Inmates, Doctors, and Battle Over Trans Medical Care


Stephen Levine was born in 1942 in Pittsburgh. I wanted to be a doctor when I was little; he saw how much his parents and people in his community respected the profession. At Case Western Reserve University School of Medicine, he decided to go into psychiatry, attracted by how the field explored human history and biology. In 1973, while he was conducting his residency, Levine heard that his alma mater was looking to hire someone to develop a medical school curriculum in human sexuality. Levine got the job done. Over the next few years, he helped establish several clinics focused on sexual disorders in college. In 1974, he co-founded the Case Western Gender Identity Clinic to treat people who are unable or unwilling to live like the sex they were assigned at birth.

In the 1970s, when Levine entered the field, scientists and doctors had spent years discussing what “caused” the transness — and how to treat it. As Joanne Meyerowitz describes it in her 2002 book How sex has changed, from the middle of the 20th century onwards, two schools of thought competed for primacy. The first saw the desire to change the body through a psychoanalytic lens, as symptomatic of an unresolved initial life trauma or sexual difficulty. Initially, most psychiatrists belonged to this group, believing that doctors who helped their patients to physically pass only allowed their illusions. The attitude was summed up in the words of prominent sexologist David Cauldwell, who wrote in 1949, “It would be criminal for any surgeon to mutilate a couple of healthy breasts.”

The second field highlighted biological factors. While its adherents generally accepted that a patient’s upbringing and environment could influence their gender identity, they considered that a person’s chromosomal or hormonal makeup was more important. Prominent figures, including endocrinologist Harry Benjamin, have reported that “curing” transness through discussion therapy was almost always failed, in which case he favored a different intervention: “If it is evident that the psyche does not it cannot be brought into sufficient harmony with the soma, then and only then is it necessary to consider the reverse procedure ”.

As these fields emerge, some trans people have continually pushed against their prospects, insisting that transness was not a medical disorder and that access to hormones and surgery should not be predicated on approval. of cis and male doctors. In the late 1960s and early 1970s, some trans people tried to organize their own treatment clinics, providing advice and support from peers and referrals for surgery.

However, these clinics did not survive, and the primary medical model continued to engage. In his research and scholarly work, Levine relied on the psychoanalytic approach, theorizing that the desire for transition was a way for his patients to “avoid painful intrapsychic problems.” She discovered what she considered the potential causes of these feelings, including a “too long, overly symbiotic” maternal relationship. When a person declared himself transgender, he liked to say, it was the mind’s attempt to offer him a solution. In psychotherapy, patients could interrogate and resolve the problem that gave rise to these feelings. As in other clinics across the country at the time, Case Western has offered surgery to a few transgender patients — about 10 percent since 1981. Many trans people were frustrated by this approach, but at least they found a degree of sympathy and of understanding at clinics like Levine’s. They were seen as people in need of treatment rather than as deviant.


Through the 70s and 80s, Levine’s stature grew. His clinic has attracted patients and published articles in prestigious journals. In the early 1990s, however, the scientific consensus among trans health care providers and researchers began to move away from psychoanalytic theories. More people have seen evidence of innate biological factors. A growing proportion of providers argued — with ever-increasing quantitative data to substantiate their claim — that medical interventions were more effective than therapy in relieving gender dysphoria. An area of ​​the human brain connected to sexual behavior is larger in men than in women. In 1995, a reference study published in Nature found that this area was the same size in trans women as in their cisgender peers, regardless of their sexual orientation or whether they had taken hormones. The finding suggested that “gender identity develops because of an interaction between the developing brain and sex hormones.”

Two years after the Nature study came out, Levine was named chairman of a committee of the International Association of Gender Dysphoria Harry Benjamin, the nation’s primary organization for medical providers caring for trans people. The most important role of the organization was to develop and publish a regularly updated document that describes best practices for diagnosing and treating trans people, called Standards of Care. Levine has been invited to lead the team producing the next update, the SOC 5.

The revision of the standards has been a process for years. In 1997 the organization held its biennial conference in Vancouver, British Columbia. Jamison Green, a trans man and a health activist who was then living in San Francisco, came to the event to find that he was one of the few trans people present. “It wasn’t a welcoming environment,” he tells me. “They weren’t happy to see it.” Levine was due to lead a Saturday afternoon session on the draft standards plan. Green was sitting in the auditorium, waiting for the event to begin, when he heard a commotion outside. Technically, the meeting was open to members of the public, but there was an expensive registration fee. Many other trans activists, particularly those living locally, were outraged that, due to the high price, they had essentially been excluded from a meeting that would directly influence their care. They “started knocking on doors and asking to be let in,” Green says.

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