Living Outside the Binary

Health Concerns and Disparities for Transgender and Intersex People

a talk in the 2013 University of Denver One Book, One College series focusing on The Immortal Life of Henrietta Lacks and health disparities among marginalized communities

Intersex: Medical Abuse

So when a child is born and people ask “Is it a boy or a girl?”, what criteria do doctors use to make this life defining assignment? Although there are many scientific factors that can be used to measure someone’s sex—such as chromosomes, gonads, hormones—the criteria that is used is visual inspection of the genitals. Specifically, babies born with genitals over 1 inch long are classified as boys and babies with genitals under 3/8 of an inch are classified as girls (pass around ruler).

But what of the babies whose genitals fall between 3/8 of an inch and 1 inch? These babies, previously labeled hermaphrodites but now called intersex, are immediately subjected to genital surgery to “normalize” them—i.e. locate them within the confines of the gender binary. Obviously they do not consent to such surgeries as they are infants, but oftentimes neither do their parents—sometimes parents do not even know, but even in cases where they do give their consent, we can ask if it is truly informed consent since the way the situation is framed gives parents little choice than to go along with doctors.

Not unlike Henrietta’s family, most parents are intimidated by medical authorities who tell them there’s a problem with your baby, and one that can be fixed—and they don’t realize (and aren’t told) that there are non-medical options, that most surgeries are not medically necessary, and that embarking on the course of medical intervention means not just one surgery but a lifetime of medical interventions.

Intersex genitals are disturbing to the strictly maintained and comforting social order…which has everyone believing that bodies come in only 2 ways. However, such genitals are surprisingly common. Approximately 1 in 1500 infants are born with genitals that are not unambiguously male or female. Rather than allowing for the seemingly obvious presence of sexual variation, physicians continue to stubbornly insist that male and female are the only “natural” options and medical teams are urgently mobilized to deal with this psychosocial emergency. As Suzanne Kessler argues in Lessons from the Intersexed (a terrific resource for the medical context of intersexuality), the way that the medical establishment manages intersexuality is guided by our culture’s beliefs about gender and genitals rather than the needs of the child.

As Kessler writes, after extensive interviews with doctors who perform such surgeries, “Genital ambiguity is corrected not because it is threatening to the infant’s life, but because it is threatening to the infant’s culture.” It is medical protocol to assign a gender quickly, decisively, and irreversibly (lest you “weaken your credibility,” according to one doctor), contributing to the general impression that the infant’s “true” sex has been found. Initial surgery usually takes place immediately, as it is believed that reduction of phallic tissue delayed beyond the neonatal period would leave traumatic memories of having been castrated (though there is no corresponding concern that delayed vaginal reconstructive surgery is traumatic for those labeled female).

While doctors may order chromosomal and hormonal tests for intersex infants, results can take several months (and they don’t always match up in consistent ways), so they are generally not incorporated into the decision about gender assignment, especially given the intense pressure by parents and other family members, as well as by hospitals who often must submit birth certificates within days of a baby’s birth. Although doctors claim (as one stated) “I don’t think many social factors enter into it,” the guidelines for determining sex are dictated entirely by the size of the phallus.

In other words, doctors are not choosing between boy and girl, but between boy and not boy. Specifically, the criteria for an adequate penis are whether a boy would be able to pee standing up and whether, as an adult, his penis could penetrate a vagina (assuming, of course, that such a person would necessarily end up heterosexual). The idea is that a male cannot be a successful man in society without an adequate sized penis.

If these two criteria cannot be met, surgery is performed to make the infant into a girl. As one doctor explains, “In the absence of maleness, you have femaleness”—being female is, in essence, the consolation prize, the catch all category for any infants who couldn’t cut it as male. As a result, far more infants end up designated as female than male because, as one doctor puts it, “it’s easier to make a hole than build a pole.”

And making a sufficient “hole” is the main aim of surgeons for those designated girls—one that could accommodate a “normal sized penis” (the medical criteria again assuming the eventual heterosexuality of all patients). Most traumatically, the clitoris is severely reduced or eliminated entirely so that parents can clearly distinguish their child’s sex so as to curb any potential negative response to the baby and so the girl as an adult will have “normal-looking” genitals.

This results in the total loss of sexual sensation for most intersex individuals designated female, simply for the sake of genital appearance (as one intersex person raised female describes in Intersex in the Age of Ethics: “Big clitorises aren’t allowed in America”). (This book is a terrific resource for the voices of intersexed people themselves.)

Once initial surgeries are undertaken, repeated surgeries—as well as hormonal intervention—over the course of childhood, adolescence, even into adulthood are required. The nature of these surgeries is generally disguised. Repeated lies are told, ostensibly for the good of patients, and medical textbooks frequently have advised doctors on how to lie to intersex patients. Although doctors claim to know what is best for their intersex patients, there are no published studies on how intersex adolescents experience their condition and their treatment by doctors. In fact, there is a shocking absence of follow up studies on intersex people period. Once doctors have solved the “mystery” of determining (i.e. creating) the child’s gender, they quickly lose interest.

However, we do know quite a bit about the experiences of intersex people with medical treatment—not from the medical profession, but from intersex organizations. The Intersex Society of North America (ISNA) was founded in 1993 (it is now defunct) in an effort to advocate for patients and families who felt they had been harmed by their experiences with the health care system.

What ISNA found was a whole generation of kids who had been surgically and hormonally “fixed” to fit neatly into male and female who were left traumatized and damaged. Again and again intersex people report “People treated me like a freak, they lied to me, they cut me up, they harmed me in ways that prevent me from being romantically or sexually intimate with people, they caused me to feel like my body is disgusting.”

They have been left with physical complications such as pain, incontinence, and lack of sexual sensation, as well as emotional trauma from the stigma, shame, and secrecy surrounding their condition, resulting in societal marginalization, anger, and suicidal inclinations (many in the video share their fantasies of finding their doctors and cutting off the doctor’s genitals, 1 decided to commit suicide and wanted to do it in front of her doctor, what happened to David Reimer—Money lied and said the study was a success).

Medical Arrogance

Despite the fact that intersex people have spoken out loudly to the medical profession about their pain and anger and called for new protocols of care for intersex babies, the medical profession has been resistant to change. The main recommendations have been that the functional outcome of genital surgeries must be emphasized, not just cosmetic appearance, and that parents must be fully informed about evidence (such as the David Reimer case), risks, and alternatives instead of just being told that without surgery their child will be stigmatized).

Here is a list of other recommendations made by intersex folks (go through the list). Despite such recommendations, most medical centers still practice the concealment-centered model of care and prescribe “normalizing” (i.e. medically unnecessary) genital surgeries and hormone treatments not consented to by the patient. Adult patients and parents of minors are still routinely denied access to medical records and the views of patients have been continually disregarded.

In 2006 the National Institute of Health released new standards of care, called The Consensus Statement on Management of Intersex Disorders, but as of now no institution has fully implemented them. There are no mechanisms in place to foster implementation nor to evaluate to what extent these changes improve health care experiences and outcomes for persons and families affected.

Intersex conditions continue to be referred to as Disorders of Sex Development (DSD) instead of the less pathologizing Variations of Sex Development and genital ambiguity is “corrected” to conform to a “natural” gender dichotomy. As Suzanne Kessler writes, “The belief that gender consists of two exclusive types is maintained and perpetuated by the medical community in the face of incontrovertible physical evidence that this is not mandated by biology.” (31)

Intersex and Race

In thinking through parallels with the Henrietta Lacks book, I would like to mention a couple of interesting historical and contemporary connections between intersex and race.

First of all, intersex has been used as an argument to justify racism. It has been believed in the medical community (particularly strongly promoted in South Africa, where I do my research, and used to justify medical experimentation on Black bodies during the apartheid era) that intersex is more common among Blacks, that increased sexual dimorphism is an aspect of human evolution and therefore Blacks (long believed by western science and policy makers to be sexually excessive and bearing the physical evidence of that “excessiveness” in their larger than “normal” genitalia) are less evolved, i.e. less human.

An example of this logic is found in Saartjie Baartman, a Khoikhoi woman from South Africa, who was displayed in 19th century European “freak shows” under the name of “the Hottentot Venus” to show off her large buttocks and enlongated labia. Her genitals were actually kept in a French museum long after she was dead and her remains were only returned to South Africa in 2002.

Intersex children are routinely subjected to repeated genital exams—often just to satisfy the curiosity of medical personnel who have never seen such genitals before. In addition, extensive photographs of their genitalia are often published in medical textbooks without their consent.

This experience of being fetishized, objectified, and photographed—although obviously can’t be directly compared to Saartjie Baartman’s experience—has exemplified for many intersex people, according to the ISNA website, “the powerlessness and humiliation felt during medical investigations and interventions.” Non-normative genitals continue to be a societal spectacle used to pathologize and dehumanize some groups while reinforcing the normativity and power of others.

Finally, the meaning and regard of genital surgeries depends on the race and culture of those performing the surgeries. Clitoral excision done in African countries is routinely called “female genital mutilation” and the practice of it by Africans is outlawed in the U.S. However, the same surgeries done by doctors in the service of the gender binary is called standard protocol.

Trans: Medical Neglect

While there are similarities between the medicalized treatment of intersex people and transsexuals (such as: prescribed secrecy for both, desires to disappear both into the gender binary, and the medical assumptions/even requirements that both end up heterosexual), their main relationship is one of contrast: whereas intersex infants are forced into surgical and hormonal interventions without their consent, these same medical interventions are routinely denied to adult transsexuals who are seeking them. It is the will of the doctors that prevails in all such decisions, not the wishes of the patient.

In fact, transsexuals are routinely denied access to gender affirming treatments widely available to non-trans people (who are also called “cisgendered” or “cissexual”—meaning their gender matches their assignment at birth). For instance, cisgender men can have breast reduction surgeries denied to transmen; electrolysis will be provided for cisgender women but not transwomen; hormonal therapy and genital surgeries are readily available to non-trans people for the sole purpose of enhancing their gender appropriateness, as the social consequences and mental health impact to those considered gender-normative are recognized but the same feelings expressed by transgendered people are pathologized. (We are even now seeing the emergence of a medical condition called “testosterone deficiency” for older men—that was previously just called “aging”). In fact, any cisgender woman off the street can go to a plastic surgeon and have her breasts enhanced, even to ridiculously huge, medically ill-advised sizes, or have her vagina rejuvenated (while cisgender men can pursue penile enhancements) without needing the permission from a therapist and the diagnosis of a mental disorder required of trans people.

When such trans-specific healthcare is denied to trans individuals, depression, anxiety, and even suicide frequently result. For instance, according to a 2011 national transgender discrimination survey, 12% of transwomen and 21% of transmen who had not begun treatment attempted suicide, while among the same patients after having begun treatment, there were zero attempts. Such medical interventions are necessary for many trans people to be able to live successfully in their chosen gender, impacting their ability to find employment, housing, as well as to avoid violence and murder. Trans-specific healthcare is considered by insurance companies and many in the medical profession as “cosmetic” and medically unnecessary and so is not covered by insurance. In fact, many trans people actually lose their health insurance if their transsexual status is revealed.

Despite the fact that transgender hormonal therapy and sex reassignment surgery are excluded by nearly all U.S. health care insurers and that, as a result, most trans people experience significant financial barriers to accessing treatment, criteria for changing identity documents to reflect current gender is entirely medicalized. To legally change any of your identity documents—whether your driver’s license, your passport, your social security designation, or your birth certificate—is bureaucratically extremely complicated and depends upon having a letter from a surgeon saying that you have had “sex reassignment surgery,” which most trans people have not had—either because they don’t want to (surgical procedures are much more common—and much more medically advanced—for male to female transsexuals than female to male) or because they don’t have the financial resources to pay for such expensive procedures out of pocket.

Making access to medical services that most trans people do not have access to as the main requirement for changing identity documents means that most trans people do not have a way to alter their legal identity. Indeed, a 2009 study found that 79% of trans people have not been able to update their identity documents to reflect their current gender (myself included). And of course, we are only talking about moving between the two choices of M or F, which is not an accurate descriptor of many trans and intersex peoples’ bodies/identities (myself included). In Australia they recently created a third category “X” for passports to encompass intersex and some trans people, but we are light years away from any such changes in the U.S.

Not having identity documents that match your physical appearance, especially in a post 9/11 world, is a major health hazard. In the current intense national security climate, you can be regarded with hysterical suspicion—especially if your race, religion, or immigration status has already marked you an object of state surveillance. As identity verification procedures have expanded (so that your status under multiple state bureaucracies can be more readily cross-checked), anyone found having any discrepancies in their identity documents (which is extremely common for trans folks as there is tremendous variability in what is required across state jurisdictions as well as between different areas of government bureaucracy [for instance, it is much more difficult to change your Social Security designation than your driver’s license]) means they can have their driver’s license immediately revoked and their employers can be contacted, potentially resulting in dismissal—especially if one’s transgender status was hidden.

Not having identity documents that match your physical appearance can actually make you unemployable as well as unable to take care of the basics of day to day survival, such as being able to write a check or use a credit card, open or access a bank account, or travel (especially given new technologies such as body scanners).

Although there are particular challenges in accessing trans-specific healthcare, access to healthcare period is compromised for several reasons. First, trans populations are disproportionately poor and jobless. The national rate of unemployment for trans people, according to the Human Rights Commission, is an extraordinary 70% and trans people are four times more likely to have a household annual income of less than $10,000 compared to the general population. Why is this?

First, many trans people, as I just mentioned, are unemployable. While this can result from not having proper identity documents, it also stems from gender norms that operate in the workplace. Many jobs—especially blue and pink collar work—are essentially gender segregated. For those transwomen, for instance, who were trained in male-designated fields such as engineering, finding a job post-transition can prove impossible.

Being successfully employed is generally dependent upon one’s ability to “pass” as gender-normative, which for many (especially trans women) is not a possibility (and is almost always predicated on one’s access to medical technologies—which is very proscribed if one is jobless). Many trans people lose their jobs due to their transgender status, especially if they try to transition while employed. 90% of trans people surveyed reported experiencing harassment, mistreatment, or discrimination at work, while 47% were fired or not hired due to being gender non-conforming.

Second, many trans people also have difficulty finding employment because they never completed their education. Gender non-conforming youth report alarming rates of harassment (78%), physical assault (35%), and sexual violence (12%) in educational institutions, harassment so severe (and without recourse) that at least 15% leave school as a result. Although peer harassment has highly damaging effects, those who report being harassed and abused by teachers in K-12 settings demonstrate dramatically worse health and other outcomes.

Trans people frequently develop bladder problems due to lack of access to gender-neutral or gender-appropriate bathrooms (prominent case happening currently in Colorado Springs with a trans-identified kindergartener battling for bathroom access at school—trans adults can be arrested for using a bathroom not corresponding to their birth sex).

Being able to use a public restroom safely is a HUGE issue for trans people. When I used to use the women’s restroom prior to going on hormones, I continually had negative or difficult experiences—women screaming at me and slamming the stall doors, people confronting me about being in the “wrong” bathroom, little kids saying, “Mommy, why is there a boy in the ladies room?”

Public restrooms are sites of not only harassment, but violence as well: in 2010 a 27 year old transman named Colle Carpenter was attacked in a men’s restroom on the campus of Cal State Long Beach where Carpenter was a grad student. In the attack, Carpenter’s assailant—who has never been found—pushed him into a stall, pulled his t-shirt over his head, and, with a blade, carved the word IT into his chest before fleeing.

In addition to not completing their schooling, gender non-conforming youth (who can be found “ungovernable” by parents and schools due to their gender expression) are disproportionately funneled into the juvenile system (where they represent 15% of youth in detention centers) as well as psychiatric hospitals. Once institutionalized, they are harassed by staff, subjected to “conversion therapy,” prohibited access to other queer youth and adults, and find their access to trans healthcare in the hands of unsympathetic judges and institutional authorities. They remain institutionalized longer and in harsher conditions (such as solitary confinement), largely because their gender non conformity is read as part of their “pathology” and so meeting traditional gender norms is expected as part of their “rehabilitation.”

Without an education and unable to find employment—or even housing as 20% of trans people report having been refused housing or evicted due to their gender expression—many trans people find themselves on the street, especially given that over half of trans people surveyed have experienced significant family rejection. Many, especially transwomen of color, are compelled to work in the underground economy, doing sex work or selling drugs, in order to survive. This puts them at extreme risk for violence and murder, HIV infection (where rates among African American transwomen have been documented as high as 63%), police abuse, and incarceration.

(It also means that, due to lack of access to legitimate healthcare, many trans people acquire their hormonal therapy, for instance, on the street which can not only be dangerous due to lack of medical supervision of appropriate doses, etc, but can further increase risk of hepatitis and HIV due to needle sharing, as many hormonal therapies require injections.

In addition, many transwomen on the street forgo hormonal therapy and instead inject silicone as a fast, cheap alternative to provide feminine curves and a passing appearance required for some measure of safety. Though providing safety on the street, such silicone injections are highly dangerous and can lead to disfigurement, systemic illness, and even death.)

Once incarcerated, trans people are placed in facilities according to their birth sex, meaning that transwomen are placed in men’s prisons where they are subjected to extreme harassment, violence, and sexual assault by both other inmates and prison officials. The dominant institutional response to the extreme danger trans people face in prison is to place trans prisoners in solitary confinement for months, even years, seriously jeopardizing their mental health. In prison, hormonal therapy is taken away from trans inmates, also resulting in devastating mental and physical health consequences.

For those who manage to escape incarceration, and who instead turn to social service agencies for shelter, financial assistance, mental health services, or substance abuse treatment, they frequently find themselves turned away. Gender segregation is a primary mechanism of management and control in facilities where poor people and/or people of color are concentrated—and any area of society that is segregated by sex is going to be trouble for transgender people.

Transwomen are routinely turned away from women’s shelters—as personnel feel they represent a danger to other residents, or will make them uncomfortable—and they tend to avoid general homeless shelters because they will be placed according to birth sex, regardless of their current gender presentation, which—like in prison—puts them in severe danger of physical and sexual assault.

Similar to juvenile detention facilities, mental health and substance abuse treatment centers frequently regard gender non-conformity as “symptoms” that need to be resolved for treatment to be “successful.” If someone is in a substance abuse treatment program as an alternative to imprisonment, having such criteria for “success” means that trans people are disproportionately returned to prison (and indeed 30% of trans people have been incarcerated).

Even in the best case scenarios, among the most protected trans people with stable access to resources, receiving any medical care is fraught with challenges. A recent survery of 6,450 trans and gender non-conforming people in the U.S. found that 19% of trans/gender non-conforming people have been refused medical treatment due to their gender, 28% have been harassed at a doctor’s office or hospital (2% even report being violently assaulted in a doctor’s office!), and, while 48% had postponed medical care when they were sick or injured because they could not afford it, 28% postponed medical care due to discrimination, often not seeking medical care until extremely symptomatic which jeopardizes successful outcomes. There are many ways this can play out. Here are some examples:

Tanya Hunter was a trans woman in New York City who was critically injured in a car accident. When paramedics arrived on the scene, they tore her pants off to treat her and discovered that she had a penis. Medical personnel were disgusted and refused to treat her and she died.

Robert Eads was a transman from Georgia who is featured in the award winning documentary Southern Comfort. He developed ovarian cancer and went from gynecologist to gynecologist seeking treatment. He was turned away by more than 2 dozen doctors who refused to treat him on the grounds that it would make their other patients uncomfortable to see a man in the waiting room.

Max was an intersex person featured in the documentary we just saw a clip from. He lived as a man, but developed vaginal cancer and subsequently died. Although he had insurance, his treatments were routinely denied coverage because men don’t get vaginal cancer. (And I had similar experiences when I was at the University of Missouri—because I was listed as male in their computer system, anytime I had any gynecological services, they would refuse to pay which I was never actually able to get resolved.)

When I was at the University of Minnesota, medical personnel at the student health center refused to perform a blood draw on me because they didn’t believe that I was who I said I was because my physical appearance did not match my medical chart.

Even something as simple as a doctor’s office form can negatively impact transgender health care. Nearly 85% of transgender patients surveyed listed paperwork reflecting their gender identity (for instance, forms that only list M or F) as a significant health barrier. Those whose legal names or anatomy do not match their gender presentation are especially likely to avoid healthcare settings.

Trans people are in a difficult relationship to the medical profession. On the one hand, our very identities may be dependent upon accessing medical technologies. However, our experience with medical providers has been largely pathologizing and humiliating. Since most doctors are not trained in transgender issues (trans health concerns are generally not included in medical curriculum due to the designation of transgenderism as a mental health issue)—and most have never seen a trans person before—trans people can be subject to at best, curiosity and incompetence, and at worst being physically harmed or even detained on psych holds. 50% of trans people report having to teach their medical providers about transgender care and many describe the humiliation they feel as word of their transgender status travels among titillated medical personnel.

Given the kind of power that doctors have over our bodies, and the degree to which we are at their mercy when we are feeling sick, encountering their prejudice or hostility can be extremely dangerous. [When I was in Missouri and having gall bladder problems, of course the prescribed treatment was surgical removal—but as various medical personnel came into my room, about half calling me “he” and half calling me “she”—all looking disgustedly at me, I decided there was no way I was going to be unconscious while these people cut into my body and decided to forgo the surgery]

As one trans person writes, “With doctors is the only time I am afraid to continue on the path I’ve chosen. Even in Boulder County, thought of as a progressive environment, one outreach coordinator reports, “Because we don’t have many trained providers here, a number of transgender people don’t feel safe going to the ER even if they break their leg, though that doesn’t have anything to do with their gender.”

Comparison to Henrietta Lacks:

I would like to conclude by drawing 4 parallels between what I have just presented about trans and intersex folks and the story of Henrietta Lacks. Though there are many parallels I could make, I am cautious about making such comparisons due to the ignorant and insensitive ways many white LGBT folks have compared their own struggles to the struggles of people of color, particularly African Americans—and the ways they have co-opted leaders such as Martin Luther King in service of their own, usually privileged, political and social agendas. So I offer these comparisons with humility and restraint.

The 4 parallels that I would like to draw are: a common institutional location, common dehumanization, health hazards due to structural location, and distrust of the medical profession. In each case, I will use a quotation from The Immortal Life of Henrietta Lacks to illuminate a particular dynamic.

1) Shared Institutional Location: Johns Hopkins Connection
The first parallel I would like to point out is the common institutional influence of Johns Hopkins. I don’t have a lot to say about this other than it struck me as significant the influence one medical institution has had on all 3 situations.

As you saw in the video, in the 1950s, during the same time that Henrietta Lacks was receiving treatment at Hopkins, John Money established the problematic global care guidelines for the treatment of intersex children that is still used today. In 1966 the Johns Hopkins University Gender Identity Clinic opened. It was the first American university medical center to conduct sex reassignment surgery—not only giving transsexualism its first taste of legitimacy in the U.S., but it also made sex reassignment surgery more accessible for poor and working class transsexuals who couldn’t afford to travel to Europe for surgery. Their first complete genital surgery was performed on an African American male to female transsexual named Avon Wilson. Although doctors at Johns Hopkins fielded hundreds of requests for operations during this time, at least 20 potential patients per week, they turned away almost all of them for fear of negative press.

2) Common Dehumanization
“I thought, Oh jeez, she’s a real person…and it hit me for the first time that those cells we’d been working with all this time and sending all over the world, they came from a live woman. I’d never thought of it that way.” (91)

Historically speaking, trans and intersex people and people of color have been dehumanized by many of the same, oftentimes medicalized, discourses. Several scholars have written about how the tools and premises of 19th century scientific racism were used to classify and measure the bodies of lesbians and gays, searching for essentialized characteristics of the body to explain “difference” (i.e. pathology) and to justify societal inequality. Although methodologies such as anthropometry (measurement of the head, genitalia, and other physical features) have largely been abandoned, the underlying racialized and sexualized assumptions of normalcy and abnormality, superiority and inferiority, that make some humans seem more or less human than others have not shifted much at all.

Nowhere is this differential valuation of human life reflected more starkly (currently) than in the global two-tiered standards of care that is taken for granted medical practice around disease epidemics such as HIV and tuberculosis—whereby poor black people in South Africa, Haiti, and elsewhere are left to die of HIV and treatable tb because treating them is not seen as “cost-effective.”

Because gender—and, in particular, the gender binary—is so fundamental to the structuring of society and the distribution of resources, it can be difficult for many people to recognize the humanity of trans and intersex people when we can’t be clearly identified as man or woman. Any blurring of the boundaries of gender, and especially sexed bodies, is frequently responded to with revulsion and panic. The #1 health issue for transgender people, named by the National Coalition for LGBT Health in their Overview of U.S. Trans Health Priorities, is actually violence and murder.
An initiative of the Remembering Our Dead project, the Trans Day of Remembrance, held on college campuses and in communities all over the world each November, memorializes all of the transgender people who have been known to have been murdered that year. There is, on average, one transgender person per month who is killed somewhere in the U.S. (disproportionately trans women of color), and this statistic drastically underrepresents the staggering violence against transgender people, as it only documents those individuals whose murders were reported as transgender murders. This does not account for those bodies that were never recovered, nor does it count those transgender people who end up taking their own lives because they could no longer stand to face the kind of scorn and contempt that is part of living as transgender.

And these murders are not just clean and simple killings. The transgender women spoken about at the most recent vigil I attended were shot in the chest ten times each. This is typical of such murders—multiple stab wounds, dismemberment, especially removal of the genitals. They are crimes of intense hatred and frenzy—signs of a very insecure and disturbed society. And yet it is transgender people who are labeled as mentally ill.

Our very existence has been subject to erasure by the medical profession and society in general. While sex, gender, and sexuality appear to be most accurately described as a spectrum, such breadth is routinely reduced to its polar extremes and called a binary, with any evidence to the contrary being dramatically concealed, even if it means mutilating the bodies of infants and advising trans and intersex patients to lie and disown their own existence.

3) Health Hazards Due to Structural Location
“They spent their days breathing in toxic coal dust and asbestos, which they brought home to their wives and daughters, who inhaled it while shaking the men’s clothes out for the wash.” (26)

Just as people of color and other poor and marginalized communities experience damaging health effects due to being confined to hazardous and physically taxing sectors of employment and to geographical locations that are used as dumping grounds for toxic waste and other environmental hazards or that are subject to continual police surveillance, transgender people also suffer specific health consequences due to their marginal locations in the informal economy and urban landscape.

Just as we can think of exposure to asbestos as a health hazard to those in Henrietta Lacks’ community, exposure to HIV can be seen as an occupational hazard for many trans people, especially trans women of color who turn to sex work as their only option for survival. Further, trans people share with other marginalized communities the health hazards that result from marginalization: habits of tobacco, alcohol, and drug abuse to cope with enormously stressful lives.
In the case of Henrietta Lacks, her medical fate was sealed not due to one factor, but to several co-related factors, the cumulation of which left her prognosis for survival as very slim. Similarly, trans people face multiple intersecting threats to their health and well-being, leading to what researchers have called “catastrophic” levels of discrimination and hardship. According to a 2011 national transgender discrimination survey, 63% of trans people surveyed had experience at least 1 of these serious acts of discrimination, events that would on their own have a major impact on a person’s quality of life and ability to sustain themselves financially or emotionally. However, almost a quarter of respondents (including myself) have experienced at least 3 of the listed major life-disrupting events, exponentially increasing the difficulty of bouncing back and establishing a stable economic and home life.

I’m about as privileged as you can get for a trans person: I have white privilege, class privilege, education privilege, male privilege, passing privilege, family support, and a loving and stable life partnership. Nevertheless, I have been fired from 3 jobs due to my gender expression and I do not have health insurance, despite having a Ph.D. I made a total of $12,000 last year and receive almost all of my food from the food bank, I do not have a health care provider knowledgeable about transgender health care and have not had routine medical care for over 3 years, all of my identity documents correspond to my birth sex and so do not match my current gender expression and likely never will, I have been refused medical treatment because medical personnel didn’t believe I was who I said I was, I have been refused use of my credit card because merchants didn’t believe I was who I said I was, total strangers have threatened my life and told me I was going to burn in hell for being who I am, I am routinely detained by airport security if I am required to go through the invasive body scanners (which predominate at DIA) because my outward physical appearance doesn’t match my body scan, and I can be arrested for using the men’s room in public.

Finally 4) Distrust of Medical Profession
“It is no surprise that she hadn’t come back all those times for follow-up. For Henrietta, walking into Hopkins was like entering a foreign country where she didn’t speak the language.” (16)

People of color all over the planet have well-founded reasons for distrusting western medicine, which has been dominated by and continually reinforces the authority of white male elites. The role of western medicine in colonial expansion, medical experimentation on and abuse of Black bodies in apartheid South Africa and projects like Tuskegee, the use of people of color as human subjects in pharmaceutical testing (largely due to lack of any other access to health care for many who participate), and the forced sterilization of indigenous women and other women of color are just a few examples of the history of extreme harm that the medical profession has done and the ways that medicine has been at the center of regimes of oppression.

Just as how the white middle class tends to regard the police as protectors from violence, while people of color and other poor people frequently see the police as primarily agents of violence, so too medical settings and providers that societally normative people view as neutral or helpful, trans and intersex people are likely to regard with fear, anger and suspicion.

For intersex kids, doctors are the enemy. They lie to you, take parts of your body without your permission and without even telling you that’s what they’re going to do, they objectify your body and treat you like a spectacle, and make you feel like you have done something wrong or there is something drastically wrong with you. Intersex people often grow up without the ability to trust anyone after their experience with the medical profession because they see their parents and others as collaborators with the doctors in their suffering. They have been severally physically and emotionally scarred by their interactions with the medical establishment.

For transsexuals, doctors are the gatekeepers. They have all the power and you must always tell them what they want to hear and affirm their authority or they will revoke the medical services that you need. They do not respect you as an authority over your own body—you are not regarded as a reliable informant—and, in fact, if you do share your own perceptions or desires, they will likely intentionally work to thwart your success. If you interact with medical personnel for reasons other than gender, you can be assured that your gender status will become a major—and negative—aspect of the medical encounter, even if you are there for a broken leg or strep throat.

Conclusion

In conclusion, obviously both trans and intersex cut across race, class, and culture and the distribution of life chances, especially for trans people, is dependent upon where people are situated in relation to multiple axes of power. Although hardship and discrimination are pervasive throughout trans communities generally, the combination of anti-transgender bias and persistent, structural racism is especially devastating. Trans people of color in general fare worse than white trans people across the board, with African American trans individuals—especially African American transwomen—faring far worse than all others in most every area of life. Here are further resources if you would like to learn more. Thank you.

1931 first human sex change—Germany—Magnus Hirschfeld’s clinic
1952 Christine Jorgensen had surgery in Copenhagen, made sex change a household word

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