Alumni Interview

How Medical Expertise Shapes Gender-Affirming Health Care: An Interview with Tara Gonsalves

Tara Gonsalves

Increasingly, trans people are seeking out gender-affirming health care, whether counseling, hormone therapy, or surgery. Such care often requires expensive treatments under a health care system that is still figuring out how to respond. How do insurance processes determine who has access to care and under what conditions?

Tara Gonsalves, a recent PhD graduate of UC Berkeley and Assistant Professor of Sociology at Northwestern University, studies how social categories like “transgender” are contested and transformed over time, and the consequences of these transformations. Using quantitative and qualitative tools, she has three primary streams of research: how the term transgender has become an umbrella category for understanding gender variance, how medical experts produce new racialized understandings of gender through surgery and insurance, and how LGBT organizations worldwide emerge and integrate into advocacy networks.

For this interview, Social Science Matrix Content Curator Julia Sizek interviewed Gonsalves about the challenges of the categories of sex, gender, and transgender, and how the term transgender has become an umbrella category for understanding gender variance.

How has the category of trans come to represent gender nonconforming people today? 

There are many different ways of thinking about this question. First, we might think about why this is happening. International human rights groups are tasked with making coherent claims at the global level, so they need a global category. Given the enormous violence that people who are gender and sexually variant face around the world, this seems like a crucial task. And the category that is increasingly being used to articulate diverse forms of gender variance is one that has been used in the United States and Western Europe for some time – “Transgender.” And yet, gender variance takes on different forms, however, from hijra and bakla  (gender variant groups in South and Southeast Asia) to travesti and muxes (gender variant groups in Latin America). Gender variance takes on different forms in different parts of the world, resulting in diverse configurations of gender, sexual desire, and the sexed body. Some of my research looks at how the category “transgender” is coming to articulate these multiple modes of understanding gender variance and its relationship to sex and sexuality.

Answering this question is further complicated by the fact that the groups described by “transgender” are defined not only through gender identity, but also through diverse gender and sexual practices that are not heterosexual or that do not conform to conventional configurations of sex, gender, and sexual desire, as encapsulated by Judith Butler’s metaphor of the heterosexual matrix. While the term bakla is now often interpreted by scholars and activists in the United States as a Filipino version of “transgender,” for instance, the term can encapsulate both gender variant expression and non-normative sex practices. My work is part of a growing body of work in Transgender Studies that looks at the complicated relationship between postcoloniality, representation, and gender and sexuality. (Other scholars working in this space include Aren Aizura, Aniruddha Dutta and Raina Roy, and Christoph Hanssmann). 

In the United States, medical organizations and LGBT rights organizations converged around a three-part definition of transgender, especially in the early 2000s: a gender identity (1) that is different from the sex assigned at birth, (2) that is ontologically distinct from sexual orientation, and (3) that presumes a gender binary. In recent years, this definition is increasingly being contested by trans and gender-nonconforming theorists and activists, though it is still widely used in reports and government documents. My transnational research examines how this category, which comes from a particular place and time, is coming to represent gender variance globally.

When we introduce studies of the social construction of gender in undergraduate courses, we often begin with reproductive organs as a proxy for femininity and masculinity, tracing how early psychology studies influenced our understanding of gender during the mid-20th century. What were those understandings of gender? 

Medical understandings of gender and its relationship to sex have changed rather dramatically over the past half century. 

Sex has historically been defined based on external genitalia and secondary sex characteristics. Gender, which emerged as a social concept distinct from “sex” in the mid-20th century, was primarily understood to derive from external genitalia and secondary sex characteristics (such as breasts). Femininity derived from the female sexed body, and masculinity derived from a male sexed body. Again, this is Judith Butler’s concept of the heterosexual matrix.

Even before the concept of “gender” had been named, sexologists (mostly writing in Europe) had begun to classify variant sex-based practices, such as style of clothing, mannerisms, voice pitch, preference for decor, etc. That is, if someone had a male body but preferred to wear feminine clothing, stand in a feminine way, and be read by others as feminine, this was considered “deviant.” Magnus Hirschfeld coined the term “tranvestism” to distinguish this group from those who had non-normative sexual desires.

How do scientists consider the relationship between sex and gender today?

Later in the 20th century, medical scientists began to define gender as deriving not from external genitalia or secondary sex characteristics, but rather from genes and neurology. That is, gender identity was understood to have a sort of primacy in genes, or to exist “prior” to the development of the sexed body. Rather than attempting to explain “deviant” or non-normative gender identity — i.e., gender that did not correspond to the sexed body — in early childhood socialization, medical scientists have come to accept gender identity as something that can be explained neurologically or genetically. 

Similar to the search for a “gay gene” that has been well-documented (for example, see Conrad 2016, Brookey 2002, and Conrad and Markens 2000), some medical scientists are now searching for the gene that predicts gender identity. “Deviant” gender identity is becoming “normalized” through a turn to genes and brains. In other words, if genes, which some have referred to as the “essence of an individual,” can predict or explain a person’s gender identity, then gender can be understood as “naturally occurring” and therefore deserving of social recognition and rights. In a certain sense, the geneticization of gender identity might help normalize “deviant” gender identity, working as a means to rally around a marker of identity akin to “strategic essentialism,” Gayatri Spivak’s fraught concept that describes how minoritized groups use aspects of their shared identity for their political agendas. 

However, it may not be wise to rely on the concept of a “gay” or “trans” gene for making political claims because it forces gender and sexual minorities to rely on a genetic marker to “prove” themselves rather than believing people’s accounts of their own bodies and desires. Additionally, because gender identity and sexual desire are complex and may change over time, manifest differently in different situations, and emerge differently in different people, I wonder whether isolating a “gay” or “trans” gene is even possible in the first place. 

Today, trans people often seek gender-affirming medical care, which can include a various array of surgeries intended to help people’s bodies fit their gender.  You consider how insurance companies, who often determine access to medical care, have shifted their understanding of what makes a surgery for trans people “medically necessary.” What methods did you use to track the changes in insurance policy over time, and what institutions are responsible for determining the boundaries of medical necessity? 

Trans people are often violently sanctioned for embodied gender that does not match their gender identity and have pushed insurance companies to dramatically expanded coverage for gender-affirming care over the past two decades. My research draws primarily draw from qualitative analysis of national health insurance policies from five large insurers, and reviews of appeals for coverage that were completed by state-appointed reviewers. In some of my other research related to the medical field and gender, I also draw from interviews with experts and from my observation at transgender health conferences in the United States. 

Medical necessity determinations are complicated. Medical necessity is ostensibly determined by medical experts and medical institutions like the American Medical Association, but variation in coverage suggests that insurers also play a role in determining what care is medically necessary. Federal and state governments often publish guidelines that private insurers then follow. In the unusual case of gender-affirming care, however, private insurers developed their own coverage plans in the late 1990s and early 2000s, before the federal government allowed public funds to be used for gender-affirming care.

In the broadest sense, social categories like “gender” shape what is seen as medically necessary for particular patients, as can be seen in contemporary studies of gender and care. In the book Trans Medicine: The Emergence and Practice of Treating Gender, Michigan State University professor stef shuster outlines how medical providers, rather than drawing from prior medical knowledge, actually produce expertise when caring for transgender patients. (See also Piper Sledge’s work on non-normative gender and cancer care.) This work shows, in part, how gender shapes the kind of care patients receive. 

For surgeries like facial feminization or masculinization, medical experts have to determine whether and under what conditions these surgeries are necessary. How do they make these decisions, what kinds of evidence can they use, and how are these decisions shaped by beauty standards?

What I have found is that medical experts are drawing on their understandings of what ideal masculinity and femininity are. In other words, medical experts are tasked with creating boundaries that relate to ideal femininity and masculinity — beauty, in a certain sense. So, when deciding whether or not someone needs facial feminization surgery, for instance, they look at photographs of the person applying for insurance coverage, and compare the person’s face to their own interpretation of a feminine face. These understandings of femininity and masculinity, in turn, are structured by race. The ideal feminine nose, according to one of the reviewers, has thin nostrils and an uptilt at the end. Thin nostrils, of course, are associated with white femininity, as is an uptilted nose. (Check out Eric Plemons’ work on facial feminizations surgery and Jules Gill-Peterson’s work on the racialization and gendering of trans bodies.) I find, in other words, that insurer adjudication of medical necessity flattens differences across race and body size. Expansions in coverage, therefore, are bringing people closer to normative gender based on a thin, white, young ideal aesthetic.

One of the things I found most interesting about your research on insurance policies is how older transgender people interact with the medical system, for example, as they petition to have surgeries like facial feminization surgeries covered under insurance. Although many would have been ineligible for surgeries 15 years ago, some applicants are now ruled as ineligible due to their age. Can you explain this phenomenon?

This is such a great question, and something I would like to think about more. It is certainly the case that many trans people who may have wanted to apply for gender-affirming health insurance coverage a few decades ago were not able to, because insurance companies only started providing coverage in the early 2000s, and public coverage came a decade later. And, as you point out, the irony here is that older people are less likely to get insurance coverage for gender-affirming procedures because of the general assumption that older people “lose” gender as they get older. More broadly, older women are assumed to look less feminine, especially if ideal femininity is defined by young women, and older men look less masculine, as defined by ideal masculinity. Perhaps there is a kind of circle, in terms of social assumptions about femininity and masculinity. Babies are less easily distinguishable based on embodied gender than adolescents, for instance. Parents put bows on girl baby heads to distinguish them from boy babies, since it might be hard to gender them otherwise. Similarly embodied gender is perhaps assumed to become less distinguishable as people get older. 

The move toward surgical intervention has been complemented by a turn in in the fields of psychology and biology toward trying to understand gender identity through both genetics and neurology. How has research in these fields changed our understanding of where gender is located in individual bodies and, in turn, how trans people can access medical care?

Genetics has become a subject of enormous interest. We can see this across a variety of social domains, including the number of scholars who are studying the sociology of genetics, and the growth in research institutes on genetics and society. Genetics is coming to be seen as a sort of haven, with endless possibilities for explaining all kinds of human variation. The rising faith in genetic (and neurological) science does not necessarily correspond, however, to increasing evidence that genetics does indeed explain different conditions of illness and wellness. 

Despite a lack of evidence, this increasing faith – and the linking of gender identity to the search for genetic explanations – suggests a belief that gender identity is innate. A belief that gender identity is innate, moreover, is compatible with “born this way” political strategies. These strategies claim access to gender-affirming healthcare coverage and other services on the grounds that people do not choose to be non-binary or trans. The increasing faith in genetic explanations for gender identity points to a belief that gender identity is innate (i.e., explainable by genes or neurology) and therefore requires or necessitates health insurance coverage for the body modifications that will enable people to be socially legible (i.e., to be seen by others as)  men or women, if they so choose.

The trend toward gender-affirming health care is positive, as trans people have better access to care, but also troubling, as it often reinforces gendered stereotypes. What are the implications of gender-affirming health care for trans people, and for the growing non-binary community? 

Legal scholar and activist Dean Spade puts it very well when he writes that saying ‘no’ “to transgender requests for bodily alteration…props up a naturalized version of the sexual binary,” but that saying ‘yes’ “can support and sustain standard forms of gender and embodiment.” My research, echoing Spade, Eric Plemons, and others, has shown that increasing access to and coverage of gender-affirming body modifications brings with it a normalization of particular forms of femininity and masculinity — in this case, white femininity and masculinity. So there are racial implications, in that racialized gender — based on a white, thin-bodied aesthetic — is institutionalized as an ideal form of masculinity or femininity. Some within the growing non-binary community are also seeking body modifications that enable them to be read as non-binary (or, conversely, illegible as “man” or “woman”). As a result, there are a rising number of surgeons who are becoming specialists in non-binary surgery, and with this comes the possibilities for a “normative” non-binary body. Yet there are trans and non-binary people who do not seek body modification and who wish, in the spirit of Sandy Stone’s call over three decades ago, to be recognized as trans and as non-binary, and thereby disrupt conventional understandings of gender and sex with more complex configurations of sex, gender, and the body. A liberatory politics would, perhaps, see both or all of these possibilities, such that people could seek the body modifications they desire (or do not), regardless of the relationship between the sex they were assigned at birth, their current gender identity, or the physical characteristics of their sexed body. 


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