By Dr Michael Toze (Senior Lecturer in Public Health and Social Determinants of Health, Medical School, College of Health and Science)
Gender diverse people existed well before modern medicine. One relatively well documented example is Erauso, who escaped from a convent in Spain somewhere around the year 1600 and spend much of the next fifty or so years living as a man, eventually receiving permission from the Pope to go on wearing male clothes even after his birth sex became known. It is difficult, and arguable entirely anachronistic, to determine how Erauso would have lived and what he would have called himself had he lived now, and this raises questions about how we narrate his story. It is also important to note that Erauso’s story is inextricably located in a context of class, race and colonialism. Nonetheless, it seems clear that in his own time and place, Erauso sought to live his life as a man. Velasco (2001) explores how Erauso’s life story has been reshaped over the centuries in line with the fears and desires of others.
Catalina de Erauso (San Sebastián, España, 1592 – Cuitlaxtla, México, 1650), llamada “La Monja Alférez”, fue una monja y soldado española.
In the late 19th and early 20th century, the work of sexologists often blurred what most people in the UK would now see as distinct categories of sexual and gender diversity, usually with a very medicalised focus. In the Transgender Studies Reader, Chapter 1 includes excerpts from Krafft-Ebbing’s 1877 work Psychopathia Sexualis, which provide accounts of “homosexuality” that seem to align with what we would now call trans identity.
By the 1960s, Harry Benjamin’s ‘The Transsexual Phenomenon’ had codified a medicalised model of ‘transsexualism’, including a classification of trans people into sub-types, with discussion of symptoms, aetiology and treatment recommendations. Late 20th century clinical practice in the UK and elsewhere was largely derived from Benjamin’s work, and for many years the international standards of care for trans people were named after Benjamin.
While lesbian, gay and bisexual political movements from the 1970s onwards have generally been consistent in calls for depathologisation of sexual orientation, these questions have always been trickier for trans people. Many trans people do seek interventions like hormones and surgery to help alleviate gender dysphoria or to live in line with their authentic identity. The medicalised model has frequently helped secure access to these interventions. In the context of stigma and prejudice, medicalisation has sometimes also helped to secure legal protections against discrimination. At the same time, however, the medical narrative is often seen as implying that being trans is itself pathological. One proposed approach to these questions has been to think about other situations that may require medical or surgical intervention but are not “disease”. For example, being pregnant – or not wanting to be pregnant – is not a disease, but contraception, sterilisation, termination and antenatal care often do need to be offered in clinical settings. Similarly, menopause or age-related testosterone decline are not diseases, and the hormone therapies taken by trans people are often virtually identical to HRT taken for these reasons. It has therefore been suggested that being trans could be classified within health systems as being similar to reproductive or menopause care – not a disease, but a situation where medical care may be helpful. However, these comparisons do not necessarily secure access to care in a global context in which access to reproductive and menopause healthcare is also frequently limited or under threat, leading to some trans people being worried about the political implications of depathologisation. Questions around medical categories and whether and how trans people should engage with them remain tricky and contested, and Ruth Pearce explores these in more depth in her book ‘Understanding Trans Health’
Medicalisation also sometimes overlaps with the law. The World Professional Association of Transgender Health states that legal recognition should not be dependent on medical intervention. The ECHR has ruled it a human rights violation to make gender recognition dependent on specific medical interventions, and countries like Sweden and the Netherlands are now paying compensation
to trans people who were required to undergo sterilisation. However, while the UK has never mandated surgical intervention, UK law does require trans people to receive a medical diagnosis and provide medical reports in order to (for instance) be able to marry their partner as a ‘husband’ or ‘wife’.
In recent years, there has been much more recognition that many trans people don’t need or want medical interventions, alongside increasing social recognition of diverse identities and pathways. Sally Hines sets out some contemporary and historic explorations around fluid, non-binary and other identities in her book ‘Is Gender Fluid?’
Medical categories, particularly when those are interlinked with the law, have historically not been responsive to elements of fluidity and diversity in gender identity. This has been highlighted for many years within trans studies. One classic text in this regard is Sandy Stone’s 1987 ‘Posttranssexual Manifesto’, a pushback both against medicalisation, and the ways in which medicalisation has been used to impose gender normative standards on trans people. Ironically, however, close to 40 years later, we seem to be seeing a growing number of popular and media narratives that paradoxically both uphold medicalisation (for example by resisting changes in the law to remove or reduce diagnostic requirements), while also frequently seeming to blame trans people for the existence of medicalised narratives of gender.
Relations between medicine and trans communities are likely to continue to be contested in future years. In many respects, these debates form part of much wider social narratives of the interplay between gender, medicine and the law. However, it’s important to remember that seemingly abstract debates can and do have a significant effect on people’s lives.
Hines, S. 2018. Is gender fluid?: a primer for the 21st century. Thames & Hudson.
Krafft-Ebing, R. von, 2013. selections from Psychopathia Sexualis with Special Reference to Contrary Sexual Instinc: A Medico-Legal Study. In Whittle and Stryker, The Transgender Studies Reader (pp. 21-27). Routledge.
Pearce, R., 2018. Understanding Trans Health. Policy Press, Bristol.
Stone, S., 2013. The Empire Strikes Back: A Posttranssexual Manifesto. In Whittle and Stryker, The Transgender Studies Reader (pp. 221-235). Routledge.
Velasco, S., 2001. The lieu