Gender, Sex and Tech: Continuing the Conversation
Episode 10: Interview with Jennifer Hites-Thomas
Transcripts by Ganesh Pillai
Jennifer Jill Fellows: Currently in Canada, as cis man can go from an initial surgical consultation to a genital enhancement surgery in about a week. By contrast, a trans person often has to go through a process that can take years before they can access gender confirmation surgery.
If you dig into this issue, as our guest for today has done, the reason for this disparity seems to hinge on society-wide beliefs regarding naturalness, authenticity, the place of technology with regards to the body, and also a lot of weird and some worrying beliefs about what it means to be a cis man.
Jill: Hello and welcome to another episode of Gender, Sex and Tech: Continuing the Conversation. I’m your host, Jennifer Jill Fellows. And today I’m joined by Dr. Jennifer Hites-Thomas.
Jill: Jennifer Hites-Thomas has a PhD in sociology from Simon Fraser University. Her scholarship examines gender, sex, and race, with a particular focus on the medical production of Cisitude, endosex bodies and whiteness. She has co-authored publications in Sexualities and The Journal of Gender Studies, analyzing how trans-friendly mental health professionals determine which patients will gain access to medical transition. In her recent research, she investigates how medical discourses, such as authenticity, operate within gender-confirming genital surgery for trans folk, juxtaposed with how they function within male enhancement for cis men. Her current project examines how medicine both defines the borders between intersex and endosex bodies, and constructs the so-called female body as natural. And today, she’s here to talk to me about gatekeeping and gender confirmation surgeries.
Jill: Hi Jennifer, welcome to the show.
Jennifer Hites-Thomas: Thank you for inviting me.
Jill: I want to take a moment, and I want to resist being sucked into this illusion that digital and physical space are separate. Digital space is physical space. It functions because of the servers and cables that occupy physical space connecting us over a very vast distances. As such, I want to be mindful that I am recording Gender, Sex and tech: Continuing the Conversation on the unceded territory of the Coast Salish people of Qiqéyt nation where I live, learn, play, and today, do my work. And where are you joining us from, Jennifer?
Jennifer: I am currently located on the traditional ancestral and settler-occupied territories of the confederated tribes of the Grand Ronde, and Siletz Indians, as well as the Kalapuya and Atfalati people’s. This land is now known as Forest Grove, Oregon and is the former site of the Forest Grove Indian training school, which was a residential school where at least 12 Indigenous children died from abuse and neglect from white settlers. Many more experience the harm from forced assimilation. And in our talk today, we will be discussing the gender and sex binary, which alongside settler-created racial classifications, was forcefully imposed on Indigenous peoples as part of the colonial nation building project of Canada and the US. So I hope listeners remain mindful that the binary is not a natural division of human bodies and behavior that exists across time and throughout cultures, and to instead ask themselves what systems, including colonialism, continue to be served by gender and sex binary.
Jill: So before we jump into talking about gender and sex binaries, which we will, can you tell us a little bit about your academic journey? For example, did you always want to be a sociologist?
Jennifer: Thank you for this question. I was first introduced to sociology in my first year of undergrad. And what I love about being a sociologist is I can be all the things I wanted to be when I was growing up. I can be a historian, mathematician, Gender and Sexuality expert, an activist. I can also be a teacher. So when I learned that there are scholars who study, for example, the sociology of blushing, I knew that sociology would enable me to examine all facets of human behavior, including those like blushing that seem biological or physiological, yet are entirely informed by social norms, cultural expectations, and historical context. And that’s when I knew I wanted to be a sociologist.
Jill: That’s really cool. I had no idea there was a sociology of blushing?
Jennifer: Right? As a sub-field, it seems so specific and physiological. And yet sociologists have a field day with that.
Jill: No that’s really neat. And this idea of kind of the, the wide lens that you get to have, or the wide number of opportunities that you have if you’re going to research as a sociologist. So you referenced, for example, history, but also looking at things that might be thought of as biological, of course there’s social aspects to those. I think that’s really neat. And in the context of that, this kind of wide topics of study that sociologists can have, what drew you specifically to an interest in gender and medicine.
Jennifer: I often tell my students that asking an academic why they research what they research can be one of the most personal questions one can ask. It’s a good question. I have many loved ones who are queer, trans, and intersex. And they defy many of the sexuality, gender, and sex categories that Western society deems are the only options. So from a young age, I was regularly questioning how we’ve structured so much of our world around these categories. And later I began to wonder how we could structure our world differently to make life more livable for more people. When I was 19 I read Suzanne Kessler’s article, “The Medical Construction of Gender and Anne Fausto-Sterling’s book, “Sexing the Body.” These two texts really radically transformed my understanding of the world. I saw how science and medicine are not beyond the reach of culture. To paraphrase Fausto-Sterling, “medicine and science use truths taken from our social relationships to structure, read, and interpret the natural.” So I wanted to know, and I continue to want to know, how our social relations inform science and medicine. And in turn, how that science and medicine reproduces and naturalizes oppressive social arrangements for LGBTQI people, for cis women, for disabled folks, for people of color. Because equipped with this knowledge, we can actually attempt to disrupt the violence enacted against historically oppressed communities.
Jill: And I think that point, this has come up a few times, in a few different episodes of the podcast as listeners will know, this idea that we have a cultural perception that science is neutral or objective. And there are various ways of trying to push back at that. And so one thing I take that your research is doing is pushing back at this idea that science somehow floats free of social norms when it comes to medicine, and particularly when it comes to influence that medical science and medical research can have on our thinking about gendered bodies and gender itself.
Jennifer: Absolutely. I think one of the benefits of a feminist of science perspective is it recognizes how even the things that seem to be so objective, so value-neutral are situated within a particular historical context, and even the questions that we think merit investigation are informed by social norms and expectations, and the situated positions of the scholars who were asking those questions. What they find valuable and the results that they’re looking for, even if they’re trying to be neutral, informs the kinds of research that they perform, or the knowledge that they produce.
Jill: Yeah, and the kind of research that doesn’t get done.
Jennifer: Absolutely, absolutely.
Jill: So in your chapter in the book, “Gender, Sex and Tech: An Intersectional Feminist Guide,” you interview a number of doctors, medical practitioners. Can you talk a little bit about this research? Like who was interviewed, and how or what research questions were you’re seeking to answer? Kind of paint us a picture of what this was like.
Jennifer: Absolutely. I began my research, my project, with the aim to understand what medical discourses do in the materialization of cis men’s bodies, which is a very academic way of saying, how does medicine as a cultural practice make some bodies possible while limiting other options for bodies. For example, how does medicine frame penis augmentation as acceptable, normal and enhancing the quote unquote, “natural body,” but inserting beads into the skin of the penis is constructed as unnatural, abnormal, and a racialized practice not acceptable in Canada or the US. Or as another example, how does medicine frame wanting a larger penis as a healthy desire, yet it frames wanting a smaller penis as pathological, and therefore does not permit people to shape their bodies in these ways. So how does medicine enable some formations of the body and not others? So from that orienting question, I recruited medical practitioners who perform penile and scrotal augmentation procedures. And my sample consists of 20 urologists, cosmetic and plastic surgeons, and doctors who formally trained in other specialties. We conducted interviews in person at their offices, over the phone, and via Skype. This was before the pandemic, so I had the opportunity to be in their medical practices, be in their offices, sometimes seeing the day-to-day interactions that they have with patients.
Jennifer: So during the recruitment process, I saw that a considerable number of male enhancement practitioners also advertise that they perform transition surgeries for trans folks. So I crafted a targeted interview question where I asked practitioners, why do transgender patients need to acquire approval letters for mental health professionals before they can gain access to surgeries, whereas your cisgender patients do not? And this question really stems from many of the observations made from within trans communities about the contradictory medical management of trans and cis patients. Specifically that a cis woman can get breast implants, or a cis man can get a phalloplasty at the age of 18 without two notes from a therapist, but a trans person must subject themselves to mental health evaluations before gaining access to appropriate healthcare under the current standards of care. So I wanted to explore this contradiction in my research, and this interview question that I posed recently, it provided the majority of the material I analyzed in my project. But my primary research question, the research question that I wanted to answer through the broader project, it shifted to understanding what medical discourses do in the materialization of both cis mens’ bodies compared to trans people’s bodies. And in my larger project that the article comes from, I argue that medical discourses such as authenticity render cis mens’ post-surgical bodies, and whiteness, as natural, while constructing post-surgical trans, and racially marked, bodies as unnatural. So as a results of these discourses, these discourses work to deny appropriate health care for trans people, yet are means of access for men who are seeking to enhance normative forms of embodiment. And the last thing that I wanted to state was that this research developed as an act of solidarity with trans communities. I should note that while I’m an expert in my own research ,and I am knowledgeable of trans studies literature, as a cis woman, I am not an expert in trans lives. Trans people are experts in trans lives. And cis researchers need to take seriously Jacob Hale’s rules for non-trans people researching trans issues, particularly, to ask what researching trans issues reveals about themselves, particularly what it reveals about cisitude. And so I hope that my research begins to contribute to the emerging field of critical cis studies, and supports the work of trans scholars and activists who are advocating for change to the medical management of transition care, and that they have been advocating for these changes for decades.
Jill: Okay. There’s so much there and it’s so cool. So I’m going to back up and kind of look at this research project as a whole. So you started out with this project not necessarily looking to discuss the barriers or the gatekeeping that many trans patients of these practitioners that you were interviewing faced, but more to look at the things that are allowable, or expected, with regards to cis men’s bodies. So you talked about, for example, penis augmentation being something that is normatively understood as something that cis men want. But the idea of perhaps wanting a smaller penis is not something that the medical community necessarily recognizes an authentic desire. So you already have this kind of narrative of authenticity, or what’s normal or natural, kind of appearing in your research. And then we add on this question about why is this gatekeeping present for trans folk who are trying to access gender confirmation surgery. And I just find this really, really interesting because it seems to me to kind of go back to what we were talking about earlier, that you started out kind of examining the ways in which science in general claims to be objective, and isn’t. And so here we have another kind of claim that certain desires are understood as being authentic, or natural. And others, either you just can’t do it at all, there is no medical technology that lets you do this, or it’s viewed as non-normative, or it’s viewed as something that needs to be, that’s trepidatious, that needs to be gatekept and approached with caution. And I find that really interesting, that technology of discourse coming together with the medical technology.
Jennifer: What’s interesting on that level is that there are technologies, in the typical notion and the ways in which we define technology, to reduce the size of the penis. It exists, and it has been done before and has been performed before. But practitioners refuse to actually conduct that surgery unless there’s a congenital disorder that’s recognized within the medical community.
Jennifer: So folks who have, you know, there’s a website called large penis support group for folks who feel as though that their penis is too large and they want to have it reduced in size. They’re barred access from those technologies despite them existing. So you’re right in identifying how what is natural and normal versus pathological existed in the background of my research from the very beginning, but then sort of transformed once I asked this question of practitioners comparing how trans folks are kept in relationship to how cis folks gain access to genital surgeries.
Jill: So we’ve already kind of highlighted that your chapter deals with medical technology, and specifically talk about genital augmentation surgery and gender confirmation surgeries. Can you talk a bit about both of these surgeries for people who may be unfamiliar about what this is?
Jennifer: Yeah, absolutely. My participants, the physicians, the medical practitioners, perform a range of gender confirmation surgeries elected by some trans people. They don’t perform all potential gender confirmation surgeries. But they do perform vaginoplasty and phalloplasty procedures that constructs, or reconstructs, a vagina or penis. For cis men, they also perform male enhancement procedures. For example, there are penile and testicular implants made of silicone, fat that comes from patients’ own bodies that can be injected around the erectile tissue of the penis. This is intended to increase penile girth. Fillers like hyaluronic acid and polymethyl methacrylate can also be injected to add girth. Suspensory ligament release divides the ligaments that keep a portion of the penis anchored inside the body. And this procedure allows the internal portion of the penis to extend outward from the body to add length to a flaccid penis. There are many, many more procedures. But for the sake of brevity, I’ll limit it to those ones. But each practitioner made different claims about the success of their respective procedures, and how many centimeters in penile girth and length could, could be gained.
Jennifer: I should note however, that my conceptualization of medical technology extends beyond silicone implants, liposuction machines, scalpels, and other typical notions of technology. Technologies are also the forms of knowledge and discourses that justify, or prohibit, shaping the body in particular ways. For example, authenticity discourse, where practitioners suggest that trans folks are confused about their gender and are actually just cis, whereas cis men’s anatomy confirms their gender as authentic according to practitioners, these discourses are a technology in and of themselves, that enables bodies to be shaped and particular ways.
Jill: Yeah, I was just going to ask about that because one thing I think is really cool about your chapter in the book is that we have this very physical medical technology. And I think many people, even if you aren’t necessarily familiar with what’s involved with gender confirmation surgeries, you would know that some kind of technology is involved, and it would be recognized as a technology. But the other technology that you look at in this chapter is this technology of discourse, and particularly in this case, discourse of authenticity. And technologies of discourse, I mean, we kind of know about them and in academia, but I don’t know if language and discourse is as readily recognized in popular imagination as a technology.
Jennifer: Yeah, I think that’s where somatechnics as a particular lens to analyze ways in which we intervene upon the body is really useful in that respect.
Jill: So can you tell us a little bit about what somatechnics is?
Jennifer: Yeah, I am thrilled to actually share this lens with broader audience. Somatechnics is a theoretical and analytical tradition that originally arose out of a body modification conference that was hosted in Australia in 2005. But to back up just a little bit, and provide some context, in dominant Western culture, the body and technology are typically regarded as separate. But a somatechnics lens troubles this separation between the body, the soma, and technology, techne. All bodies are formed through technologies, according to this lens, not only those bodies that carry the most visible traces of modification. And just to provide an example, grooming practices like body hair removal, or corrective devices like braces that reposition our bones, as well as eating habits, all shape our bodies. And we take these somatechnologies up in particular ways that are related to gender, race, socioeconomic status, age, etc.
Jill: So this reminds me of something you said earlier, where you talked about, for example, penis enhancement being a use of technology that’s seen as augmenting a natural or authentic body. So we can see somatechnics I think working kind of there, that the, the technic part is being applied to something that has been classified or normalized as somehow authentic and natural. So then you said adding beads was not considered augmentation of a natural body. And so we can see automatically here that there’s some discourse work being done in terms of what kind of technological interventions are seen as appropriate, versus what kind of technological interventions aren’t. Is that right?
Jennifer: Yeah, and I think it really hinges on this understanding of what the natural body is. And, or one of the claims that I make in the article is that what is considered natural is often reduced to how cisitude is considered natural and normal. And so putting beads up and down the shaft of the penis may not necessarily relate to this cisitude, it may relate more to racialized practices associated with the body. So we can see how both gender and race can intersect in this dense nexus point of genitals, to render some bodily interventions as natural and other bodily interventions as unnatural.
Jill: So some uses of technology are naturalized and accepted and others aren’t. And in the case of beads, I think it sounds quite plausible that it’s gender and race. But you’ve also now, I think at least twice, talked about cisitude. So can you tell us a little bit more about that concept?
Jennifer: About what cisitude refers to you?
Jennifer: Yeah. Put very simply, cisitude refers to the nature of being cis or similarly transitude refers to being trans.
Jill:So is there something here when it comes to cisitude, not just about the nature of being cis, that is having your gender identity be the same as the gender assigned at birth, but also this idea, it seems like perhaps, when we’re looking at how this plays out with regards to medical technology and the determination of what is authentic, that we’re also getting this kind of idea that being cis is somehow viewed as natural. And I think you talked about that with regards to the proof of the body. Cis men are seen as augmenting what they quote unquote “already have.” And so there’s this way in which the sexed body is supposed to provide authentic proof for the gender identity in this kind of technology of discourse of authenticity.
Jennifer: I think I see what you’re saying where, according to practitioners, their theory of gender acquisition is that gender naturally emanates from the sexed body. And so if one is assigned male at birth, then they should naturally be a cis man. Is that what you’re getting at?
Jill: Yeah, I think so. Is that also part of cistitude or am I reading too much into it?
Jennifer: So I think what you’re getting at more is cis normativity, the assumption that being cisgender is natural and normal, whereas cisitude as simply being cisgender.
Jill: Okay. Those are good divisions to have, I think, as we work through the material that you’ve covered in your chapter.
Jennifer: It is concept dense, so it’s good to operationalize all of the concepts we’re using.
Jill: So we have somatechnics, this is the idea to trouble the division that we usually draw between the natural body versus technology, that this division doesn’t really exist. The body is always already being affected by technologies, whether it’s by cooking food, whether it’s by surgeries, what have you. We’re already being affected.
Jennifer: Yes. And I’d like to provide one last example because this might help elucidate some of the sometechnics as a perspective. This example comes from Dr. Travers’ research for their book, “The Trans Generation,” where a gender-nonconforming kiddo was so harassed at school when using the restroom that she would hold her pee all day long to avoid that harassment. And she held her urine so much that the shape of her bladder permanently changed, causing her to have issues urinating for the rest of her life. And so I consider that form of gender harassment a social technology of cis normativity, right? This idea that being cisgender is natural and normal that caused such intense fear, it actually shaped her internal organs. In other words, the ways in which we’ve organized our society around binary categories, including how we’ve organized our infrastructure to go to the bathroom, and the gender-policing that stems from that binary, materializes in her internal organs. So our bodies are not these natural versus purposefully modified corruptions of nature, but instead, all bodies are formed through socially and historically specific technologies.
Jill: That is deeply sad. I think what’s really helpful about it for me is that you can clearly see here, as you said, physical space, the technologies of physical space in terms of how we have designed and built public restrooms to reproduce a gender binary in most cases, we’re starting to see this change, but it’s, it’s not common. In addition, we have this technology of discourse, right? So the way in which people are policed or shamed, or made to feel uncomfortable, bullied, harassed, and in some cases, assaulted, in order to prevent people from accessing these spaces, and how that actually shapes the physical body.
Jennifer: Yes, absolutely. It takes into consideration the ways in which these social categories organize our institutions, our physical spaces, and the ways we interact with each other, and how all of that, like you said, shapes the human body.
Jill: So now that we have kind of this idea of somatechnics, we have this idea of the physical body, not as something independent of technology, some kind of given natural body, but as a body that is always already interacting with a variety of technologies, technologies of discourse, physical technologies, digital technologies, what have you, we also have understandings of cisitude and cis normativity. Can we return to the research that you did, and talk about what’s involved in a cis patient having access to genital augmentation surgery, and what’s involved in a trans patient having access to gender confirmation surgery?
Jennifer: Based on my interviews cis men schedule a consultation with a male enhancement practitioner. And during this appointment, practitioners asked cis men a series of questions such as what their medical history is, what their desired outcome for the surgery looks like, if they’ve had surgeries in the past, especially if they’re dissatisfied with the outcomes. Practitioners told me that they’re often trying to screen out patients who have unrealistic expectations for the procedure outcome, or those who may have body dysmorphia, patients who pose a medical malpractice risk, as well as those who are likely to threaten or aggressively act towards practitioners and staff, which was a common experience amongst most of my participants.
Jennifer: Some practitioners offer cis men patients access to male enhancement within that same day of that first consultation.
JHT: Most would wait about a week or two after the initial consultation, go through the screening and consent process one more time, and then open the gate to male enhancement technologies. Patients pay out of pocket for these procedures, except in rare cases when they have insurance that recognizes them as having a congenital disorder. And for patients who have unrealistic expectations, or body dysmorphia, practitioners would often refer them to other doctors who may be more willing to take the risk of performing a procedure for them. And only a few practitioners said that they would refer patients to see a mental health professional, and usually only when they displayed signs of body dysmorphia.
Jill: Wow. So in the case of cis patients, and in this particular context, cis men, what we’re seeing is that from the initial interview to actually getting the surgery, in many cases it’s about a week.
Jennifer: The time is very condensed, yes.
Jill: Okay. And what their screening for then is to make sure that the patient’s expectations of what’s going to happen as a result of the surgery are realistic. And I assume, like also I think you mentioned this briefly, any kind of medical contra indications to surgery as well?
Jennifer: Yes. And I would say those are the primary reasons for screening patients. Secondary reasons would be more in terms of psychological distress that the patient might be experiencing
Jill: And fears for the medical staff as well in terms of the patient getting aggressive is something you also mentioned, right?
Jennifer: Yes. I had some practitioners really intense stories about former patients, or patients who were denied care, who threatened them, who came to their place of work armed with weapons, and all of the ways in which they had to navigate safety concerns of their patients who they framed as really, really unstable.
Jill: Would that get a referral to a mental health practitioner?
Jennifer: Only in rare cases. I found that a lot of practitioners would say, in response to that question, “well, even if I referred them, I can guarantee that they wouldn’t go. So what is the purpose of trying to refer them to mental health support?”
Jill: Okay, wow, So how are things different in terms of trans patients for these practitioners?
Jennifer: It contrasts quite sharply. Before trans folks can undergo genital surgery under the current standards of care, they must obtain two letters from qualified mental health professionals.
Jill: So before they’re even screened by the people you were interviewing, is that right?
Jennifer: Absolutely, yes. So before they can even have that initial consultation with a surgeon or medical practitioner, they must be seen by qualified mental health professionals. And acquiring professional letters in support of medical transition often requires trans people to prove to largely cisgender medical gatekeepers that their gender is authentic, and that’s where authenticity really comes in here. Trans patients are expected to demonstrate that they’re not just going through a phase, that they’re not going to regret transitioning. Trans people who want genital surgery in Canada and the US commonly have to wait years to secure these letters, all while paying mental health professionals for mandated therapy, often out of pocket. And gender confirmation surgeries are also paid out of pocket in most cases.
Jill: Wow. So what we have here, then, is that a cis male patients going to see one of the practitioners that you interviewed could be in and out in a matter of a week or two. And a trans man patient going to see these practitioners, first of all, wouldn’t even see them for the first year or two. This is a lot longer and a lot more involved process is what I’m hearing.
Jennifer: Yes, absolutely. And this is despite how both of these procedures act on similar parts of the body, using overlapping medical techniques and technologies, especially since a lot of the practitioners who perform male enhancements also perform gender confirmation surgeries. So similar medical knowledges are involved, and similar outcomes are expected from these kinds of procedures. And yet they’re gatekept in fundamentally different ways.
Jill: So to return to some of the lenses that we have, in terms of the medical technology in place, it’s very similar. The medical procedures and medical technology and medical know-how that’s used for cis patients, and for trans patients, is very similar here. So it’s the technology of discourse that’s quite different, isn’t it?
Jennifer: I want to make sure that I’m clear that the procedures, for example, to perform a phalloplasty on a cis man versus a trans person is not identical.
Jennifer: You know those, those are fundamentally different kinds of procedures. But the medical knowledge that goes into urogenital surgeries are quite similar.
Jill: Okay. So it is the discourse technology that is radically different. Is that right?
Jennifer: Yes, absolutely.
Jill: And when we’re talking about the discourse of technology, we’ve already kind of mentioned the role of the word and the concept of natural, but I was really struck, in reading your chapter, by how much of the gatekeeping that you speak of really relies on this idea of natural. So at one point in the chapter you say, and I’m quoting from you, “again, the materialization of cis bodies, through male enhancement technologies, is rendered as acceptable ‘improvement’ to a ‘natural’ body. In contrast, transition surgeries mark trans bodies as unnatural constructions.” And I was hoping you could talk about this language of naturalness, when applied to cis bodies, and unnatural constructions with regards to trans bodies.
Jennifer: I think to start, some background information about the context in which these surgeries emerge is important. So to start, this dichotomy between the natural and unnatural body is situated within a broader cultural view of technology. Technologies are proliferating in almost every field, increasingly gaining access to the body. I’m thinking about fitness and sleep trackers. I’ve seen sex toys connected to cell phones that enable self-administered oral sex,
Jennifer: Implantable art technologies, powered by energy from our blood, from our bodies. There’s so many technologies proliferating everywhere, yet, in Canada and the US, despite our consumption of these technologies, we culturally value the unmediated body, exempt from social interventions. This is reflected in one of the most common responses that I received from colleagues, friends, even strangers. After they learned about the substance of my work, they were surprised. There was uncomfortable laughter and disgust, there was disgust from the quote, unquote, “unnaturalness” of genital surgery. And these reactions I came to recognize are largely predicated on the broad assumption that body should be, let alone can be, natural and free from technological and social materialization. In my chapter, I quote trans historian Jules Gill Peterson who says, “the ontological separation of technics and living beings underwrites the notion of an integral body, according to which incorporation of technology is a fall from the original wholeness of birth.” So there really are these dominant bodily imaginaries in the contemporary West that assume and value the existence of this natural body. However, not all bodies that undergo surgery are regarded as constructed. To quote to Trish Garner from their work “Stitching up the Natural,” they say, “it is important to emphasize that the attribution of construction is not strictly associated with surgical intervention. Some bodies pass through surgery unscathed. Rather, the accusation of construction is a hierarchical judgment used to perpetuate injustice and violence in the name of the natural body.” So in terms of my own project, cis men’s bodies pass through surgery unscathed.
Jennifer: They’re still considered natural despite surgical intervention, because of the ways in which cistitue is naturalized. Practitioners’ theory of gender acquisition really rests on the assumption that one’s gender naturally emerges from one’s sexed body assigned at birth. So surgeries that maintain or augment a cultural alignment between one’s sex assigned at birth, and gender, these are not considered unnatural interventions into the body precisely because cisitude is considered natural and normal. Yet trans bodies are rendered unnatural because transition technologies are constructed as harming the nature of gender and sex congruence. In other words, technologies that defy cis normativity are regarded as constructing an unnatural body. And labeling post-surgical trans bodies as unnatural really functions to legitimate the injustice and violence enacted against trans communities. Right, like claiming that post-surgical trans bodies are unnatural, legitimates the gatekeeping of transition surgeries, the gatekeeping of appropriate medical care.
Jill: I really like something that you said in this answer, that I just wanted to tease out. And it’s this idea that natural body is assumed. Because it has to be, right, especially given what you’ve already told us about the ways in which technologies of discourse, physical tech, medical tech, digital tech, tracking apps, right, tons of my friends wear FitBits, for example, all the ways in which the body is already interacting with, and shaped by technology, and the technology has shaped by the body. FitBits have to fit on us. And so there is this interrelation of technology and body, and thinking that we can have kind of a resting, natural body that os just a given, that can only exist as an assumption. And now that it’s an assumption, and we recognize it as an assumption, we can really dig into what the natural body is assumed to be. And here, I take it, is where we find a whole bunch of other very problematic assumptions. And in this case, we’re really narrowing in on the assumption that the natural body is cis, so this cis normative assumption that is working in the creation of this idealized image of a natural body, and that that facilitates this discourse of what normal and natural is, facilitates cis men moving through these surgeries in about a week, where trans men can’t. Is that right?
Jennifer: Yes. So despite having similar medical knowledges, overlapping medical techniques from the same kinds of practitioners, the thing that is slowing trans folks down is the assumption that cisitude is natural, and therefore creates a natural body, whereas for cis folks, if this cisitude is natural, there’s no need to slow that process down. And so you can open the gate to male enhancement procedures without the same gatekeeping practices of requiring mental health evaluations.
Jill: Okay. So related, and I think it’s very closely related, related to this idea of the category of natural, we have the technology of discourse of authenticity. So you point out in your chapter that gatekeeping relies quite heavily on this idea of authenticity. And something you’ve already alluded to in your answers to earlier questions, this fear that trans people are not who they say they are. So there’s this idea that trans patients are not authentically who and what they say they are. And I was really struck, in reading your chapter, by this quotation from one of the people you interviewed, Dr. Fray who said, so I’m quoting from Dr. Fray, “there’s intended discrimination by the medical and insurance establishment against adults who feel trapped in their own gender, for the purpose of trying to weed out the real ones and the ones who are in flux. My guess is that there was one surgery done out of a hundred that resulted in reassigning someone who either was for the wrong reasons, or somebody who recanted their intent, and maybe there was a lawsuit.” So that’s the end of the quote. And I’m wondering if you could speak more about this intended discrimination, this intentional discrimination, and the role authenticity plays here.
Jennifer: Right. So because medical authorities invest in the idea that the sexed body provides that material truth of gender identity, then transitude defies the theory of gender acquisition that runs behind the majority of medical practice in the United States and Canada. Cisgender authorities are expressing these wider social anxieties that people who claim to be trans are not authentically trans. Anxieties about quote unquote, “fake” trans people are compounded by a perceived threat to a physician’s medical practice if the patient later decides they’re not trans, and seeks to hold their doctors accountable for permanent bodily interventions. This positions trans people to have to prove that they’re authentically trans in ways that particularly align with an established array of criteria that’s often defined by the cis authorities on gender, before they can access any kind of medical care. As we’re seeing with the current revisions of the standards of care, cisgender authorities tend to have more license to decide what the standards will be for trans populations. If trans folks do not live up to these expectations, cis authorities gatekeep their access under the false assumption that most people who claim to be trans are likely confused cis people, who will inevitably regret transitioning, especially permanent forms of medical transition like genital surgery. And as many from within the trans community have pointed out, under this approach, trans healthcare prioritizes protecting cis people from accidentally transitioning,
Jennifer: Rather than providing appropriate, officially-recognized care to all trans patients, right? All trans patients are losing out because of this fear that you need to protect a few cis people who may be confused.
Jill: Yeah. So one thing I think is really interesting here is that Dr. Fray says “my guess is that there was one surgery done out of a hundred.” So this isn’t knowledge that this person is claiming. He’s saying this maybe happened. So that means we’re protecting the one cis person out of a hundred. Maybe. The guess is we’re protecting the one cis person out of a hundred. And that’s, that’s astonishing to me.
Jennifer: And yet it’s the foundation of medical practice and in a lot of countries, not just Canada and the US, right? And so by using this comparative method, by comparing trans medical care, and the management of male enhancement, my work really demonstrates that certainty in the authenticity of cis mens’ identities is not required. Practitioners assume cis mens’ identities are authentic based on patient desire and the anatomy of the sexed body. In other words, the sexed body as a supposed origin of gender identity was evidence enough that cis men were eligible for male enhancement. And doctors assume that cis patients’ bodies and identities are stable despite patients’ desires to do something about a quote unquote “issue” with their bodies, like perceiving their penises to be small. So as a result of those assumptions, practitioners do not explicitly ask men about their gender, you know if they’re really men, much less engage in any kind of formal process of seeing a mental health professional to decide if male enhancement will fulfill their gender desires, or if these patients are stable, which as I spoke to previously, a lot of these patients have demonstrated that if they’re willing to threaten or act aggressively towards practitioners, that there is a question mark hovering over whether or not these patients are stable. And all of this is despite the possibility that cis men may also pursue post operative litigation for semi-permanent to permanent male enhancements that, according to the Primary Urological Association in the states, the American Urological Association, has found that male enhancements are not safe or efficacious.
Jill: Oh my goodness.
Jennifer: These procedures are being performed.
Jill: Oh my goodness.
Jennifer: And there’s a nearly unfettered access to them, even though they’re not safe or efficacious. These men may experience a mental health struggles. And they could also pursue postoperative litigation.
Jill: Right, and so the doctors don’t seem to be as concerned about protecting themselves from post-operative litigation from their cis patients, or protecting their cis patients from accidentally reshaping their body as one with a larger penis that they end up regretting later on. We’re interested, in other words, it sounds like, and I say we, but I mean, kind of, this discourse is interested in protecting cis patients from accidentally transitioning, but it’s not interested in protecting trans patients, or in protecting cis patients from making other choices that they may regret.
Jennifer: Yes. So it really hinges along this border between transitude and cisitude, less so in terms of actually causing harm to the body, or regretting permanent changes to the body. It’s less about interventions into bodies generally, and more about passing that border between cisitude and transitude.
Jill: This goes back to this issue of how we are constructing the discourse of authenticity, that the authentic identity of cis patients is being assumed for, again, no real good reason except cis normativity is a very widespread Western cultural phenomenon, I suppose.
Jennifer: There’s a lot of heavy investment into thinking about the sexed body assigned at birth as where gender comes from. And that’s where it really hinges upon.
Jill: And particularly, and this is something related to you right at the start, this idea of in Western North American culture, the gender binary, the idea that there are only two genders, and that they are tied to the body as the sex assigned at birth.
Jennifer: Yes, which is something that is very specific to Western, colonial and white understandings of the body. We can see how whiteness shapes, and colonialism shapes, the gender and sex binary as it is. And yet it doesn’t applying to so many other cultures throughout the world, throughout time and space, or even to the current time-frame where binary expectations for bodies are squarely situated within whiteness, and racialized bodies are commonly seen, within medicine and beyond, as violating the expectations of binary bodies. We see this in the Olympics, preventing folks like Caster Semenya from competing. We see this in all facets of how colonial notions of the gender and sex binary are being reproduced in culture.
Jill: Thank you for adding that. I know it goes a little bit beyond the research we’re discussing today, but I think it’s helpful to situate what’s happening in terms of discourse regarding authenticity, specifically with regards to the surgeries in this kind of wider context of how authenticity is constructed along all these other lines. So, constructed in terms of cis normativity, heteronormativity, constructed along racial lines, all this kind of stuff is coming together to give a very constructed picture of what an authentic and natural body is assumed to be in this specific cultural context.
Jennifer: Yes, and narrowly defined by which for majority of bodies don’t even fit into it.
Jill: So we’ve talked a little bit about how this, this quote from Dr. Frey, that the fear, or the motivation, behind all the gatekeeping with regards to trans patients is this idea that there might be a lawsuit, or that they might be patients who are in flux and not genuinely trans. So can you talk a little bit about, from your research, how likely statistically it is that a trans patient may come to regret the surgery they receive, versus something you’ve already kind of alluded to, whether or not a cis patient may come to regret the surgery that they receive.
Jennifer: Yeah. So questions about trans regret are really common and in many ways they reproduce this association between trans people and regret. And as scholars like A. Lawrence have found, conducting research to measure predictors of trans peoples’ post-op regret is not warranted on the basis that trans folks do in fact regret their surgeries in any way that should meaningfully impact their care as a class of people. They don’t. But rather that this research on regret is only meaningful in so far as people expect it to be meaningful. And those expectations impact the lives of trans folks through the institutions that are responsible for managing their care. In other words, concern about trans regret reinforces how regret continues to exercise discursive power in the lives of trans folks.
Jill: So it comes back to this issue of if there’s regret then this isn’t authentic?
Jennifer: Yeah. So if someone wants to detransition, for example, the assumption is that they weren’t ever authentically trans to begin with. Now a lot of scholars have pushed back against that kind of idea. One person to look into is Florence Ashley’s work about how detransitioners don’t represent how we need to restrict trans folks from transitioning, but rather we need to have more open discussions around gender. Rather than trying to dissuade people from pursuing transition, we need to open up that as a possibility, so folks don’t double down on their transitude, only to later find out that that wasn’t the best choice for them. So for folks who want to find out more, I highly recommend checking out Florence Ashley’s work.
Jill: I’ll link it in the show notes.
Jennifer: Excellent, Great. To answer your question, however, your original question, because regret is defined as a real problem in the lives of trans folks, then it’s real in its consequences, right? So according to clinical research conducted over the last 60 years, the incidents of trans people regarding transition surgery is about one to 1 to 1.5 percent, depending on the study. So it’s incredibly rare, incredibly rare. And commonly, the few people who regret surgery are regretful not because they’re actually cisgender and made a mistake transitioning, but rather because they don’t have the social support, and are navigating a violently trans-oppressive society.
Jill: So it’s kind of the experience of going through the gatekeeping? Am I understanding that correctly?
Jennifer: Going through the gatekeeping, but even after going through gatekeeping, securing transition technologies, they are existing in a world that is violently trans-oppressive, and that’s difficult to navigate, especially if you don’t have other forms of social support beyond sort of institutional, society-wide support. And so in those ways, folks can experience regret. But again, it’s incredibly, incredibly rare.
Jill: And do you know the likelihood that a cis patient would regret having genital augmentation surgery?
Jennifer: Yeah, cis patients are much more likely to regret genital surgery. There have been multiple studies conducted, on and various forms of genital surgeries that cis people can elect, both cosmetic, and more related to a condition that they have, but they found that researchers found that cis patients are up to 23 times more likely to regret genital surgeries. So just by comparing these two figures alone, using the comparative method that I employed, we can see that the concern about trans people regretting genital surgery is not based on high incidences of confused cis people regretting transition, right, but rather that the medical concern that trans people regret transition stems from the cis normative assumption again, that being cisgender is natural and normal. So being trans must be a phase of confusion that people will inevitably regret if allowed to undergo medical transition.
Jill: Right, so it’s upholding this cis normative construction of the authentic body again.
Jennifer: Again and again.
Jill: Wow. And it also seems like the, I don’t want to call it the dismissal, but the lack of worry regarding possible regrets of cis patients, is another way of kind of upholding cis normative authenticity. Well, this is authentically their body, and authentically their desire, and so we’re going to do it.
Jennifer: Yeah, so regret is socially distanced from the cis body, where it makes it so that it doesn’t even make sense to ask about cis regret, especially in the case of something like male enhancement. Why would a cis man ever regret making his penis bigger? It doesn’t make sense according to the current, the current logic.
Jill: And there’s also a bunch of stuff about gender binary and gender roles and assumptions about masculinities that seem to be wrapped up in that as well.
Jennifer: Yes, and assumptions that are never really explored with patients themselves.
Jill: So since we brought up the gender binary in a couple of places here, can we talk about intersex patients for a moment? Can you tell our listeners what an intersex person is, and how you found that your interviewees deal with intersex patients?
Jennifer: Intersex refers to bodies that display a range of sex traits that do not align according to cultural expectations for binary sexed bodies. You know, there are many ways in which one can be intersex, lots of different presentations of intersex bodies. As just one example, a person who is both culturally and medically assigned as intersex could have XY chromosomes, commonly thought to be quote unquote, “male” chromosomes. But their body could also be resistant to androgens, which are constructed as male hormones, and have a vagina as well as hair, fat, and muscle distribution that is culturally interpreted as female. Many intersex infants are subject to nonconsensual, and medically unnecessary, surgeries called normalizing surgeries, that the intersex community has been actively fighting to abolish because they cause such irreparable harm. Listeners can find out more about intersex issues and activism, if they’re interested, at Interactadvocates.org.
Jill: I’ll put that in the show notes too.
Jennifer: Thank you. I appreciate it. More resources for folks.
Jill: Yeah. I also find it really interesting that literally the discourse, like when you were talking about these surgeries that are done non-consensually on infants, you used the phrase that they’re normalizing surgeries. So we can see this technology of discourse right there, right? This idea that people speak of these surgeries that well, they’re normalizing them. They’re putting them in one of the two binary genders.
Jennifer: Right, which automatically positions being intersex as abnormal.
Jennifer: And while a lot of folks say that there’s only 2% of the population is intersex, which is about the same amount of people who exist in the world with red hair, not to say that people who are redhead are intersex, but just that, that number is comparable, and yet, a lot of feminist biologists would claim that all bodies are intersex in varying chemical, genetic, physiological, and morphological ways, since not all of these traits align within one body according to cultural expectations. So they’re calling these normalizing surgeries to force bodies into a binary, and yet, what I’m trying to claim here, and feminist biologists’ claim, is that what is more typical, what is more common, is for sexed bodies to not fit within this binary, whether they’re medically recognized as intersex or not.
Jill: Right, so the sex binary that we often hear people say, “Well, it’s just science. You like, you have an XX or you have an XY chromosome, and it’s just science.” And first of all, those are not the only chromosomal options that exist.
Jennifer: Of course.
Jill: But also when it comes to the sexed body, there’s a lot of different features that are used to make a judgment regarding which binary sex box a body gets placed into, if we’re going with the binary, right? So theres, the chromosomes, there’s hormones, there’s primary and secondary sex characteristics. There’s there’s a lot going on in terms of this determination. It isn’t just self-evident, existing naturally in the world. It is another construction.
Jennifer: Absolutely. One of the examples that I provide for my students is if an infant is born with what’s called tumescent tissue, tissue that can engorged with blood and become erect, that can be a clitoris, that can be a penis, that can be something that’s not a clitoris or a penis. But I asked my students, at what point do we decide something is a small penis, or something is a large clitoris. You know, where’s that dividing line? And anywhere that we put that dividing line is a social determination of our bodies, not what nature is communicating about the body itself.
Jill: Right, but then we use the technology of discourse of authenticity to disguise that this is social and not natural.
Jennifer: Yeah, and that’s what naturalization as a concept really refers to – the process by which these things that are socially determined are thought of as natural and normal.
Jill: So how did your interviewees deal, did they deal with intersex patients? And if so, how?
Jennifer: Yeah, So since my participants consisted that the sexed body is what determines one’s gender, I also was really interested in how they handled intersex patients. So most practitioners treated intersex men for what they call a micropenis, and testicular feminization. These are the medical terms for it. They defended the authenticity of these patients by asserting that they are quote unquote, “really male” despite an intersex diagnosis. And this is a common practice within the medical management of intersex bodies that’s observed by gender scholars like Georgiann Davis, Suzanne Kessler, that assigning someone as a really male, stems from presuming a patient’s gender to construct their sexed bodies into a binary. And we can see from these cases that the sexed body is not what determines gender as practitioners claim. Instead, gender is used to determine sex. Or as I wrote in the, in the paper, in the article, “gender is not the effect of the sexed body. Rather, it is the cause.”
Jill: That is such a great quote. Yeah, so we have this narrative that’s saying the sexed body is natural, that sex binary is natural. And now we’re seeing that the gender of a patient is used to determine the sex body in kind of a reversal of what these doctors were claiming to be doing.
Jennifer: Yeah, it really flips things on its head.
Jill: I think that’s so interesting. But again, the discourse of authenticity is there to reach for to kind of hide that this reversal has happened?
Jennifer: Yes. Yeah. And so my research demonstrates that practitioners locate patients’ intersex conditions in parts, like gonads and the penis of this larger whole, the male body. In many ways that has been seen in other people’s work, like Trish Garner’s work, who I quote in the paper that I wrote, where they looked at gynecomastia surgery, so quote unquote, “excessive” breast tissue in cisgender men, compared to trans top surgeries, chest surgeries. They also found that medical texts tend to look at intersex conditions as secluded to these parts, to rescue patients from an intersex diagnosis to the, to the whole of the body.
Jill: And so this is terminology like testicular feminization, which locates the feminine in the testes, not in the whole body.
Jennifer: Yes, absolutely. It isolates that feminization from the rest of the body, while suggesting that the gonads are by essence, still testicles. And similarly, practitioners could use the term “large clitoris,” but instead they use the term like “underdeveloped penis” to reaffirm this part as male, while distancing its shortcomings of under-development from the rest of the body. And this has the effect of naturalizing the maleness of the body, rescuing his patients from an intersex designation.
Jill: Yeah, If you’re saying okay, so the body as a whole is male, and this parts of the body is feminized. And we’re going to use medical technology to bring this feminized part of the body in line with the rest of the body. Now you have a discourse of authenticity that seems to be supporting the idea that the intervention of technology is to reaffirm the authentic body, to bring it all kind of in line, so to speak.
Jennifer: Right, and it gives medical practitioners the authority to read nature’s intention.
Jennifer: That medical doctors know the intention of the body, the whole of the body is male, and that this feminized part is not what nature had intended, because what is natural is the sex binary.
Jill: So then it gives license to proceed with the medical technology, with the surgery, without all the gatekeeping?
Jennifer: Yeah. Male enhancement is framed as an acceptable technology that reaffirms the body as male, unlike transition surgery, which requires so much more gatekeeping as a result.
Jill: Because they’re not reading the whole body as male in those cases.
Jennifer: Because there’s this border that’s crossed.
Jill: The binary.
Jennifer: Yes, that the border of the binary has been violated in those cases.
Jill: The binaries that we made up, anyway. What I really appreciate about your research is that you flip it back to have cis people really reflect on our own cisitude, and on our own internalizations of cis normativity, and just like how messed up that is.
Jennifer: Yeah, and that really is the intention of the work is to respond to a lot of the folks within trans theory. Now I’m thinking about Susan Stryker’s words to Victor Frankenstein above the village Chamounix where she says, “I challenge you to confront your nature as I have been compelled to confront mind,” this idea that cis folks need to reflect on their own cisitude, and how that shows up in the world in many ways are there that are not only harmful for trans people, but also harmful for themselves.
Jill: So I really appreciated this conversation, and this opportunity to reflect on my own cisitude. Is there anything else you’d like to leave our listeners with regarding medical gatekeeping of gender or somatechnics?
Jennifer: Yes, thank you for asking. There are many lessons that we can take away from comparing these two sets of patient cases in the different ways that their health care is managed. Comparing these similar genital procedures that have different gatekeeping practices really underscores the lack of attention to cis mens’ gender, and the paucity of mental health support for cis men, while also revealing alternatives for managing trans folks’ medical transition through an informed consent model, rather than the pathology model that we currently have. My work attempts to join others, many from within the trans community, who advocate for an informed consent model that treats trans patients as trustworthy patients who know their gender better than mental health professionals or medical doctors ever could. So I’ve already referenced Florence Ashley’s work. I encourage listeners to check out their work to find out more about using an informed consent model. The one thing that I should clarify is that I’m not arguing that male enhancement and gender confirmation surgeries are the same, and therefore they should be subject to identical practices, or codified regulations, but rather that because we naturalize cisitude, we’ve created this system in which cis men have limited means for critically reflecting on their gender, and nearly unfettered access to shaping their bodies in gendered ways, including in ways that they might regret. But at the same time, because we naturalize cisitude, trans folks who have thoughtfully reflected on their gender are treated as suspicious, untrustworthy, confused. They’re essentially being gaslit while being denied, or delayed, access to health care that is officially recognized as appropriate for shaping their bodies. In short, the naturalization of cisitude in medicine perpetuates harm, for both trans folks, and for cis men.
Jill: This episode of Gender, Sex and Tech continued a conversation begun in chapter ten of the book “Gender Sex and tech: An Intersectional Feminist Guide”. The chapter was called “Gatekeeping authentic gender: The somatechnics of transition surgery and male enhancement.” And it was written by Dr. Jennifer Hites-Thomas. I would like to thank Jennifer for joining me today, for this stimulating discussion. And thank you, listener, for joining me for another episode of Gender Sex and Tech, Continuing the Conversation. If you would like to continue the conversation further, please reach out on Twitter @tech_gender, or you might consider creating your own material to continue the conversation in your own voice. Music provided by Epidemic Sound. This podcast is created by me, Jennifer Jill Fellows, with support from Douglas College in New Westminster BC, and support from the Marc Sanders Foundation for Public Philosophy. Until next time, Bye!!