Anatomical Authorities: On the Epistemological Exclusion of Trans-Surgical Patients.

Medical Anthropology Cross-Cultural Studies in Health and Illness

ISSN: 0145-9740 (Print) 1545-5882 (Online) Journal homepage: http://www.tandfonline.com/loi/gmea20

Anatomical Authorities: On the Epistemological Exclusion of Trans- Surgical Patients Eric Plemons To cite this article: Eric Plemons (2015) Anatomical Authorities: On the Epistemological Exclusion of Trans- Surgical Patients, Medical Anthropology, 34:5, 425-441, DOI: 10.1080/01459740.2015.1036264 To link to this article: http://dx.doi.org/10.1080/01459740.2015.1036264

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Date: 09 November 2015, At: 22:46

Medical Anthropology, 34: 425–441, 2015 Copyright © 2015 Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI: 10.1080/01459740.2015.1036264

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Anatomical Authorities: On the Epistemological Exclusion of Trans- Surgical Patients Eric Plemons School of Anthropology, University of Arizona, Tucson, Arizona, USA

American feminist health activists in the 1970s created representations of genital anatomy intended to replace the abstracted images of biomedicine’s ‘modest witness,’ with what Michelle Murphy has called the ‘immodest witness,’ authority explicitly derived from personal and embodied experience. Decades later, a feminist publication in the tradition of the immodest witness called Femalia was adopted into the practice of an American surgeon specializing in trans- genital sex reassignment surgery (GSRS). Based on ethnographic and textual research, I show how oppositional claims to represent the ‘natural’ female body—one valued for its medical objectivity and the other for its feminist subjectivity—effectively foreclosed these as modes of authority through which the trans- patient might contribute to her surgical care. I argue that trans- patients’ double epistemological exclusion contributes to a broader asymmetry in the use of patients’ subjective reports in the everyday practice of GSRS and the clinical research by which it is evaluated. Keywords feminist epistemology, sex reassignment surgery, surgical practice, trans- medicine

I sat down to talk with Dr. Neal Wilson1 in his small and rather run-down office in suburban Detroit. Professional and personal upheavals had recently led him to relocate here from a grander office in a major medical complex some miles away. According to Wilson, his current professional and geographic displacement was the result of a ‘witch hunt’ carried out by a new generation of hospital administrators who were trying to keep him from performing genital sex reassignment surgeries (GSRS)2 at the hospital where he had been doing them for decades. Because he was basically working full-time to fight what he thought was an unfair and pointedly transphobic persecution, his surgical schedule was clear. As we talked, the shrill sounds of a daytime talk show clattered down the hall from where Wilson’s receptionist sat tending to an empty lobby. Wilson began his long-time work in GSRS around 1977. The opportunity came through the Medical Gender Identity Clinic of Detroit, then unofficially affiliated with Wayne State University ERIC PLEMONS is a member of the School of Anthropology, University of Arizona, Tucson, Arizona, USA. He has studied sex reassignment surgical practice in North America, South America and Europe. His book on facial feminization surgery is forthcoming from Duke University Press. Address correspondence to Eric Plemons, PhD, School of Anthropology, University of Arizona, P.O. Box 210030, Tucson, AZ 85721-0030. E-mail: [email protected]


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where Wilson was on the plastic surgery faculty. A gynecologist named Dr. Mario Petrini began running the clinic around 1966, and made a name for himself doing surgical revisions for transwomen,3 whose vaginoplasty (the surgical construction of a vagina and, usually, a vulva) from other surgeons had led to what he called “disasters.” As his reputation grew, Petrini began doing primary procedures himself and had nearly 300 patients requesting surgery at the clinic each year, although he could only treat a tiny fraction of them.4 In addition to his growing practice with male-to-female (MTF) patients, Petrini also performed hysterectomies on female-to-male (FTM) patients and arranged for a general surgeon to perform their bilateral mastectomies. When an FTM patient requested a phalloplasty (surgical construction of a penis), Petrini made a call to the plastics department. Wilson had had no direct experience with the procedure but decided to take on the challenge.5 He also began assisting with male-tofemale patients, and when Petrini left for the University of Minnesota in 1981, Wilson started to perform MTF genitoplasties on his own. He estimates that since that time, nearly half of his plastic surgery practice has been devoted to trans- genital reconstruction. Like other surgeons who perform GSRS, Wilson’s surgical aim is to produce ‘natural’ and ‘normal’ genitalia in order that patients’ bodies allow them to live as natural and normal men and women (Plemons 2014). But what counts as ‘natural’ and ‘normal’ genital anatomy is hardly a settled issue, especially where female bodies are concerned. In the introduction to their article on clitoral anatomy, O’Connell and colleagues describe the impact that the turbulent medical history of the female genitals continues to have on surgical practice. They write: Because surgery is guided by accurate anatomy, the quality and validity of available anatomical description are relevant to urologists, gynecologists and other pelvic surgeons. Accurate anatomical information about female pelvic structures should be found in classics, such as Gray’s Anatomy, the Hinman urological atlas, sexuality texts such as the classic Masters and Johnson Human Sexual Response or any standard gynecologic text. These texts should provide the surgeon with information about how to preserve the innervation and vasculature to the clitoris and related structures but detailed information is lacking in each of these sources. (O’Connell, Sanjeevan, and Hutson 2005:1189, emphasis added)

Echoing studies that have shown how social values and expectations have influenced the production of knowledge about female bodies, including how they are represented in medical texts and elsewhere (Lawrence and Bendixen 1992; Laqueur 1990; Moore and Clarke 1995; Schiebinger 1993), O’Connell and colleagues argue that surgically inadequate knowledge of female genital anatomy is “a result of active deletion rather than simple omission in the interests of brevity” (2005:1190). Faced with a dearth of adequate models, surgeons develop operative techniques tuned to their own sense of anatomical and functional ideals. Surgeons who perform female genital cosmetic surgeries (FGCS) and those who operate on the genitals of children diagnosed with disorders of sex development acknowledge that they work in reference not to established measurements, but their own sense of what looks right (Howarth, Sommer, and Jordan 2010; Karkazis 2008, 2010). Scholarly engagements with GSRS have paid little attention to operative technique, training critical attention instead to the processes of diagnosis and evaluation that precede a trans- person’s access to surgery (e.g., Butler 2001; Namaste 2000; Dewey 2008; Bolin 1988; Stone 1991; Rudacille 2005; Irvine 1990) and the ways that racial and cultural difference impact patients’ experience of these procedures (Aizura 2009, 2010; Swarr 2012; Roen 2001). As a result, the


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surgical work of trans- GSRS remains implicitly characterized mostly as a technical challenge— the complex surgical details of transforming ‘opposite’ genital structures from one to the other after the cultural and political work of access and diagnosis has been sorted out. Framing GSRS primarily as a technical problem not only confers an artificial and spurious stability to genital anatomies but also works to obscure the political, economic, and ethical specificities of how surgical technique in GSRS is created and enacted, treating technique as though it evolves apart from these conditions of its possibility. A technical framing also has the effect of authorizing surgeons as the only people with knowledge relevant to an analysis of GSRS practice, effectively subverting the contributions of patients on whose bodies these procedures have been performed. As a surgical intervention intended to enact a psychologically therapeutic effect, the postoperative outcomes of GSRS have proven difficult to assess. Lacking a consensus on esthetic and functional ideals and how to produce them (Plemons 2014), as well as a precise articulation of how particular surgical outcomes may be psychologically therapeutic while others may not, the ongoing development of GSRS practice and evaluation is primarily oriented to assessments of ‘patient satisfaction.’ Valued for its capacity to capture patients’ individual and subjective feelings about their surgical results, the centrality of ‘patient satisfaction’ in GSRS practice and evaluation also introduces a tension between the objective assessments of experts (surgeons) and the subjective assessments of nonexperts (patients) (Linder-Pelz 1982; Pauly 1981; Williams 1994). In both surgical literature and ethnographic research, I have seen this unequal dynamic result in an asymmetrical use of patients’ subjective inputs in the surgical scene.6 When patients’ subjective reports of either presurgical expectations or postsurgical results are favorable, they are taken as both confirmatory evidence of surgical success and also confer upon the patient the status of credible and competent reporter. When patients’ subjective inputs contradict surgeons’ sense either of presurgical capacities or postoperative results, that input is frequently taken as evidence of patients’ naïveté or ignorance, marking them as ‘impossible’ or ‘unreasonable’ people whose contributions lack credibility and are therefore easily dismissed. This kind of epistemological exclusion is enacted in a number of ways. In this essay, I show how the epistemological exclusion of transwomen patients was enacted in Wilson’s practice. In 2002, after performing GSRS for more than 20 years, Wilson asked his transwomen patients to identify their ideal genital surgery outcomes from a feminist collection of 32 color photographs of vulvas. Denied the authority of both the ‘modest witness’ of biomedical science (Haraway 1988, 1997b; Shapin and Schaefer 1985), and that of the ‘immodest witness’ whose authority is derived from a feminist claim to embodied experience (Murphy 2012), I show how transwomen’s participation in selecting ideal genital forms also ensured the surgical exclusion of their subjective input. Patient inputs and feedback on surgical outcomes has long been excluded on the grounds that ‘problem patients’ (Lorber 1975) are ‘non-compliant’ (Playle and Keeley 1998), incapable of participating in valued expert discourses (Fox 1993), establishing ‘realistic expectations’ (Honigman, Phillips, and Castle 2004), whose self-reported surgical outcomes vary considerably from those valued in clinical knowledge (DeVine et al. 2011). In addition to these, the unique surgical project of SRS can leave trans- patients in a space of additional exclusion. Lacking the technical expertise and moral authority valued in surgeons’ assessments of surgical work, and the embodied knowledge of living with female genitals authorized by the feminist literature to which his patients were asked to refer, in Wilson’s practice transwomen’s incapacity to assess their surgical outcomes was framed not only in relation to their nonexpert status, but crucially their nonfemale status, too. As a result of this double

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exclusion, patients could neither generate what he took to be reasonable preoperative expectations (of surgery or of genital anatomy) nor credibly assess postoperative results. I argue that this instance of using feminist images to solicit feedback on biomedical practices, in which oppositional claims to represent the ‘natural’ female body—one valued for its medical objectivity and the other for its feminist subjectivity—is one among a number of forms by which trans- patients’ authority to contribute to their own surgical care is effectively foreclosed, thereby rendering the story of GSRS a technical one limited to the study of surgical experts.

OPERATING IN ISOLATION Wilson began his work in GSRS in the late 1970s, just as the clinical and institutional organization of trans- health care in the United States underwent a major shift. Although a few American surgeons had performed genital sex reassignment surgeries in the 1950s and early 1960s (Meyerowitz 2002), comprehensive programs for evaluating patients and providing medical and surgical services did not emerge in the United States until the Gender Identity Clinic at Johns Hopkins University opened in 1966.7 Although interest in conducting research on the fascinating new problem of ‘transsexualism’ prompted the establishment of a number of university-based gender clinics around the country in the early 1970s, by the end of the decade they were rapidly closing their doors.8 Clinic closures and the concomitant reduction in federal social services under the Reagan administration resulted in a ‘treatment vacuum’ (Denny 2002:36) that preceded the development of a private, market-based system of trans- health care in the United States. Many surgeons stopped performing chest and genital procedures for trans- patients when they left the clinics. A small number of others went into private practice, adopting a more patientcentered approach than the clinics had offered (Bolin 1988; Meyerowitz 2002; Stryker 1999). Now isolated both geographically and by the dynamics of a competitive market, American surgeons began to set their own surgical priorities and develop their own technical styles. “No one gets trained in this business; you just train yourself,” Wilson told me of his GSRS technique. “No one’s ever trained us. We’ve always picked it up by ourselves. It’s highly individual.” This individual, stylistic difference remains in contemporary practice. A facial feminization surgeon with whom I conducted long-term fieldwork told me that he could look at the neo-vagina of a trans- woman and, 9 out of 10 times, tell which American surgeon had performed the operation. Surgeons’ stylistic choices and surgical priorities result in a kind of historically and geographically distinct corporeal signature that remains visible in/as the body. Wilson’s GSRS work had taken shape alongside the emergence of the Harry Benjamin International Gender Dysphoria Association (HBIDGA), the first professional organization dedicated to developing best practice treatments for people seeking hormonal and surgical sex reassignment (Matte, Devor, and Vladicka 2009). The biennial meetings of the HBIGDA provided opportunities for surgeons and other practitioners to share information about their practice but, then as now, membership and participation in the organization (which changed its name to the World Professional Association for Transgender Health in 2005) is optional. Practitioners make very different use of the organization; some take advantage of the collegial resources it offers while others use the credential of membership for little more than a marketing tool to attract new


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patients. Wilson’s participation in the early years of HBIGDA was beneficial to him, providing guiding information that changed his practice: Early on I was doing cosmetic work around the edges for Petrini. But Petrini didn’t leave any penis or glans behind for a clitoris. All he did was an anterior fourchette [a fold of skin where the labia meet], a posterior fourchette and two labia majora. I went to a Harry Benjamin [HBIDGA] meeting and some way or another I saw a presentation of a standard male penis being cut down and folded up leaving a lump of glans about the size of a thumbnail [to form a clitoris]. So I thought, we could do that. So I then started doing that. But as far as a model, there was basically nothing. You cut the pieces off. You fold the tissue up and it ends up looking like what it looks like. It’s basically the way the cut pieces of tissue end up folding, you know? If there’s excess anywhere you cut it off and sew it up. You end up with what you end up with.

Wilson’s story of how techniques have changed over time provides one way of understanding what for him—and for Petrini, at least at one time—constituted the ‘female’ in male-to-female sex reassignment. The central procedures were penectomy and vaginoplasty, the removal of the penis and creation of the vagina. Producing the clitoris and labia were of secondary concern, so much so that their features were determined more by what was left over after the central procedures had been finished. The effect of this approach was that the labia especially had no characteristics of their own but were simply the folds that ‘end up folding’ over and around the parts that occupied surgeons’ attentions. Despite its one-time utility to his practice, Wilson stopped attending the meetings of the World Professional Association for Transgender Health (WPATH) when they shifted from the ‘gentlemanly’ practice of corresponding through the postal service to a more vulgar and impersonal online platform. When we spoke, he acknowledged that he really did not know anymore what other surgeons were doing or where innovations were being developed. He had established his technique and had seen a steady stream of patients for decades. Surgical progress is often driven from behind by failures rather than pulled ahead toward a well-defined goal. Wilson had developed his own techniques through trial and error, and in response to his patients’ input. His practice was distinct, as were those of his American peers. Nearly 20 years after he began his GSRS work, Wilson solicited his patients’ surgical goals in a new way. In early 2000, he gave 23 MTF patients a copy of Femalia (Blank 1993), a small book containing 32 color photographs of vulvas. He “asked all the post-operative and immediately pre-operative MtF [sic] patients to choose, without any limitation on number, which vulvas they thought were esthetically most appealing, and which they would ideally choose for themselves” (Wilson 2002:np). In an article on this survey, Wilson stated that his patients’ responses constituted ‘impossible standards.’ This characterization introduced a disjuncture between his expert understanding of surgery and their lay misunderstanding. It also set up a later dismissal of patients’ postsurgical assessment of the kind that is ubiquitous in outcomes literature. As the article goes on, Wilson detailed through both text and photographs how he had changed a variety of techniques with the aim of producing the anatomical features that his patients had identified. I will address the particular forms of these desired characteristics in a moment, but first I want to focus on the models used to articulate them. A publication in the tradition of 1970s US feminist health activism, Femalia’s claim to know and represent ‘the natural body’ rested on a form of authority very different from the one that authorized Wilson’s expert surgical gaze, but one from which trans- patients would similarly be excluded.

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FEMALIA Femalia was created by Joani Blank. Now in her early 70s, Blank became a prominent feminist activist in San Francisco in the 1970s. In 1975, two years before founding Good Vibrations—the first fully-lit, woman-centered sex toy shop in the country—Blank founded Down There Press, the imprint under which she would go on to author or edit nearly a dozen books on sex and to publish many more. The idea to create a book of color photographs of vulvas grew out of her long-term work in women’s sex education and sex therapy. Part of the wave of feminist health activism in the 1970s, Blank and colleagues conducted masturbation workshops and encouraged women to explore and learn about their own genital anatomy and that of their friends. The need for anatomical self-discovery was articulated in response to what feminist activists saw as the inaccurate and otherwise inadequate representations of female anatomy presented in medical texts and popular guides to the human body. Books such as Our Bodies, Ourselves (Boston Women’s Health Book Collective 2011[1971]) and A New View of a Woman’s Body (Federation of Feminist Women’s Health Centers 1981) offered illustrations of female genital anatomy that seized the tools of vision through which medical authority is largely constituted, with the hope of marshalling them to different ends (Foucault 1973; Haraway 1997a). For Blank, a photographic collection demonstrating the variation of vulvas was a critical part of the movement to reclaim female genital anatomy and assert feminist authority over its representation. In the introduction to the first edition of Femalia, Blank lamented that “outside of ‘men’s magazines’ where the women’s genitals were often powdered and half-hidden, and the images often modified and airbrushed, women had no resource for photographic representations of vulvas” (1993:n.p.). The effect of this absence of representation, according to Blank, was that “a majority of women believe to this day that, in one way or another, their genitals are not quite ‘normal’” (n.p.). This claim illustrates an important strategy of the US feminist health movement that Nancy Tuana has called “the epistemology of ignorance” (2004, 2006). For Tuana, claims to what people do not know—in this case that their genitals are normal—should be “understood as a practice with supporting social causes as complex as those involved in knowledge practices” (2004:195). Resources such as Femalia were meant to respond to a type of ignorance that feminist activists saw as deliberately produced by medical doctors whose claim to expertise was produced, in part through the exclusion and devaluation of women’s experience of their own bodies. Feminist health activists leveraged embodied experience as an important source of female anatomical knowledge, but such epistemological grounding is by definition unavailable to those who occupy other kinds of bodies. “I really don’t remember anything about them,” Jill Posener told me of the women she photographed for Femalia in a makeshift, after-hours studio in the backroom of the original Good Vibrations store on Valencia Street. “They just lined up and, one-by-one, took their pants down and sat on the chair. Their faces weren’t in the photographs and they weren’t going to be identified, so it really wasn’t personal.” After the shoot, Blank selected the images that would be included in Femalia based on “variety mostly. And some of them are really great photographs. It was an esthetic decision on my part. There were four photographers and I took eight from each. If there was something else, I don’t remember it.” Most of the photographs in Femalia are of women laying in repose, with their legs spread, using their fingers to hold open their labia. They are basically photographic versions of the kinds of drawings that appeared in feminist health movement literature (see Moore and Clarke 1995;



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Murphy 2012). After the three-page introduction, no text appears in the book other than the names of the photographers. The absence of descriptive information portrays the variety represented in the book as the kind of ostensibly context- and value-free anatomical variation that Alexander Edmonds (2010:32) called “bare sex.” Obscuring the conditions of its production, but foregrounding the stakes of its producers, Femalia has become an authoritative object because of its feminist commitment to show ‘natural’ genitals that are not ‘modified’ or ‘airbrushed.’ Photographic variation refused the schematic and abstracted line drawing of medical texts, both relying on and helping to produce the feminist ‘epistemology of experience’ that valued a woman’s own embodied knowledge above that of physicians’ research (Murphy 2004, 2012). At the same time, it relied on the supposed objectivity of photographs as unmediated, mechanical reproductions of the natural body (Daston and Gallison 2007). Rather than the ‘modest witness’ who constituted the objectivity of scientific knowledge by portraying him or herself as a disembodied, disinterested and, at the same time, assiduously trained conduit of the natural world (Shapin and Schaffer 1985; Haraway 1988, 1997b), Michelle Murphy describes the subject of the feminist health movement as an ‘immodest witness’ whose claim to knowledge derived explicitly from her particular and embodied experience. Photographs and illustrations presented in movement literature were set in living rooms rather than medical examination suites, and included the faces of the women whose genitals were being pictured. This kind of representational specificity located authoritative knowledge about female bodies in those who inhabited those bodies, rather than those who studied them. Grassroots promotion of women’s self-knowledge was an explicit challenge to biomedical authority. “The careful attention lavished on the minutia of reproductive anatomy produced more than a fine-grained apprehension of bodies,” Murphy writes, “it was also a political act intended to redistribute power” (2004:135). Offering an alternative to the twin terrors of idealized porn genitals and schematically pathologized medical genitals (Howarth et al. 2010; Schick, Rima, and Calabrese 2010), Femalia was widely taken up by those who wanted to change dominant narratives that leave women feeling sexually inadequate, including those that lead them to seek cosmetic surgery to ‘enhance’ their genital appearance with FGCS (Braun and Kitzinger 2001; Braun 2009; Liao 2006; Lloyd et al. 2005; Peasgood 2011). These writers attribute the growing demand for FGCS to a general lack of representations of ‘normal’ vulvas. Mislead by idealized and digitally modified media representations that are primarily produced for the consumption of heterosexual men (Schick et al. 2010), they reason, a growing number of women seek surgery because they are ignorant to the realities of genital form. Visual representations of genital variety are intended to offer a way for such women to see themselves as normal, thereby eliminating the need for surgery. The feminist commitment to ostensibly unmediated representation of ‘natural’ female genitals is one whose value has also been recognized by medical experts; Femalia has had an unanticipated life in clinical literature. It has been cited as a source to prove that variation in female anatomy exists (Schoeber et al. 2010:352; Green 2005), as a means through which clinicians may educate themselves about female genital variety (Liao and Creighton 2011; Pugh, Obadina, and Aidoo 2009), and as a resource that physicians can use to demonstrate to patients what the range of normal vulvas look like (Paarlberg and Weijenborg 2008). The reason why this small book of photographs depicting the genitals of sex shop employees, customers, and activists is such a widely cited resource is that according to clinicians, it is one of very few photographic collections of ‘normal’ vulvas that exists (Liao 2006; Lloyd et al. 2005). Wilson agreed that Femalia was a rare resource. When I asked why he used the book in soliciting his patients’ ideal outcomes,

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he replied, “Because nobody else has got unretouched photographs of pussies!” He wanted his patients to see ‘real’ female bodies, and Femalia’s ‘by women, for women’ origin helped to ensure that its bodies were not pornographic and false, but natural and real. He intended the book to help patients understand what kind of ‘natural’ their surgery might aim to produce, though he acknowledged that any standard set from the book would be an ‘impossible’ one.

CONTESTED KNOWLEDGES Since he began using the book in his trans- GSRS practice, Wilson’s copy of Femalia has become well worn. His patients’ preferences had been literally spelled out in the margins of the book: their signatures, rendered in blue ballpoint pen, adorning the white space that framed the full-page photographs that his patients most admired. After this exercise—23 patients rendered 67 opinions—a few clear favorites emerged. “I try to design mine after those,” he explained, gesturing at the book in my hands. In the article that resulted from his patient survey, Wilson described the features common to the images his patients rated most highly: A brief analysis seems to suggest that the following are of importance: a relative paucity of hair; a short, rather delicate clitoral shaft; relatively delicate, not florid, labia minora which form a continuum from the cleft in the ventral surface of the glans all the way around the posterior fourchette [fold of skin where the labia meet]; a small but distinctive glans clitoris; a clitoral hood, conjoined to the labia minora, which can be retracted to reveal the glans; an elliptical posterior fourchette with no gaping of the vaginal introitus [vaginal opening]; a definite, rather flat, perineum between the posterior fourchette and the anal margin [area surrounding the anus] and so on. (Wilson 2002:n.p.)

When Wilson compared the most favored photographs to those that were selected less frequently, the most salient differences he saw were based on the size of various features. Reflecting the trend that drives a considerable amount of FGCS, his patients indicated ‘small’ and ‘relatively delicate’ characteristics as those “they would ideally choose for themselves.” Noting the preference for small and thin labia across many groups of women, Blank was not surprised to see which of the photographs had received the highest praise. “I’m sure that transwomen are not going to start to ask for big puffy fleshy vulvas. It’s sort of more demure to have them not be that way,” she said. The relation between ‘natural’ and ‘ideal’ that haunts so much elective surgery and blurs the line between enhancement and cure is here mapped onto the gendering of anatomical forms. Although the project of Femalia was to disrupt idealized images of female genitalia by demonstrating (a limited range of) variation as itself the norm (cf. Canguilhem 1991), in Wilson’s practice the book had been put to very different use. Rather than opening space for variety as other surgeons are rumored to have done (Blank 2011), Wilson used the book to help locate an ideal. As we talked, he pulled dozens of Polaroid photographs from his center desk drawer. Some photographs were taken during procedures but most showed outcomes. Clothing fashions indexed some as decades old and others as quite recent. As he sat arranging and rearranging the photos on his desk, I asked why he called his patients’ choices in Femalia “impossible standards.” Instead of responding descriptively, as I’d hoped, he just kept handing me photographs. “I mean look at that,” he said, referring to the most highly rated image in Femalia. “Now look at this.” He tossed a Polaroid across the width of his desk and it spun a circle before settling in front of me. I looked



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at the photograph, shot at the same angle and at roughly the same distance as those in the book. It was bright and unevenly exposed in that Polaroid sort of way, and depicted a body that had fully healed from surgery. I wasn’t sure what he wanted to show me, or how I was supposed to apprehend the differences between the images. “But I’m not a surgeon,” I insisted, “so I assume you see something different in these photos than I do.” Despite my best efforts to coax a verbal response and assessment, or to get a more technically specific description of how the tissues themselves posed practical challenges, I just ended up with a stack of thick Polaroids fanned out in my hands like playing cards. While he could have used this photo sharing exchange as a way to demonstrate his own technical limits—the gap between the idealized ‘natural’ and his capacity to surgically reproduce it—Wilson read the difference between the images of natural and surgical as one of patients’ impossible expectations. For him, their expectations not only reflected the kinds of ignorance to surgical capacities common to most non-surgeons, but a more basic problem that transwomen do not know how vulvas really look and therefore do not know what to want or expect. Like other women who seek surgery to change the appearance of their genitalia, transwomen’s exposure to genital esthetics most often comes from pornography curated for the sexual consumption of straight men. But unlike women who have had the embodied experience of their own vulvas for their entire lives and who are therefore imagined to come to terms with their own normalcy through viewing resources like Femalia, transwomen view such resources only as objects of desire and aspiration. Especially when their surgeon asks them to do so.

EPISTEMOLOGICAL EXCLUSIONS AND THE MAKING OF SURGICAL AUTHORITY When Wilson handed his patients Femalia and asked them to sign their names next to the vulvas “they would ideally choose for themselves,” he placed them awkwardly between two forms of knowledge from which they are differently excluded. Neither a modest witness with the biomedical authority he wielded, nor an immodest one with authority derived from the embodied experience of living with female genitals, the trans- woman patient was asked to negotiate between them. She could indicate her ideal, not shop for an outcome. Although Wilson responded to his patients’ most popular choices by attempting to shift technical priorities that reflected their preferences, he did so on the understanding that his patients’ signatures were ultimately indicative of their ‘impossible standards.’ To him, patients’ ‘ideal’ and ‘impossible’ expectations attested to their fundamental misunderstanding of what surgery could do. In this way, Femalia was used both to ground a claim to the natural body, and to subvert trans- patients’ authority to speak to it as a form of their own surgical future. Patients’ affirmations of desire for particular forms were seen to indicate that they did not understand surgical capacities and so could not formulate expectations outside of a fantastical ideal. Trans patients’ authority to speak on their own behalf has been undermined in a number of ways. In its earliest formulations, the definition of transsexualism included a desire for transformation that was described as ‘desperate’ and ‘obsessive’ (Benjamin 1954; Hausman 1995; Meyerowitz 2002). In 1979, American psychiatrist Leslie Lothstein described his transsexual patients as “depressed, isolated, withdrawn, schizoid individuals with profound dependency conflicts. They were immature, narcissistic, egocentric and potentially explosive” (1979:434). He


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characterized their attempts to obtain sex reassignment surgery as “demanding, manipulative, controlling, coercive and paranoid” (ibid). A decade later, Betty Steiner, former head of the Clarke Institute of Psychiatry in Toronto, warned clinicians that “gender-dysphoric patients as a group can be difficult to manage. They can be manipulative, demanding and narcissistic. . . . You must be aware that some patients tend to be poor or unreliable historians” (1990:95). Inconsistent personal narratives have been interpreted as indexes of more substantial psychological problems. In, Transsexualism and Sex Reassignment, Burnard and Ross maintain: “Transsexuals’ own reports on their sexual history is often incomplete, fragmented and vague, reflecting the mechanisms of repression, selective forgetting and inattention to detail in the hysterical personality” (1986:58). Such psychological admonitions have long been reflected in surgical literature, as clinicians warn each other about the special stresses of dealing with trans- patients. A Belgian surgeon recently wrote that “the risk is high that the surgeon and his team will suffer burnout” unless they have “a coherent and well-organised team” that can “resist the stress” of dealing with trans- patients whose expectations of their surgical result are not met (van de Ven 2008:294). An American surgeon reported that while the benefits of working with trans- patients are great, “the risks and stress faced by physicians likely are higher than in any other clinical situation they face” (Spiegel 2008:234). Like many of his colleagues, this surgeon noted that “unrealistic expectations” of surgical outcomes were a significant cause of pre- and postoperative problems between surgeons and trans- patients. Establishing and maintaining ‘realistic expectations’ is important for surgeons and patients in all surgical specialties. Surgeons work to establish realistic expectations in order to ensure that patients understand procedures preoperatively, and ultimately respond favorably to their outcomes. Patients work to develop realistic expectations both in the interest of their own well-being, and as a condition of possibility for surgery itself. If prospective plastic surgery patients fail to craft a rhetoric that “simultaneously articulates a wrong body and a healthy mind,” for example, surgeons may refuse to operate on them (Jordan 2004:337). This gatekeeping dynamic is especially strident in the case of prospective trans- surgical patients who must not only meet the screening criteria of their individual surgeon but must also meet the approval guidelines recognized as best practices by the WPATH.9 Although considerably less strict than when they were instituted in 1979, the WPATH Standards of Care10 require that prospective patients be approved for surgery first by two psychotherapists and then by the operating surgeon (for a discussion of the ethics of this exception, see Selvaggi and Giordano 2014; Latham 2013). Patients with ‘unrealistic expectations’ of what surgery can accomplish are considered ‘poor candidates’ for GSRS and surgeons may refuse to operate on them. ‘Realistic expectations’ of genital surgery for transwomen do not refer to the ‘real body’—neither the abstract and universal one produced by biomedicine, nor the particular and embodied one depicted in feminist health publications—but the one that a particular surgeon can make in the particular moment in which the patient requests surgery. Because the success of GSRS is measured by ‘patient satisfaction,’ the efficacy of surgery depends on patients cultivating expectations of their surgical outcome that reflect the individual capacity of the surgeon who will operate on them. Patients may only ‘realistically expect’ what their surgeon can realistically do. Surgeons can sometimes identify a patient’s inability to formulate realistic expectations before surgery, but sometimes it is not clear that a patient has ‘impossible standards’ until after the surgery has been performed. Such a designation may emerge when a surgeon feels that a procedure went well but the patient disagrees. In the matter of postoperative assessments, patients’ opinions and subjective evaluations are often dismissed



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when they contrast with the surgeon’s definition of success, with outcomes studies elaborating on patients who were ‘satisfied’ by surgery, and noting but declining to expand on those who were not. Patients who complain or request revisions that the surgeon feels are ‘unreasonable’ are frequently recognized as ‘problem patients;’ fault is found with the patient herself rather than with the surgeon or procedure (Lorber 1975; Werner and Malterud 2003; Wright and Morgan 1990). Calling up a characterization of transwomen as paranoid and incapable of understanding the realities of womanhood into which they are newly thrust, identifying transwomen as having ‘impossible standards’ ensures that it is unhappy patients rather than wanting surgical technique that absorb (and constitute) the gap between the ‘natural’ and its surgical approximation.

CONCLUSION People seeking GSRS procedures have been excluded from the discourses of authority and knowledge about that surgical care in a number of ways. In some cases, psychologists and other mental health professionals have undermined (prospective) patients’ authority to meaningfully contribute to their own care—medical and otherwise—by characterizing trans- patients as a group frequently marked by multiple comorbid psychosocial disorders. Although such explicit characterizations have become less acceptable in recent years, surgeons’ emphasis on the particular and stressful aspects of working with trans- patients make such disparaging generalizations implicit and, I argue, continue to influence surgeons’ perceptions of the role that patients’ input can and should play in their practice. One important part of the surgeon/patient interaction before surgery is the process by which ‘realistic expectations’ for surgical results are negotiated and established (Gimlin 2002). A surgeon who feels that a prospective patient has ‘unrealistic expectations’ of surgery will likely refuse to operate on that patient since such expectations are likely to lead to disappointment, dissatisfaction and complaints postsurgically. While ‘unrealistic expectations’ are sometimes (and ideally, from a surgeon’s standpoint) identified prior to an operation, sometimes such expectations cannot be recognized until after the operation has been performed. Even when patient inputs are accepted and solicited prior to surgery, their characterization as ‘subjective’ do not have the same value as the ‘objective’ evaluations leveled by the surgical professional. In this way, patients’ capacity to comment on their surgical results is often taken as not credible. Although the devaluation of patient assessments is not unique to trans- surgeries (see Jordan 2004 and citations in the opening section), it is important to see the means by which the delegitimized presurgical subject position is reincorporated into explanations of why such a person is also incapable of understanding their post-surgical results. To forms of exclusion predicated on the denial of trans- surgical patients’ authority to meaningfully engage in the expert discourse of surgical capacities and outcomes, in this essay I have shown that trans- patients are also excluded from their care on different epistemological grounds. In addition to the question of who has the authority and credibility to comment on the technical aspects of surgery, the epistemological exclusion that occurred in Wilson’s office was based on the claim that transwomen cannot formulate realistic expectations of surgery because they cannot know what real female genitals look like. Denied legitimizing epistemological positions of the ‘modest witness’ whose disinterested gaze is a fundamental precept of biomedicine (and upon which the surgeons’ claims to authoritative pre- and postsurgical assessments are based), and the ‘immodest witness’ whose feminist claims to embodied and experiential knowledge have allowed Femalia to travel from activist literature to a medically endorsed representation of ‘real’ bodies,


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transwomen patients could not know; they could only desire. Enacting a desire whose form and content have been marked by the historical and institutional stigma of psychosocial pathology, trans- patients are often cast as lacking both epistemological and moral grounds to meaningfully contribute to the regimes of care they seek. Returning to Tuana’s ‘epistemology of ignorance,’ then, we might ask after the conditions by which genital forms become knowable to some, unknowable to others, and the ends to which such knowledge and access to it are enacted. What are the particular ways in which trans- patients ignorance is produced and understood by those who specialize in their surgical care? I have used one clinical example here to begin to think through some effects of this produced ignorance both for surgeons and their patients. There is, of course, much to do in this effort. “To the extent that practitioners are successful in establishing their expertise,” writes E. Summerson Carr, “they can create hierarchies and distinctions by determining the qualities, authenticity, or value of objects within their purview” (2010:20). Excluding patients’ inputs, or classifying them as kinds of knowledge that matter differently or matter less than surgeons’ is one means by which surgical expertise is created and enforced. It is, in large measure, a condition for the practice of surgery itself. Among the effects of such exclusions in the field of trans- medicine is that the practice of surgery has remained an experts-only discourse seemingly limited to the development and enactment of particular technical knowledge. An anthropology of trans- medicine and surgery must attend not only to the cultural, political, and economic conditions by which such surgical procedures become desirable and possible, but also the means by which the surgical procedures themselves are created and performed. Wilson’s surgical work reflected the time and place of his training, his own sense of anatomical form and priority, and the kinds of patient feedback he was willing to incorporate. These forms and relations of knowledge are as central to the analysis of surgical technique as are the motions of scalpel and suture by which they are enacted. They also demand that we attend to trans- medicine as situated in times and places that give shape to the particularities of desirably sexed and gendered bodies and negotiate the authority and capacity of surgery to enact these bodies. Such technologies of surgical practice instantiate historically and geographically particular sexed norms that differentiate one surgeon from another; they help to create bodies in whose post-op form negotiations between the authorities of knowledge, desire, politics, and capital inhere.

ACKNOWLEDGMENTS I would like to thank Elizabeth F. S. Roberts, Todd Meyers, and Theresa MacPhail for their helpful readings of early drafts of this article, and three anonymous reviewers for comments to improve its form. This article also benefited from discussions following its presentation in the LGQRI Research Initiative at the University of Michigan and the CSTMS Conference at UC Berkeley.

FUNDING I am grateful for the Michigan Society of Fellows for support of my ongoing research.


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NOTES 1. Wilson was quite adamant that I use his real name. Like many of the surgeons I interviewed, he was proud of his work and welcomed the opportunity to have it recorded, even in light of my explanation that my treatment would be analytical rather than hagiographic. For my part, I value the opportunity to include specific and accurate information because this type of historical record is sorely lacking in the study of trans- surgery. I am happy to enrich that record here. 2. These surgeries are known by a variety of names, each of which reflects particular political and moral understanding of the effect the procedure is intended to produce. Changes in the nomenclature—first ‘sex conversion operation,’ later ‘sex reassignment surgery,’ and more recently ‘gender confirmation surgery’ or ‘gender affirmation surgery’— correspond not to changes in surgical technique so much as changing understandings of the nature of the problem surgery is meant to address, as well as a democratization of who—experts or otherwise—have been allowed to speak authoritatively on the topic. I use “sex reassignment surgery” here because that framing most closely matches Wilson’s approach to his patients. It also matches the orientation of surgeons trained in the United States in the 1960s, 1970s, and 1980s. I use the term “genital sex reassignment surgery” to call attention to the genital nature of these procedures, as opposed to chest, facial, or vocal surgeries that are also employed in the name of surgical sex reassignment. 3. A note on the use of trans- : Whereas Stryker, Currah, and Moore (2008) used the term trans- in order to leave open the possibility of kinds of crossing that are not limited to gender, here I use it in order to draw attention to the multiple gendered endings to the word trans that have come to hold important personal and political stakes for those who use this word to identify themselves. Because this article foregrounds surgeons’ practice rather than patients’ narratives, it is important to use this open-ended descriptor rather than assign people into categories that they did not self-designate. Trans- leaves this space open. 4. “Sex Change Facility Is Closing.” The Argus-Press. March 5, 1981, p. 5. 5. Wilson estimated that he has performed between five and eight phalloplasties each year since that initial procedure in the late 1970s. 6. I have conducted a year of fieldwork in the offices and operating rooms of two American surgeons who specialize in Facial Feminization Surgery, a month with a European plastic surgery team focusing on trans- surgeries, and conducted in-depth interviews with other surgical specialists in North and South America. 7. The first American gender clinic was founded at the University of California at Los Angeles in 1962. Focusing on psychological research, it did not offer surgical services. 8. For an explanation of the factors that lead to the rapid closure of the clinics see Stryker 1999, Irvine 1990, and Rudacille 2005. 9. WPATH recommendations are widely followed in North America and Europe, although less strictly followed elsewhere in the world. 10. The Standards of Care are a set of professional recommendations that guide the hormonal and surgical treatment of people variously classified as transsexual, transgender, and gender dysphoric. Adhering to the guidelines set forth in the Standards of Care helps to safeguard clinicians from claims of professional misconduct.

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