but a "disease of gender" foisted upon us. Medicine's cultural authority and power to know the "truth" of our identities came from its professional standing. Claiming "objective", scientific knowledge, these "scientists" engaged in the political activity of imposing their negative meaning and their order, upon identities that contradict socially constructed sex-gender coherence. Such techniques of naming, specifying and controlling tied us to identity categories in constricting ways and set up a power imbalance. Medicine colluded with social institutions dominant ideologies and practices which deny trannies cultural understanding ­except as ill or disordered.

This process of labeling and control was founded on the idea of "sex" as irreducible; upon the supposed "natural" dichotomy of male/female, upon the idea of identity itself as primarily founded upon "sex". The idea that one's sex formed their basic "core", human potential and social/political standing was an outcome of 19th century Victorian, political maneuvers. (Foucault 1978)

The availability and demand for a technological fix, or "sex-change", arose from the centrality of "sex" and led to an adversarial relationship between doctors and trannies (Stone 1991) The "Official Story", given the quasi-scientific name of "gender dysphoria", became the disease for which transsexual medicine was the "cure". We were shaped as the problem by a medical technocracy regulating gender and sexuality. Homosexuals first entered the D.S.M. III, in 1958. The removal of this as a "sickness" and the rise of gay and lesbian cultures show us that "scientific" regimes of "truth" and social structures of sexuality are open to contestation and change.

The idea however, of a unified, fixed, singular and non-contradictory identity held by many people, gay, lesbian or otherwise, is quite problematic. Claims to a "true" or pure identity are however exaggerated. The findings of H.I.V. / AIDS research on sexual practices shows that the identities to which people lay claim, don't by any means correlate with their practices. Transgender research shows that trannies have sex with numerous partners whose sexuality is not necessarily what they declare it to be. Hooley 1996) For example, 47 trannies reported having sex with "heterosexual" men, 6 with "bisexual" men, 30 with gay men, 21 with other trannies, 14 with "lesbians", and so on. (Hooley: 1996) Another report showed that one-sixth of the sample of 692 homosexually active men also had sex with men, women and trannies. (B.A.N.G.A.R.: 1994)

Classification is of course, a political act; and classification of transgenders as "mixed-up", "pathological" or "gender disordered" is a violent political act by those presuming to have "expert" or "scientific" knowledge of us. The psychiatric diagnoses of "gender dysphoria" or "disorder of gender identity", derived from dominant notions of sex/gender as innate and dichotomous, are dominant meanings and terms which disempower us. I feel any "service organisation" which complies with rather than challenges an outmoded medical "disorder" model, will fail us. Critical management with this model and use of knowledge produced by trans gender is required.

Another issue is that a trany welfare agency is never merely "servicing clients" nor can it ever produce "objective" knowledge; such organisations, workers produce and communicate knowledge, values and meanings. This knowledge is always situated. It is the product of the subjective world view of some person or profession. No knowledge is "value free". Some kind of position is communicated, even one that poses as a non-­position, or as "impartial". It is important therefore, that workers interrogate their own subjectivity and openly, explicitly impart their views and invite "clients" to challenge them. Welfare/health organisations may be contradictory in their effects, ameliorating the conditions of people's "disadvantage" or marginality, yet also generating dependency and control of "clients". Therefore, there must be room for contestation of the practices of welfare agencies, for independent political agency and self-representation by the service users, and the 'target group may be more easily accessed and serviced by trannies from within the target group, given trannies" reluctance to disclose to non-trannies. (Perkins: 1994)

Larbalestier notes that social work endeavours operate within dominant discourses premised upon oppositional shapings of difference, and that these discourses are embedded in relations of power and domination. Her assertion is borne out by the positioning of worker/client as a set of unequal relations, serving to objectify and feminize "clients". This subject/object or self/other relationship is comparable in its structure to the historically, socially produced opposition or hierarchies of man/woman, white/black, heterosexual, homosexual or West/East. Workers are assumed to have the superior or authoritative reference point and the ability and knowledge to act "for" or "with" us. Welfare service organisations, forged through the benevolent paternalism of the welfare state, cannot avoid shaping their "clients" ideas, views and identities in some way. They are engaged in power relations whatever they do; moreover, social workers operate within a framework which places their "clients" in a position of subordinated difference. (Larbalestier: 1996)

A trany service organisation must above all, blur or collapse boundaries that arise from a worker/client, or provider/user hierarchy and engage in continuous reflection upon its practice-theory relationship. It must use the knowledge of skilled, experience or qualified trannies; it must employ trannies. It must allow input, vigorous debate, opposition and resistance by members of the community it arguably "serves". It must hold forums. Such practices at least acknowledge the power imbalance and address the symbolic violence that occurs within unequal worker/client relations, set up by social work theory and practice, as a discourse of privileged professionalism. Whether there is any way of this "privileged professionalism", theorises Larbalestier, is doubtful and ambiguities, tensions and contradictions will remain. (Larbalestier: 1992)

Perhaps workers may ask themselves; how have you come to know and understand transgender people; whose knowledge do you privilege, and what gaps are there? Is your knowledge produced by trannies - or by others, the "experts" on our identities - psychiatrists, doctors or sexologists? For the knowledge workers have of trannies, from the street and in books, or discourses, shapes the way you frame, or see trannies. Multiple, cross disciplinary ways of seeing are invaluable, especially those taking account of the social and cultural constitution of who, or "what" we are.

Finally, I want to draw an analogy. The proclaimed "great philosophers" of western culture have usually been men. The power to speak and know was not conferred upon women. Men in the emergent medical professions of the 19th century saw women as over-emotional, mad or hysterical. We may ask - how is it that transgenders came to be seen as "gender disordered" or mad, in the late 20th century West? Modern feminists saw that their subordination and oppression was founded upon men's knowledge, on men's construction of women's difference in terms of an unequal male/female dichotomy, spuriously based upon a culturally developed dichotomy. Thus do some modern trany scholars, (Stryker 1994, Stone 1991 et al.) see that the foundations of medical knowledge constructing us as pathological, are just as subjective as men's version of the "facts", the "truth" of sex/gender.

Men, doctors, psychiatrists - not trannies, were seen as having the "authoritative" knowledge, rather than experienced trany workers, activists and scholars. It was a meeting set up by a trany service agency, with a dozen doctors, without any prior community consultation - without any invitation to trany academics or trannies in community organisations (whom it sought to exclude) that initiated the conflict between trannies and their service organisations. I interpreted the giving of power to the doctors to label, define and decide what is best for us, as contemptuous ­as an insult, a deprivation of power for trannies seeking active involvement. This meeting's agenda assumed the efficacy, necessity and "truth" of the "gender dysphoria" diagnosis. The participants assumed trannies" passive, "feminine" compliance with medical professionals who assumed command of the floor and the right to pontificate on ways to "treat" and "manage" our "disorderly natures". Trannies who resist such subordination, rather than enact a passive, compliant femininity, may rightly displease those in "authority", who ignorantly interpret trannies' justifiable anger as madness and exclude trany advocates and scholars from forums.

I feel we do not need to be told who we are by "experts"; we maybe freed from certain ways of knowing and seeing ourselves. Should doctors, medicine, be in a dominant and controlling position? A position powerful enough to shape our very identities - as mad, sick? Considering the emerging research findings of Roberta Perkins and others, and the emergence of new information about the nature of identity, sexuality and gender, the concepts of categorical, pure, singular, non-­shifting identity, and of "true self" and "gender dysphoria" are very tenuous. The "truth" of self-identity lies only in the story we tell; and there is always excess and exclusion.

The flawed conception of our identities in terms of medical illness means that the need for medical intervention is created by deep misunderstandings of gender variability as illness; as a merely "private" issue for "the individual". This reduces the issue to the "purely personal" or private, appearing to take it out of the realm of power and politics. The false polarisations of man and woman, public and private individual and society, nature and culture, civilised and primitive were crucial to the emergence of modern, patriarchal sexuality and gender relations, in western capitalist countries. They enabled the suppression of forms of sexuality and gender that did not comply with the dominant white, western middle class heterosexual family, based on gender polarity.

The power of this privileged, cultural norm to shape our own identities is evident in the film "Paris Is Burning". Venus, one of the coloured or black trannies in this revealing film tells the camera, "I want to be a spoilt, rich white girl." As Stone's work suggest, "gender dysphoria" is a strategy for rationalising medically and socially shaped "needs" and desires. "Transsexualism" was only made possible by advances in surgical techniques, which are not equally available to all. As "or Venus, she didn't make it, for she was murdered. Medicine has no concept of empowerment, rendering us passive recipients of "treatment" and "cure", for a "disease" of gender that only exists in the stories we tell.

It is time that empowering stories were told. We may feel proud of who we are and value what makes us truly unique or individual, rather than elevating certain attributes - or attempting to conform to some impossible, idealized norm of gender or fantasised "truth" of sex.

Bibliography:

Polare is published in Australia by The Gender Centre Inc. which is funded by the Department of Community Services under the S.A.A.P. Program and supported by the N.S.W. Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion and debate on gender issues. Advertisers are advised that all advertising is their responsibility under the Trade Practices Act. Unsolicited contributions are welcome, though no guarantee is made by the Editor that they will be published, nor any discussion entered into. The editor reserves the right to edit such contributions without notification. Any submission which appears in Polare may be published on our internet site. Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc.I, the Department of Community Services or the N.S.W. Department of Health.