Sexuality and the ethics of body modification: Theorizing the situated relationships among gender,sexuality and the body

Abstract

Drawing from our qualitative, in-depth interviews of 35 professionals who write referral letters for “gender transition,” we explore how practitioners’ decisions to approve, delay or refuse access to body modifications speak to the centrality of normative concepts of sexuality and the social function of bodies in the cultural politics of gender identity. We argue that practitioners construct what we call an ethic of body modification that tends toward reducing the body to its symbolic function—as a representation of the subject’s true gender and a basis for sexual identity. We also discuss the views of a minority of practitioners who resist this tendency by creating an alternative path for body modification independent from identity claims. We conclude by discussing the cultural/political implications of pseudo-scientific discourses that assume gender identity is natural, stable and universal, whereas bodies are flexible and malleable social representations.

Keywords

Body gender identity gender identity disorder sexuality transgender

In the USA, not all modifications to sexed bodies are treated equally. Ciswomen¹ only need a checkbook to gain access to medical interventions that tighten vaginas, enlarge g-spots, or create balance and symmetry of the labia, thus aligning “malformed bodies” with hegemonic standards of femininity (Braun, 2005). On the other hand, those who wish to have access to some of the same technologies for the purpose of gender transition require an officially diagnosed mental illness. In most states in the USA, medical practitioners will not prescribe hormones or conduct sex reassignment surgery (SRS) for the purpose of transition without a letter of authorization from at least one mental health practitioner (Meyerowitz, 2002). Mental health practitioners in the USA who see clients considering or directly requesting hormone therapy or SRS are advised to follow professional guidelines defined by the Diagnostic and Statistical Manual of Mental Disorders, IV (DSM-TR) in its section on “Gender Identity Disorder” (GID) and/or the World Professional Association for Transgender Health’s² Standards of Care (SOC).

This particular structure of accountability and authority puts some self-described “trans-positive”³ therapeutic practitioners in the uncomfortable and ambivalent position of the “gatekeeper” who must determine if their clients “should” undergo medical body modifications. “Trans-positive” practitioners see themselves as a progressive alternative to the long history of mental health practice known for narrowly profiling authentic trans identity and patrolling patient narratives for evidence of a core trans self (Stone, 1991). On the other hand, practitioners must evaluate possible risks to their professional careers in the event that they authorize clients to undergo modifications that they may later regret. Practitioners’ ambivalence to gatekeeping medical intervention is also fueled by a lack of consensus about the legitimacy of the GID diagnosis that many argue force a biological or social phenomenon to be diagnosed as a mental health issue (Lev, 2009; Winters, 2005). The difficulty of the gatekeeper role is magnified by a relative lack of agreement about how practitioners should make these decisions in a way that affirms the client’s self-determination, but also avoids the potential irreversible or negative effects of medical interventions and risks to practitioners’ careers.

In the context of this diagnostic lacunae we find that practitioners (some with the help of their self-made consultation groups) craft what we call an ethic of body modification that posits when it is appropriate to alter sexed bodies. Unlike a professional code of conduct or a formalized moral system, an ethic of body modification is not codified and it often operates as an unarticulated set of malleable guidelines. In what follows, we explore a handful of specific cases where understandings about the client’s sexual identity or erotic desires informed the practitioner’s decision to open or close the gate to body modifications. We argue that these cases reveal how the current psychiatric model, in practice rather than in terms of codified texts—such as the DSM and SOC—provides a context in which the gendered meanings and sexual identities that bodies are supposed to reflect may come into conflict with the erotic desires that bodies are allowed to enact. The majority of the practitioners we interviewed conceive of the body as a symbolic scaffolding that represents core identities, even when this denies certain sexual practices, orientations or erotic desires. While on the surface it may seem that GID is only tangentially or indirectly related to sexuality through the concept of heteronormativity, our findings indicate that sexuality is central to practitioners’ ethics of body modification, as clients’ potential sexual orientation and erotic desires can act as independent reasons to deny or allow access to hormone therapy and SRS. In this way, “trans-positive” practitioners, while working to respect patients’ rights to self-determination, still authorize or deny access to medical interventions based on an ethic of body modification that cannot be reduced to gender.

We contextualize this clinical moment as it speaks to our understanding of the contested relationship among gender identities, sexuality, and the body.⁴ The relationship between gender and sexuality is a foundational concern in the feminist, lesbian/gay studies, and queer literature including insightful debates about the inherent, interconnected relationship (G Rubin, 1975; Wilton, 1996) or the need to analytically separate gender and sexuality (Halperin, 1995; Martin, 1998; G Rubin, 1984; Sedgwick, 1990). This scholarship also includes arguments asserting sexuality as foundational and gender as derivative (Ingraham, 1994, 2005; MacKinnon, 1982) and others suggesting that sexuality cannot be understood without a gendered lens (Delphy, 1984, 1993; Jackson, 1999, 2005; Wittig, 1981, 1992). Recent interventions in these long-standing debates include the work of Diane Richardson (2007) who emphasizes the situated nature of this relationship, and (characteristic of the sociological perspective) aims to understand gender and sexuality in their contextual configurations that have no essential or universal character. Richardson (2007) argues for work that improves our understanding of gender and sexuality as “grids of intelligibility [that] may be overdetermined at some points of intersection, barely held together at others” (2007: 465). Coining the term “patterned fluidities,” Richardson (2007) aims to encourage new avenues of social research and thought attentive to the multiple constellations of gender and sexuality, recognizing that these configurations are neither logically consistent, nor inherently stable across social space.

We take up this call, but do so in a way that explicitly theorizes sexed bodies as socio-material objects that offer a malleable plane in the larger grid of gender and sexual intelligibility. Our work highlights pseudo-scientific discourse that posits a natural and unchangeable gender identity as a pivot point that stabilizes western gender and sexual ideologies at the same time that it calls for an ethic of somatic flexibility.

We begin with the assumption that sexed bodies attribute (Kessler and McKenna, 1978), materialize (Butler, 1993), and act as agents (Connell, 1995) of socially constructed gender identities; however, we focus our analysis on how bodies simultaneously act as socio-material agents of western sexual ideologies that carefully patrol an individual’s experience of erotic desire and sexual access. Suzanne Kessler and Wendy McKenna’s (1978) now classic extension of Garfinkel’s ethnomethodological perspective implies that with the process of transition, the body is asked to carry the symbolic weight of gender attribution, rather than simply aligning itself with a pre-social “core gender identity.” This position highlights the importance of the body in gender attribution, yet it does not consider how sexed bodies also represent sexual identities and materialize erotic desires. From an ethnomethodological perspective, because the symbolic potential for bodies is found within practice—not hegemonic discourses as it is for Butler—what the sexed body is asked to represent depends on the demands and contours of particular social contexts. The ethnomethodological perspective leaves room for the sexed body to have equally fundamental symbolic functions in social practice beyond the burden of representing gender identity, but it is not designed to capture the recursive power of bodies to “matter” beyond their representational capacities.

Alternatively, feminist theorist Donna Haraway (1991) and sociologist RW Connell (1995) stress the agency of bodies to produce, rather than simply represent relationships and emotions. In her manifesto of “cyborg feminism,” Haraway rearticulates the problematic of objectivity in terms of her model of “situated knowledges.” Haraway rescues the body from social constructionist, postmodern, and modernist biological perspectives by theorizing it as a “material-semiotic actor”; one that is active in the practice of meaning creation. Haraway rejects how each of these models either theorize the body as a blank page for social inscriptions or, in the case of biological discourse, shape the body without reflection. For Haraway, the body acts as an agent of the social world, rather than a resource for symbolic production. Furthermore, biological agents, like widely recognized symbolic entities, are situational and engaged rather than intrinsic and prepackaged by nature. Similarly, RW Connell theorizes men’s bodies as “sharing in social agency, in generating and shaping courses of social conduct” (1995: 60). Coining the term “body-reflexive practices,” Connell argues that men’s bodies do not just symbolically represent masculinity, but direct sexual experiences, structure fantasy, and construct “fresh sexual relationships” (1995: 62). Rather than disregarding the body as an interpretive canvas, Connell sees bodies as agents structured by the social world of symbolic representation and interpretation. But as Haraway and Connell both note, the agency of the body is formed by social context rather than individual will; the agency of bodies is never free from the restrictive or productive force of social power. In our case, this power is revealed when mental health practitioners deny or allow hormone therapy or SRS to those “trans” clients who ask for a resexed body in order to reshape their sexual identities or enhance sexual experiences.

The importance of the sexed body and its relationship to gender identity in the case of transgender experience is well documented in sociology and gender studies (Dozier, 2005; Ekins and King, 2006; Hausman, 1995; Hester, 2004; Prosser, 1998; H Rubin, 2003; Schrock et al., 2005); unfortunately, the relevance of the sexed body is often reduced to gender embodiment, leaving the body’s symbolic and material capacity to represent and produce erotic desire an undertheorized motivation for “trans” body modification. This conceptual gap is most evident in work that focuses on the meaning of the body for those considering hormone therapy or SRS. Raine Dozier’s (2005) sample of FTMs, for example, cited comfort with the body as an object of self gender identification and male gender attribution in social interaction as the primary motivations for transition. Based on interviews with nine transsexual women, Schrock and his colleagues (2005) argue that subjective gender identity is not just a motivation for transition, but also a malleable product of body modifications that gave their respondents, “permission and opportunities to further feminize their subjectivities” (2005: 329). Unfortunately, these accounts rarely speak of individuals who request medical body modifications for reasons that cannot be reduced to gender identity, including practical concerns like increasing the number of available sexual partners or avoiding a stigmatized sexual identity. Moreover, these investigations seldom account for individuals who have been officially denied access to body modification; thus they have self-selected respondents who convincingly articulate a gender narrative often required when seeking letters from social workers and/or counselors.

Moreover, current psychiatric guidelines and clinical procedures for determining access to transgender body modifications provide a particularly profound vantage point for viewing the entangled relationships among gender, sexuality and bodies. In addition to critiquing the role of psychology and the medical establishment in defining “authentic trans identity” and policing access to body modification according to standards that deny the fluid nature of gender identity (Billings and Urban, 1982; Risman, 1982), queer theorists and sociologists have explored the relationship between allegedly “disordered” gender identities and homophobia (Bryant, 2008; Sedgwick, 1990, 1993). Eve Sedgwick’s (1993) now classic critique of the GIDC (Gender Identity Disorder in Childhood) code in the DSM as a replacement of homosexuality warns against a rigid separation of gender and sexuality, as it explains how “depathologization of an atypical sexual object-choice can by yoked to the new pathologization of an atypical gender identification” (1993: 73). Karl Bryant (2008) extends Sedgwick’s critique by confirming that proponents of GIDC use the separation of gender identity from sexual orientation to deflect critics’ suggestions that GIDC is a homophobic attempt to prevent homosexuality. More importantly, Bryant finds that GIDC does not simply repress homosexuality in general, but its discourses produce a “pro-gay homophobia” that threatens queer subcultural variation and gender nonconformity.

We extend this analysis in two primary ways: first, because our sample of therapists, social workers, and professional psychologists tend to disregard or explicitly ignore guidelines found in the GID diagnosis in the DSM, formal texts and research programs (such as those studied by Sedgwick and Bryant) do not account for how practitioners make their determinations. As Billings and Urban point out, access to SRS, “depend[s] less on formal, rational or fixed criteria than on the common sense of clinicians” (1982: 275). In this sense, we maintain a focus on the production of bodies within “situated social practices” (Jackson, 2005: 18) rather than as a product of codified forms of discourse. Second, we explicitly theorize the role of the body as it is asked to bear the symbolic weight of representing one’s “authentic” gender identity, even when clients see their own bodies as malleable agents of erotic desire.

Our work is not designed to assess the motivation of “trans” clients seeking hormone therapy or sex reassignment surgery; instead our interviews with practitioners speak to an ethic of body modification that posits the primary role of the sexed body as a signifier of core gender identity. In this way, almost all of our respondents view the sexed body as a social project that is malleable and should be “worked at and accomplished as a part of an individual’s identity” (Shilling, 1993: 5), specifically one’s gender identity. Our interviews revealed differences in practitioners’ ethics of body modification when discussing the small number of cases where clients asked to modify their sexed bodies for reasons other than representing their true gender identity; such as to (1) avoid a stigmatized gay identity, (2) increase the number of sexual partners or (3) enhance erotic pleasure. While each practitioner agreed that clients ought to be able to change their bodies to reflect their true gender identity, in these three cases, practitioners parted ways, most feeling reluctant or abruptly refusing to open the gate to medical interventions. We conclude by arguing that sociological models and clinical practices that reduce the significance of sexed bodies to the representation of gender identity are ill-equipped at explaining why many practitioners craft an ethic of body modification that rules out the practical and symbolic importance of trans body modifications to enhance erotic desire or avoid the pressures of social stigma attached to homosexuality. Thus we explore how social power drives the potential for material-semiotic agency of sexed bodies, even in cases where social agents assume bodies have a substantial amount of representational elasticity.

Methods

Our conclusions are based on 35 qualitative, in-depth interviews conducted in the summer of 2008 with mental health practitioners from San Francisco (n = 9), Seattle (n = 6), and Portland, Oregon (n = 20). Research participants include Licensed Marriage and Family Therapists (LMFT), Clinical Social Workers (LSCW), and clinical psychologists (PhD or PsyD). We selected our first wave of potential respondents from a list of available print and internet guides to counselors and therapists specializing in transgender clientele. Subsequent participants were selected through a snowball sample. We invited practitioners to participate in our study if they advertised their services or were known in the larger community as “trans-positive” or “trans-friendly.” In general, practitioners use these labels to signal experience in writing letters for hormone therapy and body modifications, as well as a more specific rejection of reparative therapy.⁵

Our participants shared a “trans-friendly” approach, but they differed in terms of their professional training, level of experience, and opinion of the DSM. More than half of our sample (n = 21) are credentialed and licensed counselors and social workers and the remaining participants are practicing or recently retired psychologists. The experience of practitioners in our sample ranges from expert to novice: some of our respondents have worked with more than 500 clients over a 30-year period or more; others are relatively new to the field and have only seen a handful of trans clients. We characterize most of our respondents (n = 22) as experts because they have had over 10 years of experience working with trans clients and/or over half of their practice is dedicated to these clients. In addition, five of our participants (three MTF and two FTM)⁶ have personal experience with transgender issues, having undergone a process of transition before becoming practitioners. The majority of our respondents were Caucasian women in their 40s and 50s, six respondents identified as men and a handful of practitioners articulated multiple, fluid or context-dependent gender identifications.

With the exception of two practitioners, our respondents express mild reservations to outright rejection of the GID diagnostic code in the DSM. Reasons for this rejection include a dispute over its scientific rigor as well as unintended consequences of labeling clients as “disordered.” Even though they feel the code does not adequately describe their trans clients who request body modifications, over 70% of practitioners who reject the GID diagnostic code have used it when referring clients for hormone therapy and many forms of SRS. In this sense, it is the “treatment” that fuels practitioners’ uneasy use of the GID diagnosis.

Our original research question did not stress the importance of sexuality as it informed practitioners’ decisions to open or close the gate to trans body modifications; however, we did ask open-ended questions in the interviews that later revealed the importance of sexuality in granting access to hormone therapy and SRS. Indeed, all but two of our respondents explicitly mentioned sexual identity and/or sexual desires, leaving a subsample of 33 practitioners for the following analysis. Much of the research we present in this article emerged when we asked the practitioners the following two questions: (1) Have you ever denied a client access to body modifications? If so why? (2) Can you talk about a specific example of one such case without revealing any identifying information about the client? Other practitioners mentioned sexual pleasure and identity when referring to hypothetical reasons why they would deny access to body modifications. Because our interest in how the practitioners understand their clients’ sexuality did not emerge until the process of data analysis, we focus our discussions on those practitioners who addressed these issues without prompting by the interviewer.

We analyze practitioners’ ethic of body modification with the following two questions in mind: (1) How do practitioners define the authenticity of a client’s gender identity in relation to their clients’ sexual practices, orientations, or erotic desires? (2) How do practitioners navigate and respond to clients’ sexual or erotic motivations for body modifications, regardless of clients’ stated gender identifications? The overwhelming majority of our respondents articulated an ethic of body modification that assumed erotic pleasure and sexual identity as inappropriate or superficial reasons for gaining access to hormone therapy or SRS. In our analysis of the data we use crucial case examples—or cases in which the practitioner either would hypothetically deny or had previously denied a referral letter in practice—in order to clarify how practitioners’ decisions assumed gender attribution and identity as the legitimate grounds for body modification. Although it was uncommon for sexuality to be a critical element in the practitioner’s decision to open or close the gate to body modification, these cases are significant in terms of what they reveal about the relationship between gender, sexualities, and bodies.

In the section that follows, we point to a handful of crucial cases when practitioners closed the gate to hormone therapy or SRS for clients whose suspected sexual identities—in this case a repressed gay identity or pansexual⁷ identity—did not merit modifications to the body according to the practitioner’s ethic of body modification. We also highlight cases when practitioners grant or deny access to body modifications for clients who experience an erotic charge associated with their resexed bodies. In these cases, some practitioners treat the body as a signifier of core gender identities and claim that it should not be modified in ways that would misrepresent or symbolically contradict those immutable identities; other practitioners adopt a more reflexive ethic of body modification that acknowledges the body’s material-semiotic agency to produce affective release and erotic desire that may be detached from a somatic representation of gender or sexual identity.

Internalized homophobia and pansexuality: The body and sexual identities

For most practitioners, the client’s sexual orientation (homosexual, heterosexual, or bisexual) is usually irrelevant to his or her gender identity. In other words, most practitioners would agree that having sex with a man does not diminish a FTM’s claim to a masculine gender identity. However, sexual identity emerged in our interviews as an important element in cases where practitioners suspected that clients desired transition in order to avoid a homosexual identity (“internalized homophobia”) and in cases where clients refused to see their sexed bodies as essential to their sexual identity. Even though these cases are rare, they have profound analytical significance, as they form boundary cases for practitioners’ ethic of body modification that assumes the primary function of the body is to symbolically represent core identities, even at the expense of producing desired erotic feelings. Moreover, these cases reveal how the same practitioners who find it unethical to question or impossible to assess their clients’ “authentic” gender identity will interrogate one’s claim to a heterosexual identity.

The majority of our respondents do not believe that “internalized homophobia” is the general trend among straight MTFs, but in the rare cases that it does emerge, practitioners were unanimous in their belief that it was not a “healthy” reason to undergo body modification. Practitioners reason that altering the body to change one’s sexual orientation is inherently unethical and even dangerous, because the body should not be molded in opposition to what practitioners assess as core identities: a logic that is consistent with practitioners’ ethic about gender identity. Although only five of our respondents discussed cases of internalized homophobia, each used such cases without being prompted by the interviewer as examples of inappropriate reasons to resex the body.

Nancy Pan became a Licensed Social Worker in the early 1980s. Drawing from her years of experience working with clients in Portland who request body modifications, Nancy maintains that “who you have sex with or want to love or hold or whatever [has nothing] to do with being trans.” In other words, from Nancy’s point of view, being attracted to men is not evidence for being a “real woman.” Sexual object choice, in Nancy’s mind, should not factor into her decision to give someone a letter for hormones. However, Nancy does feel compelled to explore the client’s sexual orientation in the rare case that she suspects that a client wants to transition in order to avoid a gay identity. Nancy explains:

I think maybe I’ve asked this once in all the years I’ve worked … ‘[Do you want to transition] because you’re afraid of being gay? [Do you think you are] a transwoman because you don’t feel comfortable being a gay man?’ That has only come up once … and I think … that there was some of that in there. But … ultimately underneath everything, she was woman enough to transition and feel good about transitioning [emphasis added].

While she was largely articulate throughout the interview, when discussing internalized homophobia, Nancy seemed unsure of her words, and slightly uncomfortable with the discussion. In this passage, Nancy suspected that her client was working through issues of internalized homophobia that led to the client’s decision to transition, but she came to the conclusion that her client was “woman enough” to proceed with hormone therapy. Ultimately, Nancy made this determination because she was convinced that the desire for an accurate gender presentation trumped this client’s desire to avoid a “gay” presentation of self.

Kathryn McFarr is a Licensed Mental Health Counselor in Seattle who believes that “Hormones are somewhat of a test … [If clients] start feeling better then they’re probably on the right path.” On the other hand, Kathryn warns of using hormones as a diagnostic tool by relaying an example from one fellow practitioner who signed a letter for an allegedly homosexual client to begin hormone therapy:

After seeing him a few times, she decided that … he wasn’t able to accept [himself] as gay … He was on hormones … and it was just driving him crazy; it was not a good mix and so she got him off hormones and um re-diagnosed him, and then he went into therapy to help him deal with himself as a gay man.

In this case, attempting to resex the body can be a test of one’s “innate” gender identity; moreover, resexed bodies will not function properly if they are altered to avoid sexual stigma. Thus practitioners like Kathryn reduce the agency of the sexed body to its semiotic function to represent gender identity, at the same time she attributes this social power to the natural function of hormones.

These cases provide insight into how perceived sexual orientation helps define an ethic of body modification: practitioners assume their client’s sexual identity is as primary, internal, and fixed as their gender identity. In this formulation, identities should remain fixed points, whereas the body offers a malleable surface that primarily carries the burden of accurately representing one’s true gender and sexual identity. Curiously, this ethic of body modification posits that being a lover of men uncomfortable in a man’s body does not grant one access to body modifications, but being a woman trapped in a man’s body does. Most of our respondents do not see this as a conflict or contradiction, primarily because they see homosexuality as an identity that is as core as one’s gender; in both cases it is unethical to allow clients to alter their bodies because their core identities are socially stigmatized or culturally undervalued. In other words, these views are entirely consistent when one restricts the agency of sexed bodies to representing “innate” identities (gender or sexual). On the other hand, the case of “internalized homophobia” indicates that the same practitioners who do not see themselves assessing a client’s “authentic” gender identity, believe they can discern the client’s authentic sexual orientation.

Moreover, the concept of internalized homophobia conflates same-sex sexual desires or acts with a core homosexual or gay identity. According to this logic a male-bodied person having sex with a man is the only prerequisite for a complex social identity, and any man who engages in same-sex sexual acts must be gay whether he “admits it” or not; thus disregarding multiple forms of same-sex male sexuality that do not represent one’s core identity (Ward, 2008). As Karl Bryant found in his analysis of the GIDC diagnosis as a site for the production of pro-gay homophobia, “charges of homophobia may stigmatize other forms of queer expression” (Bryant, 2008: 456). In our cases, charges that they have “internalized homophobia” limit clients’ ability to transform or queer their sexed bodies in ways that might be more practical, facilitating desired socio-sexual relationships rather than representing “core” identities. This ethic of body modification thus posits the sexed body as only ethically altered when it conforms to pre-given identities, thus the limits of the sexed body’s malleability are anchored by allegedly core sexual identities.

In addition to illuminating how social power works through bodies, by restricting their form to representational functions, this ethic of body modification also assumes that some sexual identities are more core than others. This distinction became clear as practitioners discussed the small number of clients who sought access to hormone therapy and/or SRS in order to increase available sexual options.

Kathryn McFarr shared that she denied a client access to body modifications because the client was motivated to transition for love. Seated on her plaid couch, Kathryn tells us of a patient who requested body modifications for whom she decided it was not appropriate:

[This person] was not having any luck finding love as a man [laughs] and so, it’s a thought, maybe as a woman [she could find love] … she was an MTF and in that role then would seek male partners and then when that didn’t work would go back to male and seek female partners; not a good reason to transition.

For this client, love and sexuality appeared to be “without a gender” (Martin, 1998); her erotic desires, acts and identity were independent of her gender identity. This case challenged Kathryn’s understanding that core, stable identities compel people to transition rather than more practical approaches to finding love by embracing pansexuality—a form of sexuality that emphasizes one’s ability to love and lust in whichever way best fits their current situation in life without binding people to their gender or sex.

In another case, Don Jettsa, a therapist in Portland who began working with trans clients over 15 years ago, declined to even work with a client on trans issues because the client wanted body modifications in his pursuit of reconnecting with a previous partner. Don explains:

I declined to take the referral because it was really clear on the phone, from my perspective, that he wanted to reattach to his old girlfriend who had come out as a lesbian. That’s what he wanted. That’s not a reason to transition. He didn’t react very nicely to me declining the referral, and I told him that there were other things I thought he should work on.

Here, Don is articulating an ethic of body modification that assumes that sexed bodies should not be altered for practical purposes. Moreover, even imagining that altering his body is a sensible method for rekindling his past sexual relationship is a sign this potential client has a mental health problem (“other things to work on”).

Both internalized homophobia and the more practical approaches to body modification that increase one’s romantic and sexual options indicate the symbolic weight sexed bodies are asked to represent in the case of trans body modification. All but a handful of our respondents, even if they did not directly discuss cases of internalized homophobia or pansexuality, articulate a similar ethic of body modification; one that assumes healthy individuals must have sexed bodies that correspond with core gender identities. In this particular tangled web of gender, sexuality and the body it is the distinction between the “core” and the “surface” that dictates the logic and ethic of materializing resexed bodies. This is a logic consistent with the practitioner’s belief that the primary psycho-social purpose of the body is to act as a signifier of deep identities, but obviously inconsistent with some clients’ desire to change their bodies for far more practical purposes, such as the pursuit of pleasure or avoidance of social stigma. The rare cases of “internalized homophobia” and “pansexuality” reveal some practitioners’ assumptions that the sexed body operates as a symbolic surface first, and a sexual agent later. As RW Connell and Donna Haraway suggest, the symbolic weight western culture asks the body to shoulder masks more practical orientations to body sensations that are not about molding bodies in correspondence with identities.

Autogynephilia: The body and erotic desires

Cases of “internalized homophobia” and “pansexuality” were rare for the practitioners we interviewed, and it was slightly more common for sexuality to emerge as a “red flag” in cases where male-bodied clients experienced an erotic charge when picturing themselves as women—a condition known in the mental health literature as autogynephilia or the “love of oneself as a woman” (Blanchard, 1989, 1991), and referred to by some of our respondents as fetishistic cross-dressing. Seven practitioners in our sample discussed such red flags, and their differing approaches to such clients reveal a lack of consensus about a broader ethic of body modification grounded by core identities. Only one of seven, Don Jettsa, discussed denying hormones to clients who claimed to experience a sexual charge from cross-dressing; the remaining practitioners either grant hormones for fetishistic cross-dressers who currently (or have the potential to) articulate convincing gender identity claims, or, in two cases, practitioners discussed opening the gate to body modification even without a gender claim.

Lauren Lairs—a Licensed Clinical Social Worker operating out of San Francisco whose practice is primarily geared towards treating gender-variant patients—distinguishes between cross-dressing, autoerotic clients and those who are authentically trans when determining who should receive access to body modifications. Eager to share her experiences working with trans folk over the last ten years, Lauren explains that if the cross-dressing is “fully erotic” and thus distinct from the client’s gender role, then the client is not truly trans. However, Lauren suggests that trans people can experience autoerotic desire as long as it corresponds with their gender identity through testosterone:

there are some people who get aroused when they cross-dress, engage in the female role who are transsexual. But in my mind I feel like testosterone’s a really strong hormone and when you do anything taboo it can feel sexy or if you’re feeling really good about your body and how you appear you may feel sexy, and I think for people in a male body that might result in arousal or erection. And I don’t think that that’s necessarily something that’s gonna take someone off the transsexual list just cause they may feel aroused or, you know, a little turned on if they cross-dress sometimes.

It is evident that sexuality is relevant to practitioners’ determinations of who should gain access to body modifications in terms of how it impacts one’s gender identity. For Lauren, a MTF client could be authentically trans, despite her arousal from cross-dressing, due to an “inappropriate bath” of testosterone that triggers autoerotic desires. According to this logic, once the client receives the appropriate bath of “female” hormones, her autoerotic desires will diminish, and her female identity will remain, unlike a cross-dresser who will become more anxious with the inappropriate bath of “female” hormones. Even though Lauren granted access to hormones to someone who Don would have considered a cross-dresser, her decision to grant this access is grounded in a similar logic to Don’s since Lauren rejects autoerotic desire in general as a valid and core sexual identity that bodies ought to symbolically represent. And like Kathryn’s description of the client with internalized homophobia in the previous section, Lauren attributes the appropriate alignment between identities and bodies to nature, rather than social power.

Judy Diner offers an alternative ethic of body modification as her approach to treating cross-dressers is not predicated on the client’s gender identity at all—a difference possibly due do her unique background as a sex therapist. Judy’s practice has been dedicated to patients with gender variance since the early 1990s after she earned her doctorate in human sexuality. Like Don and Lauren, Judy distinguished cross-dressers from trans clients by the existence of an erotic charge. Despite this distinction, Judy provided cross-dressers access to hormone therapy:

Well it’s always men who want to have surgery but if they’re really honest with you they do not believe they’re really women. But they want to be a woman and they are erotically aroused by the thought of them being a woman. And these are the people who don’t often really meet the criteria. But I, and most of my colleagues, we pass them through because it’s something we don’t yet understand but we know that they’re unhappy … So, sometimes I will [approve] a low dose of hormones which may have a placebo effect, may make them feel better … There are people who … don’t believe that changing a body could make a person happy. They think it is in the mind, in the brain, which in fact it is. But if you can’t change the brain, I think the second best is to change the body and there are a lot of people quite happy on hormones, surgery, and making a life for themselves.

Here Judy appears to embrace a more “reflexive” (Connell, 1995) model of the body as inducing feelings that can have the power to change one’s state of mind. Even though they may not fit the GID criteria, Judy allows the materialization of resexed bodies for those who present with a transvestic fetish or autogynephilia because her understanding of the relationship between gender identity, sexed bodies and eroticism demonstrates that changing the body—which is more malleable than the brain—“may make them feel better.” Seeking body modifications for sexual pleasure—or to avoid living as a gay male as we saw in Kathryn’s narrative—is typically viewed by other practitioners as inappropriately and recklessly attempting to change one’s “core identity.” Judy’s reflexive ethic of body modification drastically differs from the majority of our practitioners, who maintain that transition is only suitable when it aligns core gender identities with wrongly sexed bodies. Judy admits that practitioners have little understanding about cross-dressing except that body modifications have the ability to bring the person happiness so she permits the materialization of particularly sexed bodies that other practitioners such as Nancy, Kathryn, Don and Lauren would not allow.

An ethic of body modification that gives primacy to the body’s capacity to symbolically represent core gender and sexual subjectivities precludes enacting certain erotic desires, thereby limiting the body to its semiotic function. Conversely, Judy’s reflexive ethic of body modification promotes a degree of agency to reshape intelligible sexual identities or enhance erotic desire, offering one avenue that subverts western gender and sexual ideologies at the same time that it perpetuates a model of corporal malleability. Each ethic of body modification, however, is a form of social power that facilitates the production of specific forms of material-semiotic agency, and thus the production of particular gender, sexual and somatic realities.

Conclusion

Clients’ requests for body modification to increase their pool of potential romantic partners, to maintain relationships with former significant others, to avoid the stigma of a gay identity, or for enhancing a sexual experience are commonly rejected by practitioners who claim that these motivations are too superficial to permanently alter one’s sexed body. By highlighting these cases, we do not intend to advocate open access to body modifications, nor do we regard cosmetic surgery as a preferred path to satisfying romantic and erotic desires. In both instances, the individual agency to choose body modifications must be analyzed in the context of normative power that compels social actors to work on their bodies. We wish to spotlight practitioners’ ethics of body modification that speak to the limits and possibilities for what sexed bodies are allowed to do in dominant western culture.

The symbolic weight dominant culture asks bodies to carry is clearly revealed in the case of autogynephilia; the majority of those who discussed these cases expressed hesitation to outright rejection of clients’ desire to modify their bodies for the purpose of enhancing a sexual experience, reasoning that these proclivities were not deeply rooted enough to justify permanent and invasive alterations of the body. In other words, bodies are made to carry out deep representation functions before practical pursuits, such as those that will enhance sexual pleasure—a logic Judy Diner exposes in her efforts to prioritize the client’s happiness in cases she characterizes as under-studied and misunderstood.

While the clients highlighted in this article ask to work on their bodies as if they are primarily agents of pleasure (both erotic and romantic), practitioners see these as superficial, and in some cases dangerous reasons to transition, because they understand the body in a fundamentally different way—as a somatic representation of gender and sexual selves. Even in a context where sexed bodies are viewed as malleable, their social significance is anchored to the function of representation; both in terms of anchoring a natural gender identity, and appropriately embracing a core and stable sexual identity. In each case, the ability to change the body is predicated on renouncing this social power to nature.

In this particular pseudo-scientific “entanglement of gender with sexuality” (Richardson, 2007) the body remains the malleable surface that anchors and represents innate and core gender and sexual identities. As Sedgwick notes, the practitioners we interviewed base their practice on distinguishing gender from sexuality in a way that “radically renaturalizes gender”; however, according to the level of practice, it does not, as Sedgwick predicted, “denaturalize sexual object choice” (1993: 73). Internalized homophobia is not a good reason to transition, according to practitioners, precisely because homosexuality is natural and should not be altered under social pressure. Similar to Bryant’s (2008) analysis of GIDC, practitioners thus encourage homosexuality, but unlike his results, ours demonstrate that “trans-positive” practitioners largely disagree that being gay requires gender conformity. Our findings regarding internalized homophobia indicate that both gender and sexual orientation are naturalized in practitioners’ discourse, while sexed bodies remain “radically denaturalized.”

To the extent that the integrity of “trans-positive” body modification is premised on improving one’s mental health, which is assumed to logically stem from congruence between the sexed body and gender identity, the agency of the resexed body remains primarily confined to doing the political work of representing allegedly stable gender and sexual identities. Anchoring transgender body modification to a stable, core identity functions to refute reparative therapy efforts to restore binary gender identities, and solidifies the importance of the counseling field in the process of transition. By refusing these clients access to hormone therapy and SRS, practitioners protect their view that only stable, core gender identities are legitimate grounds for body modifications at the same time as they rescue their “authentically trans” clients from the dehumanizing prospects of reparative therapy. Where does this process leave clients who seek SRS and hormone therapy, but do not claim to need these authorizations to symbolically represent their pre-established, core gender identity?

As more individuals seek alterations to their sexed bodies for reasons that cannot be reduced to gender identity, the transgender literature would benefit from work that theorizes sexuality as an independent yet interrelated element in the process of resexing bodies. This includes examining the transgender clinical context for entanglements of gender and sexuality that call for a more pragmatic and reflexive approach to the sexed body. What can we learn from understanding body modifications as reflexive practices that aim to produce identities, feelings, and relationships rather than simply represent pre-established selves? Such work might also bring us closer to understanding the double standard in sexed body modification that encourages cisgender people to make their bodies agents of sexual desire, but discourages the same motivation for those seeking transgender modifications. Cisgender individuals seek breast implants, circumcision and laser hair removal in order to feel sexy and to appeal to potential romantic partners, but clients like Nancy, Kathryn, Don and Lauren’s are prohibited from modifying their bodies in equally practical pursuits of love and sexual pleasure.

Footnotes

Acknowledgements

The authors would like to thank Bradley Forkner, Dana LaMonica and Leia Franchini for their expert research assistance.

Funding

The authors acknowledge Pacific University’s Elise Elliott Trust for funding this project.

Notes

Jaye Cee Whitehead is an Assistant Professor of Sociology at Pacific University. She is the author of The Nuptial Deal: Same-Sex Marriage and Neo-Liberal Governance (University of Chicago Press, 2011), an ethnography of the marriage equality movement in the USA.

Jennifer Thomas is a PhD candidate in the Department of Sociology and Anthropology at Simon Fraser University. Her previous work includes in-depth qualitative research on male body depilation and heteromasculinity.

References

Billings

Urban

(1982) The socio-medical construction of transsexuality: An interpretation and critique. Social Problems. 29(3): 266–282.

Blanchard

(1989) The classification and labeling of nonhomosexual gender dysphorias. Archives of Sexual Behavior. 18(4): 315–334.

Blanchard

(1991) Clinical observations and systematic studies of autogynephilia. Journal of Sex and Marital Therapy. 17(4): 235–251.

Braun

(2005) In search of (better) sexual pleasure: Female genital ‘cosmetic’ surgery. Sexualities. 8(4): 407–424.

Bryant

(2008) In defense of gay children? ‘Progay' homophobia and the production of homonormativity. Sexualities. 11(4): 445–475.

Butler

(1993) Bodies that Matter: On the Discursive Limits of ‘Sex’. London: Routledge.

Connell

(1995) Masculinities. Cambridge: Polity Press.

Delphy

(1984) Close to Home: A Materialist Analysis of Women’s Oppression. London: Hutchinson.

Delphy

(1993) Rethinking sex and gender. Women’s Studies International Forum. 16(1): 1–9.

10.

Dozier

(2005) Beards, breasts, and bodies: Doing sex in a gendered world. Gender and Society. 19(3): 297–316.

11.

Ekins

King

(2006) The Transgender Phenomenon. London: SAGE.

12.

Fausto-Sterling

(2000) Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books.

13.

Fujimura

(2006) Sex genes: A critical sociomaterial approach to the politics and molecular genetics of sex determination. Signs. 32(1): 49–82.

14.

Halperin

(1995) Saint Foucault: Towards a Gay Hagiography. New York: Oxford University Press.

15.

Haraway

(1991) Simians, Cyborgs and Women: The Reinvention of Nature. New York: Routledge.

16.

Harry Benjamin's International Gender Dysphoria Association (2001) Standards of Care for Gender Identity Disorders, Sixth version.

17.

Hausman

(1995) Changing Sex: Transsexualism, Technology and the Idea of Gender. Durham, NC: Duke University Press.

18.

Hester

(2004) Intersexes and the end of gender: Corporeal ethics and postgender bodies. Journal of Gender Studies. 13(3): 215–225.

19.

Hird

(2002) For a sociology of transsexualism. Sociology. 36(3): 577–595.

20.

Ingraham

(1994) The heterosexual imaginary: Feminist sociology and theories of gender. Sociological Theory. 12(2): 203–219.

21.

Ingraham

(2005) Thinking Straight. The Power, the Promise and the Paradox of Heterosexuality. New York: Routledge.

22.

Jackson

(1999) Heterosexuality in Question. London: SAGE.

23.

Jackson

(2005) Sexuality, heterosexuality and gender hierarchy: Getting our priorities straight. In: Ingraham

(ed.) Thinking Straight. The Power, the Promise and the Paradox of Heterosexuality. New York: Routledge, pp. 15–38.

24.

Kessler

McKenna

(1978) Gender: An Ethnomethological Approach. Chicago, IL: University of Chicago Press.

25.

Laqueur

(1990) Making Sex: Body and Gender from the Greeks to Freud. Cambridge, MA: Harvard University Press.

26.

Lev

(2009) The ten tasks of the mental health provider. International Journal of Transgenderism. 11(2): 74–99.

27.

MacKinnon

(1982) Feminism, Marxism, method and the state: An agenda for theory. Signs: Journal of Women in Culture and Society. 7(3): 515–544.

28.

Martin

(1998) Sexualities without genders and other queer utopias. In: Merck

Segal

Wright

(eds) Coming Out of Feminism?. Oxford: Blackwell, pp. 11–35.

29.

Meyerowitz

(2002) How Sex Changed: A History of Transsexuality in the United States. Cambridge, MA: Harvard University Press.

30.

Prosser

(1998) Second Skins: The Body Narratives of Transsexuality. New York: Columbia University Press.

31.

Richardson

(2007) Patterned fluidities: (Re)imagining the relationship between gender and sexuality. Sociology. 41(3): 457–474.

32.

Risman

(1982) The (mis)acquisition of gender identity among transsexuals. Qualitative Sociology. 5(4): 312–325.

33.

Rubin

(1975) The traffic in women: Notes on the ‘political economy' of sex. In: Reiter

(ed.) Toward an Anthropology of Women. New York: Monthly Review Press, pp. 157–210.

34.

Rubin

(1984) Thinking sex: Notes for a radical theory of the politics of sexuality. In: Vance

(ed.) Pleasure and Danger: Exploring Female Sexuality. London: Routledge, pp. 267–319.

35.

Rubin

(2003) Self-Made Men: Identity and Embodiment Among Transsexual Men. Nashville, TN: Vanderbilt University Press.

36.

Schilt

Westbrook

(2009) Doing gender, doing heteronormativity: ‘Gender normals,’ transgender people and the social maintenance of heterosexuality. Gender and Society. 23(4): 440–464.

37.

Schrock

Reid

Boyd

(2005) Transsexuals’ embodiment of womanhood. Gender and Society. 19(3): 317–335.

38.

Scott

(1999) Gender and the Politics of History. New York: Columbia University Press.

39.

Sedgwick

(1990) Epistemology of the Closet. Berkeley: University of California Press.

40.

Sedgwick

(1993) How to bring your kids up gay. In: Warner

(ed.) Fear of a Queer Planet. Minneapolis: University of Minnesota Press, pp. 69–81.

41.

Shilling

(1993) The Body and Social Theory. London: SAGE.

42.

Stone

(1991) The ‘Empire’ strikes back: A posttranssexual manifesto. In: Straub

Epstein

(eds) Body Guards: The Cultural Politics of Gender Ambiguity. New York: Routledge, pp. 280–304.

43.

Ward

(2008) Dude-Sex: White masculinities and ‘authentic’ heterosexuality among dudes who have sex with dudes. Sexualities. 11(4): 415–435.

44.

West

Zimmerman

(1987) Doing gender. Gender and Society. 2(2): 125–151.

45.

Wilton

(1996) Which one’s the man? The heterosexualisation of lesbian sex. In: Richardson

(ed.) Theorising Heterosexuality. Buckingham: Open University Press, pp. 125–142.

46.

Winters

(2005) Gender dissonance: Diagnostic reform and gender identity disorder for adults. Journal of Psychology and Human Sexuality. 17(3): 71–89.

47.

Wittig

(1981) One is not born a woman. Feminist Issues. 1(2): 47–54.

48.

Wittig

(1992) The Straight Mind and Other Essays. Boston, MA: Beacon Press and Hemel Hempstead: Harvester Wheatsheaf.