Joanne Meyerowitz: When Sex Changed

In How Sex Changed: A History of Transexuality in the United States, Joanne Meyerowitz defines transexuality as well as a once used but now outdated term, transexualism, as “conditions in which people hope to change the bodily characteristics of sex. (The terms apply whether or not the individual has undergone surgery.)” She goes on to say that, in modern usage, “transsexuals are a subset of ‘transgendered’ people, an umbrella term used for those with various forms and degrees of crossgender practices and identiacations. ‘Transgendered’ includes, among others, some people who identify as ‘butch’ or masculine lesbians, as ‘fairies,’ ‘queens,’ or feminine gay men, and as heterosexual crossdressers as well as those who identify as transsexual. The categories are not hermetically sealed, and to a certain extent the boundaries are permeable.” (This book was published in 2002; since then, the term ‘transgendered’ has fallen out of usage, to be replaced by transgender, or simply, trans. In discussing the book, I will use some of the terms that Meyerowitz uses, such as transsexual defined specifically as a trans person who has had, or is seeking, medical intervention toward gender confirmation. I will avoid other terms which in my opinion are now too outdated to be respectful of trans experience, or which define a trans person solely by their type of transition, which Meyerowitz does throughout the book. Readers are therefore cautioned that they may find the terminology is this book to be reductive, outdated, or even traumatic.)

Thus, the book focuses on a particular subset of trans individuals, specifically, those who feel that some degree of medical intervention or body modification is part of satisfying their personal sense of their gender identity. It looks at the history of expression and fulfillment of this desire in the North American context - those who have sought to ‘change their sex,’ and those who have provided, or sometimes withheld, that process.

There have always been people who did not feel that the gender assigned to them based on their physical sexual anatomy was who they really were; in some cultures, there have been acceptable social avenues for them to take on the gender they identified as, in others, some have simply lived in discomfort, or found individual ways to ‘pass’ as their true gender. But it has only been in the past hundred years that the idea of devising surgical procedures that could give a person at least a semblance of functioning sexual organs that matched their gender identity has been part of the conversation, and only in the past 50 or so that the techniques have become relatively available to most of those seeking a physical change.

Meyerowitz notes: “ ‘transsexualism,’ defined in part by the request for surgical sex change, did not appear as a medical category until the late 1940s and early 1950s, when doctors David O. Cauldwell and Harry Benjamin first coined and publicized the English term transsexual and when Christine Jorgensen first appeared in the press.

But the concepts of ‘sex change’ and ‘sex-change surgery’ existed well before the word transsexual entered the medical parlance. In the early twentieth century European scientists began to undertake experiments on ‘sex transformation,’ first on animals and then on humans.”

Much of the early European research and experimentation into what is now referred to as gender confirmation surgery took place in Germany, home of such leading researchers into the psychology and physiology of sex as Dr. Magnus Hirschfeld, but this research was abruptly halted when the Nazi party came into power. Still, many individuals had by this time received various kinds of surgical treatment intended to remove unwanted sexual organs and in some cases, create functional vaginas for transexual women.

Many of these techniques had already existed for some time - it was the use of these techniques to help transgender individuals that was new. “Sex-change surgery, then, did not take root when and where it did because of new or unusual medical technology. It took root in part because Germany had a vocal campaign for sexual emancipation. In Berlin, Hirschfeld and others worked to remove the legal and medical obstacles to sexual and gender variance, to enable homosexuals, crossdressers, and those who hoped to change their sex to live their lives as they chose.”

However, while the awareness of surgical possibilities became part of the American sexological landscape, beginning in the early 1930s, most American physicians did not offer the procedures, despite a large number of individuals seeking such surgery. In a few cases, sympathetic surgeons were warned that surgery to remove healthy organs was illegal and could result in serious ramifications if they attempted such procedures.

Meyerowitz devotes several chapters to accounts of early transsexuals whose stories were extensively covered in the media - such women as Christine Jorgensen, Charlotte MacLeod, and Tamara Rees - noting how these stories made the public - including other transgender people who might otherwise have thought themselves alone, the only person with such feelings - aware of trans people and the possibilities of gender confirmation surgery. Unfortunately, publicity did little to distinguish between transvestites and transexuals, or transsexuals and intersex persons seeking surgery to establish their chosen biological sex, nor did it affect the prevailing notion that transsexual women were more akin to gay men than cisgender women. And curiously, there was little interest in the stories of trans men. In fact, most physicians who provided care for trans people believed that trans men were rare, perhaps as few as 10 percent of trans individuals, and some questioned “whether there should be such a diagnosis as ‘transsexualism’ for females.”

Meyerowitz also discusses the development of better surgical techniques over time. Since surgeons mostly saw trans women in their practices, techniques in vaginal construction were a major point of concern. Trans women, however first had to find doctors willing to remove the penis and testicles. This was a major roadblock for some time. Some trans women were so determined to receive confirmation surgery that they attempted to remove their own penes and testicles, leaving doctors with no choice but to complete the desired surgeries. Trans men were less likely to seek out surgery in the early years, perhaps because hormone treatments were sufficient to help most achieve a body they could feel somewhat comfortable in, and phalloplasty techniques at the time were notoriously unsatisfactory. Trans men did seek out mastectomies and hysterectomies, but the reluctance to remove healthy, but unwanted, organs made these surgeries difficult to obtain.

The media focus on transsexuals also brought about a debate, in both the public and professional spheres, over the nature of sex and gender. Among the European sexologists who pioneered gender confirmation surgery, the predominant concept of biological sex was of a universal bisexuality, with individuals located on a spectrum. The transsexual person simply moved along the spectrum, bringing out more if the characteristics associated with the other end of the spectrum. This concept, however, was not common in America, nor did it find much acceptance when proposed.

What came to predominate, and to influence future thinking about sexual identity, was the idea of a psychological sex that was distinct from, though usually in accord with, biological sex. This was the ‘invention’ of gender as a concept.

“In the first half of the twentieth century the theory of human bisexuality had, for some doctors and scientists, redefined sex and legitimated sex-reassignment surgery; in the second half of the century a theory of immutable gender identity came to replace it. In the 1940s and afterward, scientists who studied intersexuality adopted the concept of a deeply rooted sense of “psychological sex.” Some of them suggested that hormones or genes created psychological sex, but others considered it conditioned, imprinted, or learned. In any case, they claimed that no one could change an adult’s psychological sex. Once established, they asserted, the sense of being a man or a woman remained armly entrenched, immune to both psychotherapeutic and medical interventions. They applied this conception of psychological sex—which they later labeled “gender role and orientation” and “gender identity”—first to people with intersexed conditions and then to transsexuals. In this view, the mind—the sense of self—was less malleable than the body.”

However, instead of bringing about an acceptance of surgical intervention to match biological sex to gender, the overall response was to promote the enforcement of rigid standards of gendered behaviour in childhood and support psychotherapy to correct apparent gender non-conforming begaviour, to ensure that the child developed the ‘right’ psychological sex by adulthood. Interestingly enough, the same attitudes prevailed among those who thought that human were to some degree bisexual, in that everyone had some characteristics of the “other” sex - firm education in appropriate gender roles was necessary to minimise the consequences of this bisexuality. Few questioned the necessity of a clear demarkation between male and female. The result was the pathologising of transsexuality as a psychiatric disorder.

Physicians were already gatekeepers, due to their power to offer or withhold available surgical procedures. Pathologising trans people further added to the adversarial relationship developing between doctors who had the technical knowledge to do the surgeries desired, and trans people who sought surgical interventions. Many doctors tried to ‘cure’ their trans clients first. Trans people tried to figure out what they had to say and do to obtain surgery. Many trans women sought to appear hyperfeminine to persuade doctors that there was no way they could live as men. Discussing sex was a dangerous topic - acknowledging desire for men, while appropriate behaviour for a straight trans woman, ran the risk of being diagnosed instead as a gay man, ineligible for surgery. For trans lesbians, the problems were even more difficult, as their sexual orientation could be read as male heterosexuality, and cause for attempting treatment rather than surgery. Many insisted they felt no sexual desire. The need to tailor their life experiences and presentation to convince doctors to approve surgery led to an assumption among doctors that trans people were inherently deceitful. And so the gatekeeping became a major obstacle in the quest of trans people to reshape their bodies to match their identities.

Adding to the problems faced by trans people seeking surgery was the confusion of the medical establishment between transsexuality, transvestitism, and homosexuality. Some felt that trans women were gay men so horrified by their homosexuality that they needed to erase it by becoming women. The debated how to distinguish true trans people from gay people or cross-dressers. Similar discussions developed in the queer community, with various groups - gay men, lesbians, drag queens, heterosexual transvestites - arguing over how trans people should be viewed. One of the difficulties her was that some people who had identified as gay men, drag queens, or butch lesbians, eventually realised that they were in fact trans women and men. Meanwhile, trans peoples’ attempts to define themselves simply as people assigned a gender that was not congruent with their identity were often ignored.

In the 1960s, one consequence of the general ‘sexual revolution’ was a relaxation of defined gender roles, and an openness toward sexual experimentation, that on the one hand, gave many young people the chance to explore androgyny and even living as another gender, and on the other, made it easier for distinct subcultures to emerge, drawing distinctions between those who were gay or lesbian with marked preferences to adopting behaviours associated with another gender, and transexuals who identified as a gender other than the one socially assigned them. Lines of demarkation grew up between those who sought gender confirmation surgeries, and those who identified as ‘fairies’ or ‘butches’. Transsexuality was at least for some distinguished from homosexuality.

Unfortunately, the medical profession was making distinctions based on the path patients had followed to an awareness of their gender identity. They tended to favour the person who had tried to live a conventional life, followed the heterosexual rules for their assigned gender, and lived lives of quiet desperation. Those who came to a desire for gender confirmation surgery through experiences as living as gay men and drag queens, who had been sexually adventurous, were often seen as poor candidates for surgery.

Another consequence of sexual freedom was the eroticisation of trans people. Pornographic images of the feminised bodies of post-surgery trans women began appearing. This was accompanied by erotic images of ‘half-men, half-women’ - trans women who had received hormone treatments and thus had both breasts and a penis. “The sexualization of MTFs went hand in hand with the legalization and commercialization of sexual expression. In this changing sexual climate, the tabloids and pulps presented their stories as less concerned with what the main-stream press dubbed ‘desperately unhappy lives’ and more concerned with titillating adventures.”

Meyerowitz records the low changes in the mainstream medical profession’s attitudes toward gender confirmation surgery, and the work of transgender activists in bringing about greater awareness and acceptance for their situation. Slowly, hospitals began to open gender identity clinics where surgeries were performed on trans men and women, starting with Johns Hopkins in 1965: “By the end of the 1970s more than a thousand transsexuals had undergone surgery at the hands of doctors based at American universities, and fifteen to twenty “major centers” conducted transsexual surgery in the United States.”

Unfortunately, demand far exceeded supply, and the doctors running these clinics set up strict conditions. Again, professional gatekeeping came between the transgender individual and their right to control their own body: “By the end of the 1960s the doctors required psychological evaluation to ascertain that patients had longstanding crossgender identiacation and no severe mental illness. The doctors also wanted patients to live as the other sex and take hormones for a number of months or years before undergoing irreversible surgery. They looked for patients with the intelligence to understand what the surgery could and could not do, and with what they considered realistic plans for the future, especially employment.” Preference was given to those whom doctors felt could most easily ‘pass’ and who presented as ‘quiet’ and highly conventional in their gender expression. Trans lesbians and gay men were unlikely to be approved.

As the availability of surgery grew, legal issues became more important, and courts were increasingly asked to rule on whether a trans person could change their birth certificates and other key documentation from their assigned gender to their true gender. Thanks to the supportive testimony of a number of doctor-advocates, a series of precedents were established where the courts did order the official change of sex on birth certificates, which was the first step to obtaining new documentation of other kinds, and offered a trans individual the ability to provide legal proof of their gender when required. However, where the courts were tending to define gender by reference to genital appearance, governments held onto older ideas and defined gender by (presumed) chromosomal composition. And even the courts provided no hope fir trans people who had not, or could not, have surgery. This was particularly onerous for trans men, for whom phalloplasty remained an unsatisfactory option lacking in both sensation and function.

As the era of liberal sexual freedom that marked the 60s and 70s began to change, Meyerowitz documents shifts in acceptance among both gays and lesbians, and feminists, toward transgender men and women. The prevailing gay culture had adopted the “cult of the macho” and rejected the drag and fairy culture that had supported trans women in transition. At the same time, lesbian culture began to see trans men as butches who were deserting the fold for a safer, moe privileged life. Feminists critiqued trans men and women as reactionaries who reinforced gender stereotypes that the women’s movement was fighting to change, and distrusted trans women who, they believed, had grown up with male privilege and could never be, culturally or psychologically, women, thus establishing the trans-exclusionary (TERF) streak in feminism which remains a problem to this day.

As the conservative 80s set in, the few legal victories trans activists had achieved were rolled back, and existing surgical clinics came under attack from both the right, with a renewed insistence that surgery enabled mental illness and that trans individuals required treatment to restore the ‘proper’ gender identity, and from the left, with a strong critique of the rigid gender roles doctors required of prospective surgical patients. But as their rights were being denied and the few gains made eroded, trans people fought back, forming advocacy organisations, building communities and working to educate both the public and the medical profession on the realities of being transgender.

As Meyerowitz says, “The rise of the transgender movement capped the century in which sex change arst became a medical specialty and transsexuals arst emerged as a visible social group. From the early twentieth-century ex- periments on changing the sex of animals to the liberationist move- ment of the 1990s, the topic of sex change had served as a key site for the deanition and redeanition of sex in popular culture, science, medi- cine, law, and daily life. In a century when others had challenged the social categories and hierarchies of class, race, and gender, the people who hoped to change their sex had brought into question another fundamental category—biological sex itself—commonly understood as obvious and unchangeable. In the modern push for self-expression, they had taken the meanings of self-transformation and social mobility to a new level, and from the margins of society, they had grappled with the everyday ways in which unconventional individuals confounded and provoked the mainstream. In the process, they had engaged with doctors, scientists, reporters, lawyers, judges, feminists, and gay libera- tionists, among others. Together, these various groups had debated big questions of medical ethics, nature and nurture, self and society, and the scope of human rights. None of them could ax the deanition of sex, which remains a topic of debate in medical journals, courtrooms, and television talk shows, and none of them could settle the question of the interconnections among sex, gender, and sexuality. Still, by the end of the twentieth century, the transgender activists could hope at least for a future in which the variations of sex and gender might no longer elicit stigma, ridicule, harassment, or assault.”