The End of the Body, The Beginning of the Person: Biopolitics, Biotechnology, Violence, and Ethics in Transgender Medicine

Written for my graduate anthropology course on bioethics and biotechnologies.

Introduction

Biotechnologies have drastically affected the ways in which human bodies can be altered, manipulated, improved.  Some of Western biomedicine’s “advances” have been incredibly empowering, restoring sight, improving mobility, enhancing quality of life.  But all have come with a heavy and complex price tag, be it through experimentation and forced medicalization, commodification and fragmentation of bodies, or differential care and unequal access.

This price tag is particularly complex in regards to transgender-based technologies.  Biotechnologies have emerged allowing us to physically change many aspects of the biological sex of an individual.  Transgendered individuals, born and labeled as one particular sex who identify with the opposite gender, may find great empowerment through the sex-change operations now possible through Western biomedicine.  At the same time, intersex individuals are often forced into sex assignment surgery at birth, stripping them of their original body without their consent.  Transgendered bodies continue to be gawked and gaped in public; safety is an incredible concern; legal protections and policies are varied and problematic.  The possibilities of biotechnologies for transgendered individuals have not come without costs in experimentations and motivations behind the research and results, nor do these possibilities exist in a vacuum, free of ethical dilemmas, cultural norms, and biopolitical regulations.

This research seeks to explore those dilemmas, norms, and regulations, working to understand how biotechnologies can provide both empowerment and disempowerment for transgendered individuals and, ultimately, for us all.  My primary research question asks how states’ involvement (or lack thereof) in transgendered medical care shapes the gendered experiences of individuals.

This paper will first present a theoretical framework of Foucault’s Biopolitics and Marx’s Capital.  The state control of bodies and identities, as well as the commodification process, will be used to explore the numerous intricacies existent in biotechnology and transgendered interactions.  The methodology section will present how this paper seeks to understand the relationships between state, biotechnologies, and transgendered communities.  Two case studies will be discussed in the results section, exploring these connections in contemporary Iran and the United States.  Concluding observations will then be given, arguing against the current model of states’ control over the gendering of our bodies.

Theoretical Framework

This work is informed by the theories of Michel Foucault and Karl Marx, some of the first people to grapple seriously with the intersections between the market, the state, and people.  Two major issues frame the topics under consideration in this research: biopolitics, states’ control of bodies, and commodities, marketable goods produced to satisfy needs and wants.

We live in the era of the nation-state, when states have control over their territories and are considered sovereign.  The issue of state sovereignty is strong enough to be a block to even humanitarian intervention, such that nations hesitate to step in to end horrors of genocide and the like in other states’ domains.  In this era, questions of state control and legitimacy are paramount.  Against this backdrop, we encounter Foucault’s “biopolitics,” a term coined to explain the style of government that seeks to regulate and control its populations through “biopower.”  “The principle underlying the tactics of battle – that one has to be capable of killing in order to go on living – has become the principle that defines the strategy of states” (Foucault 1984, pp. 260).  Through nation-states, “regulatory controls” have created “a bio-politics of the population” (ibid, pp. 262).  Today, these biopolitics are seen in the state control of bodies themselves through programs like mandatory military service in Israel and China’s one-child policy.  Biopolitics can also be expanded to consider the state’s role in the formation and control of national cultural identities.

One way in which the state can have control over populations is through the government’s involvement in economics.  Foucault believes that “One must govern with economics, one must govern alongside economics, one must govern by listening to the economists, but economics must not be and there is no question that it can be the government rationality itself” (2010, pp. 286).  Virtually all countries have some distinctions between economics and the government, but the relationships between the two vary from state to state.  These variances can have great impacts on the accessibility and benefits of biotechnologies.  In Marx’s Capital, an early theoretical discussion of commodities is presented.  Marx defines “commodity” as “an object outside us, a thing that by its properties satisfies human wants of some sort or another” (303).  In his exploration of commodities, Marx explores the complexities in how commodities are valued.  Human labor often goes into the production of a good; thus, a commodity’s value may not be merely the sum total of its raw materials.  This is seen very powerfully in today’s Western biomedical healthcare markets, as drugs cost a great deal more than their raw goods to make up for the research and development required to produce them and the price of surgery reflects the many years of education and specialized expertise necessary to perform and care for a complex operation.  Marx gives us insight to the political nature of production as our focus on commodities results in hierarchical class structures.

Biopolitics and commodities inform my approach to biotechnologies, violence, and ethics in transgender medicine as I seek to understand states’ control of gendered bodies, the commodification of healthcare, and the commodification of body parts.

Methodology

To understand how the state’s participation or lack thereof in transgender biotechnologies and how this involvement affects the gendered experiences of individuals, this paper will employ a literature review of academic articles, policy investigation of two case study nation-states, and discourse analysis of public testimonies.

Transgender theorists and academic articles were sought from multiple disciplines in an attempt to find the most representative and insightful scholarship.  Rather than presenting a formal and distinct literature review, the findings from this appraisal will be presented in the results section as appropriate.

Two states were chosen for study based on their representative abilities and divergent transgender policies.  One, the United States, characterizes the Western capitalist market and culture of the “global North.”  It is a representative democracy and a federation of states, each with some autonomy but ultimately accountable to the federal government.  The US has no official religion, instead holding up the separation of church and state as a core value (though some may wonder at the truth of this, given current political discourse).  The country and governmental system has been stable for years and the nation is a global hegemon.  The other, the Islamic Republic of Iran, sits at a global crossroads between the Middle East and central Eurasia.  The country is Islamic but Shia Islam is the official religion, making Iran a minority in the majority Sunni Islamic world.  Iran has been through multiple regime changes and rocky transitions in the past one hundred years.  The President of Iran is elected by universal suffrage but is not the highest power in the country, nor the Command in Chief; those responsibilities go to the Supreme Leader, who is appointed by elected institutions.  Iran has a relatively high human development index but is popularly known as a country not overly fond of women’s rights or excessively accepting of minorities.

These two states have drastically different approaches to the biopolitical regulation of gendered bodies in general, and especially in regards to transgendered biotechnological access and involvement.  The results below are based on literature reviews of relevant ethnographies and sociological anecdotes, public interviews or testimonies, and policy evaluation.

Results

The United States

Healthcare in the United States is mostly privatized, though the government spends great portions of its budget subsidizing research and development as well as providing some access for senior citizens and disadvantaged populations.  Availability and access to US biotechnologies, which are some of the best in the world, are highly dependent on ability to pay. 

At first glance, then, the US case seems to be one of commodification and not one of biopolitics.  The government more or less stays out of the healthcare realm; individuals are free to go through sex reassignment surgery if they are able to pay for it.  This culture of capitalism and focus on commodification is perhaps best represented by gender-crossing economist Deirdre McCloskey’s quotation about her feminine body: “These are my cheekbones.  [Pause.]  I paid for them!” (March 2012).

But a deeper look highlights the strong biopolitical discourses present in transgendered biotechnological experiences in the United States.  The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association and used by policymakers, still classifies transgenderism as a disorder.  This means that individuals such as McCloskey can be involuntarily incarcerated in mental hospitals because of their transgender identities (1999).  The now infamous “pregnant man” and his wife had incredible trouble finding a physician who would care for them (Currah 2008).  Similarly prejudiced issues revolve around employment; questions arose about whether or not the protection of “sex” in the Employment Non-Discrimination Act (ENDA) applied to transgendered individuals.  Ulane vs. Eastern Airlines in 1984 determined it was not, such that transgendered individuals may legally be fired for being trans (ibid, pp. 332-333).

The involvement of the state can be helpful and harmful for the transgender community.  Because the DSM calls transgenderism a disorder, individuals like Deirdre may go through forced incarceration.  At the same time, having a medically diagnosed disorder can help those who need financial assistance with necessary medications to receive it.  There are serious concerns and worries in the transgender community over the gate-keeping power and process of therapists (Scarpella 2010), but therapists can be incredibly beneficial for individuals facing regular discrimination and fear, and the state sometimes helps pay for or provide these services.

Perhaps most problematic in the biopolitics of transgenderism in the United States in the individual states’ control over birth certificates and drivers’ licenses identifications.  States require a male or female label at birth; this often leads to infants with ambiguous genitalia being assigned a sex at semi-random.  This “medical management of intersexuality is linked with the biopolitical regulation of gender difference more broadly” (Rubin 2010).  When “autonomous” individuals have a transgender identity and choose to live life as the opposite gender, the fifty states have different policies about whether or not birth certificates and drivers’ licenses may be changed.  Some will do so only when an individual has gone through irreversible sex reassignment surgery, creating a class hierarchy in regards to ability to pay financially and the capacity to safely go through such a process.  Other states will never change the sex status of your birth certificate.  These differences mean that individuals born in different states who go through the same processes and procedures may have different legal classifications of sex.  This has ramifications for who transgendered individuals can marry.  For example, in a state that refuses to change the sex classification on a birth certificate, a female-to-male transgender individual who has gone through sex reassignment surgery and now lives as a man could only legally marry a man if the state does not allow “gay” marriage, because his legal sex classification would still be female.  This man could then not have what is, for all intents and purposes, a heterosexual marriage.  The issue of legal sex classifications also has serious impacts for transgender and intersex individuals’ public mobility.

The commodification of the body has meant, for the transgender community in the United States, a spectrum of ways to begin living the life they wish.  Those who cannot afford full sex reassignment surgery might be able to afford “top only” surgery (generally, the removal or addition of breasts), some hormones, etc.  Commodification of the body, here, allows individuals to change bit by bit of their body.  Generally, “[t]he flesh can be all too easily perceived as part of the fixed landscape against which gender performs itself, rather than as part of the performance itself.”  But thanks to the way in which the body is commoditized and used in the capitalist, commercial United States, “[t]ranssexuality offers a dramatic instance of the temporal instability of the flesh.  It sets embodiment in motion” (Susan Stryker quoted in Alexander 2005, pp. 56).

Biotechnologies can be critical in the identity formation of transgender individuals.  One female-to-male individual writes “I am going through my own metamorphosis.  My hips are smaller, my muscle mass is growing, and every day it seems like there’s more hair on my face and body.  My voice is deeper…When I think that I can continue with this process – get chest surgery and pass as male – I feel happier than at any other point in my life.  And when I think that something will stop me, I become very depressed” (quoted in Alexander 2005, pp. 46).  Transsexual activist and theorist Susan Stryker has written about this focus on transgender and transsexual bodies as technological bodies in Transsexuality: The Postmodern Body and/as Technology: “[t]he transsexual body as cyborg, as a technologization of identity, presents critical opportunities similar to those offered by the camera.  Just as the camera offers a means for externalizing and examining a particular way of constructing time and space, the transsexual body – in the process of its transition from one sex to another – renders visible the culturally specific mechanisms of achieving gendered embodiment.  It becomes paradigmatic of the gendering process, functioning, in Sandy Stone’s words, as ‘a meaning machine for the production of ideal type’” (quoted in Alexander 2005, pp. 67).

In the United States, the commoditized and biopolitical backdrop translate into a focus on “realness” for transgender bodies.  The more fully an individual is able to transition (i.e., the more they are able to pay for better and fuller biomedical transformation), the more likely they are to be accepted by society (i.e., “pass” for an individual whose sex and gender are aligned).  This focus on “You look so authentic” can be problematized (Boucher 2010), but it remains a strong motivating factor for many and a serious problem for those individuals who are unable or unwilling to use biotechnological “fixes” to their sex-gender misalignment.

Biotechnological sex reassignment surgery can be classified, in many ways, with other forms of surgical body modifications and cosmetic surgeries.  “Interview findings showed that cisgender and transgender people reported similar presurgical feelings toward their bodies, similar cosmetic and psychological motivations for surgery, and similar benefits of surgery. For both transgender and cisgender people, surgery enhanced the inner self through improving the outer gendered body” (Windsor 2011, emphasis added).  These findings highlight the ways in which commodification and biotechnologies can serve as a liberating force for individuals.  But biopolitically, “Despite these similar embodied experiences, having a cisgender gender status determined respondents’ abilities to pursue surgery autonomously and with institutional support.”  “[P]sychomedical institutions subject people who seek gender-crossing surgeries to increase surveillance.  They manage and regulate cross-gender embodiment as disorderly” (Windsor 2011).

In the United States, the transgender community has a rocky relationship with the lesbian, bisexual, and gay communities.  Often, the communities are grouped together and do joint activism.  However, there are heavy feelings in the transgender community that the LBG communities are all too willing to leave the trans community behind (in many communities, there are protections for lesbians and gays but none for transgender individuals).  From the LBG side, some feel that transgender individuals “buy into” the gender dichotomy all too often.  In How Sex Changed: A History of Transsexuality in the United States, Joanne Meyerowitz describes the vague and complex ways in which transgender lives and surgeries break down or reinforce the male-female and man-woman gender binaries: “Transsexuals, some argue, reinscribe the conservative stereotypes of male and female and masculine and feminine.  They take the signifiers of sex and the prescriptions of gender too seriously.  They are ‘utterly invested’ in the boundaries between female and male.”  But, problematizing this critique is another line of discourse, claiming that transgender people “represent individual autonomy run amok in the late modern age…some theorists identity transsexuals as emblems of liberatory potential” (Meyerowitz quoted in Alexander 2005, pp. 71).

Turning to Iran, we will see similar competing implications of transgender biotechnologies, as they buy into gender dichotomies and are thus disempowering while they also liberate individuals from societal expectations and are thus empowering.

The Islamic Republic of Iran

Iran has one of the world’s highest sex reassignment operation rates, second only in Thailand in the number of operations (Barford 2008).  The government pays up to fifty percent of the costs when financial assistance is needed (ibid).  Across the country, the legal sex classification is switched, as the sex change is recognized on your birth certificate (ibid).

How?  How, in an Islamic country, generally conservative and oppressive to women by Western standards, where homosexuality is illegal, does this occur?

Iran has had sex changes taking place through biotechnology (a combination of surgery and hormones) since at least the early 1970s (Najmabadi 2008, pp. 23).  But in 1976, the Medical Association of Iran (MAI) ruled that sex change operations, unless an individual was intersex, were ethically unacceptable.  This ruling lasted more than a decade (ibid, pp. 26).  Then, a fatwa (religious ruling) was issued giving religious authorization for sex change operations (Tait 2005).  The religious rationale behind this is that most people have harmony between the body and the soul; where there is disharmony, biotechnologies have made possible changing the body but not the sole.  Sex reassignment surgery, then, creates harmony, and harmony is good (Najmabadi 2008, pp. 27).  The discourse around transgender ethics and biotechnologies in Iran is thus both jurisprudential and biomedical (ibid, pp. 28).

For some, these religious (and thus political, in an Islamic republic) rulings are a source of great pride and promise.  Transgender individuals have safe access to biotechnologies, and the government will help them pay to have their bodies reflect the persons they identify as.  But for others, these policies are incredibly problematic.

Biopolitically, Iran has a great investment in gender roles.  Sex is seen as a potentially dangerous force (Higgins and Shoar-Ghaffari 1991, pp. 220).  Gender roles, as desired by the state, are enforced and taught.  Education is centralized in Iran, such that all Iranian textbooks are made by the government, so “the texts of each era bear the stamp of their respective government’s position on sex roles and male-female relationships” (ibid, pp. 214).

Sex reassignment surgery, in Iran, is less about social justice or individual freedom and more about upholding biopolitically important models of male and female, ensuring that everyone categorized and viewed as “male” is “masculine” and that all those labeled and known to be “female” are “feminine.”  Gays and lesbians are legally prohibited from same-sex acts and face a great deal of societal and state pressure to not be “sissy boys” or “butch girls.”  Individuals who would identify as homosexual in the United States but would not consider themselves transgender are encouraged by the state and their communities to undergo sex transition (ibid, pp. 35) so that the relationships they engage in will be considered heterosexual.  “The legal process of gender transition is firmly framed by the pivotal distinction between homosexuality and transsexuality,” and a four-to-six month “filtering” period of psychotherapy and tests is meant to segregate the “true transsexuals” from misguided homosexuals (ibid, pp. 32).  For “true transsexuals,” same-sex leanings are symptoms of their transness, of the disharmony between body and soul.  “Misguided” homosexuals, in contrast, can be put on the right path to their proper gender role, as the name suggests.  Psychotherapy is used by the Iranian state, then, to properly enforce the gender roles critical in Iran’s biopolitical strategies and national cultural formation.

Conclusions

In both the United States and Iran, we see a complex and contradicting set of facts, through which biotechnologies and sex change operations and policies are simultaneously empowering and disempowering.  Some worry that while “many transgenderists believe that their actions and identities are radical challenges to the binary system of gender, in fact, the majority of such individuals reinforce and reify the system they hope to change” (Gagne et al 1997, pp. 478).  It is important to remember, though, that people have used the spaces that have been created by perhaps misguided biopolitical motivations to empower the marginalized, even when these policies and discourses have the potential to be dangerous or harmful (Najmabadi 2008, pp. 33).  Transgender individuals are not agentless, powerless victims entirely subject to the whims of biopolitics.  They have agency and can push at cracks in the system where they see them, and the do.

The contradicting nature of biotechnologies are recognized within the transgender community.  “The multiple, and often contradictory, functions and effects of medicalization result in a tension between resistance to and reliance on medicine within the transgender rights movement,” so that “constructions of transgender identities as pathological are rejected at the same time as bio-medical models are accepted or advocated as a means to gain rights and recognition” (Burke 2010).  The biopolitical and commodified systems are resisted even as they are used to make gains where possible.

The United States and the Iran case studies both indicate the harmful role that legal sex classifications and state control of the gendered embodiment of individuals can have.  A helpful parallel is offered by Bow (2009) in her analysis of transracial and transgender issues.  What are those who identify with both classifications of the gender binary supposed to do in a system of sex-segregated bathrooms?  What are those of multiple racial identities supposed to do at segregated facilities?  Which drinking fountain should the girl who is both white and colored and yet neither drink from?  Quoting Leslie Feinberg, “Why is the categorization of sex a legal question at all?” (pp. 76).  Foucault’s biopolitics tells us why it is in the state’s rationale to make the categorization of sex a legal question.  But ethics and biotechnologies can help us to ensure that this categorization is not allowed to be a violent one.

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