Are You A Girl or A Boy? A Study Into The Reinforcement of The Gender Binary Through Medical Transition and The NHS.

Goldsmiths, University of London
SO71089A - Gender, Media & Culture

Student Number 33304956
‘Are you a girl or a boy?’ A

study into the reinforcement of
gender binary through medical
transition and the NHS.
Word count: 14,540

August 2014
Abstract
An in-depth critique and discussion into the medicalization of the

transgendered person in both historical and current contexts, and
the ‘normalization’ of transsexuality through the implementation of
the gender binary model in terms of language and medical interven-
tion.
Contents
Abstract i
Contents ii
1 Introduction 1
2 Background 3
2.1 Clarifying ‘Trans’ Terminology . . . . . . . . . . . . . . . . . . . . . 4
2.2 The Issue with ‘corrective’ and Intersex surgery . . . . . . . . . . . 5
2.3 Assigning gender – The case of David Reimer . . . . . . . . . . . . 7
3 Medicalizing Trans: The Problem with Medicalizing bodies and

Medical Terminologies 11
4 Legitimizing Trans Identities 17

4.1 Gender Recognition Act and Acceptable vs. Unacceptable Trans
Identities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4.2 Medical Treatment Narratives and Gendered Citizenship . . . . . . 21
5 Citizenship 29
6 Issues with the ‘De-Medicalization’ Of Transgendered People 32
7 Independent Study 37
7.1 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7.2 Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7.3 Online Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
7.4 Online Survey Results . . . . . . . . . . . . . . . . . . . . . . . . . 38
7.5 Skype Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
7.6 Skype Interview Results . . . . . . . . . . . . . . . . . . . . . . . . 42
8 Conclusion 47
A Appendix 49
B Bibliography 64
ii
Chapter 1
Introduction
This dissertation will be looking into the ways trans people must conform to
specific gender binaries in order to be legitimized as a Transgender person and to
receive and gain access to surgery and hormone treatments, specifically through
the national healthcare system.
I wish to explore the way stereotypical gender roles are encouraged in order to
legitimize medical transition, and how access to gender reassignment serves as a
reward for fulfilling the quota of ‘masculine male’ and ‘feminine female.’
I will look into the e↵ect this has on non-binary identified trans people and the
extent to which medical conceptions of sexed identity associated medical practice
have a detrimental e↵ect to the encompassing of all trans people with varying
gender identities within society and with access to medical care.
I will do this by firstly looking into the history of medicalization of trans and gen-
der variant people in both historic and current contexts. This will include a look
into ‘corrective’ surgery on Intersex people and the way ambiguous gender is per-
ceived as ‘abnormal’ within medical practice. I will also be looking into the initial
conception of ‘trans’ into medical discourse and the changes and progression made
over time with replacement of terms such as ‘gender identity disorder’ to ‘gender
dysphoria’ within the DSM-V manual. Do these changes in medical terminology
reflect a change in attitude and a new understanding of gender identity?
I will address issues of Gender binary as a system of oppression by looking at texts

such as; Kate Bornstein’s ‘Gender Outlaw’ (1994) and Alison Rooke’s ‘Telling
Trans Stories,’ (2010) which focuses on a project involving debates between young
1
Chapter 1. Introduction 2
Trans people and medical professionals involved in their care as well as Oral History
taken from literature by Zowie Davy. (2010)
In the final part of this dissertation I will be drawing upon my small scale research
study of non-binary identified trans interview participants, and an online survey
that asked questions relating to the medical interactions and care they had received
as a non-binary person. With this approach and by drawing upon each individuals’
experience, I hope to illustrate the ways in which the healthcare system is failing
non-binary trans people.
Chapter 2
Background
2014 has been a good year in regards to raising visibility of Trans people and
putting issues of Transgender rights into the spotlight. From Laverne Cox making
history as both the first transgender actor to be nominated for an Emmy (Cullen,
2014) and for being the first Trans person to feature on the front cover of Time
Magazine. (Haché, 2014)
However, increased visibility has meant that mainstream media and society have
constructed their own ideas and ideals of what ‘trans’ signifies to them based on
potentially outdated ideologies and definitions of ‘transgender.’ BBC Online for
example, defines a transgender person as, “Someone who has a conviction that
they’re trapped in the wrong body.” (bbc.co.uk)
There have been many criticisms of the ‘wrong-body’ model such as Talia Bettcher’s
‘Trapped in the Wrong Theory,’ in which she states,
“. . . The wrong-body narrative is deeply connected to genital recon-

struction technologies, the narrative, just as the technologies, is open
to worries about class and race-di↵erentiated access. The wrong-body
narrative outlines a standard genital reconstruction surgery, and any
identity that fails to desire that is ruled ineligible. It thereby attempts
to restrict access to womanhood or manhood itself through hegemonic
class-, race-, and culture-inflected modalities.” (Bettcher, 2014:402)
Bettcher outlines how limiting Trans identity to a wrong-body narrative dictates

the ‘authenticity’ of a trans person’s identity that must follow the guidelines of an
3
Chapter 2. Background 4
oppressive medical definition, such as: the desire for ‘corrective’ genital surgery
which I will discuss further, in the section ‘The problem with Corrective surgery.’
2.1 Clarifying ‘Trans’ Terminology
To ensure clarity of the subject, I feel it necessary to define what I mean by

‘trans people’ throughout the context of this essay. The term ‘trans’ can usually
be incorporated within many levels of gender ambiguity. In fact one of the first
problems I encountered was giving it a narrow definition as it is utilized as such
an extensive umbrella term.
This notion of a term that encompasses gender variance on such a huge scale
is emphasized in Vanessa Sheridan’s ‘Complete Guide To Transgender In The
Workplace.’ As Sheridan explains:
“Transgender is a very big tent that covers a lot of territory, with

much of it difficult to categorize. A useful understanding of the term
is this: transgender includes everything not covered by our culture’s
narrow terms for ‘man’ and ‘woman.’”(Sheridan 2009:1)
In this dissertation, I will use the term ‘trans’ to describe those who do not identify
with the biological gender they were assigned at birth. One important factor that
Sheridan (2009) fails to mention is that the medicalization of trans people does
not seemingly acknowledge this vast spectrum of alternative gender identities that
the term ‘trans’ covers.
This way of viewing gender has been debated by many queer theorists (Whittle,
2000; 2006) who argue that gender is very complex, is a social construct (Phillips,
2006; Kessler and McKenna, 2006) and even a performance, which is not based on
your genitalia or your internal organs (Butler, 1999; 2004).
A good example on the issue of defining gender on the distinction of ones physical
anatomy is illustrated in an article by Geertje Mak appropriately entitled, ‘So we
must go beyond what the microscope can reveal.’ Mak focuses her attention on
late 19th century studies into genitalia and gender identity, critiquing the work of
Alice Dreger’s ‘Hermaphrodites,’
“. . . Most physicians agreed that the true sex had to be defined by

the structure of his/her gonadal tissue. Dreger labeled this period ‘The
age of gonads.’ Arguing that no matter how an individual lived in a
gender role- they would be labeled male or female by their anatomical
gonads.” (Mak 2005:69)
As Mak (2005) explains, the belief was held that the construction and appearance
of your genitalia ultimately defined ones gender identity. Whilst Mak argues there
had been queries and disputes regarding the concept of sex/gender long before-
hand, Dreger argued that Blair Bell, a surgeon in Liverpool (1915), was one of the
first to publicly question this practice by asking “Whether we are justified. . . in
branding patients with a sex that is often foreign not only to their appearance but
also to their instincts and social happiness” (Mak, 2005: 69).
We can conclude that Bell was advocating the idea that anatomy should not
necessarily reflect gender identity, and by drawing upon the ‘social happiness’ of
individuals, Bell recognizes the adverse a↵ects that ‘branding patients’ can have
on ones emotional wellbeing.
With this in mind, Mak (2005) states how a new understanding of ‘biological sex’
began to influence the language used to define gender. Mak writes, “Other kinds
of biological sex were being discovered, e.g. hormonal sex and chromosomal sex.
A shift in conceptualization also attributed a shift in name, from hermaphrodite
to intersex.” (Mak, 2005:69)
2.2 The Issue with ‘corrective’ and Intersex surgery
In this section I will look into the concept that Intersex surgery as ‘corrective’ is
a Westernized cultural idea influenced by a belief system that considers gender
ambiguity ‘abnormal’ and in need of medical intervention by way of surgical nor-
malizing (in this case) sexual organs to make them appear more ‘male’ or ‘female.’
In other words; enforcing a binary gender identity on an otherwise gender-neutral
individual.
To illustrate this, I am going to focus on Nancy Ehrenreich’s essay ‘Intersex
surgery, FGC and the selective condemnation of cultural practices’ (2005) In which
she compares criticisms of African cultural practices of ‘Female circumcision’ more
commonly known as ‘Female Genital Mutilation (FGM),’ and looks into why these
same criticisms are not applied to the practice of intersex surgery.
Ehrenreich states that much of the argument for Intersex surgery is based around
the way it is represented as respected practice purely within a medical context,
“The Western medical community has represented its genital cutting as modern,
scientific and above reproach.” (Ehrenreich, 2005:71) By the same token, African
genital cutting is presented as a ‘barbaric, irrational and harmful’ practice due
to it being considered ‘uneccessary’ (Ehrenreich, 2005:71) due to there being no
scientific or medical explanation for the practice. Ehrenreich argues that playing
FGC under in the category of the ‘other’ means that Western feminist scholars
(and medical practitioners alike) fail to acknowledge the similarities between the
two practices.
One such procedure, she argues, that of surgical genital cutting once considered
necessary to be performed on intersex infants carried far greater risks than African
genital cutting, Eisenreich comments that these procedures are ‘medically unec-
cessary’ (Eisenreich, 2005:74) which is one factor upheld in arguments against
African FGC. The important point is made over the use of ‘medical terminology’
and acceptable language that harbor positive and harmless connotations such as
‘circumcision over the use of terminology used to describe FGC such as ‘mutila-
tion’ and ‘cutting.’ (Eisenreich, 2005:72)
The di↵erence in how these surgeries are referred shows how one type of genital
surgery is considered acceptable over the other due to the belief that one is ‘neces-
sary’ and scientifically justified because the medical professional sees the surgery
as corrective, even if the procedure itself holds more health risk and is more in-
vasive than FGC. Eisenreich argues that it is the construction of African societies
and practices being presented as ‘primitive, patriarchal and barbaric’ (Eisenreich,
2005:75) essentially implying that African understandings of the body are merely
‘cultural’ that serves as justification to condemn such practices.
Considering the similarities between to the two surgeries in that they both run
the risk of infection, are medically unnecessary, can a↵ect sexual function and
can cause problems later in life, how is surgery on Intersex infants justified? One
explanation as illustrated in an article from The Independent argues that it is due
to the medical professional’s refusal to allow for the existence of those babies who
‘do not fall neatly into the category of male or female.’ (Morrison, 2013)
Sarah Morrison reports that,
“[Intersex people] argue that their very existence has been ‘erad-
icated’ by British society. Generations of children have been oper-
ated upon to ‘normalize’ their genitals. . . while official documentation
from birth certificates to passports requires a male or female box to be
ticked.” (Morrison, 2013, my emphasis)
Morrison not only highlights the fact that Intersex people are being forced into
a gender binary by way of having their genitals ‘normalised’ and their intersex
identity subsequently eradicated, but also introduces the concept of being forced
into a gender binary by default due to lack of appropriate documentation such as:
having to tick a male or female box on a passport.
“In the 1960s it became the norm to operate on children with atypical sexual
anatomy at a young age. Doctors assigned the child’s gender and operated to
reinforce it.” (Morrison, 2013) This concept of surgical intervention on sex organ-
s/anatomy enforces the idea that genitalia/sex equates to gender identity and the
two become indistinct from one another.
2.3 Assigning gender – The case of David Reimer
This section will be looking into the issues of medical professionals assigning gender
markers and gender identity.
One of the earliest and well-known cases ever recorded involving a doctor assigning
a child’s gender was that of David Reimer, whose penis had been ‘burned beyond
surgical repair’ during a circumcision attempt. (Woo, LA Times, 2004)
In an LA Times article Elaine Woo reports that ‘At 8 months of age Reimer became
the unwitting subject of ‘sex reassignment’ . . . The American doctor whose advice
they sought recommended that their son be castrated, given hormone treatments
and raised as a girl.’ (Woo, 2004) The prospect of a child without a penis was
immediately equated with the idea that he could be raised a ‘girl’ regardless of the
child’s gender presentation and gender identity. Dr Money – the Doctor involved
in the experiment and acclaimed sex researcher argued that sex roles were largely
the product of social conditioning, essentially gender was nurture over nature.
Money argued that ‘through surgeries and hormone treatments’ he could turn a
child into whichever sex seemed most appropriate. (Woo, 2004) In the case of
Reimer however, the sex that was ‘deemed appropriate’ was purely based on the
failed circumcision attempt as opposed to the child’s gender identity and expres-
sion.
Importantly, Money is also quoted as stating he had experienced success changing

the sex of babies born with ‘incomplete or ambiguous genitalia.’ (Woo, 2004)
‘Ambiguous genitalia’ implies that it does not correspond what would medically
be considered normative, i.e. male or female genitalia.
We can subsequently presume that Dr Money performed what would thus be
considered ‘corrective’ surgery on intersex infants.
Dr Money’s experiment was unsuccessful as David ‘was rejecting his feminized

self,’ “. . . David had steadily rejected (his) assignment from male to female, at 15
he refused to continue living as a girl.” (Woo, 2004, my emphasis) David eventu-
ally committed suicide due to bouts of depression namely brought about by his
traumatic childhood. (Daily mail reporter, 2010) This shows how gender is intrin-
sic to the individual. Surgery cannot be performed to dictate whether a child is
one binary gender or the other.
In Judith Butler’s ‘Undoing Gender,’ she illustrates how the failure of Dr Money’s
experiment gained him many critics within the medical field including sex re-
searcher Milton Diamond, who according to Butler believes in the hormonal basis
of gender identity. (Butler, 2004:60) Butler states that those critical of Dr Money’s
theories believed that David’s failure to be accept his socialized role as a girl shows
us that there “was some deep-seated sense of gender. . . one that is linked to his
original set of genitals... as an internal truth and necessity, which no amount of
socialization could reverse.” (Butler, 2004:62)
Butler comments that the Brenda/David case was now being used in order to
provide evidence for the reversal of Money’s thesis.
As such, these new arguments were, “. . . supporting the notion of essential gender
core, one that is tied in some irreversible way to anatomy and to a deterministic
sense of biology.” (Butler, 2004:62)
Butler draws upon Gender studies professor Anne Fausto-Sterling to question this
ideology stating,
“Her (Anne’s) view. . . is that although a child should be given a

sex assignment for the purposes of establishing a stable social identity,
it does not follow that society should engage in coercive surgery to
remake the body in the social imagine of that gender. Such e↵orts
at ‘correction’ not only violate the child, but lend support to the idea
that gender has to be borne out in singular and normative ways at the
level of anatomy.” (Butler, 2004:63, my emphasis)
It could be argued that by suggesting a child should be assigned a sex, this puts
the focus back onto the biological and medicalized aspect of sex rather than the
child’s own gender identity. Although Anne strongly criticizes the idea of corrective
surgery and ‘normative’ ideas of gender and the anatomy, it seems hypocritical to
critique social norms of gender while implying the necessity of ‘sex assignment,’
especially on a child whose gender identity may not fit into a male/female binary.
Alice Dreger illustrates the problems of Dr Money’ ‘Concealment-centred’ ap-

proach of intersex patients in her paper ‘Shifting The Paradigm of Intersex Treat-
ment,’ which directly compares the concealment-centred model (such as the one
utilized on David) with a patient-centred approach.
The paper was prepared for the Intersex society of North America (ISNA). Dreger’s
comparisons drew attention to the way being Intersex was interpreted within med-
ical discourse within concealment centered model as being ‘a rare abnormality
which is highly likely to lead to great distress,’ to the patient-centered model of
Intersex which states that it is merely ‘an anatomical variation from the ‘standard’
male and female types; just as skin and hair color vary along a wide spectrum.’
(Dreger, ISNA, 2014) The Concealment approach regards Intersex as an abnor-
mality whereas the Patient approach rightfully understands gender ambiguity as
merely a variation of what is considered the norm.
In the section ‘Are Intersexed genitals a medical problem?’ The concealment ap-
proach argues that if untreated, it is highly likely to ‘result in depression and
suicide.’ Intersexed genitals must be ‘normalized’ to whatever extent possible if
these problems are to be avoided.’ (Dreger, 2014) There is a direct connotation
with Intersex and abnormality as well as an implication of mental health issues
in the Concealment approach. The Patient-centered approach argues that ‘Inter-
sexed genitals are not a medical problems’ and that there are no evidence for the
concealment paradigm.’ (Dreger, 2014) Arguably the belief that an Intersex per-
son will grow up to be ‘depressed’ or ‘suicidal’ due to not having ‘normal’ genitalia
are merely preconceived ideas of the medical professionals as opposed to the lived
reality of the Intersex person.
Chapter 3
Medicalizing Trans: The Problem

with Medicalizing bodies and
Medical Terminologies
In the book Transgender Nation (1994), Gordene Mackenzie discusses this notion
of the damaging e↵ects of medicalization,
“Often we lose sight of the individual with clinical categorizations

and rigid definition. . . As Foucault and Planner suggest, they have
stigmatized, dehumanized, condemned and justified the barbaric tor-
ture of whole groups of people as ‘sick and deviant,’ simply because
they did not conform to the status quo.” (Mackenzie 1994:55)
Mackenzie (1994) continues: “Much of the medical and legal pressure for sex
reassignment surgery is based on the persistent American belief that somehow,
gender emanates from the genitals” (Mackenzie, 1994: 56). Similar to the critique
of the Age Of Gonads, it is apparent that there is a lack of separation between
gender identity and biological sex. Mackenzie (1994) notes;
“This idea of trans people ‘born in the wrong body.’ Common sense
dictates that the idea of wrong bodies assumes the existence of right
bodies. Right bodies, according to transsexual ideology must match
11
Chapter 3. Medicalizing Trans 12
the gender of the individual accordingly. Masculine-male, feminine-

female, thereby reinforcing sex and gender congruence demanded by
contemporary American society.” (Mackenzie, 1994:61, 62)
Here we can argue that trans people’s gender identities are dictated by societal
presumptions on gender binaries; male and female. This, once again, shows the
reinforcement of gender dialectics and binaries.
In Kate Bornstein’s ‘Gender Outlaw’ (1994) she discusses how these binary ide-
ologies on gender influenced her decision to have surgery,
“I never hated my penis; I hated that it made me a man – in my

own eyes and in the eyes of others. For my comfort, I needed a vagina –
I was convinced that the only way I could live out what I thought to be
my true gender was to have genital surgery to construct a vagina. . . ”
(Bornstein, 1994:47)
Bornstein’s desire for surgery was born out of her desire to conform to what she
believed at the time – would make her more of a ‘woman,’ and this was directly
equating genitals (sex) to gender.
This next section will be focusing on the Parliamentary Guidelines for the commis-
sioning of healthcare treatment services for trans people, and some of the issues
this brings up in regards to the language used and the definitions put forward
within the guidelines.
The guidelines define gender dysphoria as,
“(The) experience of oneself as male or female that is a gender

identity which is incongruent with the phenotype (the external sexual
characteristics of the body). The personal experience of this incongru-
ence is termed gender dysphoria.” (GIRES, 2009:3, my emphasis)
From the outset, gender dysphoria is defined as experiencing oneself as ‘male’ or

‘female’ outside the biological sex. It immediately presumes the dysphoria will be
experienced as one binary gender or the other as opposed to merely an experience
of incongruence which deviates from the normative gender role.
The guidelines go on to state, “. . . The individual may need medical assistance to

facilitate a transition of status to live in accordance with his or her gender identity
rather than with the phenotype.” (GIRES, 2009:3) Again, the guidelines presume
the trans person to be identifying as male or female and that they would also
require medical assistance to live adequately in this ‘role.’ What then of gender
ambiguous trans people requiring or desiring surgery and/or hormones to facilitate
their feelings of gender dysphoria? The guidelines fail to take non-binary trans
people into consideration and presume all dysphoria must equate to a desire of
transitioning to male or female.
The next section in the guidelines become confusing as it states, “The services
should be flexible and patient-led, taking into account their particular needs and
circumstances. . . the aim of the treatment services is to achieve lasting personal
comfort with the gender role.” (GIRES, 2009:3) How can a service be flexible when
it denotes how one must feel to legitimately be experiencing ‘gender dysphoria?’
On the one hand it emphasizes the fact that treatment should be ‘patient-led’
implying it must accommodate to a patient-centred treatment approach to ensure
each individuals personal needs. This gives a sense that there is some acknowl-
edgement that each case will be di↵erent to each trans person, but again, failing
to acknowledge how each trans person’s dysphoria and gender identity may not
reflect the rigid definition of what gender dysphoria encompasses since there is no
mention of anything outside of the ‘male’ ‘female’ binary.
In the section marked ‘terminology’ the guidelines illustrate the extent to which
the definition of gender dysphoria and ‘transsexualism’ still utilize gender binaries
to dictate how the trans person will identify. Interestingly, they also acknowledge
the ways in which many of the terms are evolving. “The language used in the fields
of gender dysphoria is constantly evolving as understandings and perceptions of
these conditions change.” (GIRES, 2009:4) If it is understood that perceptions are
changing, why is it not necessarily reflected within the medical terminology?
“A person who is transitioning. . . should be addressed according to the name

and title (Mr, Mrs, Miss or Ms).” (GIRES, 2009:4) The guidelines once again only
foresee binary gender titles as applicable to the trans individual. The gender-
neutral title ‘Mx’ of example, has not been included within the guidelines. The
reason why this is important is due to the fact ‘Mx’ has been implemented by
many major organisations and corporations as a legitimate title choice, reflecting
a change in attitude regarding gender identity and the freedom and right to express
oneself outside of the binary.
An article taken from polyinpictures online magazine entitled ‘The Growing Use
of ‘Mx’ as a Gender-Inclusive Title in the UK’ (2014) illustrates this by listing
various companies and organizations of which Mx is an accepted or o↵ered title
form. These include the ‘DVLA, DWP, NHS, HMRC, Post Office Ltd, and most
of the major banks including Barclays, HSBC, RBS Santander, Halifax and Co-
Op.’ (polyinpictures, 2014, online article) It is puzzling therefore, that in-depth
guidelines set about to educate and inform medical professionals and organizations
regarding treatment of trans people do not encompass this. If the guidelines state
that the terminology is evolving, then this should be reflected within the literature.
Other aspects of terminology evolving in regards to understandings of Trans and

gender identities is in the teachings of Transgender issues, as illustrated in Laurel
Westbrook’s ‘Becoming Knowably Gendered.’ Westbrook comments, “In challeng-
ing dominant understandings of gender, teaching transgender articles promote an
idea of gender as a ‘continuum’ as ‘diverse’ and as ‘fluid.’ These understandings
explicitly argue against a belief that the world is comprised of two mutually ex-
clusive genders.” (Westbrook, 2008:49) It is interesting to see that in teaching
transgender articles, it promotes the ideology that there are more than two binary
genders, since much of the information based on medical knowledge of transgen-
dered people does the opposite.
“Besides challenging current gender norms. These teaching trans-

gender articles dispute dominant understandings of gender by arguing
that all people should be allowed to choose their gender and that gen-
der should not be determined by sex.” (Westbrook, 2008:49)
Westbrook argues that it is the individual who should choose their gender identity,
directly opposing the idea that medical professionals are the ones who get to
dictate an individuals gender identity or a Transgender person’s status by way of
legitimizing the Trans status based on a diagnosis of ‘gender dysphoria.’
In Holly Boswell’s ‘The Transgender Alternative’ she states,
“Many confuse sex with gender. Sex is biological, gender is psy-

cho/social. If biology does not truly dictate gender or personality,
then dichotomies of masculinity and feminity may only serve to coerce

or restrict the potential variety of ways of being human.” (Boswell,
1991:31)
Boswell is essentially implying that masculinity and femininity do not represent

or coincide with either gender identity, and are in fact social constructs that work
against a notion of gender fluidity.
The guidelines go on to state, “It is important to note that many people. After
receiving the appropriate medical care do not identify as trans, but simply as ‘men’
and ‘women.’” (GIRES, 2009:4) The concept of trans people ‘simply’ identifying
as men or women give a notion of normalization, and the implementation of the
word ‘simply’ implies that identifying in this way is a far less complex identity
than it is to identify as transgender. Remove the ‘trans’ status and underneath
they are just regular men and women like everyone else. By stating that Trans
people identify in this way ‘after receiving the appropriate medical care’ suggests
that trans people could only really identify as ‘men’ or ‘women’ post surgery or
hormones.
When a trans person discounts their trans identity, this is what is known within
literature and trans communities as living in ‘stealth.’ Opinions on ‘stealth’ vary
drastically with some advocates of trans people denouncing it as having negative
consequences on the community. An article in The Transadvocate for example,
stated how it is only when transpeople are out and open about their gender iden-
tity, that change within societal opinion and policy happen. “. . . Only being out
and proud of being trans has led to the major gains we’ve made in the public
policy realm the last few years.” (Roberts, 2013)
Roberts argues that being stealth perpetuates the narrative of trans people being
forced to hide their trans identity, arguably associating being transgender with an
innate sense of shame.
“How are they helping the trans community by NOT being out at
the two large gay inclusive organisations? They will be more concerned
about hiding their trans status at all costs than being fierce advocates
for our community alongside these organisations.” (Roberts, 2013)
This statement is in regards to the 6 alleged stealth trans people working at

HRC and GLAAD. It could be argued that social and medical reinforcements
on acceptable gender identities have an impact on a trans person’s willingness to
disclose certain information about themselves.
Another way of interpreting this is by looking at it from a perspective of ‘Nat-

uralizing’ Transgendered people, and instead of considering being transgendered
outside of the normative, understanding it as something that has merely been
considered as such by years of social conditioning. Laurel Westbrook discusses
this idea by looking into Transgender articles that address issues of ‘Naturalising’
Transgender.
“Through their tone and formatting, as well as explicit claims that

transgender practices come from nature, these teaching transgender
articles naturalise the concept of ‘transgender’. . . Authors frequently
argue that transgender is natural and biological. For example, Holly
Boswell writes ‘It is our culture that has brainwashed us and our fam-
ilies and friends, who might otherwise be able to love us and embrace
our diversity as desirable and natural – something to be celebrated.’
(Westbrook, 1991:31)”
For Boswell, it is culture and society that has made transgender identity or gender
ambiguity ‘abnormal’ as opposed to the identity itself, which she states is ‘natu-
ral.’ It could be argued, that medical diagnosis of ‘Gender Dysphoria’ and medical
literature have also contributed to an ideology of Transgendered people not nec-
essarily fitting in with the norm. It is also important to note, that for those Trans
people who do not identify into either binary gender, fail to have the opportunity
to be granted ‘normalisation’ due to the fact that their identity is not considered
legitimate.
Chapter 4
Legitimizing Trans Identities
4.1 Gender Recognition Act and Acceptable vs.

Unacceptable Trans Identities
This section will be focusing on what kinds of trans people qualify for legal citi-
zenship and are recognized within the legal system and society and importantly-
those who don’t. It will also look into legislative changes such as the Gender
Recognition Act (2005) and whether this has been beneficial for trans people and
if not, why, and if it has been beneficial- for who? To aid the discussion I will
be focusing on Sally Hines ‘Transforming Gender: Social change and Transgender
Citizenship.’ (2006)
The Gender Recognition Act came into force in April 2005 allowing trans people
to ‘become the acquired gender’ by way of applying for a Gender Recognition Cer-
tificate that had to be approved by a Gender Recognition Panel. The Certificate
would allow the trans person to have their birth certificate and passport altered
so that the gender would match their ‘lived’ gender. In Sheila McLean’s ‘First Do
No Harm’ (2013) she comments that the acquiring of a GRC is:
“. . . Subject to certain expectations.” (Mclean, 2013:563) “The ap-

plicant (must have) have gender dysphoria, has lived in the acquired
gender for at least two years, and intends to continue to do so for the
rest of his or her life. As such, the Panel’s decision is one of fact rather
than judgment.” (McLean, 2013:563)
17
Chapter 4. Legitimizing Trans Identities 18
McLean highlights the fact that the GRC can only be obtained by fulfilling certain
quotas such as the diagnosis of gender dysphoria, and ‘living in role’ for two years.
As previously established, the quota needed to fulfill a diagnosis of gender dyspho-

ria rests quite firmly on a notion of identifying oneself ‘male’ or ‘female’ that di↵ers
from biological sex. This would make it increasingly difficult for a trans person
who does not identify within a binary to be eligible for a Gender Recognition Cer-
tificate. But why does this matter? It matters because the GRA was considered a
shift in changing attitudes towards transgender people and in encompassing them
as legal citizens as illustrated by Sally Hines. (2013)
Hines commented that the Gender Recognition Act ‘represented the civil recogni-
tion of gender transition’ and marked ‘an important change in attitudes towards
transgender people.’ (Hines. S, 2013:2)
This specific change in attitudes was in reference to the fact the legislation no
longer required surgical intervention as a requirement to obtain a GRC. Hines
states that this “. . . brings a new framework for understand sex and gender, and
the relationship between these concepts.” (Hines, 2013:2)
Whilst it is positive that shifts in understandings of gender and sex have progressed
so far as to not dictate gender via genitalia, in her paper ‘Transforming Gender,’
Hines argues that the GRA is still rooted in medicalised ways of thinking that
marginalize practices of gender diversity. (Hines. S, 2007:1) In other words- the
GRA still limits what is acceptable and legitimized gender diversity and what isn’t.
“Normative binary understandings of gender underpin recent social and legislative
shifts.” (Hines, 2007:1)
This is evident in the fact the GRA only accommodates those trans people looking
to change the gender on their birth certificate from M to F or vice versa, and the
right to marry in their ‘new’ gender.
One of Hines’ interviewees ‘Christie’ highlighted the fact that the rights the GRA
granted were not extended to non-gendered people commenting,
“I could only successfully apply for gender recognition if I were to

identify within the gendered societal construct. . . . The law does not
recognize human existence outside the gendered societal structure.”
(Hines, 2010:100)
The legislation only serves those trans people who have the desire to change from
one binary gender marker to the other.
In Stephen Whittle and Taryn Witten’s ‘The greying of Transgender and the
Law,’ they discuss these exact issues in relation to the GRA commenting, “It is
both medically incorrect and ethically wrong to assume that trans people’s needs
only relate to gender reassignment therapies and surgeries.” (Whittle, Witten,
2004:511) This acknowledges the fact that the needs of Trans people go beyond
medical intervention. Whittle and Witten highlight the fact that the pathologising
of Trans bodies can be extremely damaging to individuals.
This is illustrated in the case of Trans man ‘James’ who at 71 and with early
stages of alzheima’s was placed within a local authority where every other client
was female. (Whittle, Witten, 2004:513)
“The sta↵ at the care home were very uncomfortable with meeting his bodily
needs and were very unhappy with his constant removal of his incontinence pads.”
(Whittle, Witten 2004:513) Incidentally, James had undergone chest reconstruc-
tion surgery, but not genital surgery. A local volunteer contacted a support group
after discovering James very distressed. A Trans man met up with James to dis-
cover he was very distressed with the use of incontinence pads used, and regarded
them as ‘women’s aids.’ (Whittle, Witten, 2004:513) After a threat to invoke Dis-
ability Discrimination James was eventually moved into a Men’s home and became
much happier. Whittle and Witten comment,
“The Western biomedical healthcare sustem, with few exceptions,

pathologises trans-behaviours and intersexed bodies – ‘right mind/right
body vs. wrong mind/right body or right mind/ambiguous body. . .
‘Trans’ is invisibilised as well as pathologised, through a classification
of mental pathology.” (Whittle, Witten, 2004:513-514)
The emphasis on ‘marriage’ highlights an idea of acceptability that is rooted in

heteronormative ideals, such as marriage and binary gender. Hines comments,
“. . . Notions of citizenship are heterosexualised, such boundaries of tolerance de-
pend upon rights based claims (such as the right to marry) which fit with a het-
erosexual model of the ‘good citizen.’” (Hines, 2007:7) It could be argued that the
same can be applied to notions of ‘acceptable trans person’ vs. ‘unacceptable.’
For example; a binary identifying trans person vs. non-binary trans person. Hines
utilizes the fight for lesbian and gay rights as an example of the way articulating
the rights of lesbian and gays through the concept of ‘citizenship.’ (Hines, 2007:7)
In Michael Warner’s ‘The trouble with Normal,’ he comments that “Marriage, in

short, would make for good gays – the kind who would not challenge the norms
of straight culture, who would not flaunt sexuality, and who would not insist on
living di↵erently from ordinary folk.” (Warner, 2000:113)
Warner makes an important point; the concept of ‘not living di↵erently’ from
‘ordinary folk.’ This notion could definitely be applied to Transgender people in
the sense that those who comply with medical transition in order to present as a
binary gender are ‘ordinary folk’ compared to those who don’t.
Warner goes on to illustrate the fact that marriage is not just about two people
taking a vow; marriage is much more to do with having that relationship acknowl-
edged by the state. (On this occasion, those marriage privileges tied to marriage in
the United States.) “Let us begin with the menu of privileges directly tied by the
state to marriage. Marriage is nothing if not a program for privilege.” (Warner,
2000:117)
Warner mentions how marriage as a social institution is constructed and the stereo-
typical ideologies surrounding marriage are perpetuated,
“. . . Advocates of gay marriage assume that marriage as a social

institution is, in the words of Bishop John Shelby Spong, ‘marked by
integrity and caring and. . . filled with grace and beauty’; that it will
modify ‘behaviour’ (that) is desperately in need of virtue.” (Warner,
2000:113)
Essentially, Warner implies that advocates of gay marriage believe a↵ording mar-
riage to gay people will, in a sense – ‘normalize’ them and eradicate the idea of ‘bad
queers.’ Marriage will allow gays to be accepted within heteronormative society
by following the alleged sanctity of marriage.
The idea of acceptable vs. unacceptable in regards to alternative sexual identities

can also be noted in Kath Browne’s ‘Geographies of Sexualities,’ in which it is
argued that success if granted by the state always lead to negotiations and a
‘burden of compromise’ that results in an agreed to “acceptable’ mode of being a
sexual citizen.” (Browne K, 2007:162)
“State and gay and lesbian acceptance of certain forms of homo-

sexuality – forms of ‘homonormativity’ – reflect forms of discipline and
constraint that e↵ectively close o↵ spaces that support various forms
of alternative ‘erotic citizenship’ (Bell and Binnie 2000:19) Alternative
sexual practices and identities are pushed into the private and invisible
sphere, causing a division between ‘good gays’ and (disreputable) ‘bad
queers.’” (Browne. K, 2007:162)
If we can come to an understanding that those minority groups who follow the
heternormative ideal tend to fare better within state protection and acceptance,
then the same argument could be applied to transgender people. Specifically those
who do not fit in with social ‘normative’ gender roles.
4.2 Medical Treatment Narratives and Gendered

Citizenship
This section will look into the medical narratives a Trans person must usually fol-
low in order to be seen as a legitimate case for medical intervention and treatment.
I will also be looking into the ways Trans people are a↵orded Citizenship by look-
ing into the concept of what is seen as ‘acceptable’ and ‘unacceptable’ in regards
to identities that are situated outside the norm, and the pattern of acceptability
one must follow in order to attain citizenship.
Hines comments that, “. . . Whilst some new forms of trans femininities and mas-
culinities are benefitting from recent policy developments, other experiences and
practices of gender transformation remain marginalized.” (Hines, 2007:2)
It could be argued, that there is a real lack of research on the topic of marginalized
trans people due to a lack of representation and acknowledgement of these trans
people’s existence. In many cases, a non-binary trans person will follow a medical
narrative of a binary trans person purely in order to move through the healthcare
system. Providing these trans people identify as one binary gender or the other
and present themselves in a satisfactory way that proves they can conform to a
specific ‘gender role,’ they are able to fulfill the medical professionals expectations
and thus receive access to medical care and access to certain legislation and rights
to citizenship. Other trans people are excluded because they do not conform to
the rules set out by the heteronormative state.

This idea is illustrated in Zowie Davy’s ‘Transsexual Agents’ (2010) in which
she interviewed various self-defining Trans people and their experiences within
the health care system. One such participant named Benjamin responding when
asked about the positives from the NHS stated, “The positives are only that you
get what you need from. The negatives were. . . very generalized and out of date
questioning which resulted in standard answers.” (Benjamin, transman from Davy.
Z, 2010:115)
Davy states that this response follows a ‘standard narrative,’ (Davy, 2010:115)
and the responses are therefore not truthful accounts of the trans person’s iden-
tity per se, but rather obligatory responses rooted in preconceived knowledge of
what requirements are necessary to access medical care.
“As with the majority of participants in this research. . . Benjamin understood

that taxonomic legitimacy and a diagnosis are required to actualize transforma-
tion of (his) body.” (Davy, 2010:115, my emphasis) Davy highlights the fact that
Benjamin had prior knowledge that the ‘condition’ (in medical terms) of “Trans-
sexualism” (Davy, 2010) had to be legitimized by a medical professional, and
subsequently persuading the gatekeeper to allow for access to the treatment.
“Most participants demanded medical services even though some

were skeptical about the psychiatric process within the NHS. The pro-
cesses involved in persuading their psychiatrist (gatekeeper) that they
were legitimate candidates for hormonal and surgical intervention were
viewed as ritualistic. . . ” (Davy, 2010:11)
The concept of medical Transition as ‘ritualistic’ is a notion suggested in Whitney

Barnes paper ‘The Medicalization of Transgenderism.’ Barnes states that Trans
people are fully aware of the procedures that need to be followed and are not
‘passive agents in the medicalization of their existence.’ (Barnes, 2001)
“The evidence that transgendered individuals find it necessary to

circumvent the rules governing their access to legitimate and adequate
health care, often through means of dishonesty and/or embellishments
brings one to question the very existence of those regulations they must
work within and against. Any institutional structure which causes
people to provide their health care providers with less than entirely
honest information is subject to scrutiny.” (Barnes, 2001)
Here, Barnes criticizes the medical institution by suggesting that the rules that
are put in place to decide who gets access to healthcare and who doesn’t forces
Trans people to lie and give dishonest accounts in order to receive the healthcare
they need. This is not a negative reflection on the Trans person, but a reflection
of the rigid regulations set out by the medical professionals.
This is a notion reflected by Scholars such as Califia and Namaste, who suggest
that, “Transgendered people read what psychiatrists write about them. . . so that
they can enter the clinical setting, present the ‘classic’ transsexual narrative, and
receive the health care and medical technology they desire.” (Califia, 1997:192)
And that “The gender community has at this point accumulated a lot of folk
wisdom about what you need to tell the doctors to get admitted to a gender-
reassignment program.” (Califa, 1997:224)
The idea of medical professionals acting as ‘Gatekeepers’ for treatment and the
pathologised treatment of Trans individuals is also reflected in Juliet Jacques ar-
ticle published in The Guardian (2010) in which she documents her experiences
as a Transgender patient of the NHS going through gender transition.
Jacques comments,
“’Charing Cross’ (London’s Gender Clinic) – struggles to shake a

reputation for being cold and overly demanding. This is not always di-
minished by the experiences posted online by patients, some of whom
have reservations about gender services being pathologised under men-
tal health.” (Jacques, my emphasis, 2010)
Jacques addresses the issue that the gender clinic has a ‘reputation,’ arguably fu-
elled by online discourse of people’s experiences at the clinic who are dissatisfied
with the pathologised approach of treatment and services.
Jacques comments, “If you arrive prepared to work with the clinicians, you shouldn’t
have many problems. . . I had plenty going for me. . . having changed my name
and begun living ‘in role.’” (Jacques, 2010) Here, Jacques illustrates the ways
in which it is possible to get through the system more efficiently providing you
work ‘with’ the clinicians. She mentions having changed her name and lived in
her desired gender role, implying these are factors taken into consideration by the
Gender Clinic.
What exactly is meant by ‘living in role?’ (Sometimes called Real Life Experi-
ence) In a document taken from Ontario Human Rights Comission (OHRC, 2014)
entitled ‘Medicalisation of Identity,’ it discusses the issue of ‘real life experience’
(or living ‘in role’) and the problems this can encompass.
“The real life experience requires the pre-operative individual to

‘live’ in their felt gender for a prolonged period of about one to two
years. . . There is significant controversy within the transgendered
community about ‘RLE’ and its medical necessity. One individual
with a medical background stated that RLE does not provide useful
information to the patient. . . it is rather a period of compliance with
a rigid set of criteria.” (OHRC, 2014)
This is an important point, as it addresses the fact that ‘living in role’ does not
serve to inform the Transgendered person about what should be expected in ‘sex
reassignment’ or indeed any kind of medical intervention that Trans person may
choose to undertake, but instead is merely a medical requirement one must comply
with in order to gain medical services.
Concepts of ‘living in role’ and ‘real life experience’ also bring about the concept
of ‘Passing.’ According to Lori Girshick (2009)
“The word as it is used today generally refers to fitting into the

gender binary as a man or a woman. In order to pass in this sense
it is not enough to be who you are – you have to alter your gender
appearance and behaviors to fit notions of masculinity and femininity.”
(Girshick, 2009:108)
Girshick highlights the fact that to pass within society means living up to soci-
ety’s expectations of male and female. Leslie Feinberg stated that Passing was
a ‘product of oppression,’ (Feinberg, 1996:89) whilst Kate Bornstein comments
that “Passing becomes silence. Passing becomes invisibility. Passing becomes lies.
Passing becomes self-denial.” (Bornstein, 1994:125)
However, what is failing to be acknowledged is the way in which ‘Passing’ can

also prove extremely positive for the Trans person by way of having their gender
identity taken seriously within society, and also furthering their chances for medical
treatment.
In Josephine Ho’s ‘Transgender body/subject formations in Taiwan’ (2006) she

explores the ways in which ‘passing’ often allows for easier integration within
society for the Trans person.
“. . . The concept of ‘passing – along with its connotations of decep-

tion – entails profound knowledge/power maneuvers for Trans subjects.
For passing presupposes the unchallengeable ‘naturalness’ and ‘truth-
fulness’ or ‘evidentially’ of the physical body, and affirms the meaning
and status assigned to such a body by the social culture.” (Ho. J,
2006:230)
Ho suggests that passing as their chosen gender grants acceptability and status of
the Trans person within the society in which they move.
“The operation of such as truth regime thus serves to reduce/stig-

matize the trans subjects’ bodily self realization as nothing but scams
and deceit, not to mention creating a profound sense of shame and
insecurity in the subjects in regard to the clear discrepancy between
one’s body and one’s chosen identity.” (Ho, 2006:230)
Ho argues that the negative connotations and criticisms of ‘passing’ encourage the
idea that a Trans person’s body (post surgery) and the living in role of that gender
identity or ‘passing’ is nothing more than a ‘scam.’
Ho suggests that bodies are not given, fixed materials and instead comments that
they are physical embodiments of the self (Ho, 2006:230).
“Trans subjects di↵er from other subjects only in that they have formed a very
di↵erent feeling of ‘at-homeness’ as their endowed body completely fails to provide
that feeling.” (Ho, 2006:230-231)
It could be argued that a Trans person’s body post surgery or hormones is no

di↵erent from any other gendered individual and is not an attempt at ‘passing’ as
one specific gender or another. The need for medical intervention is separate from
the need to be ‘accepted’ within society,’ and is merely a way of feeling ‘at home’
within a body. However, Ho’s paper mainly focuses on those Trans people who
wish to ‘Pass’ within society and she fails to address issues of gender ambiguity
within the Trans community in which her paper is based.
Concepts of medical intervention and Trans Bodies have always been a topic of
debate and disagreement between medical professionals and Trans people them-
selves.
In Alison Rooke’s ‘Telling Trans Stories,’ (2008) she brings together a paper in
which both Medical Professionals and Transgendered people are able to put their
opinions on medical services and the treatment of Trans bodies together in the
same forum. Rooke focuses on the ‘Scidentity Project’ which was a workshop/-
panel discussion bringing together academics, arts practitioners, medical profes-
sionals and a group of 18 young transgendered and transsexual people between the
ages of 15-22 who were ‘living their sex and gender with a degree of complexity.’
(Rooke, 2008:65)
By bringing together both medical professionals and Transgender people and al-
lowing a dialogue to initiate between the two parties, it allows the Trans person
to voice their experiences. Rooke suggests that their trans identity may allow for
a more complex understanding of sex and gender that say – a medical professional
would not have. In light of this, it brings about the question, who has the right
to diagnose? If we separate gender dysphoria from a medical definition and un-
derstand it as more of an identity that is individual to each person as opposed to
a medical condition – who holds the right to give the go ahead for surgery over
someone else’s body?
Rooke comments,
“. . . Young trans people could form their questions, explore, deepen

and express their understandings of gender and sex, interrogate scien-
tific discourses of sex, gender and transsexuality and respond to the
‘authority’ and apparent certainties of science. . . ” (Rooke, 2008:65)
By using the term ‘interrogate’ Rooke suggests that the trans people in the project
may disagree or have issues with the scientific discourses of ‘Transsexuality’ –
subsequently utilizing their own experiences to directly challenge the medical dis-
course. Placing the word ‘authority’ in quotations also suggests that Rooke has
her own doubts on the authoritarian stance placed on medical discourses.

The two phases of the project featured a creative engagement, and outreach work-
shops aimed at a variety of audiences such as teachers, youth workers, activists
etc. The workshops served to inform and educate those who worked in the private
sector so they would be better equipped in dealing with trans youth.
“There was space where the participants could relate with other young trans peo-
ple and explore their own identities through the relations with others.” (Rooke,
2008:66) Rooke outlines the fact that the creative segment was made interactive
in the hope that non trans participants would be better able to understand gen-
der non conformity, by finding and relating to similarities through the stories and
experiences of trans people.
This implies that it is possible to educate and inform cis-gendered people (non
trans people) of gender ambiguity and gender variance through Trans narratives.
It also brings medical definitions of what it is to be Transgender/Transsexual un-
der scrutiny and medicalization of Trans people into question. How can one truly
comprehend and define what makes a legitimate trans person unless they have
experienced the feelings of ‘trans-ness’ themselves?
Group discussions allowed transpeople to discuss their experiences, worries and
feelings about their identity in a safe space. The presence of medical professionals
also gave them the opportunity to challenge the status quo.
“The participants own histories and experiences were transformed through chal-
lenging the authority of the science of sex and gender.” (Rooke, 2008:68)
They developed critiques of the scientific and medical practices that reproduce the
coherence of sex and gender in the figure of the ‘man’ or ‘woman.’
We could argue that the practice of telling trans stories and narrative means the
medical professional will hear the trans person’s individual experience and own
relationship with their gender identity as opposed to basing treatment of all trans
people on one specific protocol or structure according to medical guidelines.
If all trans people are not the same, then the treatment model to which they are
ascribed should not be the same for all trans people.
One Trans participant in the project named Shannon brings up quite an important
point regarding cosmetic surgery.
“To get your tits enlarged you need money, but to get them cut o↵
you need a gender shrink. That’s bloody weird! . . . .Why is one more
of a problem for society than the other? Why does society require that
we have an either/or gender?” (Rooke, 2008:69)
Shannon makes and extremely valid point. If one experiences body/gender dyspho-
ria, why does the desire for a specific body modification surgery require someone
to jump through medical and gender binary hoops in order to access one specific
type of surgery.
Chapter 5
Citizenship
“Bell and Binnie propose ‘queering’ citizenship to acknowledge and

celebrate the ways in which normative practices and arrangements (e.g.
non monogamy) challenge the institution of heterosexuality and tradi-
tional conceptualizations of citizenship.” (Hines, 2007:7)
It could be argued that if ‘queering’ citizenship can challenge normative ideology

of the regulations one must follow in order to be accepted as a legitimate citizen,
there is space to ‘queer’ gender in the same way, so that those who do not fulfill
the correct regulations of ‘gender ambiguity’ as set out by heteronormative ideals
and medical practitioners may too be accepted.
Can citizenship be Gender Neutral? This is a question posed by Mark Rix.

Rix looks into social citizenship and asks whether it’s possible to have gender-
neutral citizenship incorporated into the citizenship system when it has long been
‘burdened’ with the issues of gender inequality. (Rix, 2006:1)
Rix suggests that because legal citizenship focuses on the idea that ‘all citizens are
equal before the law’ it is able to escape the gender inequality embedded within
social citizenship. (Rix, 2006:1) This, Rix argues – is due to social citizenship’s
focus on ‘paid employment’ as an eligibility requirement to the public sphere and
the rights of cizenship. “This meant that womens traditional roles of child bearer,
caregiver and homemaker were usually regarded as being inconsistent with social
citizenship and full participation in the public sphere.” (Rix, 2006:1)
From the outset Rix paints a picture of citizenship being fully grounded in ide-
ologies of binary gender and traditional gender roles based around inequalities of
29
Chapter 5. Citizenship 30
citizenship through ‘gendered work.’

This is an important point, because it reinstates a notion of citizenship encom-
passing binary gender, reinforcing the fact that non-binary gendered people may
not be valid candidates for this specific citizenship model.
But it can be done. Germany is the first country in Europe to legally recognize a
third gender, while several other nations have already taken similar steps. (BBC
News, 2013) German passports now have a third designation ‘X’ for intersex hold-
ers. Allowing legal recognition of its intersex citizens is a huge first step. For
one, it acknowledges the existence of a third gender, and also indirectly acts as a
deterrent for any social and medical ideas revolving around ‘corrective’ surgeries
and the need to make an individual one gender or the other. It encompasses a
gender identity that it previously denied existed.
Silvan Agius of IGLA-Europe which campaigns for the rights of LGBTI people
said the law needed to go further. “While on the one hand it has provided a
lot of visibility about intersex issues. . . it does not address the surgeries and the
medicalization of intersex people and that’s not good. That has to change.” (BBC
News, 2013)
Silvan highlights the important issue that although a third gender option is avail-
able, the issues of medicalization still exist and are failing to be addressed. Could
it be argued that gender-variant bodies are so heavily associated with medical
interventions and surgeries, that it is hard to separate the two even when legal
recognition and citizenship is granted?
Another aspect of citizenship, specifically when we think of how it is associated

with binary gender is by looking at gender as a system of it’s own, in this case
‘Gender as a system of Oppression.’ (Bornstein, 1994:105) In Kate Bornstein’s
‘Gender Outlaw’ (1994) she looks at binary gender as a form of oppression ‘made
all the more dangerous by the belief that it is an entirely natural state of a↵airs.’
(Bornstein, 1994:105) By presenting the gender binary as ‘natural’ (I previously
discussed concepts of ‘naturalising trans’) non-binary gender becomes unnatural
and ‘the other.’
Bornstein looks into gender binaries as a system of class and power, and how one
cannot exist (or indeed, oppress) without the other. Bornstein comments,
“In the either/or gender class system that we call male and female,
the structure of one up, one down fulfills the requisite for a power
Chapter 5. Citizenship 31
imbalance. . . It’s an arena in which roughly half the people in the

world can have power over the other half. Without the structure of the
bi-polar gender system, the power dynamic between men and women
shatters.” (Bornstein, 1994:107)
Bornstein is essentially stating that the gender binary exists purely to enforce the
oppression of women and ensure that men retain their position as the ‘dominant
class.’ Without gender binaries, there would be no division of power. And without
the division of power, ‘one half’ of the population would not be better o↵ than the
other.
Does the separation of medicalization and gender identity help to eliminate gender
binaries? In what ways, if any, is the move away from medicalization detrimental
to the rights and healthcare of Trans people?
Chapter 6
Issues with the

‘De-Medicalization’ Of
Transgendered People
“The demedicalization of transsexualism is a dilemma. There is

a demand for genital surgery, largely as a result of the cultural gen-
ital imperative. . . Transsexuals, especially middle-class pre-operative
transsexuals are heavily invested in maintaining their status as ‘dis-
eased’ people. The demedicalization of transsexuality would further
limit surgery in this culture, as it would remove the label of ‘illness’
and so prohibit insurance companies from footing the bill.” (Bornstein,
1994:119)
This section deals with the potential problems that arise from arguments that call
for the moving away from a medicalized view and treatment of Transgender people.
I believe it is important to address this issue as the bulk of this dissertation has
explored the negative aspects of medicalizing trans people without acknowledging
the ways in which Medicalization also protects and allows for the treatment of
Trans people.
Bornstein (1994) highlights the fact that maintaining ‘Transsexualism’ as a med-

ical issue or a ‘disease’ means that Trans people maintain an access to medical
intervention if they need it. They are protected in the sense that with a diagno-
sis comes medical assistance. “Transsexuality is a medicalized phenomenon. The
32
Chapter 6. Issues with the ‘De-Medicalization’ Of Transgendered People 33
term was invented by a doctor. The system is perpetuated by doctors.” (Bornstein,

1994:119)
If we are to acknowledge the Transsexual or Trans identity of an individual, we

must acknowledge the term and identity was constructed by medical professionals
utilizing medical terminologies. Subsequently, can it ever be possible to demedi-
calize the Trans person and Transgender identity? Barnes (2001) comments;
“Transgender identity is claimed by the psychiatric community as

a ‘disorder’ or ‘condition.’ These regulatory functions include the ne-
cessity for transsexuals to claim ‘illness’ before being considered for sex
re-assignment hormones and/or surgery. This ‘illness’ is itself trans-
sexuality, and unless one accepts transsexuality as an ‘illness’ and as a
component of their own personality, they will be excluded from most
sex-reassignment programmes.” (Barnes, 2001)
Barnes illustrates the way that a Trans person as a patient seeking medical help
has to conform to the rules and regulations laid out by (in this instance) the ‘psy-
chiatric community’ who have given Transgender identity the label of a disorder
or a condition. To qualify for medical attention and to have their Trans identity
legitimized the Trans individual must accept, whether they feel it is the case or
not – that they have the ‘illness’ of Transsexuality. They must ascribe to the
condition already set in place by the Medical professional which in turn enforces
Transgender identity as a medical ‘condition’ as there is no other choice for the
Trans person if they want to receive treatment.
It could be argued that de-medicalizing Transgender would run the risk of remov-
ing regulations that the medical professional deems ‘necessary’ in order to treat
patients.
However many theorists argue that Transsexualism’s place within medicine and
psychiatry will continue for a long time to come (Barnes, 2001) as Barnes com-
ments the two have grown together and become intertwined.
In Janice Raymond’s 1979 publication ‘The Transsexual Empire’ she controver-
sially argues that ‘transsexuals are created through medicine’ and that ‘psychiatric
evaluation as well as the availability of surgery function to produce transsexuals.’
(Namaste, 2000:33) This is a highly problematic statement since it presumes that
one cannot identify or be Transgender without being a post-operative Transper-
son. It implies that one becomes Transgender or ‘Transsexual’ through medical
intervention. In essence, it claims Transgender is not a legitimate gender identity.

Raymond fails to recognize the distinction between biological sex and gender iden-
tity.
Barnes (2001) argues that the problem with this concept lies in the medical defini-
tion and terminology surrounding the Trans identity. This definition presupposes
the need for medical intervention.
“. . . The term ‘transsexual’ mandates some desire to attain attributes

of the ‘opposite sex.’ . . . Western medicine holds a firm monopoly over
the various possible means with which to achieve those ends.” (Barnes,
2001)
In essence, ‘Transsexual’ cannot exist without Medical intervention because Medicine

and Psychiatry created the term.
“It is difficult to imagine that people existing in cultures without

modern Western medicine. . . could have conceived of surgically and/or
hormonally altering their sex in the methods now practiced by modern
Western medicine.” (Barnes, 2001)
Arguably, the desire for these changes may have existed, but Barnes does not ad-
dress the fact that these desires and needs for surgical intervention presuppose the
existence of Western medicine. The fact Western medicine began to incorporate
such surgeries and medical options for Trans people must have been born out of a
need for it.
Leslie Feinberg (1998) addresses this point:
“It’s true that the development of anesthesia, and the commercial

synthesis of hormones, opened up new opportunities for sex reassign-
ment. However, the argument. . . doesn’t take into account ancient
surgical techniques of sex-change developed in communal societies that
o↵ered more flexible sex and gender choices.” (Feinberg, 1998:105)
Feinberg agrees that advances and development within medical treatment meant
that ‘sex reassignment’ was made further possible by way of surgeries and hor-
mones. However, Feinberg makes the important point that these Western medical
interventions are restrictive and limited since they perpetuate the notion of binary
gender by o↵ering surgery and hormones in order to change ‘from one sex to the
other.’ Feinberg also states that surgical techniques to assist Trans people existed
prior to Western medicine, and in fact accommodated gender fluidity as opposed
to enforcing gender binaries.
“Descriptions of Native American’s fluid perceptions of sex and gender poignantly

illustrate that transgendered individuals accessed recognition of their gender iden-
tities without the aid of modern Western medicine or technology.” (Barnes, 2001)
It could be argued, that because perceptions of gender identity within these com-
munities embraced notions of gender ambiguity (or in the case of tribal communi-
ties within Native American societies - ‘Two-Spirit’ people) (Barnes, 2001) there
was less of a need for ‘sex reassignment’ surgery since fluid gender identities were
accepted without the Western social expectations of fulfilling a specific binary gen-
der quota.
Therefore, we could argue that modern Western social expectations of gender have
an influence on not only the kind of surgeries and medical services a Transgender
person is able to access, but also the kind of surgeries and medical services a Trans
person desires.
At what point does Medicalization of Trans people become beneficial? One major
argument in favour of medicalizing Trans identities is the fact that through medi-
cal terminology and the articulation of ‘Transsexuality’ through medical diagnosis,
comes legislation, rights, and medical implementation in order to accommodate
those who have been diagnosed with the ‘condition.’
One example of how medical diagnosis serves to protect and accommodate Trans
individuals are in cases such as; where a Transgendered person has been incarcer-
ated.
Alvin Lee (2008) recounts the incident of Donna Konitzer, a trans woman diag-
nosed with Gender Identity Disorder (GID) incarcerated in Wisconsis until 2026.
“Recognizing their Eighth Amendment obligation to provide in-

mates with healthcare. . . Wisconsis prison officials enacted a policy in
2002 stating that those diagnosed with GID should be given access to
hormone therapy while incarcerated.” (Lee, 2008:448)
In this instance, it is evident that the law ensures Transgender people are able
to access the medical services, in this case the hormones that they require. Iden-
tity is legitimized through the medical definition of Gender Identity Disorder, and
without that definition or diagnosis, there would be no foreseeable reason to allow
medical treatment for the Trans person.
Lee acknowledges the controversy with medicalization and asks, “Does the use of
medical evidence create or perpetuate an image of trans people as mentally dis-
eased. . . does the use of medical evidence actually do more to harm than help the
trans community?” (Lee, 2008:448)
Whilst it has been established throughout the duration of this paper that medi-
calization retains focus on maintaining binary gender, it also brings about issues
of reinforcing Transgender identity. This is a notion discussed in Mary Burke’s
‘GID and the contested terrain of diagnosis’ (2011)
“Through medicalization and diagnosis in particular, patients are also able to form
collective identities, which foster the creation of support networks and advocacy
groups. . . institutional recognition, access to services and resource allocation.”
(Burke, 2011:188)
However, as previously discussed in this paper, diagnosis of Gender Identity Dis-
order or Gender Dysphoria - whilst positive in the sense it subsequently opens
gateways to treatments and legislative measures for those successfully diagnosed;
reinstates notions of femininity and masculinity and denies Transgendered people
who ‘do not conform to a particular, narrowly defined set of standards.’ (Burke,
2011:189)
My data collection deals with Trans people’s perceptions and experiences within
the NHS and medical healthcare system, and o↵ers a view of medicalization of
Transgender people from the Trans person’s perspective.
Chapter 7
Independent Study
7.1 Methodology
My research draws upon 1) A qualitative study based on 77 participants who com-

pleted an online survey that asked Four main questions, these included multiple
choice, stating their agreement or disagreement with certain statements and also
the opportunity to add their own input and opinion on certain question topics.
2) Two Skype interviews. I had conducted many more interviews over Skype and
in person, but hadn’t specified that I needed non-binary Transgender people, thus
the majority of my interviewees experiences did not reflect the issues a non-binary
Transgender person faced and had to be omitted. I also had not left enough time
to transcribe the interviews conducted.
7.2 Ethics
My ethics form was approved by Goldsmiths University Of London. The research

has been conducted in a way to prevent any harm to participants. This entails a
full briefing of the research, its purposes and the way in which it will be utilized
so the interviewees can provide fully informed consent to take part. No questions
required the participants to identify themselves and there was no way to trace
participants’ identity so the survey was automatically anonymous. The terms and
conditions are stated on the first page of the survey (see appendix 1) including
advising participants that they must be 18 or over.
37
Chapter 7. Independent Study 38
7.3 Online Survey
The survey can be viewed in full at: https://www.surveymonkey.com/s/HQZQ8YL

The only demographic that was asked was gender identity. I felt that this was the
only demographic relevant to the research since this dissertation focuses on the
complexities of binary gender and I wished to illustrate that in my results.
I promoted the survey via Internet links on my own personal Facebook page as well
as multiple Transgender/Gender variant Facebook group pages. I also attended
a Queer club night and made an announcement in regards to my survey to try
and encourage more people to take it. I focused on the Trans community since
the questions would be revolving around their own experiences as a Trans person
dealing with the NHS and medical healthcare professionals.
The survey was constructed online using a web-based survey creator called Sur-
vey Monkey, which was free of charge to use and allows the creator to analyze
the results online. I felt this was the best method of data collection due to it
being anonymous and online-based. I opted for a method I knew would be easily
accessible to people and reach a far higher number.
7.4 Online Survey Results
I will firstly address the demographic result regarding the gender identity of par-
ticipants. Question 1 asked: ‘How would you describe your gender identity?’ I
gave a total of 18 di↵erent gender identities for participants to choose from and
importantly allowed them to tick as many of the options as they felt applied.
There was also the option to add a comment to state their own gender identity if
they felt it wasn’t one of the choices o↵ered. (See appendix 2)
I will focus on the most relevant results. 52% of respondents identified with
Transgender, 50% identified with Genderqueer, 31% identified with Trans* and
24% identified as Androgynous. Importantly, only 9% identified as ‘Transsexual,’
which is a term heavily associated with medical terminology and practice.
I took into consideration the fact that many of these people may identify them-
selves as gender variant, the results indicate that this is the case. We could argue
that these people hold greater understanding of the issue due to their own per-
sonal experience of gender variant bodies. It also shows just how broad and varied
Transgender people’s gender identities can be.
Question 2 asked, ‘When consulting a medical professional (GP or Gender Clinic)

about transition, did you have any prior knowledge of the process? (This can be
anything from researching online, to talking with Trans friends)’
Respondents were only able to tick ‘Yes’ ‘No’ or ‘Unsure.’ This question was
posed because I wanted to illustrate the way in which preconceived knowledge or
direct knowledge regarding medical practice has an impact on the way Transgender
people access medical services, specifically the NHS.
A massive 87% of respondents stated that they did have prior knowledge regarding
the process of Transitioning. (see appendix 3) This result is important as it goes
on to show how this knowledge perhaps had an impact on their experience with
the medical professional in later questions.
Question 3 asked respondents to look at statements and decide whether they

agreed or disagreed. Response options were on a sliding scale of ‘Strongly Agree’
to ‘Strongly Disagree.’ (see appendix 4)
The question posed was: ”During my appointments with the medical professional
I...” followed by nine di↵erent statements applicable to experiences within the
NHS/medical care as a Trans person.
83% of respondents Strongly agreed or agreed that they ‘felt like they had to
present a certain way (i.e. binary gendered) to be taken seriously,’ and 80%
Agreed or Strongly Agreed that they ‘Knew that if they acted a certain way they
would get treated more promptly.’
These two finding are of key importance as it reflects a notion of having to le-
gitimize ones Transgender self in a binary gender in the presence of medical pro-
fessionals. It is also important to acknowledge the fact that the majority of the
Survey participants already had prior knowledge of the way the medical system
worked in order to treat Transgender people and that this must have been a factor
in the way they prepared for appointments.
80% of respondents Agreed or Strongly Agreed that they ‘Felt they had to prove
their Trans identity.’ It could be argued that this pressure to ‘prove their Trans
identity’ is a major factor in the way Trans patients approach and deal with their
appointments with the medical professional.
76% of respondents Agreed or Strongly Agreed that they ‘left out certain aspects
of their history/lifestyle when talking to the medical professional.’ It could be
argued that this supports Barnes (2001) comment that institutional structures
cause people to provide their health care providers with less than entirely honest
information should be ‘subject to scrutiny.’ (2001)

78% Agreed or Strongly Agreed that there was a ‘specific Trans Narrative they
could follow in order to get treated more efficiently.’ This supports the notion
that Transgendered people have an understanding the medical healthcare system
and realize that by following a ‘narrative,’ it is easier to access treatment. A
majority of 54% Agreed or Strongly agreed that they ‘Acted in a more masculine or
feminine way during appointments,’ arguably reflecting the way gender stereotypes
and expectations of gender dysphoria by the medical professional perhaps enforce
binary gender presentation.
Question 4 asked: ‘How do you think the NHS/Healthcare could be more accom-
modating towards non-binary gendered Trans people?’ (See appendix 5)
This was another multiple-choice question where participants were advised to tick
as many answers they felt applied, there were 13 options as well as an ‘other’ box
where participants could add their own response.
I asked this question because I felt it was important to gain insight and feedback
from Trans people of whom had experienced being treated by the NHS.
Over 80% of respondents ticked the following options, ‘Encompassing non-binary
gender identities on the ”gender dysphoria” spectrum,’ ‘Providing Nurses/GP’s
/Doctors/Psychiatrists with updated information on gender identity and Trans
people,’ ‘O↵ering treatment to non-binary individuals,’ ‘Updating medical termi-
nologies/information on Transgender people to include non-binary individuals,’
and ‘Updating language used within medical establishments/databases to encom-
pass gender neutral pronouns and gender ambiguity.’ These were the most popular
response choices and interestingly, they all incorporate a notion of better medical
services and acknowledgement of non-binary Trans people.
This reflects that the majority of participants held an understanding that non-
binary Trans people are failing to be accommodated by the healthcare system,
and hold a desire to see more done in order to accommodate them.
Over 70% of participants agreed with: ‘Treating Trans patients on a case by case
basis,’ and ‘Moving away from the ’Trapped in wrong body’ medical narrative.’
This implies that Trans people wish to have less of a medicalized emphasis on
their treatment and desire a move away from the traditional ‘medical narratives.’
69% of participants agreed that ‘Surgery should be o↵ered without having to be
on hormones.’ This too deviates from the medical requirement and treatment
narrative of having to be on hormones before surgery and would subsequently
accommodate those Trans people who did not feel they needed or wanted to begin
hormone treatment.
A minority of 42% agreed with ‘Looking at treatment for Trans people as more of
a need for ‘comfort’ as opposed to medical intervention.’ In the ‘Other’ response,
one participant stated,
“While I agree with the de-pathologisation of Trans people, I think

it’s still important to recognize that care pathways are commissioned
on medical terms. If chest reconstruction doesn’t fall under a medical
pathway specific to the ’treatment’ of gender dysphoria, then it be-
comes perceived as a purely elective cosmetic surgery, and then there’s
a danger that that care could be taken away from people who really
need it and can’t a↵ord private treatment.” (Anonymous, 2014, see
appendix 5.1)
This participant re-iterates the fact that whilst it is positive to resist the pathol-
ogization of Trans bodies – if surgery and medical intervention is reduced to ‘cos-
metic’ needs, then it will no longer be covered by health services. This would put
those Trans people who desire medical transition and cannot a↵ord it, at risk.
The final question was another multiple choice where participants could tick as
many statements they agreed with and asked ‘How do you think the Governmen-
t/Society could accommodate non-gendered people?’ (See appendix 6)
Over 90% agreed that ‘there should be better education on non-binary gender iden-
tities and di↵erences between sex and gender identity in schools and the workplace.’
Over 90% also agreed that there ‘should be acknowledgement and the o↵ering of
gender-neutral titles and pronouns in all application forms (such as ‘Mx’). This
shows that the vast majority of Trans people would like to see the option of gender-
neutral inclusivity in documentation. It also highlights the desire to have better
information within education system and the work place in regards to Trans and
non-binary gender identities, suggesting that the information out there already is
potentially inadequate and outdated. Or that it does not represent non-binary
gendered people.
Over 80% of respondents agreed to ‘Allowing citizens to self-define as gender-

neutral/third gender without a medical diagnosis.’ This is important as it illus-
trates the belief that Gender Identity shouldn’t necessarily need a medical diagno-
sis in order to legitimize ones Trans status. It also reinstates the fact that people
should be able to self-define as third gender (not just ‘male’ or ‘female’)
7.5 Skype Interviews
The Skype interviews were conducted via Skype text chat. The two interviews
utilized in my research were conducted utilizing the text chat method as this
made the transcribing far easier. The Skype interviewees were also informed of
the terms and conditions prior to the interview and had to state ‘I Agree’ to signify
they had understood the terms of the interview and that their responses would
be utilized in my dissertation. (see appendix 7) All names have been altered to
protect anonymity.
All quotes taken from the interviews have been directly cited from the Skype text
chat interviews. The full transcription from which the interviews are quoted can
be located in appendix part II.
In order for me to be reflexive it is important to recognize that my own gender

identity is similarly aligned with those whom I am studying; I am also a trans
person highly active within LGBT issues. This in itself enabled me to gain access
to a potentially hard to reach social network of people. By using my own identity
to gain participants in this research through social capital it has enabled me to
access my sample more easily and I acknowledge this fact.
7.6 Skype Interview Results
My two interviews were conducted using Skype’s online Text Chat feature. The
interviews followed a very loose structure of 9 preset questions (See appendix 8)
based around the interviewee’s gender identity and experiences as a non-binary
Trans person with the healthcare system. However due to the nature of inter-
views, topics would occasionally branch o↵ into more personalized areas of the
participants life and experience and my questioning would subsequently reflect
this.
My first interviewee was a 27-year-old non-binary Trans identified person named

‘Edward.’ I will utilize male pronouns, as these are what Edward had requested.
Edward explained his understanding of the term ‘Transgender’ to me,
“I think transgender is a really complicated term that can mean

really di↵erent things to di↵erent people... I found out about the term
pretty late, only really properly in my last year of my undergrad degree
from what I can remember. So it was through academic texts and
through a course on feminism.”(Edward, 2014)
Edward’s understanding of the term hadn’t been influenced by medical ideologies

of Transgender(ism) and had instead he had come to an understanding of Trans
identity through Trans literature and academia – and also through feminism.
It could be argued that learning about the term in this context may have helped
in understanding Trans identity in a more varied spectrum than if he had learnt
about Trans identities through medical discourse that tend to utilize more narrow
and binary definitions.
When asked about his experiences with the NHS, Edward emphasized that he
didn’t feel like what he was doing was Transitioning, “...Straight away I don’t feel
like I fit what the NHS system would want me to say to them.” (Edward, 2014)
Edward noted that some of the things he had heard through other Trans friends of
whom had been through the NHS system that had made him apprehensive about
appointments at the (in this instance) Charing Cross Gender clinic,
“I had heard complete horror stories about gender policing, about

trans women who weren’t taken seriously because they turned up to
appointments wearing trousers. I knew about the requirement to take
T (testosterone) and the phrasing used such as ’living in role’. Basically
I knew a lot of people who were way more binary identified than me,
who already were getting a hard time from doctors.” (Edward, 2014,
my emphasis)
Here, Edward illustrates how more binary identified people had experienced neg-
ative issues with medical professionals, and this subsequently led him to believe
that he too would be given a hard time as a non-binary identifying individual.
“I felt I had to lie because I didn’t trust them to be able to help

me if I was honest with them. I started to see it more as ’what do I
want and how can I get that’.’ (Edward, 2014)
The information Edward had access to enabled him to have a firm understanding
of the kind of Trans-Narrative he would have to follow in order to receive the
treatment he needed. Acknowledging that the medical professional could not ac-
commodate him due to his non-binary identity, he would have to ‘lie’ in order to
obtain the treatment he needed.
My next set of questions posed to Edward addressed issues of ‘proving trans iden-
tity,’ honesty with the medical professional and whether there were feelings of
having to give socially acceptable or normalized responses.
“I felt I had to present a certain way - as male/masculine as pos-

sible, so they would take me seriously. I definitely felt I was trying to
prove that I was trans, or that I was trying to convince them or make a
case for it. This a↵ected the answers I gave (not necessarily lying, but
selecting what anecdotes to tell about my childhood and presenting
one particular narrative.” (Edward, 2014)
Edward connotes presenting in a binary gender and stereotypically masculine way

to being taken more seriously by the medical professional. He also emphasized
the need to prove his trans identity a↵ected what he felt he could and couldn’t
disclose.
My second interviewee was a 36-year-old non-gendered Trans person called ‘Aiden.’

(See appendix part II.2) I will use the gender-neutral pronoun ‘they’ since that is
the one Aiden utilized to describe themself.
Aiden emphasised the issues they had experienced with their GP in regards to
getting documents changed,
“I had a Statutory Declaration drawn up and signed by a solicitor

changing my title to MX and my GP refused to amend my records, he
also refused to do anything for me from that point unless as he put it
he had a ‘green light from CHX,”’ (Aiden, 2014)
What is important to note is the refusal to amend Aiden’s records even though
they had provided the medical professional with legal documentation. By law, the
records should have been changed. It could be argued that the issue lay in the
fact the title was attempted to be changed to ‘Mx.’ As previously discussed in the
dissertation, many documents and applications fail to have or even acknowledge
this as a legitimate title – so the issue may lie more in the lack of accommodation
or acknowledgement for non-binary titles in legal documents.
Aiden also emphasizes the fact the GP would not help in any way until they had
received a ‘green light’ from Charing Cross (gender clinic.)
This implies the GP was waiting for Aiden’s Trans status to be confirmed and/or
diagnosed by the ‘Gender specialists’ – or subsequently have Aiden’s Trans Status
legitimized at Charing Cross before accepting Aiden as a treatable Trans patient.
“At my first GIC appointment I was told... ‘We see a handful of people like you
every year and we never know what to do with them.’” (Aiden, 2014)
Arguably, this illustrates the way in which the NHS do not have the knowledge or
experience to treat non-binary Trans people as their service only caters to binary-
identified Trans patients.
“I did feel I needed to ’prove’ that my identity was legitimate in

some sense. My understanding of how trans healthcare services worked
was that they were set up to assist those people they could diagnose
as ’Transsexual’ according to their definition of that term. At my
third appointment at CHX GIC I was informed quite explicitly that
the clinician would not consider endorsing me for any treatment at all
unless I was living ”as a woman.’” (Aiden, 2014)
Aiden comments that due to not identifying in a way that meant they could receive
a medical diagnosis, the clinician openly stated that they would not be eligible for
treatment unless they were living ‘as a woman.’ This shows the way in which
non-binary Trans people are unable to access healthcare due to falling outside of
the conditions of treatment.
It could be argued that updating medical literature and diagnosis to include non-
binary Trans people would better allow and encompass a variety of di↵erent gender
identities and Trans people who are in need of medical treatment.
“I had to attend a panel meeting early last year, there were about 7-8 clinicians
present, the general consensus was that non-binary identity was not stable or
permanent.” (Aiden, 2014) This illustrates the way in which clinicians do not
consider non-binary gender a stable or permanent gender identity, or even a legit-
imate identity.
Aiden also outlined the way in which it was impossible to follow through with the
clinicians guidelines due to their being no way to ‘live in role’ as a non-gendered
person.
“They (medical professional) state in the letter that in order for

them to endorse me for surgery they require me to go ‘through the
usual Real Life Experience, including 1 year of substantial occuptation
of some sort... as evidence of stable functioning in the desired gender
role (whether male, female or gender neutral)’ - despite me having re-
peatedly pointed out to them that there is no social or legal recognition
of non-gendered identity.” (Aiden, my emphasis, 2013)
Aiden points out the fact that even if a non-binary gendered person were to try
and abide by the Gender Clinic guidelines in order to receive treatment it would
currently be impossible. Requirements such as ‘living in role’ prevent a non-binary
gendered individual from qualifying or being eligible for treatment since there is
no way to legally live in their chosen ‘gender role.’
When I quizzed Aiden on what they thought needed to change in regards to

medical treatment for Trans people, they responded,
“Healthcare services for trans people should be designed in relation

to easing the symptoms of gender dysphoria rather than in relation to
notions of disordered identity... They should drop the idea of transition
’pathways’ and instead o↵er a range of services... they should o↵er a
patient centred approach to treatment based on informed consent.”
(Aiden, 2014)
Aiden emphasized the idea of treating Trans patients on a case by case basis, and
that treatment should be implemented in order to relieve symptoms as opposed
to ‘corrective’ treatments and surgeries which imply a more final and clear-cut
approach. The utilization of medical services to relieve gender dysphoria symptoms
would allow Gender Clinics and clinicians far more lee-way and broader options
in which to treat Trans patients, especially those who do not identify as a binary
gender.
Chapter 8
Conclusion
This paper has looked into the history of Medicalization of Trans people and the
way in which these ideologies and medical texts are still influencing the treatment
of Trans patients in 2014.
I have addressed the way Trans narratives such as the ‘Born in the wrong body’
ideology perpetuate the pathologisation of Trans bodies and an outdated focus
on corrective surgeries and ‘sex change’ that proves to reinstate notions of gender
binaries, roles and stereotypes.
I have addressed legislation such as the Parliamentary Guidelines for the commis-
sioning of healthcare treatment services for Trans people,’ and the way in which
the wording of such documents excludes non-binary Trans people by incorrectly re-
instating that Trans people identify as binary gendered. Also the issues associated
with the GRA and its failure to accommodate non-binary Trans people. These
normative binary understandings of gender have influenced social and legislative
shifts.
This led me to look into the way certain ‘acceptable’ Trans bodies are legitimized
through medical, social and political movements, and others are not, drawing upon
arguments of acceptable homonormativity versus deviant Queer people who, like
non-binary gendered folk, do not reflect the status quo.
I have addressed issues of gendered citizenship, and the ways in which binary
gender is heavily indebted within the system, so much so it makes the concept of
gender-neutral identity hard to implement.
But I have also shown examples of certain countries and societies where a third-
gender has been successfully instated which prove it can be done.
47
Chapter 8. Conclusion 48
I have utilized actual experiences of Trans people through oral histories from Rooke
(2008), Davy (2011), and through my own research and interviews with Trans
participants to explore how the medical system is failing them.
Through these findings, I hope to have sufficiently shown the way in which the
NHS and medical system are indirectly enforcing gender binaries through rigid
and exclusionary pathways in accessing Trans healthcare.
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Are You A Girl or A Boy? A Study Into The Reinforcement of The Gender Binary Through Medical Transition and The NHS.

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Goldsmiths, University of London

SO71089A - Gender, Media & Culture

‘Are you a girl or a boy?’ A

Word count: 14,540

An in-depth critique and discussion into the medicalization of the

3 Medicalizing Trans: The Problem with Medicalizing bodies and

4 Legitimizing Trans Identities 17

6 Issues with the ‘De-Medicalization’ Of Transgendered People 32

I will address issues of Gender binary as a system of oppression by looking at texts

“. . . The wrong-body narrative is deeply connected to genital recon-

Bettcher outlines how limiting Trans identity to a wrong-body narrative dictates

2.1 Clarifying ‘Trans’ Terminology

To ensure clarity of the subject, I feel it necessary to define what I mean by

“Transgender is a very big tent that covers a lot of territory, with

“. . . Most physicians agreed that the true sex had to be defined by

2.2 The Issue with ‘corrective’ and Intersex surgery

Sarah Morrison reports that,

2.3 Assigning gender – The case of David Reimer

Importantly, Money is also quoted as stating he had experienced success changing

Dr Money’s experiment was unsuccessful as David ‘was rejecting his feminized

“Her (Anne’s) view. . . is that although a child should be given a

Alice Dreger illustrates the problems of Dr Money’ ‘Concealment-centred’ ap-

Medicalizing Trans: The Problem

“Often we lose sight of the individual with clinical categorizations

the gender of the individual accordingly. Masculine-male, feminine-

“I never hated my penis; I hated that it made me a man – in my

The guidelines define gender dysphoria as,

“(The) experience of oneself as male or female that is a gender

From the outset, gender dysphoria is defined as experiencing oneself as ‘male’ or

The guidelines go on to state, “. . . The individual may need medical assistance to

“A person who is transitioning. . . should be addressed according to the name

Other aspects of terminology evolving in regards to understandings of Trans and

“Besides challenging current gender norms. These teaching trans-

“Many confuse sex with gender. Sex is biological, gender is psy-

then dichotomies of masculinity and feminity may only serve to coerce

Boswell is essentially implying that masculinity and femininity do not represent

This statement is in regards to the 6 alleged stealth trans people working at

Another way of interpreting this is by looking at it from a perspective of ‘Nat-

“Through their tone and formatting, as well as explicit claims that

Legitimizing Trans Identities

4.1 Gender Recognition Act and Acceptable vs.

“. . . Subject to certain expectations.” (Mclean, 2013:563) “The ap-

As previously established, the quota needed to fulfill a diagnosis of gender dyspho-

“I could only successfully apply for gender recognition if I were to

“The Western biomedical healthcare sustem, with few exceptions,

The emphasis on ‘marriage’ highlights an idea of acceptability that is rooted in

In Michael Warner’s ‘The trouble with Normal,’ he comments that “Marriage, in

“. . . Advocates of gay marriage assume that marriage as a social

The idea of acceptable vs. unacceptable in regards to alternative sexual identities

“State and gay and lesbian acceptance of certain forms of homo-

4.2 Medical Treatment Narratives and Gendered

the rules set out by the heteronormative state.

“As with the majority of participants in this research. . . Benjamin understood

“Most participants demanded medical services even though some

The concept of medical Transition as ‘ritualistic’ is a notion suggested in Whitney

“The evidence that transgendered individuals find it necessary to

“’Charing Cross’ (London’s Gender Clinic) – struggles to shake a

“The real life experience requires the pre-operative individual to

“The word as it is used today generally refers to fitting into the

However, what is failing to be acknowledged is the way in which ‘Passing’ can

In Josephine Ho’s ‘Transgender body/subject formations in Taiwan’ (2006) she

“. . . The concept of ‘passing – along with its connotations of decep-

“The operation of such as truth regime thus serves to reduce/stig-