Eenie Meenie Miney

I’ll be the first to admit that I have been left far behind in the vocabularic peculiarities that are now used to describe non-normative sexuality. Perhaps it’s Age, but more likely naïveté, that has led to this deficiency rather than lack of exposure.

I entered medical school in the mid-sixties when the youth were beginning to out themselves, and when some of the gloves were starting to come off -or maybe there was a growing awareness that a few of them had actually been wearing gloves. At the time -at least in my  school- Medicine seemed bicameral and only accepted two genders, male and female, with perhaps the door held slightly ajar for babies born with ambiguous genitalia or other genetic syndromes that made classification difficult.

For some of us, at least, it was a simpler time. Gender and sexual assignation were one and the same; preference as to which was really which was non-negotiable. But times and self-designation began to change; Medicine and the Law limped behind until the rift started to expose the consequences of their inaction.

I’d like to pretend that I saw these coming but, alas, I had no idea of the scope of the issue. In fact, in my mind, this straying from the norms was at best a marginal fashion. Anatomically, at least, we were what we had been assigned, and I assumed that perhaps the fullness of time and the machinations of society would iron any deviations into the acceptable crease. I had not reckoned with the discontent that enforced conformity might produce. When one has not experienced qualms, when one accepts the way the chromosomal dice have landed, it is not easy to grasp the uneasy restlessness of those few who will not play the game… or were not willing to join either team.

I say ‘few’ because I did not know; I did not understand. In time, of course, the discrepancies became too obvious to ignore in practice. At least in my gynaecological practice…

At first, there was confusion, I suppose -mine at first, perhaps- but theirs too. Not about their role, but mine. Initially, my lack of training forced me merely to listen, to empathize and then to help when and where I could. And, naïvely, I thought that was likely all that was required -and maybe all that they could reasonably expect. There was much psychological turmoil and disbelief that there was so little I could do, and yet I was relieved that I had heard them without disparaging their distress, or trivializing their problems.

But it soon became apparent that the eventual ramifications of their choices had the potential for far deeper consequences than either side had anticipated. And I’m not sure that I even appreciated the extent of the consequences of this disparity until after I retired. Only then, for example, did I come across an essay in the BBC Future series that touched upon some of the problematic issues. In an essay, Zaria Gorvett, a freelance science journalist for BBC, addressed the problem of why transgender people are ignored by modern medicine and what that might mean for their health:

‘[T]here are thought to be nearly a million transgender people living in the US… Rather than devising new ways to cope with changing social norms, transgender people are often shoehorned into inappropriate boxes instead.’

And the example she starts with is ‘a transgender man – he identifies as male but his biological sex is female. He has been living as a man for around 20 years… he is registered as a man on all his legal documents, from his passport to his medical records.’ All along, he had been taking small doses of the male hormone testosterone, but he suffered kidney failure and his condition deteriorated, therefore necessitating a kidney transplant. The criteria, for consideration of transplantation, however, differ between men and women and he lost valuable time in sorting out what criteria would apply to him.

As Gorvett points out, ‘When you factor in the large data gaps in everything from the average life expectancy of transgender people to the right dosages of medications for their bodies, along with the widespread lack of knowledge among doctors about how to address them – let alone treat them – and the high chance of them being refused treatment outright, it soon becomes clear that transgender medicine is in crisis.’

Indeed, in the UK, ‘“You can register as male or female, but you can still only choose between these two options – you can’t say if you are transgender or non-binary,” explains Kamilla Kamaruddin, a doctor who works for the National Health Service (NHS) and transgender woman. “So that’s quite difficult.” Or, if gender issues seem irrelevant to the visit, the patient may choose not to mention it, because of perceived stigma.

And, ‘The gender you’re registered as also dictates which screening tests you are invited to, meaning that thousands of transgender men could be missing out on potentially life-saving cervical (Pap) smears and breast exams, while transgender women could be missing out on abdominal aortic aneurism check-ups (or prostate cancer screenings, if they live in the US).’

Male and female physiology are different and many medications behave differently in each. ‘Females also have more sites for certain drugs to bind to, and are therefore more sensitive to them. They tend to clear them more slowly, so they are more susceptible to overdoses.’

Perhaps because of the stigma and subsequent lifestyle, ‘The group has higher rates of heart disease, certain cancers, mental health problems, suicide, smoking, and substance abuse than the general population – as well as an HIV prevalence which is  up to 42 times the national average. Transgender people are not only more likely to get sick, but less likely to seek treatment when they do.’

Still, I think we’re beginning to understand the problems they face. This gender dysphoria is an ancient condition, though, and actually gender fluidity may go back farther still. Gorvett writes about more enlightened recent attempts at assisting both with surgery and with hormonal replacement. The problem, however, is in the continuing stigmatization of those who are not mainstream. Those who do not fit neatly into societally condoned roles.

Maybe my age is tempering my reaction, or clouding my judgment, but I do wonder why there continues to be such marked antipathy to those who do not look like us, behave like us, or (gasp) think like us. Are we so insecure in who we are that we are threatened? And is it redress for the difference that we seek, an expectation of contrition? Do we really demand repentance, or is it homogenization?

I, for one, have come to think that the world would be a poorer place if we -the cis creatures- and we alone, were all that was on offer…

To Be or Not to Be

We are all creatures of our cultures; we are all influenced, if not captured, by the ethos that affected our parents. And for most of us, it is where we feel the most comfortable. It does not require any clarification, or justification -it just is the way things are. The way things are supposed to be. Anything else is not simply an eccentricity, it is an aberration.

I think one of the aspects of Age that sometimes earned respect in times past, was the ability of some elders to stand aside from the fray and place things in context, examine long held opinions and wonder about their value. Unfortunately, often these voices of wisdom were rare and societal acceptance even rarer. At least until the time of social media, Zeitgeist moved like a snail, and only things like war or disasters could reliably hurry it on its journey. We were limited by geography to parochial assumptions of normalcy. We had no reason to doubt that our values were appropriate, and in all likelihood, universal.

Gender was one of those self-evident truths about which there could surely be no dissenting views. We are what genitalia we possess, and our sex is assigned accordingly. Period. Indeed, for years I saw no reason to question this belief. I could understand same-sex relationships easily enough, but the need to interrogate the very idea of ‘sexual identity’ did not occur to me. As I said, I am a creature of my Time, my Culture.

There was a fascinating article in Aeon, an online publication, that helped me to understand how very blinkered my view had been. It was written by Sharyn Graham Davies, an associate professor in the School of Languages and Social Sciences at Auckland University of Technology:

‘[T]he very word ‘transgender’ came into common usage only in the past 20 years or so, and even the word ‘gender’ itself was popularised only in the 1970s. So we couldn’t even talk about transgender in a sophisticated way until practically yesterday.’ Indeed, some people seem to think that the whole idea of ‘transgendered’ people is not only strange, but also a novel, made-up aberration. ‘But there’s a problem if transgender is considered a particularly recent issue, or as a peculiarly Western phenomena. The perceived novelty of transgender people often leads to the accusation that they don’t have a right to exist, that they are just ‘making it up’, or even trying to cash in on some celebrity status, like that acquired by Caitlyn Jenner, the American TV personality who in 2015 transitioned from Bruce Jenner, the Olympian decathlete.’

Among other cultures, the author highlights the case of the bissu, an ‘an order of spiritual leaders (often framed as a priest or shaman) who are commissioned to perform all sorts of tasks for the local community, such as helping those in power to make important decisions on topics such as marriage alliances, crop harvest dates and settlements of debt.’ They were likely first described in a letter written in 1544 to João de Albuquerque, the Portuguese bishop of the Indian state of Goa, by António de Paiva, a Portuguese merchant and missionary, when he was in Sulawesi in Indonesia.

And from the author of the article, we learn that ‘The [local] Bugis people thought that when a being became a woman or a man, that being could no longer communicate with the gods. Men and women were in some sense cut off from the gods that made them. But the gods had a means of communicating with humans: the bissu. Because the gods left the bissu undifferentiated – a combination of woman and man – they are accorded a position of influence. As the bissu bring together woman and man in one person, they can mediate between humans and gods through blessings.’

Interestingly, ‘Early indigenous manuscripts also talk of the bissu occupying a special social position because they combined female and male qualities. But the analytic tools available to these earlier commentators were slim – there was no word for anything like ‘gender’. Therefore, it is difficult to assess whether the bissu were considered a ‘third’ gender or as crossing from ‘one’ gender to the ‘other’ (transgender). However, what we can say is that there was a powerful sense of what today would be called ‘gender pluralism’

But this concept of pluralism was not confined to Indonesia by any means. For example, ‘According to Peter Jackson, a scholar at the Australian National University in Canberra, gender was not differentiated in Thailand until the 1800s. Before then, Thai princes and princesses dressed the same, with matching hairstyles. But in the 19th century, to impress the British, the Thai monarchy decided that women and men should be clearly differentiated with unique clothing and hairstyles… So in fact the Western gender system created ‘transgenderism’ – crossing from one gender to another made no sense in Thailand when there weren’t two strictly defined genders.’

So Graham Davies sums up her arguments about transgenderism by saying, ‘Human nature is diverse, and any attempt to split all 7 billion of us into one of just two categories based on mere genitals is both impossible and absurd. Transgender people have played crucial roles in societies throughout history.’

I find the article intriguing for several reasons, but I suppose the most compelling is that it calls into question what seems for most of us to be self-evident: that gender assignation should be commensurate with genital (or, nowadays, chromosomal) possession. Perhaps it is a good starting point in a culture that demarcates societal roles according to gender, but even a short step back would challenge the need for such rigid rules. Yes, maybe DNA does dictate that only the female is able to become pregnant and propagate the species, but why should it also demarcate other aspects of identity? Why should gender matter in a vocation, say, or even in a sport…? Surely it would be better to depend on quality of performance. And, for that matter, why should it be irrevocable once assigned?

I realize how naïve that sounds -self-identity seems to be such an important component of our ability to function in a multifaceted society. ‘While transgender often implies a crossing from one gender to the next, the use of third gender is a way to try to frame a separate and legitimate space for individuals who want to be considered outside this binary. The debate over terms and labels is fiercely contested, as any comments around the ever-increasing acronym LGBTQIA (for lesbian, gay, bisexual, transgender, queer, intersex and asexual) suggest.’

It seems to me that a helpful way to think about these roles is to understand that they do exist, and they have probably always existed. They are not new phenomena, nor are they bizarre. In fact, they are ‘abnormal’ only in that they usually do not represent the majority in most modern societies. But ‘abnormal’ does not mean aberrant -or necessarily perverse.

And yes, I also realize that the acceptance of cultural relativism swings on a wide pendulum over time, but I have to go back to something one of my favourite poets, Kahlil Gibran, wrote: Say not, “I have found the truth,” but rather, “I have found a truth.” Say not, “I have found the path of the soul.” Say rather, “I have met the soul walking upon my path.” For the soul walks upon all paths.