Gender, Sexuality, and the Medical Industry
Introduction
Due to the ongoing efforts of the trans movement, nonbinary viewpoints, the work done by queer theorists, the stories shared by intersexed people, and countless other perspectives, we are amidst a global shift away from a heteronormative society; however, as culture moves away from rigid labels and towards gender fluidity, many are struggling to locate themselves and their rights within institutions that remain many steps behind. This tension between the cultural shift towards gender fluidity and the institutional need to categorize and label is best seen through healthcare, as the medical industry works with categorization and labeling perhaps more than any other industry, and because the industry’s outdated and discriminatory practices and persistent heteronormative perspectives are the cause of millions’ suffering.
Inequalities in healthcare surrounding gender identity and sexual orientation are brought on by stigmas, discrimination, lack of education in the medical industry, and outdated views and assumptions of gender and sexuality. All over the world, these groups suffer from the lens through which they are viewed. In India, for example, Reddy (2005: 256) discusses how the hijra community, known as India’s “third sex,” suffers healthcare consequences due to their society’s misunderstanding of and discrimination against them. Reddy (2005: 258) notes that the stigma and othering of this community render public health efforts to prevent the spread of HIV/AIDS ineffective. His argument stands that “understanding how culture matters can ultimately address [...] and redress the inequalities in health outcomes between the various margins and centers of power” (Reddy 2005: 255). I note this text here as it ties into the central argument this essay will make. Historically, outdated and exclusionary cultural perspectives of marginalized groups have been hard to shake, just as progressive and inclusionary ones are hard to take root-- among the public, yes, but more specifically within institutions. There is an overwhelming disparity in the pace with which societies and institutions progress; as this essay will highlight, this disparity is seen particularly in the medical industry. Outdated and discriminatory notions determine the treatment of marginalized groups in healthcare practices, and as this essay will argue, the medical industry must align with the most progressive cultural views of gender and sexuality for effective healthcare to be accessible to all.
This essay will highlight why the medical industry must work through an updated queer, gender-fluid lens by examining three ethnographies that demonstrate a few of the consequences of the medical industry’s lack of such a perspective. The first case, written by Scheffey et al. (2019), centers around the current problems with labeling on medical forms; the second case, written by Welle et al. (2006), examines queer youth marginalization in healthcare; and the third case, written by MacKinnon et al. (2021), problematizes medical transitioning assessment practices. My analysis of these cases ultimately demonstrates why foundational change must occur within the industry’s views of gender and sexuality. However, the issues discussed are only a fraction of the problems that non-heteronormative people face daily; my analysis does not serve as a holistic account of these issues but rather as a demonstration of the industry’s need for a drastic change in its approach to gender and sexuality.
The Categorization Catch-22
As David Valentine (2007: 5) argues in his book Imagining Transgender, “people everywhere categorize themselves and others; this is one of the most fundamental aspects of human language and meaningmaking. But the ways in which these categorizations are made, and which categories come to have effects in the world, are never neutral.” The non-neutrality of these categorizations certainly persists; however, as this first ethnography will demonstrate, perhaps we are shifting away from this human need and towards a less defined space. Scheffey et al.’s (2019) text, “‘The Idea of Categorizing Makes Me Feel Uncomfortable’: University Student Perspectives on Sexual Orientation and Gender Identity Labeling in the Healthcare Setting,” centers around gender identity and sexual orientation questions on medical forms. With a mixed-method approach of focus groups and data collection, the authors address the need to “understand how patients conceptualize and label [their] identities” (Scheffey et al. 2019: 1555). Their two main findings are that the terms their participants use to label their gender identity and sexual orientation “were not among the commonly listed labels” and secondly, that “they felt that labeling their SO/GI identities was problematic. Participants reported that choosing a label that did not fit their lived experience was not only inaccurate, but could also feel painful and alienating” (Scheffey et al. 2019: 1555). Many of their participants spoke to this. One genderfluid participant said, “The thing is, is that I’m not exactly a girl, so it’s just weird… when you’re writing, oh, female. [...] it hurts just a little” (Scheffey et al. 2019: 1558). Another asexual and biromantic participant highlights how forms render some people invisible: “I have had a few experiences where they had the box where you fill it out and then my sexual orientation isn’t on there” (Scheffey et al. 2019: 1559).
This study also brings up the problematic use of “other” on medical forms; one genderqueer and queer participant said that having to check ‘other’ because your identity is not listed as an option “feels a little terrible” (Scheffey et al. 2019: 1559). Furthermore, the term “other” speaks to the disturbing lack of effort made by the medical industry to understand the broad spectrum of gender identities and sexual orientations that exist. Rather than working to include all, these forms settle for oversimplifying and othering those whose identities they choose not to educate themselves on. This oversimplification of identity is an act of exclusion and a blatant display of the heteronormative standards seen in the world of healthcare. As Neville and Henrickson (2006: 409) argue, these “heteronormative attitudes” are sharply felt through these “assessment frameworks [which] rarely include options for nonheterosexual responses.” Valentine highlights this heteronormative exclusionary lens in his discussion of the term ‘transgender’; he writes, “despite the collectivity and inclusivity implied by this use of ‘transgender,’ I will argue that its employment in institutionalized contexts cannot account for the experiences of the most socially vulnerable gendervariant people” (2007: 14). The term ‘transgender’ is just one of many blanket terms that exclude through oversimplification and demonstrate where the industry currently prioritizes the desire for simple and manageable data above the desire to make all feel included and seen within its system.
To counter these feelings of invisibility and exclusion, some participants spoke to the benefits of having open-ended forms, of having “a blank space to self-define their SO/GI instead of having to choose from a list of generic options” (Scheffey et al. 2019: 1559). One participant who identifies as cisgender female and bisexual/queer said, “I don’t really like options… I would prefer open-ended because you can’t list all the options and that’s still checking the box” (Scheffey et al. 2019: 1559). However, while some agreed with this, others were hesitant to reduce themselves to labels altogether; one participant explained, “my gender identity is constantly evolving. And so, it’s hard to just check a box and be set” (Scheffey et al. 2019: 1559).
These participants’ perspectives reveal feelings of discomfort, invisibility, and neglect around the medical system’s current categorizing of sexual orientation and gender identity. This case speaks to the catch-22 of the collection of patient data. This kind of data is crucial-- for enhancing care, addressing inequalities in healthcare, resource distribution, educational purposes, and a general understanding of different identities and people’s varying needs. However, the current method of collecting this data does not serve the present population; it excludes, ignores, and misrepresents, leaving many not wanting to reveal their identities at all. Yet, as Neville and Henrickson (2006: 407) argue in their text on lesbian, gay, and bisexual people, “nondisclosure has been shown to have a negative impact on the health of these people. For example, an increased incidence of suicide, depression, and other mental health problems have been reported.” Healthcare systems must face the daunting fact that methods of categorizing and collecting data must change. Personalities are seen as changing, and yet gender and sexuality are still widely seen as constant. As this first ethnography demonstrates, this approach to identity must change so that every person feels seen and included within healthcare environments.
Queer Youth vs. Medical Terminology
The second ethnography I will address, “The Invisible Body of Queer Youth: Identity and Health in the Margins of Lesbian and Trans Communities,” provides personal experiences to further this notion that healthcare services must adapt to gender fluidity; specifically, they must allow for complex identities and see them as they are-- identities that ebb and flow and are constantly in development, rather than viewing them as rigid and unchanging. This case speaks to the unyielding and outdated institutional understandings of gender and sexuality, and how this pushes many to “the margins of health services” (Welle et al. 2006: 46). Welle et al. (2006: 46) write that the goal of their text is “to create an analytic space that can foster an appreciation of the contradictions, challenges, and processes involved in the pursuit of a ‘different’ (or ‘very different’) self.” This aim is accomplished by discussing the two case studies presented in this text: Samantha, a queer-identified woman, and Reid, a queer-identified transgender man, both of whom challenge fixed notions of identity (Welle et al. 2006: 43,44). Samantha shares her perspective on stating sexuality as fixed, of saying, for example, “I’m a lesbian, and I will always be a lesbian;” she says, “that to me just is so, like, rigid, [...] and has all these rigid implications for, like, gender and sexuality and, like, the body, and all these ways that just aren’t, to me, don’t make sense, [...] so that to me, like, delimits, like, anything, like, any possibility” (Welle et al. 2006: 53). Reid, on the other hand, fights against a fixed identity by choosing to stay in “an extended ‘transitional’ state” (Welle et al. 2006: 58). As the authors note, by identifying as transgender without undergoing a medical transition, Reid is able to “[reject] the medicalized norms of gender transitioning,” as well as “[generate] a ‘queer’ dimension and meaning to his embodiment as a transgender man” (Welle et al. 2006: 58).
Both Samantha and Reid demonstrate the need for healthcare services to adopt a “highly individualized approach to care for those who ‘don’t fit into one box’” (Welle et al. 2006: 64). To be able to see patients for exactly who they are, especially when that means they won’t fit into a box, these services must first view gender and sexuality as fluid. As this text stresses, patients need to be able to define themselves, however they may or may not want to, using their own terminology. The authors of this ethnography bring up the differences between academic discourse and what they call “Pier/peer” discourse, terminology more frequently used by LGBTQIA+ youth as it better represents and embodies their more fluid identities (Welle et al. 2006: 66). Because there is such a disconnect between these two domains of terminology, this demographic and their specific needs are often invisible, especially their needs for “LGBT-specific health care and mental health services” (Welle et al. 2006: 44).
As the text suggests, “health researchers, providers of LGBTQ health services, and empowered local communities” must find ways to encourage this population to care for their health (Welle et al. 2006: 67). While this is undoubtedly true, the text fails to highlight the specific need for the medical industry to adopt a queer, gender-fluid approach. Welle et al. (2006: 64) demonstrate the tensions between rigid healthcare categorization and fluid, queer identities and, in response, argue for an individualized approach; however, this argument takes the focus away from challenging the industry’s persistent heteronormative mindset. Yes, the medical industry needs to find a way for queer-identifying youth to feel empowered and supported enough to seek care; yet for this to happen, the approach to queer healthcare must adapt to the queer youth. As Hastings et al. (2021: e384) write, “we recommend that providers focus less on memorizing discrete definitions, and instead express interest and listen to what the term means to each patient.” Respecting the terminologies of queer youth above the labels more traditionally used within the medical industry is one of the first steps in this adaptation.
Problematizing Transition ‘Regret’ Prevention
This final ethnography, “Preventing transition ‘regret’: An institutional ethnography of gender-affirming medical care assessment practices in Canada,” centers around the inherently problematic and discriminatory nature of regret prevention policies for transgender patients. Through interviews with transgender participants, clinicians, and healthcare administrators, the authors highlight the strategies employed for preventing transition regret in the Canadian medical system, arguing that the relentless assessment practices in place are not for the sake of trans patients, but are “a projection of cisgender people’s priorities and anxieties” (MacKinnon et al. 2021: 7).
This study highlights the need for a gender-fluid approach to healthcare through an analysis of the harmful impacts of transnormativity in the context of prevention regret, revealing how shifting to a gender-fluid lens will solve many of the problems faced by trans patients and doctors alike. As defined by MacKinnon et al. (2021: 2), transnormativity is “a sibling concept of cisnormativity and it specifically relates to how medicalized standards, such as gender dysphoria diagnostic criteria, regulate trans people’s identities and their interactions with healthcare and legal institutions.” Transnormativity, which operates through the male-female gender binary, is problematic for countless reasons. Namely, it oversimplifies one’s gender identity and reasons for transitioning; as argued in the text, “trans people who conform to binary gender expectations and whose life experiences closely align with gender dysphoria diagnostic criteria are rendered more intelligible and ‘authentically’ trans” (MacKinnon et al., 2020a; Vipond, 2015, as cited in MacKinnon et al. 2021: 2). Additionally, viewing detransitioning through a transnormative lens silences the wide range of reasons one might choose to detransition; because those who do exist outside of transnormative norms, they are seen as “inauthentic,” as people who “were never truly trans” (MacKinnon et al. 2021: 2).
Through participant interviews, the text highlights why regret prevention policies are problematic. As the interviewees point out, these practices invalidate patients’ agency; it is inherently discriminatory for a trans patient to be put through a detailed trail of questioning on the stability of their identity and decision to transition. Doctors are trained to question vehemently rather than to support. One physician participant spoke about the need for a letter from a mental health professional: “What drives somebody like myself crazy when I think about this, is that for no other surgery do I have to do that. You’re telling a transgender person you are some sort of different type of person that isn’t capable of knowing who they are, and knowing that they need this surgery” (MacKinnon et al. 2021: 5). This view is shared from the side of the psychiatrist as well; as one explained, “Surgeons sometimes refer to me to say: ‘well, is this person OK for me to operate on?’ And it’s like, well, what’s your concern?.. More often than not it’s that the surgeon might wonder: they have a history of ‘this’ or ‘that’ in terms of their mental health, so are they ‘stable’ enough to go through with a surgery? And, it’s like, you’re a surgeon, you work with people all of the time regarding informed consent … Why can’t you do it with a trans person the same way you would with a non-trans person?” (MacKinnon et al. 2021: 5).
The questioning nature of regret prevention policies is especially problematic regarding patients’ mental stability. As Mackinnon et al. (2020: 56) note, “this phenomenon is paradoxical in that transition-related medicine is recommended to mitigate trans people’s psychosocial distress, but when patients reveal symptoms of distress they encounter significant barriers to treatment.” These patients are discriminated against in a variety of ways; a social worker in the study noted that some of her clients were denied hormone therapy for not being perceived as “stable” (MacKinnon et al. 2021: 5). As the case notes, not only are patients denied treatment, but they will often “downplay mental distress to avoid being diagnosed with a ‘complex’ mental illness and denied hormones or surgeries on this basis, thereby having to choose between accessing medical transition, or mental health supports” (MacKinnon et al., 2020a, as cited in MacKinnon et al. 2021: 3). Viewed through a heteronormative and suspicious lens, trans patients are forced into compromising positions by those who are supposed to help and support them.
From this text, it is clear that the shift to a gender-fluid approach will solve various problems. If medical transitioning, and especially detransitioning, is seen through a gender-fluid approach, those wishing to (de)transition will be met with drastically fewer barriers, particularly regarding mental health. A gender-fluid approach will also dismantle transnormative practices which view transgender and the process of transitioning through the male-female gender binary. If the industry treated gender as fluid, transitioning would not be seen as a linear process with a clear start and end, and detransitioning would not be seen as an ethical or reputational failure on the part of the clinician. Gender can always and is always changing for many, and detransitioning can be a part of someone’s gender evolution. As stated, “regret and detransition are not synonymous” (MacKinnon et al. 2021: 3). Furthermore, a gender-fluid approach will allow clinicians to be more open to working with trans patients wishing to (de)transition without “fears of legal action,” otherwise known as “cisgender anxieties projected onto trans patients who are seeking medical care” (MacKinnon et al. 2021: 1).
In these current assessment practices, by needing the nod of approval from multiple people, trans patients’ autonomy over making decisions about their bodies is taken away from them. These practices suggest trans patients are too emotional, unstable, or immature to decide for themselves. An updated approach will return the agency to the patient, which is crucial not just for general medical practice but for the level of support and respect shown to the patient. One psychologist participant spoke of an instance when one of her clients wanted to surgically detransition; she states, “I said ‘Is there anything that I should have done differently?’ And her answer to me was really important, she said: ‘the best thing you did for me was give me entirely the decision’” (MacKinnon 2021: 6).
Conclusion
This essay aimed to demonstrate the need for a queer, gender-fluid approach to healthcare through an analysis of three ethnographies. This need has been revealed through the problems addressed in these cases of medical mislabeling, marginalization in healthcare stemming from rigid understandings of gender and sexuality, and the lack of agency and discrimination felt through transnormative regret prevention policies. While this is only a brief investigation into a very profound issue, the perspectives in these three cases reveal the overwhelming need for change, for an updated approach to the collection of medical data, and for a reeducation of the medical industry on approaching healthcare through a queer and gender-fluid lens. This approach would not only return autonomy and agency to the patient, it would extend healthcare support to those who currently sit on the medical margins, giving marginalized groups the relief of inclusion after relentless exclusion from the healthcare systems to which they are entitled.
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