A Socratic Text Conversation Between My Former Teacher and Myself Outlining the Reality of Obtaining Hormone Replacement Therapy and Gender Confirmation Surgeries
by Woody Woodger
Pre-Op Thot is a biweekly column by Woody Woodger. “As a transgender anarcho-commie poetry slut, I’m here to derail the economy with my ethically sourced avocado toast and ruin every Thanksgiving with my colonialism PowerPoints. This column will have that same vibe, but I’ll jam poetry and Camus somewhere in there, and you can’t stop me. Through this column, I intend to do bite-sized deep dives into underrepresented aspects of the contemporary Zeitgeist, grounding my discussion with theory, research, and poetry that I think relative to each topic. But don’t worry, it won't all be fun. My teachers, Youtube commenters, and therapist all say my writing is a “huge bummer.” So if you're looking for a column that says “Last-Week-Tonight-but-make-it-discount-Contrapoints”, I’m your gal. So good luck out there, Gorge! God’s dead, smash the patriarchy and remember sunscreen. Love you!”
This essay format is based on an actual text conversation I had with my former poetry teacher who, through an autoimmune disorder, has had her own struggles with the medical industry. What follows is a further researched, fictional, and embellished recreation of that conversation as text messages.
Trigger warning: graphic language, transphobia
FT: My mom is struggling with her doctor. He is not listening to her symptoms, her chronic stomach troubles, her aches, and chills. And he’s being very critical of how she talks about her symptoms like they aren’t hers????
ME: OMG! That’s so horrible. I know you have trouble getting doctors to believe in your autoimmune disorder. Which is like…their job… What is there to BELIEVE?!?!?!?!?!?!
FT: Yes. It is so stressful and invalidating. Like why would I lie? Why do you think I want to hang out with your Beamer driving ass CHRISTIAN??? How is your transition going? Do you ever face shit like this?
ME: So my therapist and doctor are adamant that I should not transition at this point because like...I’ve informed them both about chronic depression and anxiety, obviously like any GOOD patient is supposed to do. Unfortunately, the open and honest discussions I’ve had with my health professionals have thus lead to some seriously FUCKED up consequences, all of which I will detail in the texts below.
ME: While the terms “gender identity disorder” and “transsexualism” have been removed from the DSM-V by the American Psychiatric Association and the International Classification of Diseases (ICD-11) by the World Health Organization respectively, both removals are relatively recent. The American Psychiatric Association only removed “gender identity disorder”, a term which diagnosis a trans person which codes the trans person as diseased, from the DSM-V as recently as December 2012, and “transsexualism” from the ICD-11 as recently as June 2018. That’s real. You can look that shit up. And like...while all the doctors and the medical professionals SAY they don't treat being trans as a disease and have taken steps to reframe being transgender on paper, the implicit bias against trans people remains embedded in the medical establishment.
FT: Holy SHIT, Woody, that sounds so horrible… :( I did want to talk to you about my mother in the hospital, but you seem like you’re in a whole thing right now. But so how is medicine biased? Is it just like your garden-variety bigotry, or does anyone point to anything?
ME: Oh, like, DEF! Medicine has ALL the bigotry built in and that bigotry extends to many populations. But an oft-reported example of the medical establishment’s systematic general fuckery of transgender people in particular is the process of explicit gatekeeping. Gatekeeping being the EXACT shit I’m facing now. Gatekeeping is the process whereby transgender people are required by doctors to undergo a number of psychological evaluations and often be forced to produce MULTIPLE letters from the therapist “~~ClEaRiNg~~” the transgender person for treatment. What’s weird is that gatekeeping puts psychologists in a really weird spot. Like, they have to do some real cognitive dissident bullshit. They gotta do their therapy duty and fully accept the patient’s reality, but unlike ANY OTHER interaction with a patient (barring immediate harm to themselves or others), they can impose their own estimation of reality and directly alter the course of their patient’s life. Like I did the fucking research (also super weird to have to yourself to recontextualize your OWN reality as it’s determined by systemic governing bodies but flex on my own damn self I GUESS).
“FT Emphasized: What’s weird is that gatekeeping puts psychologists in a really weird spot... They gotta do their therapy duty and fully accept the patient’s reality, but unlike ANY OTHER interaction with a patient...they can impose their own estimation of reality and directly alter the course of their patient’s life”
ME: Credit where it's due tho. You can see the psychological community starting to wrestle with their conflicting responsibility in this situation. Like, “Psychotherapists as Gatekeepers: An Evidence-Based Case Study Highlighting the Role and Process of Letter Writing for Transgender Clients” by Stephanie L. Budge. The study responds to the research that 75% of trans people attend therapy (duh, have you met a tran), and because of gatekeeping procedure, it’s unclear whether those trans people attend therapy to address the psychological effects of being trans, or if they are merely there as a consequence of needing to a permission slip to obtain treatment (287). I obviously editorialize, but then again, FUCK GATEKEEPING!
ME: Budge’s article also raises the concern that if trans people are going to therapy simply to satisfy these institutional pressures, trans people and the practitioner meant to serve them often face the reality that it is easier to procure “black market hormones”, putting trans people at risk for improper dosing as well as transmission of Hepatitis C and HIV/AIDS through needle sharing, as well as provide disingenuous responses to potentially pertinent medical questions so as to game the system. And THAT is, cringingly, where I went wrong. I was truthful in my mental evaluation questionnaire. I checked the boxes honestly, and precisely because of my desire to seek adequate psychological healthcare, I’m in a situation where I cannot access what I know to be my most necessary treatment. It would seem gatekeeping is just another iteration of those GODDAMN structural biases that originally framed being trans as a disorder in need of cisnormative correction and its total recapturing of institutional control over trans discourse and bodies.
FT: So should we burn down Budge’s house. I mean, Imma farm girl. A bitch HAS pitchforks.
ME: NO! First of all, it’s guillotines. #knowyourmemes, girl. And No. I DEF see earnestness in her study. Like Budge has serious ally energy, like officially not canceled. But Budge is a product of the systems that has structured her thinking. She comes to the conclusion that despite gatekeeping’s fundamental power imbalance (a power imbalance she admits) the best way to approach the issue is through reform (some real Biden-spined bullshit), offering suggestions like:
1.) prepare the trans person that their insurance will prob not cover the treatment (honestly, that’s for every patient).
2.) FURTHER inject the psychotherapist between the trans person and their primary.
3.) make the evaluation process MORE rigorous.
and 4.) if the trans person seems like they are just there to get the letter of approval and is not engaging, don’t be afraid to draw out the sessions (293-294).
FT: UGH! ARE YOU FUCKING KIDDING ME?
ME: Lol, I mean to be fair I’m NOT misrepresenting the study, but I AM phrasing it kinda snarky. To be FAIRER, dangling a permission slip in front of a patient until they demonstrate a level of cooperation that you, the practitioner, find arbitrarily satisfactory so that the patient may obtain the MEDICAL TREATMENT they need and deserve, is at best a serious presupposition of your authority, and at worst a Freudian slip of your own masochistic fetish.
FT: LOL ok. You are biased.
FT: Also, you @ the industry right now
ME: OK! I AAAAAM… But what truly fucks me up about gatekeeping (besides ALL of it) is that it exists under the faulty premises that a) trans people are somehow ill equipped to objectively evaluate their own transness, and b) that there could be any instance of a trans person who is not psychologically unwell prior to transition. That’s not just oxymoronic, that’s the fucking medical establishment. Right there, in a nutshell. A healthy pre-transition trans person is an (intentionally) unreasonable standard as it runs counter to the reality that gender dysphoria is, by definition, UPSETTING. That’s kinda, sorta the whole fucking point behind the (not desire) need to transition. People don’t transition because they are content being trapped inside some stranger's skin. Ever tried coming up for air only to hit a pool floaty that’s an eternity wide? YEAH! LIKE THAT!
FT: Well I obviously fucking hate this for you, but is there any other option? And why is it this way if it’s so bad?
ME: Yeah! Actually. As I wrestle with the facts of my situation and of any other trans person (let’s be real, ANY marginalized person accessing medical care), specifically with the medical establishment’s obstinate refusal to reexamine the harmful practice of gatekeeping, I wonder if the refusal comes not after reasoned principal, but rather out of a fundamental distrust of the validity of trans peoples’, and all marginalized people’s narratives. This questioning of motives is only deepens when alternatives are presented to the medical establishment BY trans people, and those alternatives are patently ignored. For instance, Informed Consent directly counters gatekeeping as a pre-transition approach. Informed Consent is wherein, “following appropriate education and advisement about the treatment in question, the ultimate decision regarding treatment choice rests with the patient alone” and gives the trans person full, informed agency in the final decision. Urquhart’s Slate article on the merits of gatekeeping v. Informed Consent came out after Budge’s good faith defense of gatekeeping and does say that some places such as Planned Parenthood have begun to adopted the model, but recognizes that adoption is slow and meeting resistance. What is also telling about this article for me is the final line where Urquhart states, “[b]ut in the end, the risk that certain people may impulsively or erroneously embark on treatments with permanent effects must be evaluated rationally, and weighed against the potential harm to patients for whom the requirements are onerous or whose treatment is needlessly delayed.”
ME: I would agree with the latter half, but the first half of his statement, that there are some cis people impulsively, erroneously, or irrationally claiming they want to transition is a fear more than a reality. Urquhart’s article mentions rare cases such as trans children or depressed patients (already covered that), as well as rare adult cases where the individuals regret their transition or “patients who do not regret transitioning, but who come to regret the specific decisions that they made, the speed of the process, which providers they trusted, or how they dealt with their transition emotionally.”. And while I see those issues as something to consider, most of those issues would not be solved by gatekeeping. Regret, as the word implies, normally, happens after and the majority of the regret patience face is not about the transition itself, but rather about the transition process which is entirely dependent on the structures and procedures determined by the medical establishment. And I HAPPILY offer the medical establishment take another look at their product and see if they can’t do some tweaking.
ME: As for trans children, it makes sense that they would need a parent or guardian’s signature, and, theoretically, Informed Consent would be better equipped to handle this situation because it would give the parent or guardian and their child more information and agency in making the ultimate decision. No one is asking there be no oversight, in fact having supportive medical institutions that provide the most access to information is exactly what the trans community is asking that the medical establishment work toward achieving. And yet I continue to be denied treatment because of my depression. It would seem that in their effort to protect trans people from the imagined tragedy of a cis person irrationally, impulsively, accidentally wanting to undergo a sex change operation (notice how the fear is FOR a cis person and how they might be duped into becoming trans rather than focus on the visible suffering of trans people), the medical establishment only succeeded in protecting actual trans people from receiving the treatment they need most.
“FT Emphasized: It would seem that in their effort to protect trans people from the imagined tragedy of a cis person irrationally, impulsively, accidentally wanting to undergo a sex change operation...the medical establishment only succeeded in protecting actual trans people from receiving the treatment they need most.:”
FT: Ok. I’ve really wanted to ask this for a while…
ME: Shoot.
FT: How do you KNOW you KNOW?
ME: I was rereading the poem “Schneider” by trans poet Diana Goetsch and I think that poem is a thinly veiled allusion to medicine’s relationship to transness, but is still achingly beautiful.
ME: “Schneider” is based off of the old joke where the doctor comes in and tells the patient they have a month to live. The doctor is curt and dispassionate when the poem’s speaker asks what the problem is, “‘The heart ? / The spleen?’” (2-3). The doctor says, “‘I could stand here / and explain…but is that / how you want to spend your remaining time?’” (5-6). The doctor leaves abruptly and the speaker turns inward, meditates, leaps from images of chasing tornadoes, mountain retreats, chasing girls like in the movies. The speaker remarks of a bird on the window, it’s “the kind of bird that looks at you / by looking side to side” (18-19). The doctor reenters, calls the speaker “Mr. Schneider”, but obviously, this patient, this speaker is not Mr. Schneider. The doctor asks if the speaker is sure. The speaker is. And the doctor leaves again and ask the speaker to wait, but the speaker leaves “into the world of birds, tornadoes, / skirts, mountains, movies, love.” (52-53). I didn’t get this poem until I tried to transition. Clearly the twist that the speaker’s name is not Mr. Schneider alludes to dead naming, or calling a trans person by their given name. By correcting the doctor, and by leaving the office for those things fantasized, we see a dramatized instance of the trans person accepting their transness, against medical wishes. In “Schneider”, we see a speaker who rejects the medical establishment because they’re made to feel scrutinized and disbelieved about their identity. At one point, the doctor, while reexamining the speaker, is compared to the window bird who can never fully see the speaker (42-43), and so seems to offer only suspicion. Because the bird only sees the speaker with one eye at a time, the bird is symbolic of the cis gaze, only ever able to comprehend gender as a distinct binary—one side woman, the other men—and not those that “lie-eth betwixt” as Contrapoints would say. Medicine is a science, it demands boundaries and standards. Those who challenge those boundaries due to their inevitable insufficiency, will immediately be considered a threat, a “problem patient”. Transgender people, from medicine’s perspective, make problems. A possibly healthy person electing to drastically modify their function body would look unnecessary. And sometimes I do doubt the “need” myself. But deep down I know. “Schneider" knows. That should be what they need.
FT: SO TRUE!
ME: It is this faulty premise, this societal distrust, that trans people are, in some way, unable to objectively evaluate their own transness, that lies at the heart of transphobia and it is the hardest to argue against because it actually means well. Those who continue to profess that being trans is a mental disorder or those who profess that it is a condition in need of professional evaluation in order to affirm its legitimacy, I believe, truly do want to help trans people. The help they want to give, however, is not that of actualizing trans bodies, but that of reintegrating a trans person into their assigned body because, and I REALLY think this comes from a place of compassion (OH! apologist alert!!! Cause that's how you get the cissys on your side), because a cis person can’t imagine putting one’s self through so much pain just to exchange one shitty meat sack for a different looking meat sack.
FT: PREACH!
ME: And I can understand ignorance, it’s the one universal. What I can’t abide is how, in spite of the many trans people eager to offer their expertise on the subject, the medical establishment (and the world, for that matter), systems of power continue to alienate trans people (RE: ALL marginalized communities, not just trans people, but all marginal intersections. We are all god’s childrens’ loose Cheerios strewn about their unCloroxed high chairs. Everything we know and think we love is just one node shunted into the perverse tapestry of power and exploitation that gesticulates violently across the cosmos, and we, those tender, juicy nodes, are the unremarkable sacrifice upon which these empty gods feast).
ME: Ummmm where was I...oh! The history of trans people, the stories they have to share about their own GODDAMN flesh coffins and the agency with which we have to exercise our OWN narratives about our OWN condition is systematically marginalized and it’s like…who the fuck??? Let me get this straight. You want me to show you I deserve for you to write me a permission slip to ask an 85 year old rich man to let me let him cut off my own balls. Bitch, you don’t write for me, I write my OWN letters!!! Our letters, our existence, tucked away so neatly under someone else’s PhD, stuffed up tight in the secure gaff of some white dude “expertise,” choked behind a footnote betwixt history’s symphysis pubis. Or blathered out like this, in a string of texts.
FT: Wow. You get that all out?
ME: Yeah! Oh so anyway, you were talking about your mom?
FT: OH! Yeah.
ME: How is she?
ME: Real?
ME: *Good?