Among the key aspects that are at issue in the course of establishing the patient history are, as the German Standards propose, the person’s gender identity de-velopment, psychosexual dede-velopment, including the sexual orientation, and the current life situation (Becker et al. 1997: 149). Hence, the trans person’s past and present gender performance are at the heart of the negotiations be-tween the medical professional and the so-called patient. However, medical examiners dealt, and continue to deal, very differently with the findings.
While Clement and Senf for instance stressed the importance of the exam-iner’s impression of a trans person’s current gender performance, they cau-tioned against evaluating it. According to Clement and Senf, neither a gen-der-neutral appearance nor a patient’s overcompensated gender performance indicate whether a person is trans. Clement and Senf concluded that the exam-iner’s impression is not a diagnostic criterion. It may however give an idea of whether the patient will encounter difficulties in his or her social and profes-sional life or not (Clement/Senf 1996: 16 f.).
When investigating into a trans person’s gender development, Langer tried to detect the »subjective experience of the gender identity disorder as well as objective aspects of behaviour in the desired role« (Langer 1995: 272). Beier, Bosinski and Loewit were more explicit about the indicators they perceived to be gender-typical behaviour. Among these were e. g. favourite childhood games and toys, cross-dressing, and favourite subjects in school (Beier/Bosinski/Loe-wit 2005: 379). Likewise, Langer and Hartmann sought indicators in order to assess a patient’s transsexual development. They e. g. suggested to enquire into the patient’s childhood preferred games and playmates and his or her social behaviour in school (Langer/Hartmann 1997: 866).
support groups were primarily concerned about the knowledge on psychiatric experts (Pfäfflin 1996: 26 f.) they shared among each other and instances of self-medication (Pfäfflin 1996a: 35; Eicher 1996: 49). By contrast, Seikowski highlighted the enabling effects support groups, subcultural networks and publications have in the process of self-diagnosis (Seikowski 2007: 250 f.). While Rauchfleisch, like Sigusch, insisted on psycho-medical diagnostics in the event of transsexualism, he acknowledged the significance support groups have for the acceptance of trans individuals and the exchange of knowledge and experience (Rauchfleisch 2006: 89). Unlike Seikowski, he also developed a critical perspective on support groups when pointing out to the pressure they exert on trans individuals to conform to mainstream notions of trans (ibid: 90). In his chapter,
»What can transidentified people do themselves?« (Was können transidente Menschen selbst tun?) he presents as his recommendations tasks support groups have taken on since the 1970s at the very latest, such as, offering information and consultation for trans individuals and physicians (ibid: 122).
Moreover, Beier, Bosinski and Loewit as well as Langer and Hartmann sug-gested painstakingly investigating into a trans person’s intimate life. Their pro-posed patient histories e. g. explore the individual’s masturbation scenarios and fantasies (Beier/Bosinski/Loewit 2005: 379; Langer/Hartmann 1997: 866), fa-vourite sexual positions and practices (Beier/Bosinski/Loewit 2005: 379) and sexual orientation (Langer/Hartmann 1997: 866).
Finally, Langer and Hartmann suggested inquiring into the family history with a particular emphasis on psychiatric symptoms, delinquency, depres-sions, attempts at suicide and self-mutilation. They argued that this informa-tion was relevant in order to understand the effects these incidences had on the individual’s development (ibid).
Langer’s, Langer and Hartmann’s, and Beier, Bosinski and Loewit’s ap-proach to the trans patient and his or her patient history are problematic from an ethical and analytical point of view. With regard to the latter, neither Beier, Bosinski and Loewit (2005) nor Langer and Hartmann (1997) questioned the gender norms and stereotypes that informed their perspective. Moreover, their exploration of a trans person’s sex life suggests that sexual practices, positions and fantasies indicate a particular gender identity. A trans person’s intimate life seen through the lense of normative and reductionist concepts of gender and sexuality become criteria for granting or denying trans individuals access to medical and/or surgical treatment and/or legal provisions.
Moreover, the sexologists’ gender concepts and ethics clash in a setting characterised by an unequal distribution of power. This particular diagnostic situation is prone to render psycho-medical experts’ subjective understandings of gender and sexuality authoritative.47 While Langer appeared to be aware of
47 | Langer and Hartmann’s stance on the medical assessment for a revision of gender status serves as an example of the hierarchical relationship and with that the trans person’s dependence on what medical experts deem a healthy gender identity and an appropriate gender performance. Langer and Hartmann argued that a medical assessment for the purpose of a revision of gender status should not be taken lightly, despite the fact that sex reassignment surgery and the change of first names might have taken place (Langer/Hartmann 1997: 868). They stressed that the medical assessment should state whether a change of gender has taken place convincingly or at least satisfactorily in a psychosocial sense (ibid). Langer and Hartmann did not mention what was supposed to happen in the event that a person had undergone a physical transition and did not appear psychosocially convincing to a medical expert.
The normative effect of the examiners’ subjective concepts of gender and sexuality also becomes evident in Langer and Hartmann’s example case studies. First, they called male-to-female trans individuals ›men‹ and female-to-male subjects ›women‹, which apart from being disrespectful, suggests that a person’s gender identity is necessarily linked to a particular morphology. Second, their examples also suggest that a person’s
this problem, his suggestion that the medical expert reflect upon his or her understanding of gender when assessing the psychic and physical chances of a trans person’s life in the desired gender (Langer 1995: 272) remains entirely voluntary. There is no mode of fostering or supervising the psycho-medical ex-pert’s degree of self-reflexivity and gender knowledge. Nor do any of the sexolo-gists mentioned above give a plausible reason why a medical examiner’s assess-ment of a trans person’s gender performance or experience as a trans person is less prone to misjudgement and with that superior to that of a trans individual’s concept of self.
In a setting characterised by unequal power relations and possibly conflict-ing concepts of gender, the examiner’s concept of gender becomes the trans person’s obstacle that needs to be overcome in order to gain access to medical and surgical treatment and to legal provisions during the assessment process prior to a change of first names and revision of gender status. Hence, Linde-mann’s critique of the German Standards, which in her opinion deny trans individuals their respective subjectivities acutely applies in this particular step of the diagnostic process. With regard to the investigation into the trans per-son’s intimate life, conducting the patient history according to Beier, Bosinski and Loewit’s, and Langer and Hartmann’s concept denies a trans person the right to privacy.
willingness to submit to the psycho-medical assessment regime is among the criteria that contribute to a favourable outcome. Their following descriptions in note form back up this assumption: »33-year-old man whose change of first names could not be approved despite extremely large doses of hormones (without any therapeutical monitoring) and despite benevolent statements by individuals the person is attached to. Information on the amnesis with unproblematic male professional life and without perceivable distress due to the identity considerably contradictory. Laboured short-run stereotyped ideas and travesty-like appearance. […] Diagnostic criteria for transsexuality not fulfilled« (Langer/
Hartmann 1997: 864) and »31-year-old natural scientist with a PhD and high achievement motivation. Ideal psychiatric supervision. In its setting simultaneous application and commencement of the hormone treatment. Complicated development from insecure boyishness. Postpuberal pure fetishism, experienced as deeply foreign to him, embedded in a strong sexual appetence and masochistically tinted autoeroticism. Later on diffusion of gynophilic orientation and cross-gender identification. Four relationships with women with a transvestic-penetration-ambivalent sexual style and gradual development of crossdressing. Finally self-critically completed stable change of gender. Overall a transformation of a paraphilic into a transsexual state with an apparently bisexual orientation.« (Langer/Hartmann 1997: 863)