Happiness, Biopolitics, and Transmedicine’s Necessary Contradiction: Rhetorics of Normalcy and the Narratives of Gender Transition

Peitho Volume 22 Issue 4 Summer 2020

Author(s): D.T. McCormick

D.T. (Dee) McCormick is a Ph.D. candidate in Rhetoric and Composition at Purdue University. Their work involves archival and historiographic research in rhetorics of medicine, psychiatry, and recovery movements. They are currently the Online Course Coordinator for Purdue’s Introductory Composition program.

Abstract: This article rhetorically analyzes Andrea Long Chu’s controversial New York Times opinion piece “My New Vagina Won’t Make Me Happy” by contextualizing its epideictic appeal against the continuing history of gatekeeping and diagnostic restrictions within transgender medicine. By providing an overview of the controversy surrounding her autobiographical account of transmedical experience, as well as the biopolitical relation between trans life and affective ends such as “happiness,” I argue that Chu’s essay asserts—in a somewhat flawed manner—a necessary rejoinder to the contemporary push toward trans normalcy.

Tags: biopolitics, epideictic, narrative, norms, rhetoric of health and medicine, transgender

Nothing, not even surgery, will grant me the mute simplicity of having always been a woman. I will live with this, or I won’t. That’s fine. The negative passions—grief, self-loathing, shame, regret—are as much a human right as universal health care, or food. There are no good outcomes in transition. There are only people, begging to be taken seriously.

—Andrea Long Chu, “My New Vagina Won’t Make Me Happy”

Experiential accounts of gender transition don’t often make it into the mainstream, and when they do, they tend to be framed as moments of celebratory visibility, emphasizing liberalism’s progress and the possibilities of technomedicine.¹ While these sorts of accounts may offer certain opportunities for trans rhetors to engage with and contest misinformed or ill-intentioned perspectives, they also close off opportunities for more combative accounts.² However, even when a combative and politically-charged account of gender transition does make it into a mainstream publication, trans advocates may not be entirely pleased. Such was the case when, in late 2018, trans writer and literary studies scholar Andrea Long Chu published an opinion essay in the New York Times detailing her experience of depression and anxiety that has accompanied her gender transition. Although it ultimately forwarded a trans-positive argument—that transmedicine has no ethical ground for denying or delaying transition-related care to anyone, even when the outcome is uncertain—many trans people responded to the essay with anger. In the context of transmedicine’s history of gatekeeping, as well as the current climate of renewed attacks on the legitimacy of trans life, these respondents expressed serious concern over the way that Chu frames the experience of transition. This framing, its context, and the concerned response to it will be the focal points of this article. I argue that the controversy over Chu’s essay indexes the broader problem of transmedicine’s biopolitical effects. That is, communicating in public about the experiences of being transgender is a fraught rhetorical endeavor because transmedicine, as it has emerged in the eurocolonial³ world, adopts the authority to define and describe the phenomena that make up trans life. Consequently, the act of articulating one’s own relation to the norms of transmedicine risks damaging the possibility for others to adopt those norms as viable goals—especially if that relation is an unhappy one.

The first section of this article establishes the theoretical context for my argument; I explain how I understand transmedicine as both a rhetorical and a biopolitical process, and I indicate how particular acts of clinical judgment embedded in this process serve to authorize or de-authorize particular bodies and experiences. In the second section, I give an overview of Chu’s argument, its context, and the response to it, and I introduce the relation between happiness and normalcy that I use in the following section. The third section conducts an analysis of the dominant narratives of trans life and transmedicine, which form the rhetorical and biopolitical context for the experience that Chu describes in her essay. In that section, I draw on research into the historical development of transmedicine in order to show how Chu’s argument (and the response to it) reveals a disconnection between the norms of transmedicine and the emergent ongoingness of transgender life. The concluding section poses this disconnection as a distinction between “need” and “demand”—that is, I end my argument by noting how Chu’s essay aims to put into question transmedicine’s basic practice of administering treatment based on judgments of needs and risks, rather than recognition of a demand for care. In sum, I argue that Chu’s essay represents neither a capitulation to transmedical norms nor an overly radical rejection of medical beneficence; rather, it represents a disclosure of transmedicine’s necessary contradiction, that is, the simultaneous acceptance of and intervention into the forms of trans life.

Rhetoric, Biopolitics, and Medical Judgment

Rhetoricians of health and medicine have argued that the force of rhetorical figuration in these disciplinary structures extends beyond what is typically understood as “health communication” or “medical texts.”⁴ That is, as Judy Z. Segal puts it, medicine “is also rhetorical as a system of norms and values” that forges and formulates the knowledge and experiences of patients, physicians, and medical personnel (3). This means that medical rhetorics are especially important as instances of epideictic rhetoric, the mode of rhetoric that makes arguments about what is good or bad in the shared present tense (i.e. norms and values).⁵ Karen Kopelson, in her 2019 article on the epideictic rhetoric of medical doctors’ writings on death and dying, asserts that the role of epideictic in medical rhetorics demands our attention precisely because of its normative force: “As the rhetoric that (re)consitutes what is praiseworthy and blameworthy in human conduct to (re)shape the basic codes of value and belief by which we live, epideictic rhetoric is inherently normative, and its practitioners invested with special authority and influence” (286). For medical rhetoricians, then, epideictic rhetoric can be seen as a particularly forceful mobilization of the doctor’s traditional authority. To analyze particular medical rhetorics as epideictic is thus to highlight and examine the way that the norms of health and medicine may double as social and ethical norms; tracing the way these norms emerge and take force in the world allows medical rhetoricians to evaluate the historical and political justifications for normalizing (as it were) health and medicine in such ways. In this article, I add to this body of work through a discussion of Chu’s essay and its relation to the historical and conceptual background of transmedicine—that is, the physiological, psychological, and technical knowledges that underwrite the medical facilitation of gender reassignment.⁶ By excavating some of the processes and problems through which transmedicine as it occurs today emerged (and continues to emerge), I analyze the way that it acts in the world as an array of epideictic rhetorical forces.

To be precise: by “epideictic rhetorical force,” I mean the circulation of values and norms that affect how particular people perceive good and bad within their own experience of the world.⁷ For my own purposes, then, I argue that rhetoric (and epideictic in particular) contributes to the emergence of people’s lives as such, making some actions and attitudes possible and others impossible. While I acknowledge this is a fairly radical claim to stake on behalf of rhetoric, locating rhetorical force in this way allows us to better understand (among other things) rhetorics of health and medicine. Segal argues, for instance, in her work on patient narratives as an epideictic genre, that the circulation of particular narrative frameworks (with particular plots, characters, themes, etc.) for describing the experience of particular health concerns has bearing on more than just one’s understanding of those experiences after the fact. Rather, she asserts, these narrative forms actively shape the way that those health concerns manifest for the people who encounter them. That is, such epideictic force places pressure on patients to not only “report experience” but also in fact to “interpret experience and even to experience experience in certain sorts of ways” (69). In the same way, the tropes and topoi that form transmedicine’s diagnostic and treatment models do more than just represent the experiences of its patients after the fact. Rather, this process participates in the emergence of that experience itself, such that the medical framing of trans patients is also a biopolitical forming of trans life.

By using the word “biopolitical,” I mean to suggest that trans politics—and debates over transmedicine in particular—addresses structural interventions into the forms of trans life. Transmedicine, as one instance of this, intervenes in trans life through the acts of judgment that make up its diagnostic and treatment models: for example, judgments of who is transgender, who is capable of undergoing what types of treatment, or what experiences indicate what kinds of prognoses or developmental progress. In that regard, not only transmedicine but contemporary medicine per se is fundamentally biopolitical, in the sense outlined by Nikolas Rose. He describes biopower as a form of intervening into “the vital characteristics of human existence”; in other words, biopower acts upon the material details of “human beings, individually and collectively, as living creatures who are born, mature, inhabit a body that can be trained and augmented, and then sicken and die” (The Politics of Life Itself 54).⁸ (This does not mean that medicine is bad because it is biopolitical; rather it means that medicine is an important venue for conflict over differing biopolitical valuations of life as such.) Biopolitics, then, refers to a variable set of methods and rationalities for understanding the lives of a particular set of people in a particular context, such that it becomes possible to orient those lives toward particular ends.⁹ By framing my rhetorical analysis as also an analysis of transmedicine’s biopolitical force, I am thus attuning to the ways that transmedicine forms, arranges, and narrates the vital capacities that make up trans life.

Recent discussions of the principle of “informed consent” in transmedicine may inadvertently reveal the extent to which biopolitical intervention serves as its implicit central purpose. In a 2016 overview of this principle as it pertains to transmedicine, Timothy Cavanaugh et al. explain that an informed consent model frames patient-clinician consultations not as diagnostic scenarios but as “discussion of risks and benefits of possible treatment options” in which “clinicians work to assist patients in making decisions.” In this way, the model attempts to depathologize trans identity and to counterbalance transmedicine’s history of paternalism. Thus, the authors assert that “[t]his approach recognizes that patients are the only ones who are best positioned, in the context of their lived experience, to assess and judge beneficence (i.e., the potential improvement in their welfare that might be achieved)” (1149). The intention behind the use of this principle is clearly well-meaning, as it seeks to center the experience and judgment of the trans people who seek care rather than that of clinicians. This can be especially helpful when put into practice by endocrinologists and surgeons, who otherwise typically do not offer care until a would-be patient has visited a psychologist or psychiatrist and has received a letter authorizing the legitimacy of the person’s gender dysphoria and lack of psychiatric contraindications. Replacing psychiatric gatekeeping with an informed consent process can indeed make seeking care easier and more accessible.

However, in their ethnographic work on transmedicine, stef shuster has found that there are often discrepancies between the theory and the practice of this informed consent process. They explain that some of the clinicians participating in their research “followed the informed consent process to a degree, but modified it by including an assessment to determine if a patient had the capacity to understand the information offered or was ready to make the decision to begin trans-specific interventions” (“Performing Informed Consent” 192). This suggests that as clinicians apply this ideal in their practice, it tends to morph into “a conditional concept that is qualified by a provider’s assessment of a patient having the capacity to offer consent” (193). By drawing on implicit norms of who may offer consent to care on their own behalf and who may not, clinicians who interpret the process this way have only replaced one type of gatekeeping with another.¹⁰ So, even in the context of informed consent guidelines, clinicians are oriented by the very structure of their medical authority toward making judgments about who should receive treatment and who shouldn’t.

What this dynamic indicates, then, is that transmedicine tends toward adopting the role of evaluating its patients’ capacity for affirming their own gender (or their capacity for evaluating their own capacity for affirming it). That is, the medical authority that transmedicine enacts is not simply a matter of making judgments about who deserves care and who doesn’t; rather, and more fundamentally, transmedicine enacts biopolitical authority by making judgments about the form of trans life. As an array of epideictic forces, the structures of transmedicine circulate particular sets of assumptions about what is good, healthy, and normal, and through this circulation they repeatedly translate those assumptions into the real, material forms of experience that are available to the patients, clinicians, and care workers who participate in those structures.¹¹ And this is what biopolitical intervention consists of: evaluating a form of life, making a judgment about the goodness or badness of that form’s trajectory, and posing a strategy of influence based on that judgment. As a medicalization of trans life, then, transmedicine does not oppose trans life per se; rather, it acts upon trans life in order to bend it toward the norms of cisgender life. These norms—upon which clinicians make their judgments of readiness, beneficence, risk, and capacity for understanding and consent—are intended to promote what transmedicine’s model of beneficence understands as its patients’ happiness. And thus these are the norms that Chu resists in her essay when she disavows the “happy ending” of transmedicine.

The Controversy: “My New Vagina Won’t Make Me Happy”

Chu’s essay was published on the New York Times website on November 24, 2018, with the title “My New Vagina Won’t Make Me Happy.”¹² Almost immediately, it sparked an outcry from both the online trans community itself as well as the anti-trans coalition of right-wing culture warriors and trans-exclusionary radical feminists. Trans women objected to Chu’s characterization of hormonal and surgical transition as fundamentally painful processes. Anti-transgender respondents, meanwhile, objected to her assertion that medical gatekeeping was unethical and ought to be reversed in favor of a demand-based paradigm. More supportive responses simply noted the difficulty of adequately representing trans experiences in the mainstream press, even when those experiences are autobiographical. Some trans writers who identified with Chu’s sense of frustration toward the norms of medicalized transition responded with their own accounts of distress and uncertainty in the midst of more joyful coming out narratives. Other trans advocates countered by asserting their own experience of (or research into) transmedicine’s effectiveness in achieving good outcomes.¹³ Advocates and researchers also questioned her apparent dismissal of data that suggests trans people generally become happier as they get further into their transitions.¹⁴ The central premise of Chu’s argument—that “happiness” and “good outcomes” were, in any case, dubious standards on which to base a truly gender-diversity-affirming model of care—tended to be overlooked as respondents objected to the more contrarian aspects of her essay’s ethos and framing.

In particular, trans writers expressed concern that Chu had simply chosen the wrong words and the wrong venue for her argument. The mainstream readership of the New York Times, such writers asserted, is already prone to be skeptical of radical claims to transgender rights. While trans representation in this context is therefore much needed, a “reckless” and “confusing representation of trans experience is nevertheless, they suggested, ultimately harmful. For example, Florence Ashley writes that the essay “can be very easily and very reasonably read as saying that surgeries don’t contribute to trans wellbeing,” a reading that would potentially provide “excuses to defund trans care”; while they agree with Chu’s overall point and recognize the value of her story, they suggest that “just because a story needs to be told doesn’t mean it needs to be told this way, here.” Similarly, Kai Cheng Thom points out that, despite Chu’s excellent critique of the medicalization of trans life, her dismissal of outcomes research leaves a rhetorical vulnerability that anti-trans voices are already taking advantage of. This dismissal of evidence-based perspectives, she writes, “makes her argument grievously incomplete, not to mention especially vulnerable to manipulation by prominent conservatives like Ben Shapiro and Erick Erickson, who have cited the piece as evidence that trans identity is both a mental disorder and a harmful ‘ideology.’” These critiques are well-founded. Chu’s argument is a risky one to make, not only on her own behalf but for the trans community at large. However, her argument (and the response to it) is instructive for scholars of transgender rhetorics because it reveals the significance of happiness (as an expression of—or a criteria for—a state of normalcy) within the rhetorical dynamic between trans life and transmedicine.

Happiness and the Authorized Narratives of Trans Life

Chu situates her argument in opposition to both the straightforwardly anti-transgender narrative alleging that “gender dysphoria is a clinical delusion” and (what she calls) its “liberal counternarrative.” That is, she contests mainstream accounts of trans life that equate transgender identity with “suffering” and equate transmedicine with “a duty to ease that suffering.” She singles out, in particular, a June 2018 article written by Jesse Singal that centers on, as Chu puts it, “the statistically small number of people who have come to regret their medical transitions”—which, she argues, is simply a form of “compassion-mongering,” or “peddling bigotry in the guise of sympathetic concern.” Singal argues that parents and clinicians should be more skeptical of children’s and adolescents’ assertions of trans identity because (he suggests) childhood and adolescence are themselves periods of psychological fluidity and change. The primary evidence he presents for this claim is a set of cases in which adolescents identified themselves as trans, began (or considered beginning) treatment, and later “detransitioned.” Rather than addressing his misrepresentations of actual treatment protocols for transgender youth (which other trans writers were quick to point out at the time¹⁵), Chu instead critiques Singal for buying into the most retrograde facet of the standard treatment model: the gatekeeping strategies that prioritize “good outcomes” over access to transition-related care.

This counterargument leads into Chu’s assertion that the primary assumption of mainstream narratives of transmedicine is that “[p]eople transition because they think it will make them feel better.” This assumption, Chu says, is simply incorrect. To illustrate this, she describes her experience of her own ongoing medical transition, which she paints as “a marshland of regret” that has increased her dysphoria and prompted suicidal ideation. Chu’s intentions regarding these assertions and descriptions are clear: she wishes to force her readers to acknowledge that ambivalence and distress are not limited to the “before” of gender transition, and that to pretend those affects (or their absence) can reliably serve as a measure of need for (or success of) treatment will only ultimately serve a gatekeeping function. This is a trans-affirmative argument, and not meant to be self-hating or self-serving, but it was this specific argument that sparked the objections among the trans community. By claiming that “[t]here are no good outcomes in transition,” these responses countered, Chu delegitimized the experiences of the many trans people who did feel satisfied with their medical transitions. This is a reasonable and important critique of Chu’s argument. However, the tenor of the responses often strayed past a straightforward rejection of the implication that transition is a necessarily painful process, to a full-throated defense of the medical community and its standards, and even to questions over Chu’s mental health or the stability of her hormone levels. The suggestion that Chu’s description of her own experience reveals a need for further medical or psychiatric intervention fails to live up to the expressed principle of valuing trans people’s own descriptions of their transitions. Moreover, this extreme response itself buys into the premise that Chu is critiquing: that transition care must be based on a model of medical beneficence, in which the duty of the medical discipline requires an authoritative judgment of the patient’s needs that trumps her own assertions.

It’s too simple to suggest that such objections are merely a false-consciousness-type uptake of mainstream transmedical narratives. As Dean Spade points out, the relation between trans patients and medical practitioners is necessarily structured by such narratives. He argues that this relation is formed in part by “the long-standing practice amongst gender variant people of strategically deploying medically-approved narratives in order to obtain body-alteration goals” (“Mutilating Gender” 316). In this context, the “happiness” of medical transition that Chu disavows is both a product of the medical gatekeeping she decries and a genuine goal for many if not most trans people (one that may be achievable by mimicking, in some way, the normal trajectory of an approach toward that happiness). That doesn’t make trans people dishonest or inauthentic—on the contrary, both cis and trans lives are capacitated by biopolitical structures that orient us toward various “happy endings.” There’s no outside to biopower, only different strategies of directing and making use of it.¹⁶Furthermore, trans people have a legitimate need to monitor the rhetorics that frame our existence, and claiming our story as a happy one is one strategy for that.

Underlying this controversy, then, is a conflict over the narratives that capacitate trans life, that make transgender lives recognizable as real and possible lives. This conflict occurs because of the contradictions of normalcy and pathology, concepts which (in the context of biopower) structure both medical practice and social organization, leading to an overdetermined relation between claims about bodily health and judgments about the proper distribution of power and resources.¹⁷ As an element of gender, this overdetermination leads to an imbalance of scientific and technocratic interest in bodies that exhibit gender variance. Spade explains: “Containing gender distress within ‘transsexualism’ functions to naturalize and make ‘healthy’ dichotomized, birth-assigned gender performance. It casts a critical eye on the gender performance of those transgressing gender boundaries, and produces a norm that need not be criticized” (“Mutilating Gender” 319). Thus the clinicians who administer transition care adopt norms of expression and experience—not only proper gender performance, but proper orientation toward gendered happiness—as criteria for making judgments about how trans life ought to take form in relation to the normal. It’s no wonder, then, that trans people feel a need to resist rhetorics that associate trans life with pathology, pain, and suffering. But this also means that in order to capacitate and legitimize their bodies and lives, trans people have (understandably, necessarily) relied on that same force of normalcy. This contradiction is itself foundational to transmedicine’s understanding of its own beneficence.

Patient Narratives and Affective Norms

The assumption that Chu points out—“People transition because they think it will make them feel better”—roughly corresponds to the central tenet of the liberal turn in transmedicine.¹⁸ When the third edition of the Diagnostic and Statistical Manual of Mental Health Disorders was released in 1980, it included a revised entry for the transsexual diagnosis, using the term “gender identity disorder” for the first time and adding criteria regarding “the degree to which one experiences distress from living with one’s natal sex” alongside the more traditional concern over separating out the “true” transsexuals from those who were “merely” sexually-motivated cross-dressers. As Jodie M. Dewey and Melissa M. Gesbeck explain in their article on diagnosis in transmedicine, this change in framing shifted the locus of attention from variations of gendered behavior and expression to “the stress caused by gender variation” (48, emphasis in original). Hence the shift in diagnostic terminology from the residues of a physiological paradigm (“gender incongruence”) to a more psychosocial one (“gender dysphoria”).

Yet despite this emphasis on relieving patients’ distress instead of enforcing behavioral norms, the liberal “gender dysphoria” paradigm of transmedicine nevertheless enforces norms of affect. By defining its diagnosis and its successful treatment less by expression and more by experience, this more current paradigm of transmedicine frames trans identity as a transition of attitudes, from self-denial to self-acceptance. And while this transition narrative certainly matches the life experience of many trans people, centering such a narrative on affective transformation places “normalcy” in a regulatory relation to “happiness,” and vice versa. As Sara Ahmed suggests in her work on figures and figurations of happiness and unhappiness, philosophical and psychological models of “the good” tend to frame happiness as an end that orients the action of those who strive for it (Promise of Happiness 22-26).¹⁹ Using phenomenological terminology developed in her earlier work,²⁰ Ahmed describes the relation between the circulation of such models and the formation of social norms that draw distinctions between acceptable and unacceptable affective states. In particular, she argues that shared beliefs about what happiness is and how it occurs exert a normative force on the experience of happiness itself: “If the same objects make us happy—or if we invest in the same objects as if they make us happy—then we would be directed or oriented in the same way” (38). Conversely, being “out of line” with shared objects of affective involvement results in experiences of alienation or even exclusion (41). The notion of “happiness,” Ahmed explains, thus functions as both an orienting point and a criterion for making judgments about the orientations of others, judgments which may well help shape the experiences of orienting in one way or another, such that “the promise of happiness is located as well as distributed” (45). In this way, the narrativization of happy outcomes serves as a powerful species of epideictic rhetoric, circulating forms of experience that tighten the alignment between orienting oneself toward normalcy and participating in shared feelings of pleasure, fulfillment, and contentedness. The achievement of such happiness thus may depend on whether or not one’s life lines up more or less neatly with these forms.

In a medical context, this force of affective norming takes an especially significant role in forming the tropes and expectations of being a patient. As Segal asserts, standardized narratives of patient experience do not only retrospectively frame experience but actively form experience, such that genres of patient narrative create a “generic groove” that orients patients’ experiences and sensations toward particular values and particular ends (69). Like grooves in a footpath, narratives of particular health concerns—gender transition among them—become more deeply embedded the more they are used, which itself encourages further use. Indeed, Ahmed makes the same point with regard to objects and orientations that line up in neat and normative ways: “Lines are both created by being followed and are followed by being created.” She thus suggests that we may understand such lines, such epideictic “grooves,” as “performative” in that “they depend on the repetition of norms and conventions” (Queer Phenomenology 16). In the case of transmedicine, not only has the authorized narrative of patient experience been elevated to the status of a diagnostic model (“gender dysphoria” that must be relieved through medical intervention); the “happy ending” of this narrative has itself become a criterion for judgments of whether and how to enact care. Consequently, the groove of the authorized transmedical narrative of patient experience becomes worn deeper and deeper the more it is used to adjudicate and administer the distribution of care, and in turn the individuals who make up trans life collectively perceive more and more intensely the assumed necessity of transmedical care as a pathway to a happy future.

Normalcy, Narrative, and Transmedicine

By refusing to describe her transition in resolutely happy terms, then, Chu cuts across—and in this way reveals—the grooves that form transmedicine’s authorized patient narrative. In particular, she shows how the norms of cisgender life structure this narrative and the expectations for gender reassignment that it forwards. Her own experience of transition, then, has been colored by sensing her own deviation from those norms. Explaining that her dysphoria has actually increased since beginning her hormonal transition, she indicates that this manifests as a hyperawareness of her difference from other women: “I now feel very strongly about the length of my index fingers—enough that I will sometimes shyly unthread my hand from my girlfriend’s as we walk down the street. When she tells me I’m beautiful, I resent it. I know what beautiful looks like. Don’t patronize me.” In a particularly controversial passage, she writes: “Until the day I die, my body will regard the vagina as a wound; as a result, it will require regular, painful attention to maintain.” Respondents pointed out that this was not accurate—the neovagina does in fact heal, and although there is some discomfort involved in caring for it post-surgically, it’s really not reasonable to refer to it as a permanent wound.²¹

But taken together these passages suggest that Chu’s frustration with the “liberal counternarrative” of transmedicine is also a frustration with the commonsense notion that transgender bodies ought to match up with, transform into, or otherwise become indistinguishable from cisgender bodies. And to be clear, becoming frustrated with this notion is not the same as depriving it of its force. On the contrary, this is exactly how norms work: a norm exerts its force whether or not you are paying attention to whether or how it is exerting that force. As Chu herself puts it an earlier essay, titled “On Liking Women,” “Transsexual women don’t want bottom surgery because their personal opinion is that a vagina would look or feel better than a penis. Transsexual women want bottom surgery because most women have vaginas” (emphasis in original).²² Rhetorics of normalcy are thus affectively baked into gender transition. As Ahmed might put it, transition promises the happy ending of being (or at least feeling) normal, and in this way, the protocols of gender reassignment rely on the norms of one or the other binary gender. Whether or not a particular trans person identifies with a particular gender norm, then, is immaterial to the force of that norm on that person’s experience of transition—if only because the disidentification with this particular norm puts this person “out of line” (in Ahmed’s terms) with the shared affective investment of gendered belonging (The Promise of Happiness 41). The groove is there, inertly disrupting movements transversal to it.

Just as Segal suggests of patient narratives in general, then, transition narratives imply epideictic rhetorics of how to “experience experience” (69) by engaging with and redeploying norms of (among other things) affect. In the particular biopolitical context of trans life, these experiential norms circulate between and among the spheres of transmedicine and the trans community at large. Such norms do not necessarily emerge from transmedicine directly, but its function as an access point for care means that transmedicine wields disproportionate epideictic rhetorical force, amplifying the reach and effects of such norms. Thus the historical emergence of transmedicine’s diagnostic concepts and treatment protocols exhibits a tendency toward adopting and solidifying whatever norms are most ready to hand, in order to ensure the quickest and easiest demarcation of the normal from the pathological.

Narratives of Passing-As

As indicated above, before its liberal turn transmedicine did not emphasize experience directly, but rather oriented its clinical attention toward more “external” factors such as behavior and appearance. This tended to mean that clinicians, even when they were relatively open to the notion of gender reassignment, operated under a hermeneutic of suspicion (as it were): their reliance on behavior and appearance encouraged clinicians to believe that they could nevertheless distinguish between the “true” and “false” patients. That is, patients were sorted into various pathological categories that posited different diagnoses and prognoses, and only some were actually eligible for a “complete” transition (regardless of what the patients themselves asserted). Thus Dallas Denny suggests, in her retrospective account of the university-housed “gender identity clinics” that opened up in the 1960s and 70s, that the fundamental goals and assumptions of this treatment paradigm were directly opposed to the intentions of the patients. The clinics’ interests, she explains, were research-based and oriented toward “last-ditch” interventions, since their model of gender identity assumed that only the most entrenched and desperate cross-gendered-identifications could hold together through the process of transition. They also prioritized the ability to pass as cisgender, so much so that clinicians “were prone to assume that anyone whose presentation was not strikingly that of the gender of choice were not good candidates,” while “drag queens and street hustlers, who were generally skilled at appearing as women,” were more likely to be accepted for treatment (12).²³ In addition, the research goals of the clinics often meant that patients were pressured to give up their privacy and autonomy and even adapt their lives to the specifications of the accepted treatment narrative: “Those who did not restructure their lives according to the demands of the clinician (changing jobs, divorcing spouses) were subject to punishment by expulsion from the program” (17). The use of particular behavioral and experiential norms to restrict access to transition care thus resulted in the conceptual distillation and rhetorical amplification of particular narratives of what constituted a “true” trans identity. The restrictions of the transmedical narrative consequently served as restrictions of who, within the ongoing emergence of trans life in the world at large, could assume the orientation that aligned with the norms of a gendered narrative and its happy ending.

These narratives, then, occupy an ambivalent place in the emergence of trans life—while they offer a restricted account of what it means to be trans (and thus who gets to be “trans”), they also provided tropes and topoi that gave rise to trans autobiographical narratives such as the ones that Jay Prosser analyzes in his landmark study Second Skins. He argues that the circulation of autobiographical narratives of “transsexuality” provided a fundamental venue for the emergence of trans identity out of more disparate feelings of alienation or loss: “Indeed, for the transsexual even to discover the possibility of transsexuality—to transform it from private fantasy to realizable identity plot—takes place ‘in’ narrative. To learn of transsexuality is to uncover transsexuality as a story and to refigure one’s own life within the frame of that story” (124). However, as he goes on to explain, this same reliance on narrative has come to structure diagnosis as well as personal identification. Thus the emphasis within mid-century transmedicine (extending to some degree into the more “liberal” period) on a consistent and recognizable account of “strong, early, and persistent transgendered identification” (101). Further, this clinical use of autobiography means that some patients’ stories must be judged as incorrect, or at least not good enough. As Prosser puts it, “[t]he diagnosis acts as a narrative filter, enabling some transsexuals to live out their story and thwarting others” (107).²⁴ This suggests that the emergence of “transsexual” as a coherent, public identity itself required a certain slippage between the clinical narratives that defined trans life pathologically and the autobiographical narratives that trans people have used to define themselves. The epideictic form of trans autobiography—parasitically promising access to the gendered happiness placed within transmedicine’s diagnostic restrictions—thus forwards its own norms, wearing a groove in the collective experience of trans life. Although such narrative forms provide the necessary rhetorical vectors for “transgender” to circulate as an identity, they also necessarily contribute to the distinctions between those lives that are recognizably “transgender” and those that are not. And in the context of contemporary biopower, those distinctions often form along the lines of other biopolitical vectors, such as race, class, nationality, and mobility.

Narratives of Passing-Over

Chu notes the difficulty of describing dysphoria to someone who has never experienced it, and she wields some poetic figurations that gesture toward a feeling of discomfort, aloneness, and incompleteness—“hunger without appetite,” for example, or “grieving” while “having nothing to grieve.” One of these figurations evokes the feeling of suspended movement: “It feels like getting on an airplane to fly home, only to realize mid-flight that this is it: You’re going to spend the rest of your life on an airplane.” It’s a striking metaphor because, as many have pointed out, the very term “transgender” implies a reference to travel and mobility—“trans”-as-across, movement across a space or period of time. In mainstream accounts of trans identity, however, this movement is typically framed as finished, not suspended.²⁵ Aren Z. Aizura argues that the function of such travel/mobility tropes is to contain “gender indeterminacy,” that is, to assert the fundamental normalcy of cisgender life by framing gender transition as happening “elsewhere”—thus “[t]he border between genders is figured as liminal and impossible space” (39). Chu’s evocation of living in a suspended “elsewhere,” then, subverts the typical transition-as-arrival narrative, even as she laments the discomfort of this experience.

Figuring gender reassignment as a “movement” or “journey” allows trans individuals to perceive their transition in terms of progressive development, but it also suggests a metaphysical “crossing over” from one side of an essential binary to the other. On the one hand, this trope of “crossing” has been taken up by many transgender writers and speakers as a way of articulating the experience of transition. On the other hand, framing transition as a form of movement through space indicates the close relation between one’s relative ability to pass “between” gender norms and one’s ability to appear as a normative figure along other biopolitical vectors. To illustrate this, Aizura refers to Christine Jorgensen, who has traditionally been considered the central patient figure of transmedicine’s emergence in mid-twentieth-century America. He explains that Jorgensen necessarily also serves in this capacity as a figure of whiteness, economic privilege, and physical mobility²⁶—especially considering the transnational scope of her transition. Unable to find doctors in America willing to facilitate a gender reassignment surgery, she travelled to Denmark and lived there for several years, undergoing surgery at a Copenhagen clinic and returning triumphantly to America as a fully realized transsexual woman. As Aizura puts is, “To place this story at the center of transgender history privileges whiteness and the imperative of social mobility, as well as an imperialist division of the world into a national here and a colonial elsewhere” (32, emphasis in original). An identification with particular figures of mobility and relative normalcy such as Jorgensen, then, has tended to marginalize all but the most privileged members of the trans community. Not only does this obscure the variety and unpredictability of trans life’s ongoing emergence; this orientation toward narratives of normalcy also threatens to redouble that marginalization through a process of affective norming—wearing the grooves of the authorized transition narrative even deeper.

The highly visible, highly mobile norm of the white, eurocolonial, binary-to-binary, able-bodied and neurotypical transgender person thus heightens the vulnerability of trans people who differ from that norm. And although this is not solely reducible to transmedicine’s history of restricting access to care, that history (and its contemporary echoes) is a fundamental part of the sheer force with which normalcy warps the way that trans lives occur. The force of this history ought to provide context for Chu’s rejection of “good outcomes” reasoning: even while she herself has a highly visible, highly mobile body with access to transition care, the norms of the transmedicine’s authorized narratives have diminished the range of possible trajectories of her life’s ongoingness. And for those with less visible, less mobile, less materially supported bodies than Chu’s, the diminishment wrought by these norms has been further refracted through systemic diminishment along other biopolitical vectors. The goal of arguments such as Chu’s, then, is not to demand a better future, a different (happier) ending, but rather to demand a different form of relation to the present’s ongoingness. That is, the gambit here is an epideictic one—to jar or jam the replication of norms that result in a restricted narrative of how trans people experience their own present happiness or unhappiness.

Conclusion: On Demand

Interestingly, Chu’s boldest claim went unremarked upon by all but her most antagonistic interlocutors. That claim, I would argue, is her assertion that the administration of transmedical care ought to require nothing but asking for it: “I believe that surgery’s only prerequisite should be a simple demonstration of want. Beyond this, no amount of pain, anticipated or continuing, justifies its withholding.” The trans advocates who responded negatively to the essay apparently did not see this claim as particularly controversial, perhaps because they were more irked by Chu’s discussion of happiness and treatment outcomes. But in right-wing and anti-transgender outlets, this element of Chu’s essay struck a chord, in that it served as evidence that “transgender ideology” was antisocial, perverse, and/or insane because trans people wanted medical treatment “on demand.” For instance, The Federalist’s Libby Emmons argues that the logic of Chu’s argument would seem to imply that “doctors are merely client fulfillment specialists” who must abdicate the authority of their expertise, such that “[a]nything we can dream, a doctor can be compelled to perform.” The thrust of such an argument, Emmons claims, is the abandonment of all socially reasonable limits to the use of biomedical knowledge and technology; the thrust of Emmons’ argument, I would say, is thus to suggest that people who are trans (especially trans women) would be better off getting their heads examined than demanding surgery. This response is intriguing for a couple reasons. First, in the history of transmedicine, demand actually predates dysphoria as an indicator of trans identity. That is, before the broader shift toward affective criteria such as dysphoria in the 1980s, clinicians typically regarded “patient demand for sex-change surgery” as the fundamental diagnostic criterion (Billings and Urban 270). On the one hand, this simply corresponded to the way in which the patients appeared as patients—there was no test or syndrome that would result in a person being referred to a gender clinic, only those who wrote letters inquiring about (or, indeed, demanding) the possibility of a medicalized “sex change.” On the other hand, as both supporters and critics of transmedicine have pointed out, attuning to patient demand was a good way of countering the possibility of allowing transition care for those who had “perverse wishes for self-destruction” or were merely (in this framework) “an effeminate homosexual or a transvestite.” Given these risks, “the best indicator of transsexualism was the intensity of a patient’s desire for surgery” (271).

Of course, one effect of framing trans identity as a function of “demand” was the formation of a fundamentally skeptical attitude toward the individuals voicing that demand. Since clinicians ultimately lacked a surefire method of knowing who was “really” transgender, the best option was to simply limit the availability of care, so that the people who worked to put themselves in the position of patient could be viewed as already vetted (as it were) by the sheer difficulty and frustration of getting that far. In the contemporary paradigm, this concern for certainty remains, though clinicians no longer make judgments based on the (perceived) intensity of patients’ demands. Instead, because transmedicine now frames itself as a respond to a need, clinicians assess certainty directly, as an affective criterion.²⁷ By emphasizing “need” rather than “demand,” then, the current paradigm of transmedicine attempts to sidestep the question of desire with regard to medical intervention. This question has gained new salience, Rose suggests, in the context of contemporary biomedicine, in which “[t]he old lines between treatment, correction, and enhancement can no longer be sustained” (The Politics of Life Itself 17). Hence the second reason why the specter of “on demand” care is intriguing: as an element of anti-trans rhetorics, it draws on and gives voice to this deeper anxiety over preserving the allegedly natural distinction between necessary and unnecessary care. Indeed, Emmons bears this out in her article, which posits that Chu’s experience of “cosmetic” surgical treatment “gives the distinct impression that the surgery is not medically necessary.” In consequence, she claims, Chu has revealed the flawed reasoning behind support for trans care: “Without a medically beneficial reason, what is the reason for allotting these medical resources away from medically necessary care?” As indicated above, this is exactly the sort of argument that many trans respondents feared Chu’s piece would provoke. Further, as Rose asserts with regard to biomedicine more broadly, even though any argument positing such a “distinction between treatment and enhancement” is ultimately “bound to fail,” these arguments still point to the intractability of conflict over “what we might legitimately desire and what desires might legitimately be denied” (104).

And this conflict leads us back once again to the rhetorical relation between happiness and biopower. After all, if Ahmed is correct that affective norms suggest “happiness is what you get in return for desiring well” (The Promise of Happiness 37), then the normative distinctions between good desires and bad desires, between right choice and wrong choice, are what shape the possibility of a happy ending for trans life. The extent of transmedicine’s emphasis on this sort of individual choice has led scholars from within as well as without trans studies to argue that mainstream narratives of trans life promote an uncritical ethos of individualism. Since the identity “transgender” emerged within the eurocolonial context of capitalism as it shifted from a liberal to a neoliberal form, the logic of individual choice has indeed always been part of the authorized narratives of trans life.²⁸ But such analyses of neoliberal individualism often neglect to account for the particular role of risk in this biopolitical dynamic.²⁹ That is, in the context of biopower, risk is not simply a function of making choices; rather, risk is the condition for all possibilities of choice, freedom, and indeed happiness. To be in the world at all is to engage with the norms that shape bodily involvement and affective engagement; and to engage with these norms is always to risk deviation from them.³⁰ But even further, to deviate is always to risk unhappiness. Whereas narratives of normalcy might “encourage us to avoid the unhappy consequences of deviation by making those consequences explicit,” the (sometimes happy, sometimes unhappy) histories of trans life are, to use Ahmed’s words, “histories of those who are willing to risk the consequences of deviation” (91). In the context of biopower, to live in the world as a trans person is, for better or worse, to risk one’s own happiness.

More consequently for the purposes of rhetorical analysis, to communicate about living in the world as a trans person is, also for better or worse, to risk the happy narratives of trans life as such. Just as Chu’s disavowal of “good outcomes” risks becoming a justification for restricting access to the transmedical care that itself forwards those “good outcomes,” any rhetorical engagement with representations of transgender life risks contributing to distinctions between legitimate forms of trans life and illegitimate forms of trans life, good trans life and bad trans life. This is particularly relevant with regard to transmedicine’s epideictic force: there is always the danger that the content of one’s “happy transition narrative” may become formalized as a treatment norm. Thus one fundamental condition of transgender rhetorics in the contemporary context of biopower is collective risk, a shared participation in a wager over the possibilities of deviant life. So although Chu’s demand for something other than “good outcomes” does indeed risk collective access to “good outcomes”-based care, it also reveals transmedicine’s necessary contradiction, that there is no acceptance of (individual) trans life that is not also in the same instance an intervention into (collective) trans life. Admittedly, this is an unhappy view of the possibilities for transgender rhetorics, and especially transgender rhetorics of medicine. However, more optimistically, Ahmed reminds us that “[t]he unhappiness of the deviant performs a claim for justice” (The Promise of Happiness 96). That is, trans life forwards its own epideictic, bears up charges of praise and blame in the very happiness and unhappiness that trans people experience. In demanding care, in deviating from narrative norms, perhaps even in simply “[e]xisting in the world” (Gossett and Huxtable 39),³¹ those who participate in trans life themselves embody an array of epideictic rhetorical forces; in this way, trans life itself can pose a challenge to the norms and narratives that systemically dismiss some measure of its forms in the name of preserving transmedicine’s “good outcomes.”

Endnotes

Many thanks to Caroline Jennings, two anonymous reviewers, and the editors of this special issue, GPat Patterson and K.J. Rawson, for their indispensable feedback on earlier drafts of this article.
Che Gossett points out, in this regard, that “[o]ne of the traps of trans visibility is that it is premised on invisibility: to bring a select few into view, others must disappear in to the background, and this is always a political project that reinforces oppression” (183).
By framing the context that I address as “eurocolonial,” I am asserting that my analysis is directed toward the forms of rhetoric that have emerged from the tradition of power and knowledge based in eurocentrism, imperialism, and universalism. In that regard, while I address the history of gender variance in America I do not address the histories of American Indian gender variance, which I understand to be distinct from the set of identities that goes by the name “transgender.” That is, American Indian identities such as (what is called in English) “two-spirit” are capacitated as lived possibilities by a set of political and ontoepistemological formations separate from the formations considered in this article (respectively, the various knowledges and traditions of indigenous nations, and the eurocolonial biopolitical paradigm emerging from Enlightenment and imperialist sciences). This does not mean that these two sets of formations are not related in any way; rather, the violent history of eurocolonial power has fundamentally affected the lives that are capacitated by indigenous knowledges and traditions (see Qwo-Li Driskill, “Stolen from Our Bodies”). However, to fully account for this relation between the two sets of formations and their responses to gender variance would require much more than I can provide in this essay, and would exceed the limitations of my own experiential grounding.
Elsewhere in rhetoric and communication studies, scholars have considered the role of stigma against transgender people in their experiences of health care; see Kami Kosenko et al., “Transgender Patient Perceptions of Stigma in Health Care Contexts”; Kosenko et al., “Patient-Centered Communication: The Experiences of Transgender Adults”; and Jan S. Redfern and Bill Sinclair, “Improving Health Care Encounters and Communication with Transgender Patients.” For analyses of “transgender” as an identity category in legal and public rhetorics, see Isaac West, “What’s the Matter with Kansas and New York City? Definitional Ruptures and the Politics of Sex”; and Doug Cloud, “Toward a Richer Rhetoric of Agency: Shaping the Identity Category Transgender in Public Discourse.”
Segal summarizes the traditional sense of “epideictic” as a distinct type of rhetoric: “Aristotle identifies three occasions for rhetoric: deliberative, forensic, and epideictic. Deliberative rhetoric is speechmaking directed at the future, he says; its business is exhortation and dissuasion, and its exemplary genre is the political speech. Forensic rhetoric is speechmaking trained on the past; its business is accusation and defence (sic), and its exemplary genre is the advocate’s summation in a court of law. Epideictic rhetoric is the rhetoric of the present; its business, Aristotle says, is praise and blame, and its exemplary genre is the funeral oration. Epideictic rhetoric is a culture’s most telling rhetoric, because, in general, we praise people for embodying what we value, and we blame them for embodying what we deplore” (61).
To be clear, I am distinguishing between “gender reassignment” and “gender transition” for the sake of separating the treatment protocols involved in transmedicine (“reassignment”) from the broader process of making one’s gender known to the world (“transition”). (Chu herself uses the term “transition” to refer to both.) I use the term “gender reassignment” here with the same wariness that Aren Z. Aizura expresses along with his use of this term: “In recent years some have begun using gender affirmation or gender confirmation as a way to signal that trans body modification brings the body in line with an individual’s true gender identity. Although these terms’ cultural ascendance reflects an increased acceptance that body modification is necessary to trans mental health, I question whether the language of affirmation/confirmation invests in the idea that everyone has a ‘true’ gender identity that has always been, and that surgery merely reflects that inner, lifelong identity. Hormonal and surgical body modifications should be available without the need to affirm a primary gender identity. Thus I have retained gender reassignment as a term while acknowledging its inadequacy to describe the complexity of the embodied, psychic, and social practices to which it refers” (12-13).
Cf. Catherine Chaput, “Rhetorical Circulation in Late Capitalism: Neoliberalism and the Overdetermination of Affective Energy.”
Rose draws most prominently on the theoretical work of Michel Foucault, who originally introduced his own notion of “biopower” in his History of Sexuality, Volume 1: An Introduction, asserting it as a form of power emerging in Europe’s seventeenth century related to what he had elsewhere called “discipline.” While discipline is oriented toward the physical body and its capacities (“an anatomo-politics of the human body”), biopower is oriented toward “the species body” as a living form (thus “a bio-politics of the population”) (139). In his own development of this concept, Rose points out that the distinction between these two forms of power has tended to “blur” as Foucault and others have traced the ways that “different authorities seek to act upon the one through action upon the other” (The Politics of Life Itself 53). Ultimately, Foucault himself would gravitate toward emphasizing biopower (i.e. management of and intervention into forms of life) over disciplinary power (management of and intervention into particular bodily capacities). For a useful application of both concepts in the context of the regulation of transgender people in particular, see Dean Spade, Normal Life, 50-72.
The role of “particular ends” with regard to biopower and biopolitics becomes clearer when considered in the light of Foucault’s work on the concept “governmentality,” which he began developing at about the same time as his turn toward biopolitics. In his 1978 lectures on this concept, he argues that “government” emerged in Europe’s sixteenth century as a theory of state power that referred to the total exercise of management within the state, from fathers, teachers, tradespeople, up to and including the head of state (93-94). Foucault argues that this form of power is essentially economic, rather than prohibitive. Whereas older forms of power were based in prohibition and punishment, for government “it is not a matter of imposing a law on men, but of the disposition of things, that is to say, of employing tactics rather than laws”; in other words, the action of governing is “arranging things so that this or that end may be achieved through a certain number of means.” And since “the end of government is internal to the things it directs,” whatever is to be governed must thus be described, measured, analyzed, and subsequently managed in order to achieve its “perfection, maximization, or intensification” (99). In his own elaboration of the concept, Rose writes that government, as a form of power, is “a certain way of striving to reach social and political ends by acting in a calculated manner upon the forces, activities and relations of the individuals that constitute a population”; such ends include “security for property and wealth, profitability and efficiency of production, public virtue, tranquillity (sic), and even happiness” (Governing the Soul 4-5). Paired with governmentality, biopolitics thus describes the way that certain concrete ends become instantiated as calculable and achievable outcomes at the level of both the individual subject and the governed population.
It’s instructive to consider who exactly may be denied treatment on the basis of such norms of consent. In a recent participant-observation study of diagnostic criteria at an Australian clinic, Riki Lane notes that clinicians may delay treatment due to medical, social, or psychiatric contraindications such as “extreme obesity,” “homelessness,” or “active psychosis”; further, clinicians may actually deny treatment to patients who are judged to have “alternate diagnoses such as severe autism or medical complications” that would (in this view) hinder the facilitation of transition care. Regarding the former (delay of treatment), the criteria appear to come from an attitude of pragmatism, but it’s noteworthy that each example is also a category that is otherwise stigmatized and pathologized. Regarding the latter (denial of treatment), the implication is more concerning. One participant states: “We’re seeing a lot more younger people…with not only gender variance but broader identity disturbance. That’s one of the tricky parts, one of the diagnostic dilemmas” (220). Given that this quote appears directly above Lane’s explanation of cases in which treatment may be denied, and given that Lane elsewhere includes autism as an example of “broader identity disturbance,” this suggests that, for patients who are both trans and autistic, clinicians are likely to factor into their judgment an implicit evaluation of the “severity” of the person’s autistic traits. While this may involve pragmatic questions of whether particular behaviors will interfere with the administration of treatment, it seems more likely that clinicians perceive autistic traits as risk factors that lessen the potential for good treatment outcomes as such. This is concerning on its face, but it’s even more concerning given two other factors. First, as Melanie Yergeau points out, researchers frequently suggest that autism and gender variance are actually correlated (70); why, then, should autistic behavior be regarded as a risk factor in gender transition? Second, Yergeau also details the entanglement between the history of transmedicine and the history of research into and treatment of autism. As she explains, the same cohort of researchers at UCLA operated the Gender Identity Clinic (GIC), the Feminine Boy Project (FBP), and the Young Autism Project (YAP); while the GIC occasionally referred (adult) transgender patients to receive more affirmative treatment elsewhere, both the FBP and the YAP were expressly intent on eradicating gender variance and autistic behaviors, respectively. The techniques developed in these latter two programs formed the basis for what has become known as Applied Behavior Analysis, or ABA, a process denounced as abusive by autistic self-advocates yet still frequently used to “recover” autistic children at the behest of their parents and/or doctors (101-115). This historical relation is significant, then, because it suggests an overlap in the bases of clinical expertise regarding autistic life and trans life. To frame these two forms of life as contraindications thus contributes to the erasure of their entangled emergences, and it threatens, in particular, the possibilities of life at the intersection of these two experiences.
Segal compares this “in-forming” (62) function of epideictic rhetoric to both Louis Althusser’s notion of interpellation and Maurice Charland’s notion of constitutive rhetoric (64), and she draws on the example of blogs and websites that celebrate such pathologized phenomena as eating disorders or self-harm, which “create the conditions under which one might form the idea of the attractiveness of surgical manipulation or self-mutilation” (63, emphasis in original). Obviously, I don’t intend to draw a comparison between being transgender and having an eating disorder or compulsive self-harming—but Segal’s work is instructive here in that she indicates the way that epideictic wields its force at the level of form, pressing upon those who participate in it to recognize and reproduce the tropic and generic forms that carry its values forward. We might consider this to be another way in which epideictic (in distinction to deliberative or forensic) rhetoric addresses the present (in distinction to the future or the past): this type of rhetoric instances its suasive force at the present moment of our lives’ ongoing emergence, such that the very forms of our experience take shape along with (or in defiance of) the grain of epideictic.
In the print edition of the newspaper, Chu’s piece was titled differently: “Surgery, Hormones, But Not Happiness.”
Many of the replies to her tweet announcing the essay’s publication were from other trans women who simply stated that their experiences with transmedicine did not match the description Chu gave of her own experience. See also Kristen Browde’s and Nathaniel Frank’s letters to the editor published several days after Chu’s essay.
In a reply to a tweet posted the same day as her essay’s publication, Chu responded to a question regarding peer-reviewed research indicating that trans people overwhelmingly experience positive psychological outcomes after gender reassignment. She asserted that she did not view such research as trustworthy because of its disciplinary leanings (“i don’t trust sociologists farther than i can throw them”), and because of trans people’s structural incentives toward redeploying the accepted narratives of transmedicine. Some respondents interpreted this tweet as a suggestion that interview-based studies of transmedicine (or even trans people themselves) were de facto untruthful. However, as indicated below, there is historical research indicating a structural tendency toward the rhetorical dynamic that Chu suggests—though, this appears to be more common in the context of medical and psychiatric interviews, rather than sociological ones. (Chu acknowledges in her tweet that she is conflating these scenarios.)
The same day that Singal’s article appeared online, trans writer Julia Serano posted a Twitter thread responding to these misrepresentations and linking to several of her articles addressing the broader controversy over “detransitioning” in transmedicine. See in particular “Detransition, Desistance, and Disinformation.”
Although biopolitical frameworks share with social construction frameworks an emphasis on the historical contingency of power relations, they differ in that the latter tend to assert strategies of breaking down or otherwise exiting such structures in order to establish a state of freedom, while the former have tended to insist that there is no political subject outside of historically contingent structures. This includes the forms of affect and desire that make up contemporary subjectivities. Rose, in particular, has argued that all theories of “the self” as a psychological or political entity are themselves part of the contemporary structure of biopolitical government. The discipline of psychology, most importantly for his purposes, ought to be understood first and foremost as “an ‘intellectual technology,’ a way of making visible and intelligible certain features of persons, their conducts, and their relations with one another” (Inventing Our Selves 10-11). That is, the “selves” that we attribute with desires, flaws, virtues, and genders are inevitably formed and shaped by the networks of tools, concepts, and experts that take up the task of measuring and explaining the self. However: the point here is not to demand freedom from psychology and its concepts (such as “happiness”). Rather, the point is to take stock of the way that psychology (or other such structures) enables our relations to our “selves,” and then to work toward (as Rose puts it) “turn[ing] programs intended for one end to the service of others” (36). A concept such as “happiness,” then, has real effects in shaping the lives of cis and trans people alike, and the work of trans politics with regard to such a concept is not to debunk the reality of that happiness as an achievable end but rather to reorient the force of that concept toward more equitable ends.
This overdetermined relation results, Elizabeth Stephens notes, from the double meaning of “normal” that formed through the genealogical emergence of this term. Making use of Georges Canguilhem’s work on this subject, she explains that as the term “normal” was first used in the mid-eighteenth century, it “appeared in two highly specialized and apparently distinct discursive locations: geometry, in which it was used as a less common synonym for a perpendicular line; and, second, anatomy, in which it was paired with, and used in opposition to, the ‘pathological’” (142). After this concept was transported into the (then-new) science of statistics in the late-nineteenth century, it came to mean “both statistically most common and socially preferable,” that is, “the average and also an ideal” (143). The concept “normal,” then, effects a fusion between a quantitative mean and a qualitative value, and at the same time it effects a partition between an unacknowledged standard and other, highly visible variants—that is, the “pathological.” Thus, by taking up this oppositional relation between “normal” and “pathological,” disciplinary structures such as medicine posit a need to observe, regulate, and police that relation.
Historians of transmedicine roughly mark the beginning of this turn with the closing of many of the more conservative university-based gender clinics, sparked by the publication of a negatively evaluative report by the psychiatrists Jon Meyer and Donna J. Reter in 1979 (Meyerowitz 267-268), and the formation (also in 1979) of the more liberal Harry Benjamin International Gender Dysphoria Association (Meyerowitz 255).
Recall the function of “ends” in Foucault’s notions of government and biopower—through their measurement, definition, and description, ends such as “happiness” simultaneously orient and justify the force of interventions into individual and collective life. Ahmed, for her part, does not specifically connect her discussion of happiness to Foucault’s work on government and biopower. But I would argue that her analysis may be understood as complementary to that of Foucault and Rose, in that she considers the ways that desires and emotions emerge within a material, political ecology of power that is structured by the forms and genres of the liberal, post-Enlightenment, eurocolonial world.
See Ahmed, Queer Phenomenology. In this text, Ahmed turns the phenomenological concepts of “object” and “orientation” toward the ends of queer feminist and post-colonial analysis of power structures. Her use of these terms, then, is intended to show how the phenomenological body is shaped by its surroundings, such that some actions are possible and others impossible. Building from “[t]he radical claim that phenomenology inherits from Franz Brentano’s psychology,” that “consciousness is intentional: it is directed toward something,” Ahmed claims that an “object” may be understood as “an effect of towardness”—that is, “by being posited as a thing, as being something or another for me” in the terms of one’s own phenomenological world, an object “takes me in some directions rather than others” (27). This aspect of “towardness” and “directedness” leads her to specify that “orientation” (her term for a non-reductive version of mind-body involvement in the world, i.e. consciousness embodied) may be understood as a set of relations to various objects arranged in a particular way, some near, some far, some central, some off to the side, some entirely unreachable. Thus, she explains, “Orientations shape not only how we inhabit space, but how we apprehend this world of shared inhabitance, as well as ‘who’ or ‘what’ we direct our energy and attention toward” (3). I make use of Ahmed’s work in my own argument, then, because it nicely connects the biopolitical emphases of Rose and Foucault with the more traditional rhetorical concept of epideictic as described by Segal. While Rose and Foucault describe the ways that power structures posit particular “ends” as objects of action for subjects as well as particular elements of the subject as objects of intervention for institutions, Segal describes the ways that rhetorical subjects take on forms of experience that are circulated by culturally powerful networks of influence. These two accounts are clearly related, but it’s not immediately clear how best to put them into conversation with one another. I think Ahmed’s phenomenological framework plays this role well, because her attention to the individual body’s involvement in its surroundings opens up a relation between the immediacy of embodied experience and the circulation of particular interests, objects, and forms of directedness. As she explains: “Bodies hence acquire orientations through the repetitions of some actions, over others, as actions that have certain ‘objects’ in view” (58).
In their response to Chu’s essay, Ashley writes: “But neo-vaginas heal. They heal well and they stop hurting. Our bodies don’t ‘regard the vagina as a wound’ nor do neo-vaginas ‘require regular, painful attention to maintain.’” When others responded to Chu on Twitter to point out this problem with her language, Chu explained, “this is an editorial thing unfortunately, i had a lovely metaphor about how your junk gets delicately turned inside out (‘think, slicing a mango’) but it made one of the editors too squeamish [eye-rolling emoji].” Some trans women also pointed out that this framing is a hallmark of transphobic and transmisogynist rhetorics. The argument that trans people (and trans women in particular) are fundamentally “wounded” or “mutilated” is one that goes back decades, at least to the publication of Janice Raymond’s The Transsexual Empire in 1979, and it often functions as a metonymic argument that the real problem with trans people is that they are dangerously psychotic. Take, for instance, this excerpt from a letter to the editor published in the lesbian newspaper Coming Up in 1986, addressing the figure of the lesbian trans woman: “He is not a lesbian, he is a mutant man, a self-made freak, a deformity, an insult. He deserves a slap in the face. After that, he deserves to have his body and his mind made well again” (qtd. in Stryker 110).
To suggest that sometimes transsexual women do get bottom surgery because they believe a vagina would look better than a penis is, counterintuitively, entirely to Chu’s point: at a subjective level, trans people want what they want because they want it, not because it is the expression of a political or metaphysical identity. Norms of appearance, sensation, and utility—with regard to vaginas, penises, or any other fleshly form—help shape those wants, one way or another. Thus it’s both no coincidence that most trans women desire to have their genitals surgically reconstructed to form vaginas and not at all contradictory that some trans women prefer to have genitals that are formed in some other way. Even in purely theoretical terms, a norm only functions as a norm as long as there is some variability for it to assess and regulate.
Denny suggests that this category of patients (“drag queens and street hustlers”) “often were not transsexual” (12). That assertion obviously adopts some dubious assumptions regarding whose claims of trans identity ought to be taken seriously and why—it’s likely that her perspective is both reliant on and conscious of the history of antagonism between and among the various groups of gender-variant people in the mid-twentieth century. These conflicts can be understood as just part of the process of identity distinction, but they must also be recognized as tied up with anxieties and prejudices over class, race, and sexuality. For example, “transvestites” were often white, middle-class, and “heterosexual” (in the sense of identifying primarily as men who love women), whereas “drag queens” (or “street queens”) were often poor and working-class people of color who primarily had sex with men. (For a discussion of these distinctions and the shifting antagonisms between them, see Meyerowitz 168-207.) In the case of the clinics that Denny discusses, it’s important to note that the norms of appearance and expression were often combined with (or refracted through) these norms of race, class, and sexuality. Consider, for example, the assertion of a clinician quoted in a 1982 sociological article: “We’re not taking Puerto Ricans any more; they don’t look like transsexuals. They look like fags” (Billings and Urban 275).
It ought to be no wonder, then, that patients (and prospective patients) frequently altered their biographical narrative, or even fabricated it entirely, to meet the expectations of the clinicians. In some sense, this is only a reasonable extension of the narrative-shaping that the clinical paradigm wrought on the future of the patient. It certainly, as Prosser points out, matches the logic of relying on a diagnostic premise that assigns transsexual identity to a retrospectively spoken narrative: “The diagnosis is premised on the belief that autobiography can and should function mimetically—narrative mirror to transsexual nature. While clinicians evidently fear the deliberate artifice of the transsexual narrator (author as fraudster), they yet appear to remain quite ignorant of the ways in which the autobiography is fundamentally constructed as narrative: a telling, a representation, the life thoroughly contingent on the form” (110).
Prosser emphasizes the literal, material implications of such tropes as “coming home” and “arriving in the right body,” with regard to sex reassignment surgery in particular: “What makes the transsexual willing and able to submit to the knife—the splitting, cutting, removal, and reshaping of organs, tissues, and skin that another might conceive of as mutilation—is the drive to get the body back to what should have been” (83). The sense of “movement” that tends to structure narratives of reassignment, according to Prosser, is less about “crossing over” and more about a return to a longed for ideal: “The body of transsexual becoming is born out of a yearning for a perfect past—that is, not memory but nostalgia: the desire for the purified version of what was, not for the return to home per se (nostos) but to the romanticized ideal of home” (84). Prosser’s argument thus indexes the same norms of bodily being that Chu references in her essay, and both writers productively uncover the nuances of cross-gender-identification as a form of knowingly desiring a physical ideal.
Along the same lines, C. Riley Snorton points out that Jorgensen’s public renown shows how, in contrast to the population of Black Americans suppressed and devalued by racial segregation during the same era, a white transsexual like her was “not beloved but somehow incorporable” (142). In evidence of this, he displays a set of newspaper stories and magazine profiles from the same mid-century period; the Black trans women and “female impersonators” featured in these pieces were explicitly contrasted with Jorgensen in terms of their mobility, economic status, and vulnerability to police harassment (157-166).
Thus, as shuster points out, the inherent inconclusiveness of medical or psychiatric attempts to “verify a transgender identity” tends to be displaced onto the patients themselves, such that clinicians pose on behalf of the patient “an expectation to be ‘100% certain’ of initiating trans-related interventions” (“Uncertain Expertise” 325). As a result, trans people who are nonbinary, neuroqueer, and/or otherwise abnormal (in the terms of transmedicine’s authorized patient narrative) are forced to defend and continually reaffirm their need for care.
For example, Aizura analyzes this as an example of “entrepreneurialism of the self”: if the institutions of neoliberal society “reward calculation” and “penalize behavior that does not competitively seek self-satisfaction,” then people who are trans will perceive their transition as a project of individual self-enhancement (142-143).The concept of “entrepreneurialism of the self” was first introduced by Michel Foucault in his 1979 lectures on biopolitics and governmentality (The Birth of Biopolitics 225-226); Aizura’s use of the term is also influenced by Wendy Brown’s work on neoliberalism and democracy. See also Aizura’s argument that contemporary biopolitical structures orient trans people toward notions of “infinite perfectibility” that form their desires for and understanding of transition care (47).
Foucault locates a particular sense of personal risk at the heart of neoliberalism’s reduction of life to economic rationality. That is, he argues that the form of “economic analysis” that neoliberalism adopts as a basic explanation for human conduct—a dynamic of “substitutable choices…in which scarce means are allocated to competing ends” (The Birth of Biopolitics 222)—needs to be understood as an application of a liberal, empiricist notion of “interests.” With reference to the Enlightenment philosopher David Hume, he explains that this model of the “subject of interests” posits a fundamental distinction between good and bad at the level of the individual person’s experience of choice: “The painful or non-painful nature of the thing is in itself a reason for the choice beyond which you cannot go.” That is, this distinction “is a sort of irreducible that does not refer to any judgment, reasoning, or calculation.” This means, Foucault argues, that for this model of the subject “the principle of my choice really will be my own feeling of painful or not painful”; hence, “interest” really means “an irreducible, non-transferable, atomistic individual choice which is unconditionally referred to the subject himself (sic)” (272). By adopting this definition of interest, neoliberal models of human conduct pose economic choice not as a function of pure rational decision (as some have argued) but rather as an irreducible uncertainty that must be submitted to rational processes. Foucault explains: since, in this model, interest takes the form of a set of choices that address the undisclosed (possibly painful) future, it necessarily includes elements that are “involuntary, indefinite, uncontrollable, and non-totalizable”—and yet, he explains, these elements “found, as it were, the specifically individual calculation that he makes; they give it consistency, effect, insert it in reality, and connect it in the best possible way to the rest of the world” (278). In other words, this fundamental uncertainty is good and necessary because, under the laissez-faire macroeconomic principles of the neoliberal framework, only the free pursuit of interest on behalf of individuals can result in an overall collective good. But for such a collective good to occur, the facts of the result must remain absolutely unknown and unknowable: “Everyone must be uncertain with regard to the collective outcome if this positive collective outcome is really to be expected.” This is because “[t]he collective good must not be an objective” pursued by an interest, individually or collectively, since “it cannot be calculated, at least, not within an economic strategy” (279). What this means, then, is that the role of “risk” in neoliberalism is not simply a feature of economic analysis but in fact the basis of the individual’s relation to the world. To act in the world, to make choices, is—for the neoliberal subject—to risk pain; but more than that, it is to participate individually in the collective risk of pain. That is, this participation—again, in the form of the subject that neoliberalism provides—takes the form of a pursuit of individual safety, care, and economic support, under the presumption that some pain, for someone, is always at risk. The very form of the neoliberal subject is thus participation in risk, in networks of distribution of possible pain.
Ahmed argues in Queer Phenomenology that even as such norms form “lines” that restrict our objects and orientations, “accidental or chance encounters do happen, and they redirect us and open up new worlds.” Importantly, these encounters that deviate us may be happy or unhappy: “Sometimes, such encounters might come as the gift of a lifeline, and sometimes they might not; they can be lived purely as loss. Such sideways moments might generate new possibilities, or they might not” (19).
In dialogue with Che Gossett, trans artist Juliana Huxtable describes her own sense of ambivalence and uncertainty toward the epideictic rhetorics of visibility and performativity that have recently suffused mainstream accounts of trans life. She recounts, in particular, her experience with coming to understand the fractures (generational, racial, and political) in the “community” of trans life: “When I would meet older trans women, I would be like, Oh my god, how do you do it? Oh my god, what about hormones? Oh my god, what about your sex drive? How have you supported yourself? There was a kind of apprehension, almost a distance or a dismissive attitude toward me, when I would ask those questions. And I didn’t understand that. But I think it’s because so many people of an earlier generation had to go through so much. To have someone who, from their perspective, just decides to take estrogen one day and assumes that those experiences have a shared commonality with what they went through was almost insulting to these women. They were like, ‘You have no clue what I’ve had to do just to be able to exist in this way’” (43). Huxtable goes on to explain that she herself, much like the older trans women who regarded her approach with apprehensiveness, has come to regard newer forms of trans life with distance and suspicion. For example, she asserts that she has become more conscious of the racial privilege embodied by current norms of forwarding trans visibility through gender-bending: “The other day I started thinking about what passing culture signifies specifically for Black trans women. Passing is a means to safety, the ability to navigate the world with a bit of rest. It’s so very different from what a lot of white trans people experience. I think sometimes it’s easier for them to operate in a sort of genderqueer/genderpunk way, but as a privilege. You’re allowed to operate in the space of gender variance. But that space for us can really be—and feel—like a prison. I went through that stage of genderqueerness. And now I find little ways to hold onto my refusals. But I think it’s actually really radical to insist on an idea of beauty” (53-54). I would suggest that Huxtable’s sense of her own experience here, the negotiation among varying expectations and ultimate insistence on her own articulation of beauty, indicates the particular way that trans life forwards its own epideictic force. That is, Huxtable orients herself within the not-necessarily-cohesive trans community by settling on some notion of the good (the beautiful) that takes form in relation to the norms of gendered happiness (the beautiful woman). In this way, the ongoing, disharmonious emergence of trans life bears up forms of experience that are beautiful, good, and (indeed) happy.

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