The Cruelty of "Medical Necessity"

[Content note: Transphobia. Disablism. Disallowing people from being experts on their own lives and needs. This post also contains some very triggery stuff about depression and self-harm. Please note the commenting guidelines at the end of the post.]

Last week I wrote a piece about why I don't like "love your body" campaigns. When I wrote it, I made a deliberate decision to omit any of my issues with self-harm. I've been thinking about that a lot.

First off, I think it's inappropriate to start talking about self-harm at the same time that I'm raising money for my medical bills. The whole "give me money or I'll cut myself" thing is manipulative as hell.

Just to be clear that I'm not being passive-aggressive, I've long since decided that if I ever find myself insinuating that self-harm is eminent, I'm absolutely stopping raising funds prior to doing so. It's just not cool to put folks in that position, full stop.

And you know, since friends and family are likely reading, let me just say that I'm having a fairly decent week, all things considered. I'm an old hand at managing my depression. I've got a great support network. This being trans* shit ain't fun (nor is mental illness). If it was, all the kids these days would be doing it.

As much as I like to ground my writing in my experiences, I'm not really here to talk about me as much as I am why I'm usually careful to not publicly talk about self-harm.

If you're trans* (or intimately involved in a trans* community), you've probably already noticed this: we're constantly talking amongst ourselves about self-harm.

When I first came out and was involved in face-to-face and online support networks, the subject came up all the time. In some circles, self-harm is a badge of honor. In some folks' minds (and I'm talking about trans* women here, as I haven't spent the same amount of time in gender queer or trans* masculine circles), women who don't have a history of self-harm aren't really trans. There's this whole fucked up competitive aspect of sharing your history.

"Kid, I've being trying to kill myself since before you were born. I have done the following self-destructive things on the following large number of occasions. It's bad, and it's going to get worse and so on and so forth."

That's some toxic shit, and it's the single biggest reason I don't spend more time in trans* spaces. I've got my own issues to deal with, and as much as I really want to help my sisters, I don't have the bandwidth to address that dynamic on a regular basis.

Here's the thing, and this is important. Not only are these women not lying, but I need you to remember this: cis people are the ones who created this dynamic.

I'm gonna use some html so y'all can pay attention:

Trans* women are bragging amongst themselves about their suicide attempts and other self-destructive actions. While my sisters and I have to do the work to fight this dynamic, it's ultimately cis people's fault. You created this phenomenon. It's your fault. And it's your responsibility to help us fix it. You.

And the first thing you need to understand is that trans* women talking about self-harm is not only a real response to a culture that questions our very existence and denies us access to necessary healthcare; it's also a thing we feel like we have to do in order to prove that our pain is sufficient enough to warrant access to healthcare.

Let me say that again, in case you missed it the first time: Ciscentrism obliges us to contemplate and discuss self-harm to prove we hate our bodies enough to earn healthcare.

This is one more double-bind that cis people put my sisters and I in. See, we already have to deal with all sorts of gatekeepers and financial barriers to access health care. (Even in those countries with robust government-run healthcare systems there are still significant financial barriers, although that's a topic for another time.)

In order to receive healthcare, we have to prove that it's medically necessary. This is one of those areas where the threshold for necessity depends on who's doing the talking. It goes without saying (although we should talk about it) that it's medically necessary to extend affluent white cis hetero men's lives by a few months (erections included, natch).

Cis* people tend to think that trans* people are unnecessary. They sure as hell tend to think that our medical care is unnecessary. Our bodies generally aren't going to kill us. In my case, I suppose it's possible that I'll die of undiagnosed testicular cancer, because there's no fucking way I'll ever do a self-exam, no matter how much my doctors beg me to do so. That's pretty much the only exception, though.

Nope. If I don't have another hair electrocuted out of my face, if I go the rest of my life without SRS, I'll muddle through. I'm going to have pretty regular struggles, but I'm strong. I can find a way to life my live, albeit with a reduced quality of live.

And, you know, if I have SRS tomorrow (which would be, uh, surprising) and never have to shave my face as long as I live, I'll be a lot happier and a lot less anxious, but I'll still have regular struggles with depression. That's just how it works. That's what having depression is like, and for a large percentage of the trans* women I know, that's a reality.

That story just doesn't sell, though.

See, if we can't say with conviction that we're going to off ourselves if we don't get the healthcare we need in a timely fashion, insurers, providers, and governments are always going to be able to deny us on the grounds that our needs aren't real. Don't get me wrong. Trans* people who publicly confess to thoughts of self-harm aren't lying. It's just that they're frequently going through an exercise for the benefit of cis people. It sure as hell isn't for our benefit, people.

Talking about self-harm is also the de rigueur method for getting cis people to understand what transsexuality feels like. Sure, we ask cis ladies how they'd feel about riding a bike if they had a penis and testes. Sure, we ask cis men what they'd do if they had to feel the weight of their breasts whenever they went up and down stairs. We ask questions and we share our stories all the time. Hell, a lot of times we pay cis people to listen to our stories, because that's generally a prerequisite to our getting any medical care. A lot of you aren't particularly interested in listening.

Cutting your dick off? That generates headlines. (And seriously, I can feel all the cis men in the audience cringe and grab their crotch as they read that. I'm really sorry, but that's whole dynamic is pretty central to my point.) People joke about that sort of self-harm, people feel sorry about it, people become conflicted. The important thing is that they pay attention. See, our healthcare needs are needs. Our healthcare is just as essential as yours. (There's also the issue of how it shouldn't matter if it's a "need", but that's another essay.)

The thing is, there's a flip side—the thing that makes it a double bind. While we have to demonstrate the capacity for self-harm to get folks to take our needs seriously, demonstrating the existence of serious mental illness also automatically makes us untrustworthy. To quote Liss, "you have to be 'broken' to prove you have a need; your ‘brokenness' means you aren't qualified to assess your own needs."

Yeah, contemplating self-harm is a big deal, even though it's just reality for a lot of us. I know that whenever doctors ask me if I've recently attempted or contemplated harming myself, I craft my response based on how much I've been not contemplating self-harm. Contemplating self-harm isn't really a huge issue for me at this point in my life. Not not contemplating self-harm? Now that's a major cause for concern. You know, perspective matters.

As far as most people who are in charge of making medical decisions for us are concerned, trans* people are either totally exaggerating and our body issues aren't really a big deal, or we're crazy and nothing we can say should be taken seriously. There's not a right answer. There are trans* people that have never contemplated self-harm. Seriously, if you've read this far and you're a trans* person who's never thought about harming yourself, you're not alone. (True story: I had a dear friend once confide to me that she felt left out because she didn't have a war story to tell. Okay, she actually had lots of stories, but none of them involved self-harm.)

Hell, I'm actually pretty damn careful about what parts of my mental health I disclose to providers, because I'm terrified that my perfectly understandable (given empathy) mental health issues will somehow disqualify me from being able to have any surgery, should I be able to afford it. Honestly, I have no clue what the right answer is. What I do know is that for a lot of folks, ALL of my potential answers are wrong.

Society has constructed a narrative about my life that I can't debunk, because according to the narrative I'm not an authority on my own condition.

This dynamic reminds me of Julia Serano's writing on the impossible situation trans* women face with respect to femininity. If we're not feminine enough, we're clearly not really women (e.g., we're men, and the powers that be should be able to stop us from transitioning), but if we are feminine, then we're playing into bullshit narratives about gender and should be stopped from transitioning on the grounds that we've been duped by the patriarchy. Occasionally, both conditions seem to apply at the same time.

The bulk of the people in a position to do something about it are really invested in us not getting healthcare, and I don't quite know how to deal with it on any level. I don't mean to go all conspiratorial (again: that be a sign of my unfitness to talk about my needs), but there's really not much that I or any other trans* woman can say about this without getting automatically dismissed as someone who's phishing for attention, being manipulative, or delusional.

Again, let me use html to emphasize that shit, because it's important:

The bulk of the people in a position to do something about it are really invested in us not getting healthcare.

I know that basically all of my trans* peeps have already figured that out, but seriously. Medical interventions to help trans* people aren't new. The first widely-publicized transsexual woman to undergo hormonal and surgical treatment was Christine Jorgensen, and that was back in 1951. Jorgensen wasn't the first person to receive conventional western medical aid in transition either—not by a long shot. Hell, Harry Benjamin (a name that elicits a lot of different emotions from various trans* circles), the person who developed a lot of the basic framework that's still being used to care for (a small portion of) trans* women has been dead for over 15 years.

There are medical professionals that know how to help trans* people. They've made notes that are widely available. You can tweak the framing a bunch of different ways (short-sighted greed on the part of insurance companies, aggressive indifference brought about by cis privileged, or out-and-out bigotry), but the bottom line is that trans* people aren't in the place we are today by mere accident.

We all need to talk about this. For one thing, cis people need to get serious about giving trans* people healthcare. Everybody is entitled to healthcare.

Second, we need to destroy the dynamic that led me to write this piece in the first place. Nobody should be put in a position where they view self-harm as a rite of passage. Yet we also need to erase the stigma surrounding mental health. Trans* folks need the ability to get help when we need it, without fear of retribution from gatekeepers.

We need to be free to disclose and address self-destructive behaviors.

We need to be free to disclose not being self-destructive.

Trans* people need to own this, but we need the rest of you to destroy the power structure that fuels the dynamic.

So yeah, I really didn't want to engage the subject of trans* people and self-harm, because it's not always particularly healthy to do so. However, I think it's even unhealthier to sit here and pretend that it doesn't exist.

Crossposted with slight modifications from A Cunt of One's Own

[Commenting Guidelines: In order to keep this a safe space, I'm going to request that we all agree not to share details regarding urges or attempts to self-harm. Also, the main point of this post is to bring about change so that we don't feel the need to impress anyone else with how self-destructive we are. What I want us to talk about is the dynamic around self-harm—and the ways in which we and our allies can shatter that dynamic, e.g. regarding trans*-related healthcare as necessary and routine healthcare for which there is no threshold for access defined by self-harm.]