(note: this was originally intended as a guest post, but then timing got all crazy. I think it will work nicely as an introduction instead, though.)

An important, interesting, and increasingly common question in the contemporary skeptical community is to what extent should social concerns like sexism, misogyny, racism, homophobia, etc. be incorporated into the overall agenda of skepticism. Are these things really the domain of skeptics? Are these kinds of issues something that skepticism should be addressing, or even can address, or are our energies better invested into “traditional” issues like theism, Bigfoot, psychics, natural medicine, homeopathy, creationism, and all that nutty goodness? The connections between these different sorts of issues and why skepticism can be valuable to addressing them aren’t too hard to make. After all, the same pining for a golden age that never was and belief in the inherent value of tradition for tradition’s sake that often justifies belief in the value of “traditional medicine” can also lead to steadfastly defending the sanctity of marriage, or nostalgia for the good ol’ days when men were men, women were women, and strict gender roles were brutally enforced. But there’s still a widespread hesitancy in our community to take such issues on directly.

Perhaps the desire to shy away from these more complicated and perhaps more subtle assumptions, misunderstandings and biases about gender, race, sexuality and so on is because they’re harder to unpack, harder to prove false with tests and scientific fact. But I’d imagine a large part of it is also that these assumptions are more intrinsically tied into our culture. They’re closer to us, more inherent, harder to identify because we’ve lived with them for so long, and perhaps most importantly, they’re harder to challenge because so much more of our society (and our own identities!) hinges on them. The woo is harder to see when it’s right in front of your nose, and gets harder to pull away the more is leaning on it. The social costs of accepting uncomfortable truths about race and gender are a bit higher than the social costs of accepting there’s no Loch Ness Monster. Some assumptions become so ingrained in a culture that even our science and medicine can get caught up in attempting to maintain them… so close that even people who are genuinely committed to the value of objective truth can miss their influence. That’s why not only is skepticism valuable to addressing these issues, but addressing them is valuable to skepticism. It’s hard to be an unbiased thinker when you’re immersed in a biased culture.

And that, after my long and rambly introductory paragraphs, brings us to my actual topic: the history of bias and assumptions about gender in the medical treatment of transgenderism.

It can be more than a little tricky to talk to skeptics about being skeptical of established science. That’s the MO of creationists, climate change skeptics, 9/11 truthers and homeopaths, after all. Science is our buddy, not the bad guy, right? Science welcomes doubt and questions and critique. And besides, we’re not in the 19th century anymore! Scientists aren’t measuring skulls to determine our predispositions for benevolence, melancholy or vice. We don’t compare racial phenotypes to animals and make claims about them representing “lower” evolutionary traits. Science isn’t biased anymore! It’s all good science now! …right?

The tricky part is that science and medicine is made up of human beings. Silly, irrational, gullible, wonderful human beings, possessed of exactly the same failings that make skepticism and the scientific method necessary in the first place. That’s as true today as it ever was. And as mentioned, the more ingrained an assumption is, and the more is dependent on it, the harder it becomes to exercise that skepticism.

Gender is something VERY close to us, and upon which a great deal rests. Not just socially, but for each of us, as individuals. We all want to feel secure in our gender, that it’s stable and unwavering. It’s one of the core aspects of our identity. You might even say it’s the first aspect of our identity. Before anything else about who we are has been established, the question gets asked: is it a boy or a girl? Doctors want to maintain the stability of that aspect of our identity as much as anyone else, and have just as much at stake, and that can get in the way of maintaining a truly objective approach to the times that it isn’t quite stable, binary and fixed. And on top of that, considering your patient’s quality of life also means considering how they’re going to fit into the world and live in it.

Intersexuality and transgenderism pose a strong threat to the stability of gender. They’re the loose threads in the comfy sweater of gender binaries. The existence of such people makes it clear that we can’t treat the concepts of “male” and “female” as binary, mutually exclusive opposites that stay fixed and stable. They overlap, bleed into one another, are mutable and composed of all kinds of different things that can occur in all kinds of different combinations… chromosomes, hormones, primary sexual characteristics, secondary sexual characteristics, gender identity, gender expression, sexual orientation, the ability to tell “eggshell” from “beige”, etc. Trans women also pose an additional cultural threat to the assumption that maleness and masculinity are naturally superior and preferable to femaleness and femininity. So an interesting problem comes up: how do you deal with these patients, meet their needs, address the realities they represent but still maintain the ideas of gender upon which so much of our society and identities are based?

From the moment it became a medical possibility, gender transition had to be treated not as a fundamental right or choice, but only as an extreme, last ditch, no-other-choice kind of thing to be employed only when all other options had been exhausted and the patient was on the brink of self-destruction. A system had to be arranged to weed out the “true transsexuals” who were “really” members of their identified sex from anyone who might simply “want” to change sex, or be merely “confused”. At the same time, such a system would make sure that the boundary between genders wasn’t compromised, that there was still a clear division with men on the one side and women on the other.

So… enter the World Professional Association for Transgender Health (WPATH) and their Standards of Care. This organization created a protocol for doctors and caregivers to follow when diagnosing and treating transgender patients. This served a dual purpose. The cuddly, friendly, totally reasonable purpose was providing functional diagnostic criteria, a system for making sure the patient was well-informed and able to manage the huge stress of transition, ensuring that their decision was genuine and not affected by other mental health issues, protecting the patient’s safety and well-being, and making sure they understood what treatment entailed and took the decision seriously, carefully and unhurriedly. The other, creepier, un-cuddly purpose was making sure that the patient conformed to the social expectations of gender and challenged them as little as possible. The WPATH standards of care were largely about protecting the patient, but also were about protecting everyone else from what the patient implied.

An excellent example of the kind of thing the standards of care entailed was the requirement for Real Life Experience (RLE for short, also known as the Real Life Test). This is a requirement that the patient live full-time as a member of the sex to which they are transitioning for a certain period of time before being eligible for certain treatments. This is ostensibly about ensuring that the patient can function in the new role, can adapt to the change, and will be genuinely happier and more comfortable in the new identity. There is, however, an un-cuddly aspect, of course: making sure the patient can properly conform to their new gender role and all the expectations that go with it. A notably problematic version of the RLE requirement was that in early days, it was necessary even before being eligible for hormone replacement therapy. This was hugely dangerous for the patient as very few trans people, even those who would be fully able to “pass” during and after transition, are able to do so prior to taking hormones. The consequence is a sort of “weeding out” (by proxy; through intolerance, discrimination and social enforcement of the binary) of those patients most likely to end up being visibly gender variant and therefore threatening to cisgender assumptions. It protected the cultural institutions of gender at the expense of posing a risk to the patient’s wellbeing, and potentially their life. While this particular requirement (RLE before hormones, that is) has been eased in most developed nations, it’s still in effect in some places, such as in the UK under the NHS (though I understand that it can be bypassed if you’re able to afford a private practice, like Dr. John Curtis in London). RLE requirements are still widely in effect for SRS, though…this can pose problems for those patients who have non-binary, genderqueer or androgyne identities, those who are only interested in SRS but not interested in social transition, and for butch or tomboy-ish trans women and effeminate trans men who may be considered to not “really” be living or presenting as the target sex.

What, exactly, does it even mean to live and function as female or male? It’s important to note that the standards of femininity and masculinity trans people were expected to live up to were typically outdated and far more stringent than the standards cis people were expected to meet. A cis woman doesn’t have to wear make-up every day in order to be considered living-as-female, does she? This disparity in gender role expectations has eased over time, but it’s still very much in play.

Another notable issue with the gatekeeping system was that patients were usually strongly encouraged to cut all ties with their past, take a new job, move to a new town, etc. This was justified as being about protecting the patient’s safety while helping consolidate the new identity. In actuality it would often be a humiliating, traumatic and emotionally devastating process that left the patient isolated, cut off from their support networks and often times unemployed (or forced into sex work). But no worries! The payoff is that no cis person ends up having to deal with the discomfort of knowing someone is trans, and our community gets quietly shuffled off into invisibility. This was perhaps the most clear-cut example of placing the gender binary ahead of the needs of the patient.

Where it gets cool and skepticky and a little more fun, though, is how the gatekeeping system ended up playing out amongst the researchers and doctors themselves. In order to be eligible for treatment, a trans person had to present with a very specific narrative and meet a specific set of criteria. Trans women, for instance, had to be sexually attracted to men but to have never identified as gay or been sexually active as such or ever have strongly participated in that “lifestyle”. They had to desire genital surgery without reservation, they had to present with a very conventionally femme personality and style (like notoriously being expected to wear heels to all their psych appointments), and they had to present with absolutely no co-morbid disorders. But the trans community is small and tight-knit …we may squabble a bit, but we try to look out for one another and we love to share information. It didn’t take long at all for trans people to learn the “expected” narrative and presentation, and learn that their treatment depended on telling the doctors what they wanted to hear. So when various research and surveys were conducted trying to understand transgenderism, their distrust of the medical establishment came into play, and the subjects responded with the answers they’d been taught to give rather than their actual experiences and feelings. The distorted data came back to the doctors and ended up being used as proof that their initial assumptions were correct, and as further justification for maintaining the gatekeeping system that produced those answers in the first place.

They approached the subject of gender and transsexuality with a certain set of assumptions in mind, created a system that distorted the reality into a reflection of those assumptions and forced any individuals whose narratives would contradict the assumptions out of the data, and then took the results that system produced as evidence that the assumptions were correct all along. Rather not unlike someone going to visit a psychic with the assumption that it works, offering verbal and body language cues to the psychic to work their cold read, ignoring the misses while paying exaggerated attention to the hits, and then walking away from the experience taking it as evidence that their belief in psychic powers was correct all along. THAT is why skepticism is of huge importance to social issues like cissexism, and that is why these issues are valid concerns for skeptics to address.

Over the past decade or so, the gatekeeping system has finally begun to erode. While that’s partly due to the efforts of feminism and the gradual broadening of the way we understand and treat gender, and partly due to the hard work of LGBT activism and awareness, it’s also due to many good, skeptically-minded doctors and scientists recognizing that the realities didn’t match the narrative, recognizing that their patients histories needed to be recognized rather than stifled or treated as conditional for potentially life-saving treatment, and placing the importance of good science, critical thinking, and their patients’ well-being above the assumed realities of sex and gender. As the standards of care began to loosen, the predicted epidemic of regretful accidental transitioners never happened, the satisfaction patients expressed with transition improved, and overall cultural attitudes began shifting in the direction of tolerance rather than hostility. The horrible consequences the gatekeeping model sought to prevent never came to pass. Hurray!

So… I guess, when the question of how social issues like trans-feminism and skepticism are important to one another, or when people wonder about the connections between my being a skeptic, a feminist and an advocate for trans rights, I just reflect upon the fact that I was able to transition without ever once having to lie to my doctor or distort the truth. And I can go to my appointments in a t-shirt and jeans, rather than dressing up like I’m going to a cocktail party or trying to seduce the poor guy. Honestly, I don’t know how I could possibly be a skeptic, a feminist or a trans-rights advocate without the other two.