Prisoners, doctors and the battle over transmedical care



Stephen Levine was born 1942 in Pittsburgh. He wanted to be a doctor when he was a little boy; he saw how much his parents and people in his community respected the profession. At Case Western Reserve University School of Medicine, he decided to pursue psychiatry, drawn as the field explores human stories as well as biology. In 1973, while completing his residence, Levine heard that his alma mater wanted to hire someone to develop a medical school curriculum on human sexuality. Levine got the job. Over the next few years, he helped establish several clinics focused on sexual disorders at the university. In 1974, he founded the Case Western Clinic for Gender Identity to treat people who are unable or unwilling to live according to the gender assigned to them at birth.

In the 1970s, when Levine entered the field, scientists and doctors debated for years what “caused” transness – and thus how to treat it. As Joanne Meyerowitz describes in her 2002 book How sex has changed, since the mid-20th century, two schools of thought have competed for primacy. He was the first to see the desire to change his body through a psychoanalytic lens, as a symptom of unresolved early trauma or sexual difficulties. Initially, most psychiatrists belonged to this group, believing that the doctors who helped their patients in the physical transition only made their misconceptions possible. The attitude is summarized in the words of prominent sexologist David Cauldwell, who wrote in 1949: “It would be criminal for any surgeon to mutilate a pair of healthy breasts.”

The second camp highlighted biological factors. Although his supporters generally agreed that a patient’s upbringing and environment could affect his or her gender identity, they felt that a person’s chromosomal or hormonal composition was more important. Prominent figures, including endocrinologist Harry Benjamin, pointed out that “curing” transnesse with talk therapy was almost always unsuccessful, in which case he advocated a different intervention: “If it is obvious that the psyche cannot be brought into sufficient harmony with the catfish, then only then is it necessary to consider the reverse procedure. “

As these camps emerged, some trans people were constantly pushing against their prospects, insisting that transness was not a medical disorder and that access to hormones and surgeries should not be provided for by the approval of mostly cis and male doctors. In the late 60s and early 70s, some trans people tried to organize their own treatment clinics by providing peer counseling and support and recommendations for surgery.

However, these clinics did not survive, and the primary part of the medical model was still accepted. In his research and scientific work, Levine relied on a psychoanalytic approach, theorizing that the desire for transition is a way for his patients to “avoid painful intrapsychic problems”. He explored what he considered potential causes of these feelings, including the mother’s “too long, overly symbiotic” relationship. When a person declared himself transgender, he liked to say, it was an attempt by the mind to offer him a solution. In psychotherapy, patients could examine and solve the problem that created those feelings. As in other clinics across the country at the time, Case Western offered surgery to only a few transgender patients – about 10 percent since 1981. Many trans people were frustrated with this approach, but at least found some degree of sympathy and understanding in clinics like Levine- these. They were seen as people in need of treatment, not as deviants.

Throughout the 70s and 80s Levine’s growth grew. His clinic attracted patients and published articles in prestigious magazines. In the early 1990s, however, scientific consensus among health care providers and researchers began to move away from psychoanalytic theories. More people have seen evidence of innate biological factors. An increasing proportion of service providers have argued – with increasing quantitative data supporting their claim – that medical interventions are more effective than therapy in alleviating gender dysphoria. One area of ​​the human brain associated with sexual behavior is larger in men than in women. 1995 study landmarks published in Nature They found that this area was the same size in trans women as in their cisgender peers, regardless of their sexual orientation or whether they were taking hormones. The finding suggests that “gender identity develops as a result of the interaction between the developing brain and sex hormones.”

Two years later Nature study came out, Levine was appointed chairman of the board of the International Association for Gender Dysphoria Harry Benjamin, the national primary organization for medical service providers treating trans people. The most important role of the organization was to develop and publish a regularly updated document outlining best practices for diagnosing and treating trans people, called Standards of Care. Levine has been called upon to lead the team producing the next update, SOC 5.

The revision of the standards has been a long process. In 1997, the organization held a two-year conference in Vancouver, British Columbia. Jamison Green, a trans man and health activist who lived in San Francisco at the time, arrived at the event to establish that he was one of only a few trans people in attendance. “It wasn’t a pleasant environment,” he tells me. “They weren’t happy to see you.” Levine was scheduled to chair a session on Saturday afternoon on the proposed draft standard. Green was sitting in the auditorium waiting for the event to begin, when he heard a commotion outside. Technically, the meeting was open to members of the public, but there was an expensive registration fee. Many other trans activists, especially those living locally, were outraged that because of the high cost they were basically excluded from a meeting that would directly affect their care. “They started banging on the door and demanding to let them in,” Green says.


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