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Clinician, Heal Thyself (Or, It’s All Your Problem)

I mean, even astrology gives you 12 categories. —Mistress Krista

On July 9, 2003, we had the displeasure of seeing a lecture given by James Cantor at the Centre for Addiction and Mental Health in Toronto, formerly (and infamously) known as the Clarke Institute. The lecture was on the connections between sexual orientation and gender. But we got more. Oh yes, so much more.

It was obvious from looking at the lecture description that it was going to be a discussion that furthered the polarization of trans women. Cantor works under Ray Blanchard, the man who first articulated the theory of autogynephilia. Autogynephilia, if you will remember, is the claim that the root cause of transsexuality is sexual arousal at the idea of becoming a woman or feminizing one’s body. This theory itself is interesting, and it does seem to apply to several trans women. Considering that it doesn’t account for trans men at all, it would seem to be a failure as a Grand Unified Theory of Trannies, or even as part of one. (If you want to read more about it, you can read Trans Health’s first article on the subject, or check out Anne Lawrence’s writings or even the Wikipedia entry.

A most striking and disturbing issue was raised at the very beginning of Cantor’s presentation. Like Blanchard and many members of the psychiatric community, Cantor refers to transsexuals based on their birth gender. Therefore, what any modern, reasonable person would refer to as a transsexual woman (a woman who was assigned the gender “male” at birth), Cantor and the CAMH refers to as a “transsexual man”, or even, later, a “male homosexual transsexual.” This is supremely insensitive, and quite surprising coming from caregivers. He explained that his use of such terminology was, basically, because that’s the way that psychiatrists are used to discussing the subject. What we cannot understand is why the issue is placed on the shoulders of transsexuals rather than on the psychiatric community. They are the ones using insensitive language; why do we have to tolerate that, rather than them putting forth the effort required to modernize their language? They are, after all, the ones who are responsible for treating transsexuals, and we come saddled with enough issues that demeaning us and refusing to recognize our right to self-identify seems counterproductive. Yet they persist.

Please note that for the rest of the article we are going to refer to transsexuals in the proper way: transsexual women are women who identify as women but were assigned “male” at birth, and transsexual men are men who identify as men but were assigned “female” at birth. This will be especially confusing in this article as we discuss Cantor’s insensitive language, but that’s his problem, not ours, and it’s certainly not yours.

This language extends to the issue of sexuality for transsexuals. Because he refers to transsexual women as “transsexual men,” Cantor is then comfortable referring to transsexual lesbians as “heterosexual transsexuals” because of the issue of birth gender. Excuse me: I’m a girl, I like other girls, and I’m called a “male heterosexual transsexual??”

Aside from the inaccuracy and confusion which results from this practice, we find a shocking lack of respect in their use of this language. And what about transsexuals who have intimate relationships with other transsexuals? That makes things a bit easier, because if a transsexual guy sleeps with a transsexual woman then, really, they are heterosexual (although perhaps desiring a transsexual would be seen as further evidence of insanity or narcissism in this theoretical model). But curiously, that’s the only place in which the language is consistent and respectful, though the intent is still wrong.

In defining the debate around transsexuals and situating himself as a service provider and researcher, Cantor gave some examples of non-trans feminists who are anti-transsexuals. Naming Sheila Jeffries and Janice Raymond, two of the most well-known, hateful and vocal anti-trans feminists publishing today, he described them as social constructionists; i.e., that they believe that gender is constructed. His point is well taken but it does show a flaw in his research: the arguments of Jeffries and Raymond are, in fact, based upon the same gender essentialism that pervades Cantor’s taxonomic structure. If he is naming the “enemy,” and the “enemy” is working from the same set of flawed assumptions that he is, would it not make sense for him to re-evaluate these assumptions? One worries about research which cannot even manage to correctly identify and understand its premise.

Cantor’s primary claim in this lecture is that, in contrast to the theories proposed and explored by gender theorists, sex and gender are two separate concepts, and that there is actually a causal link between the two. His analysis is based on the study of trans women, which is problematic because (among other things) he has no control group to which to compare, and restricts his study to a small part of the population. He briefly mentions trans men, as somewhat of an afterthought, and says (we shit you not), “Female to male transsexuals are pretty simple to understand. They’re all very similar. For one thing, 98% of them are exclusively attracted to women.” Sorry dudes, you are too boring and simple to mention, and transfags, you just step away from the boys right now! This absence of trans men is very telling: first, it indicates the complete lack of clinical interest in a very diverse client population; second, it homogenizes all trans men and basically dismisses them; third, it’s a totally incorrect assessment of trans men’s lives; and finally, trans men clearly aren’t included in the analysis because it really fucks up the nice neat model.

Fundamentally, Cantor’s theory hinges on the bifurcation of trans women into two definite groups: androphilic trans women, who fit into the role of feminine straight women, and autogynephilic, who might be understood as trans dykes, but with numerous significant differences (we’ll expand on these later). Of course, confusion and indignation results as Cantor persists in referring to these groups as, respectively, “homosexual male transsexuals” and “heterosexual male transsexuals.” Really, it becomes quite a demonstration of verbal gymnastics to keep these folks straight (as it were). In any case, for the sake of clarity and human dignity we’ll call them straight trans women, and lesbian trans women. These two groups, according to Cantor’s research, can be easily distinguished by biomorphic characteristics; in other words by things like height and weight, “feminine” appearance, and so forth.

One of the most significant problems with this method of understanding research subjects is that it focuses exclusively on external manifestations of an internally felt identity, as well as what the researcher or clinician perceives. For example, Cantor also distinguishes the two groups by how well (the clinician judges) each group passes. Clinician assessment of the subject’s passing also appears to be used a as a criteria for withholding or denying treatment, or to put it euphemistically, “suggesting alternatives.” How the trans person actually feels about themselves, and their ability to make informed choices about their own self-presentation, seems to be beside the point here. The model depends entirely on the authority of the clinician to make a judgement, rather than on the experience, choice, or testimony of the client.

Additionally, Cantor seems to be oblivious to the importance of social immersion and life experience. He points out that straight trans women are prone to transition earlier, be more feminine in appearance, and be smaller, while lesbian trans women are prone to transition later, usually in midlife, work in male jobs, and be larger. He also mentions that lesbian trans women experience no gender discomfort in childhood. At this pronouncement, Pandora, trans dyke extraordinaire, looked at Mistress Krista and rolled her eyes. Pandora was beaten up pretty much every day as a kid for the offense of being a complete and utter fruitcake. In any case, we know from studies of labour markets that men and women tend to perform different jobs. It’s called industrial and occupational segregation, and it’s consistent and pervasive. Someone who is male appearing and trying very hard to succeed at being a male would of course work in a male job. Frankly it’s evidence of nothing other than the gender stratification of the labour force. Also, if you transition later in life, it’s going to be very hard to switch careers from carpenter to beautician. Sure, a middle-aged trans woman isn’t going to be making much of a living as a Playboy bunny, but hell, 99.9% of people in their fifties wouldn’t get the job interview at Hef’s mansion either (not that fifty-year-old women can’t be sexy as hell— you know who you are, ladies, mrowr!).

As evidence of his theory, Cantor shows a short video clip from a documentary about transsexualism. It shows both straight trans women and lesbian trans women, and appears to support his assertion— if it weren’t for the fact that we recognize one of the women depicted as a straight trans woman and know that she identifies as bisexual and that she’s been shacked up with a woman for ages. We stifle giggles. We can also note that another television program featuring Cantor as a subject matter expert included an interview with a Methodist minister who transitioned later in life. She was married to another woman before transition, held a “male” job, had a child, and yet is now sexually interested in men. It’s obvious that categorical statements about individual sexuality are often doomed to failure, and predicating an argument upon such forced speculation is problematic.

“You’re not just telling us what we want to hear?” —Parole board member #1

“No sir, no way.” —H.I.

“Cause we just want to hear the truth.” —Parole board member #2

“Well, then I guess I am telling you what you want to hear.” —H.I.

“Boy, didn’t we just tell you not to do that?” —Parole board member #1

“Yes, sir.” —H.I.

“Okay then.” —Parole board member #1

Raising Arizona

However, at the same time as he situates the authority to pass judgement with the clinician, Cantor disavows the responsibility of said clinician for guiding the client in treatment, or limiting the options that trans people feel are available to them. In other words, clinicians should have the right to tell people who they are, but then when those people humour the clinician’s view of them in order to secure treatment, it’s yet more evidence of trans pathology. We don’t know how many trans people you know, but “pathetic dupes of the system” is not a phrase that we would use to describe them. Bullshitting the clinician is a matter of survival. If you have to play by their rules, then you do so. Unfortunately, according to Cantor, that’s the fault of the trans client, not the system which forces people into limited categories of diseased personalities. You can almost hear him humming Patsy Cline’s Crazy as he goes about his work, or perhaps taking his clinical practice from a Kafka novel.

The psychiatric community has demonstrated time and time again that it is completely unable to engage in self-reflexivity. They refuse, like many conventional scientists, to recognize their own implication in the system, and very few psychiatrists seem willing to accept some responsibility for creating an environment in which transsexuals are demeaned and ignored. This is a giant, flaming methodological flaw in Cantor’s research: the assumption that transsexuals are unable to understand and describe their own experiences.

After delineating the differences between the two groups of trans women (remember, there can be only two!), Cantor says, “It all fits neatly into this conceptual schema.” A trans woman sitting behind me mutters sarcastically in a Bette Davis stage whisper, “Of course it does.” According to Cantor’s model, men and women— transsexual or non-transsexual— fit neatly onto one of three continuums, as shown in Figure 1. Apparently we are supposed to ignore the fact that this does not account for heterosexual non-transsexual women or heterosexual non-trans men. Being “normal”, they are exempt from comment. Looking at Cantor’s model it is apparent that people are, again, classified according to external perceptions of their identities. In the library of Cantor’s theory, femme dykes are shelved next to straight trans women, even though the two might have nearly nothing in common beyond a passion for snazzy shoes. Also, there is no possibility for change over time, or multiple identities. Many of us have undergone transitions of one kind or another, perhaps small, perhaps major. In general we don’t stay the same person throughout our lives, but change our identities and how we present ourselves to the world, if only subtly. What if we dress femme and kiss the boss’ ass at work, but at home we like to put on leather chaps and a motorcycle hat, and push our naughty slave around? What if we are Straight White Gap Man at work, but screaming drag queen on the weekends? Which identity is “real”?

Figure 1: The Nice, Tidy Gender Continuum

Gay Men Heterosexual Men Lesbian Women
Masculine Gay Man Heterosexual Male Fetishist Feminine Lesbian
Feminine Gay Man Transvestite Male Fetishist Masculine Lesbian
Drag queen Partial autogynephilic Bull Dyke
“Androphile” (male-born TS who likes men) Autogynephilic transsexual FTM transsexual

If you know any transsexuals (perhaps even yourself), you will see how ludicrous this is. The theory of autogynephilia is interesting, and it obviously works for a lot of people. What is problematic is the notion that transsexuals can be divided into only two groups, and we can then state categorically that group A does action X and group B does action Y. If you actually talk to transsexuals, you’ll find out that there are just as many exceptions as there are matches. Humanity is waaaaay too complex for such simplistic thinking, but that’s the way that scientists work. We want to pummel them with Donna Haraway books.

Another amusing (and sad) point of Cantor’s was the claim that autogynephilic transsexuals are interested in women because they want to possess a woman’s body. They are incapable of loving and desiring a woman in anything other than an abstract form. Never mind that non-transsexual lesbians and non-transsexual straight men are interested in women, too, and may also demonstrate a range of interest from abstract objectification to passionate acceptance of another individual. We had assumed that the claim that lesbians are simply narcissists had fallen by the wayside when we learned to bang two rocks together to make fire, but apparently not. Lesbian trans women also fantasize about men, but apparently only in the abstract and as a prop for their (lacking) womanhood. Again, Cantor seems to have ignored a basic reality about lesbian sexuality, which is that a lot of lesbians fantasize about men.

One of the most worrisome claims, that comes up repeatedly with Bailey, Blanchard and Cantor, is that transsexuals who do not fit their models are simply lying about whatever issue is being investigated. Cantor suggests that transsexuals who self-report in ways which contradict the theoretical model are lying, perhaps to themselves, and perhaps (even more insidiously, we gather), to the researchers. This is phrased euphemistically as “not being honest with themselves”. He asserts that nearly 100% of lesbian trans women are dishonest in their self-presentation. But if these women are lying to themselves and the researchers, how do they know this? Are they watching the women 24-7, and catching them cackling to themselves with delight over misleading their therapist? “Lying to yourself” seems pretty frigging convenient as an explanation for testimony that the clinician doesn’t want to accept. Really, you can’t win. If you express a desire, then you’re crazy. If you don’t express the desire, you’re lying to yourself. And still crazy. The main thing is, you’re you-know-what. *making cuckoo motion with finger* At no point in Cantor’s presentation did he acknowledge this problem with his research, and did not seem to see it as problematic that the research made up for its shortcomings by asserting that outlying data— such as straight transsexual women who transitioned after their 20s— are in fact liars.

Liar! Liar! You are all liars! Oh, and crazy. Did we mention that?

During the question and answer period Cantor fielded questions from an audience comprised of a mixture of transsexuals and non-transsexuals. The trans audience members were clearly less than inspired by being told about their own lives. They attempted to intervene by showing how their own experiences defied the model. In an astonishing display of rudeness, Cantor told one trans woman who was telling her own story, “I don’t mean to cut you off, but I’m going to cut you off”, and grinned. Someone send this asshole back to Group Facilitation 101 and don’t let him in a room with vulnerable people until they amputate his professional arrogance and he learns to play well with others. Eventually someone asked the obvious question, “What about bisexuals?” This was answered with the familiar refrain of lying. Cantor feels that bisexuals are not being honest with themselves again, and are relying on narcissistic abstract fantasies to make up for their truncated sexual identities.

One woman said that she was scared of CAMH because of all of the negative reports about how they treat their patients. Based on nothing more than the tone and content of Cantor’s presentation, it is easy to see why. Cantor, though, claimed that people listened to the “rumours” about the Clarke and that’s why nobody felt comfortable. Except they aren’t rumours; they are widely reported issues. Our friend just won a human rights complaint against them, for pete’s sake. Do an Internet search on the Clarke and CAMH and you’ll find a plethora of horror stories written by transsexuals about dealing with CAMH. This presentation was a travesty of responsible research and professional competence. Clinicians have so many opportunities to learn from their clients. All they have to do is listen. And yet they persist in doing the opposite: talking, talking, talking and telling trans people what they need to know about themselves, defining the terms of engagement and constantly changing the rules.

Why did we take the time to write this critical piece on Cantor? His heart seems to be in the right place, or at least he thinks that it is (but then who knows, he could be lying to himself). It isn’t simply because we disagree with him. It’s because his research and practice ultimately has the potential to affect many people’s lives. Trans people in Ontario pretty much have to go through the CAMH if they want medical or psychiatric intervention, unless they have a lot of dough and the name of a sympathetic doctor or counsellor. People going into therapy to sort through their gender are at a vulnerable stage in their lives. They don’t need to be made into zoo animals which are poked and prodded, or to deal with a clinician who isn’t interested in listening to their concerns. Mistress Krista had never been to the CAMH before, and it hadn’t really occurred to her that it was set up like a hospital. When she walked into the CAMH facility, she felt a surge of discomfort and anxiety, almost fear at the sterile setting and steel doors. This was a place where someone with a degree could brand her as deranged and she might never escape. And she was just planning to be there for a couple of hours. We could only imagine the terror experienced by people who depend on this institution for their wellbeing and formal certification of sanity. Theories such as Cantor do not further the cause of trans-clinician relations, and they don’t contribute to the quality of trans people’s lives.

The whole question of where trans-ness comes from is interesting, but ultimately irrelevant. It’s not a disease, and transsexuals don’t need to (and can’t) be “cured” of it. What transsexuals need is for researchers and clinicians to listen to them, to care about them, and to treat them with the respect and dignity that should be accorded to all human beings. It’s not really that much to ask. If people don’t fit the model, change the model, not the people.

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