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"The Proof Is in the Pudding": How Mental Health Practitioners View the Power of "Sex Hormones" in the Process of Transition.

IN THE UNITED STATES TODAY, popular discourse touts the power of "sex hormones" and hormone receptors in the brain to chemically produce gender expressions (manifested in physical sex traits, behaviors, and attitudes) and identities (a sense of self as feminine or masculine). These accounts range from common assumptions that Western ideals of femininity (such as empathy understanding, cooperative orientation, nurturing behavior) and masculinity (rational/spatial understanding, competitive orientation, violent behavior) are produced by corresponding sex hormones, to studies that reduce complex gender identities and macrosocial economic phenomena to presocial, binary, hormonal processes. (1) For sociologists, accounts that reduce complex identities to internal hormonal reactions are problematic for two primary reasons: first, they are inaccurate because they fail to examine how hormonal reactions are embedded in a complex cultural process of meaning and interpretation; second, they operate as bioreductive ideologies that obscure the social power inherent to the process of gender identity construction. In what follows, we extend both of these insights by examining mental health practitioners' divergent interpretations of the power of sex hormones in the process of gender transition. (2) In doing so, we examine the cultural power of sex hormones in crafting gender identities without reproducing reductionist interpretations of trans embodiment.

Perhaps what is most perplexing about the way we speak of sex hormones is that we know it is inaccurate to describe these hormones as sexed; scientists have acknowledged since the 1930s that they are neither sex specific in their function, nor in terms of their location in male or female bodies. (3) In her extensive historicization of sex hormones, Anne Fausto-Sterling concludes that it is more accurate to call androgen-and estrogen-based hormones, "steroid hormones" as they have functions that are not confined to corresponding sexed bodies. In fact she urges scientists to "break out of the sex hormone straightjacket" and to look at steroids as just one of a number of components that are important to the creation of sex and gender, including environment and experience. (4)

Scholars also point to an inextricable link between the chemical operation of hormones and the social process of constructing meaning, both at the level of social interaction and macrocultural constructions of sex categories and gender ideologies. (5) While brain organization/activation theory attributes sex and gender differences to hormonal interactions within the developing brain, Fausto-Sterling questions the distinction between activation and organization by pointing out how "the brain can respond to hormonal stimuli with anatomical changes ... hormonal systems, after all, respond exquisitely to experience, be it in the form of nutrition, stress, or sexual activity (to name but a few possibilities)." (6) Drawing from Elizabeth Grosz, Fausto-Sterling argues that the power of hormones is best understood according to the model of the Mobius strip, wherein internal components of the self are always connected to and continuous with outer components such as culture and environment. (7) In other words, the physiological impacts of hormones are socially, as well as biologically, activated.

In her more recent review of brain organization/activation models, Rebecca Jordan-Young comes to a similar conclusion. Her extensive analysis of studies related to brain organization theory from 1967 to 2000, along with a sample of the most influential works from 2000 to 2008, unearths three problematic assumptions that undergird these models: first, that hormones have sex-specific functions; second, that these functions are mostly limited to reproduction; and third, that male and female hormones are antagonistic. Adding to a long list of methodological problems with brain organization research, Jordan-Young exposes how scientists accept masculinity and femininity as commonsense, stable, and universal categories, and they conflate gender with sexual orientation, such that desire for women indicates natural male brain organization and vice versa. She concludes by reviving the Thomas dictum--"If men define situations as real, they are real in their consequences"--to suggest that naturalized gender becomes embodied gender through the process of a self-fulfilling prophecy. (8) As with the Mobius strip model for Fausto-Sterling, Jordan-Young uses the Thomas dictum to emphasize the importance of culture and social context while also stressing that the development of gender identity is more like a process than a permanent state.

Both Fausto-Sterling and Jordan-Young question how and why hormones continue to represent gendered meanings in spite of clear evidence that sex hormones do not have sex-specific functions. Historical accounts of the "discovery" of hormones provide irrefutable evidence that scientists sexed hormones in an effort to make them intelligible in a culture that assumed a dimorphic model of sex and gender. In her archeology of sex hormones, for example, Nelly Oudshoorn argues that the current scientific model of sex hormones is not a description of a precultural reality of the body, but a complex outcome of the appropriation of prescientific ideologies within modern scientific practice and organization, including disciplinary divisions within science, research materials, and testing practices. (9) Oudshoorn sees the process of sexing hormones as fueled by cultural notions around gender, but she is careful to argue that science does not just reproduce cultural norms; it actually transforms them and creates new meanings for the body.

Celia Roberts extends Oudshoorn's findings by theorizing the relationship between prescientific ideas of binary gender differences and the integration of new scientific discoveries. Using the metaphor of a crumpled handkerchief, Roberts explains the disconnection between scientific discoveries and the cultural dimorphic model of sex hormones they falsified as a wrinkled, rather than a linear, network of scientific embodiment. Thus, Roberts provides a more nuanced understanding of the impact of culture as it is continually reproduced in the present, not simply inherited from the past. With a more contoured, less linear model in mind, Roberts rejects the social constructionist and bioreductivist perspectives on the sexed body and describes hormones as "messengers" whose communicated meaning is not predetermined by biological processes. (10) Drawing from Donna Haraway's formulation of bodies as "material semiotic actors," Roberts describes hormones as active agents in the cultural production and materialization of sex. (11) In other words, "hormones do not message an inherent or preexisting sex within bodies, but rather are active agents in the bio-social systems that constitute material-semiotic entities known as sex." (12) Thus, Roberts's work implies that we continue to view hormones as sexed precisely because they produce sexed realities at the interpretive level, whereas Oudshoorn's emphasis on scientific organization and practice points to how hormones are actually used in research and development. We think both approaches are useful and compatible, and we offer a way to understand how the continued sexing of hormones (which we see as a cultural project) plays out in one contemporary clinical context. Moreover, instead of taking the sexed body as the object of explanation, we see our work as an elaboration of sex hormones as semiotic agents in the process of interpreting and, thus, constructing gender identities. We see this relationship between sex hormones and gender identities as primarily driven and mediated by a version of Western gender ideology that posits sexed bodies as malleable representations of natural and fixed gender identities. (13)

In this way, the sexing of hormones is one component of the larger hegemonic ideological project of binary sex essentialism. Roger Lancaster has carefully documented essentialist narratives as a form of biological reductivism that operate as an "ideological fixation" of gender and sexual identity (which we know to be socially constructed) as if they were preprogrammed in the human mind and body. (14) In addition to the questionable veracity of the posited relationships between gender and hormonal processes, this bioreductive discourse is politically dangerous as it is, as Lancaster explains, "predicated on a narrow, unitary, or fixed conception of identity [that] works at the expense of human freedom ... [and] cannot grasp the logic whereby identities are really improvised." (15)

Although, as Michael Messner uncovered in his work on the construction and appropriation of gender ideology in youth sport, essentialism--the assumption that group differences (e.g., women and men) and identities (e.g., sense of oneself as a woman or a man) are products of nature--can come in more or less binary categorical forms. (16) The hegemonic sex-hormone narrative is both binary (assuming hormones are neatly classified as female or male) and essentialist (positing nature as the source for hormonal power). Moreover, hormones hold a special place in the construction of binary sex essentialism as they are not just outcomes, but primary agents of assumed natural differences between "the sexes."

In terms of trans body modifications, sociologists and gender scholars attribute the performance of sex essentialism to the psychological/ medical model that dominates both transgender theory and practice. (17) Dubbing the term "authenticity model," Myra Hird critiques psychological models of the self that assume humans are born with a stable and persistent gender identity. (18) Citing Richard Ekins and Dave King's finding that the "end result" of psychological approaches is to maintain the "binary structure of gender," Hird crystallizes the place of binary essentialism in her analysis of the gender identity disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), in which the description of successful treatment stipulates "an individual who is unambiguously either male or female." (19)

Binary essentialism is contested, yet it continues to dominate current approaches to trans body modification in the United States. For example, the "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People," a document that offers guidelines for clinicians working with trans clients, describes hormonal interventions as "the administration of exogenous endocrine agents to induce feminizing or masculinizing changes" and outlines "persistent, well documented gender dysphoria" as a criterion for hormonal interventions. (20) At the same time, however, in its definition of dysphoria--"discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth"--the "Standards of Care" document avoids language that suggests clients' identities must be binary (either female or male) in order to qualify for hormonal therapy. (21) In this sense, the binary agency of hormones doesn't require binary assumptions about gender identity. Hormones can remain binary in their impact (producing feminizing or masculinizing effects), and at the same time gender identities are described as potentially fluid and variable. Binary essentialism continues to pervade official disciplinary standards; however, at the level of practice these documents are rarely binding or determinative. Thus, an analysis of binary essentialism remains incomplete without understanding the process from the perspectives of clients and practitioners. (22)

Transgender studies literature provides an extensive and incisive critique of psychological clinical practice from the perspective of trans individuals who regularly encounter binary essentialism in gaining access to medical treatments. In fact, the transgender studies literature stakes a claim to trans subjectivity by unyoking it from discourses of medicalization and gender essentialism. (23) In unearthing a speaking subject position for subaltern trans subjectivities, the transgender studies literature turns our attention to questions of access and equity in treatment, along with practical situations relevant to the trans community. (24) Like our work, narratives focusing on trans perspectives reveal the complex nature of social power in the context of hormone therapy. Eli Clare's recent critique of medicalization includes a call for trans individuals to learn a lesson from the disability rights movement and focus on using medical technologies without letting them define trans subjectivities. (25) Taking on the structure and consumption of medical technologies, Michelle O'Brien expresses concern about how the hormones she needs to purchase in order to live everyday help fund the pharmaceutical industry's role in the larger global capitalist system of race and class exploitation. (26)

In sum, binary gender essentialism in the trans clinical encounter is well documented by the sociological and transgender studies literature, but we know little about how practitioners' interpretation of the power of sex hormones helps reproduce or resist essentialism. As we argue in what follows, some practitioners define gender dysphoria and sex hormones in strictly binary, essentialist terms while others see hormones as social cues that offer a way to influence gender attribution in everyday interactions. Practitioners' approaches vary in terms of the degree of assumed essentialism and the extent to which they see hormones as binary agents of gender identity; however, all of our respondents saw their clinical practice as the key source of evidence regarding the agency of hormones, or as one of our respondents put it, "the proof is in the pudding."

METHODS

Our conclusions are based on an analysis of 23 interviews selected from a larger Institutional Review Board-approved study that included 35 qualitative, in-depth interviews conducted in the summer of 2008 with mental health care practitioners from San Francisco (n=9), Seattle (n=6), and Portland, Oregon (n=20). After coding all 35 interviews, we pulled out a smaller sample of 23 practitioners from the larger sample for two primary reasons: some practitioners from the original sample did not have any experience recommending hormones for their clients and others didn't mention hormones as essential to their client/practitioner relationship. Practitioners' understandings of the agency of hormones was not specifically prompted by our interview schedule but emerged in response to open-ended questions meant to unearth the practitioners' working frameworks for understanding gender and their own feelings about their role in the process of transition.

The majority of our respondents practice in Portland, but we included a small sample from San Francisco and Seattle in order to assess the impact of local culture on clinical practice. We selected our first wave of potential respondents from a list of available print and Internet guides to counselors and therapists specializing in transgender clients. Subsequent participants were selected through a snowball sample.

Our sample of 23 generally reflects the basic characteristics of our primary sample insofar as participants differed in terms of professional training, level of experience, and opinion of the DSM. Our participants included licensed marriage and family therapists, clinical social workers, and psychologists. Over half of our original sample (n=21) was made up of credentialed and licensed counselors and social workers, and the remaining participants are practicing or recently retired psychologists. The experience of practitioners in our larger sample ranges from expert to novice: some of our respondents have worked with over five hundred clients for over thirty years; others are relatively new to the field and have seen only a handful of trans clients. We characterize a number our respondents (n=22) as "experts" because they have had over ten years of experience and/or over half of their practice is dedicated to trans clients. In addition, five participants have personal experience with transgender issues, having undergone the process of transition before becoming practitioners (three MTF and two FTM). The majority of our respondents were Euro-American women in their forties and fifties. In fact, only six of the practitioners who we interviewed identified as men. All respondents were assigned pseudonyms in order to protect their confidentiality.

Using a semi-structured interview guide, two of the researchers (also coauthors) interviewed each of the 35 practitioners in person, in a location chosen by the interviewee (most often the practitioner's office). One researcher acted as the primary interviewer by asking open-ended questions from a broad, semi-structured interview guide. The other interviewer took notes, managed the recording device, and asked and wrote down relevant follow-up questions. Each interview lasted from 60-90 minutes. Researchers introduced the study as a sociological project aimed at understanding practitioners' varying approaches to serving transgender clients given controversy surrounding the gender identity disorder diagnostic code in the DSM.

All the practitioners who participated in our study reject reparative therapy--approaches that seek to reorient trans clients to the gender identity that corresponds with their biologically given body--and consider body modifications appropriate and often necessary techniques in promoting the psychological and social well-being of their clients. With the exception of two practitioners, our respondents expressed mild reservations to outright rejection of the gender identity disorder diagnostic code in the DSM. Among the reasons stated for rejecting the code was a general disagreement over its scientific rigor as well as sensitivity to the unintended consequences of labeling clients as "disordered." However, even though practitioners felt that the DSM diagnostic code does not adequately describe their trans clients who request body modifications, over 70 percent of practitioners in our sample have used it when referring clients for hormone therapy and many forms of sex reassignment surgery.

In analyzing results specific to the agency of hormones in our sample of 23, we found a great deal of variation in terms of the practitioners: (a) understanding of sex hormones as binary gender agents, (b) belief in the direct and socially unmediated power of hormones to align one's sexed body with gender identity, (c) use of hormones in practice, and (d) interpretation of why hormones seem to work for their clients. Instead of evoking one essentialist or "authenticity model," our sample of practitioners have divergent attitudes and approaches best described by varying levels of essentialism and constructionism. (27) Drawing from Messner's model of gender ideologies in youth sports, we group and analyze these four patterns of variation in terms of three basic orientations: hard essentialism (biologically determined and binary), soft essentialism (biologically driven and potentially plural), and constructionism (culturally driven and potentially plural). (28) Like Messner, we conclude that soft essentialist discourse is an embodiment of hegemonic gender ideology that has many commonalities with essentialist discourses, whereas constructionist accounts leave room for challenging the bioreductive authenticity models. (29)

As sociologists, we see gender identity in terms of historically constructed expectations for human behavior, interaction, and belonging structured around the equally socially constituted model of sex-dimorphism. (30) Albeit related, one's subjective understanding of oneself as a gendered human is too localized and complex to be evaluated or reduced to these macro configurations of gender identity. At the same time, as Carole Vance reasoned in 1989, the socially constructed nature of a phenomenon does not make it any less real or deeply felt than if it were a biological given. (31) When viewing hormones as semiotic agents in the production of gender identity, we do not suggest that individual gender identities can be inauthentic or imposed by individual outsiders. We denounce psychiatric models and some feminist theorizations of gender that have posited trans identity as pathological or even predatory and have wrongly reduced the significance of trans folks' lives to what it tells us about the socially constructed nature of gender. Our research says nothing about trans individuals' experience of gender or views of the clinical encounter. Our data only speaks to how practitioners understand the agency of hormones in the construction of gender identity.

"IT'S LIKE PUTTING DIESEL IN A GAS CAR": HARD ESSENTIALIST MODELS

In the essentialist perspective, hormones and their receptors are direct agents of presocial gender identities. Practitioners view hormones as not just one component in the construction of biological sex expression (as female or male), but also the primary agent in producing gender identity. Drawing from the basic premise of brain organization theory, these practitioners believe that hormone receptors in the brain construct our gender identity before we are born, and that humans can have a sense of themselves as women or men without the work of cultural interpretation. In fact, cultural norms and social structures only have "surface" level impacts and cannot fundamentally alter one's pre-established "core" gender. In this section we describe both hard and soft versions of the essentialist model, and we emphasize how these views are informed by and shape clinical practice. The overwhelming majority (all but one) of practitioners who fall on this hard end of the essentialist/constructionist spectrum also explicitly articulate or tacitly assume some version of the brain activation/organization thesis: positing that hormones and their receptors are binary and sex-dimorphic, as if there are female and male hormones and corresponding receptors and brain structures.

Often referring to "the scientific research," practitioners see the brain as the primary locus of gender identity. Lindsey Care (pseudonym, as with all other names mentioned below), a clinical psychologist practicing in the San Francisco Bay area who has written over five hundred letters authorizing hormones for her trans clients, articulates a version of this view that assumes female is the default sex and femininity is the default gender: "The default sex of every child is female. ... So, the general notion here is that there are hormone surges at certain times of development that affect the brain.... For a male brain to develop it has to be defeminized, as well as masculinized."

As sociologists and feminist theorists have previously noted, these scientific narratives often depict female bodies and biological processes as passive compared to male processes, which are depicted as active and productive forces. (32) Given the possibility for multiple interpretations of this same process, it is clear how social power and the art of cultural interpretation are embedded in scientific narratives that consistently construct masculinity as active and femininity as passive. Practitioners such as Lindsey Care do not cite the scientific research that states that not even hormones, let alone bodies in general, come presexed into male and female categories and that such categorization is a cultural discursive process.

While this scientific research remains hidden under the folds of Roberts's interpretive "handkerchief," practitioners have a more faith-based approach to brain organization theory, often citing unspecified "studies" to conclude that women and men have inherently different brain structures and/or that fetal hormone baths can produce misalignments. Eric Jeffreys, a counselor who has worked with trans clients in the San Francisco Bay area for over seven years, regrets that his graduate course on human sexuality did not cover sex differentiation or gender identity, but he educates himself by relying on popular sources:
    They're discovering that there are real differences between the
   brain structures of men and women. The whole study of the brain is
   so new, and I don't think that the differences are such that you
   could simply take a brain out of a corpse and hand it to somebody
   and say, "Is this a male or a female brain?" But there are
some
   differences, and it is a promising theory; let's put it that
   way.... I subscribe to a magazine called Scientific American
   Mind,
 and a lot of the articles I've been reading lately have
   to do with studies about hormones in utero. 


Like Eric, most of our essentialist respondents assume, without having clearly examined the research, that hormones are primary actors in the creation of gender identity. Hybrid scientific-popular sources offer plausible stories that mistake the ideology of an essential, fixed gender identity for a cutting-edge discovery. (33)

Our practitioners, not surprisingly, also turn to examples from clinical practice rather than carefully evaluating scientific research. They are convinced of the power of hormones because they see how hormone therapy dramatically changes the lives of their clients. Terrance Vaughn, a practicing marriage and family therapist in Portland who has seen over three hundred trans clients, cites his own vast experience as evidence of the power of hormones as agents of not only sex, but gender differentiation:
    I've had people [MTFS] sitting in my office at forty years old
   saying "I feel like crying at work all the time. I don't
know what
   to do. How do women handle this?" It's the hormones.... If
you go
   the other direction [FTM], I've had people say "I
don't know how to
   cry anymore. I can't." Physiologically they cannot cry any
longer. 


Like other gender essentialists, Terrance believes that hormones directly produce two distinct gender expressions of emotional grief. Furthermore, these experiences of grief are not mediated by cultural norms or social power, but produced by a strictly chemical reaction in the brain. Terrance explains the unmediated power of hormone therapy by comparing it to treatments for depression, "Even if you had the best therapy and the best family in the world, if you don't have the right serotonin uptake levels in your brain you still need the antidepressant."

Terrance rejects "nurture" perspectives for an important reason: viewing gender identity as malleable implies that if his clients try hard enough, they can live by the gender they were assigned at birth. Discussing how some trans women try to adapt their lives without fundamentally changing their hormone levels, Terrance explains,
    Especially if they're older they grew up in a time period, as I
   did, when the belief was, and feminism did not help this at all,
   everything is all about nurture and there's no component of
nature
   to anything. Therefore everything's malleable: you can change
   people, you can change yourself, there's no difference between
male
   and female brains. Therefore it's all socialization. And if you
   grow up believing that, and you don't want to be the way you
feel
   like you are, you try all these behavioral methods to try to change
   yourself. So they'll do things like get married really young,
have
   kids, join the military. Get into some occupation like construction
   work, firefighter, an electrician, something that's male
   dominated.... Twenty-five, thirty years later when nothing has
   changed them, then they realize "if I don't do something
about this
   I'm going to die a man." By that time, they have a
twenty-five-year
   marriage, they have kids, sometimes they have grandkids. It's a
   real mess to disentangle all of that. But they also realize, "I
   can't go on like this" because they've been coping and
adapting too
   long. 


Terrance sees the innate connection between gender identity and hormones as evidence against social constructionist, or what he calls 1970s feminist, nurture perspectives. Terrance equates nurture perspectives with a more psychological socialization model that presumes a direct connection between an individual's environment and identity. Here Terrance misreads social constructionism by confusing the cultural with the individual level and wrongly assuming that social constructionism suggests individual identity is easily changed. As feminist accounts clarify, to hold that gender identity is socially constructed is precisely to say that an array of social forces, rather than individual will, shape it. (34)

Karen Davis, a clinical sexologist in Seattle who describes trans clients as 80 percent of her practice, is so confident that hormones and their receptors are the key to gender identity that she believes it will be possible one day to predict individual behaviors based on what she calls "brain gender." Karen describes how she came to this realization as a result of her work with transgender clients:
    I sit in this position of having a rare and special opportunity to
   see people transition from maleness to femaleness and from
   femaleness to maleness in terms of their hormonal constitution. To
   me that is like a perfect experiment [that] basically blasts the
   feminists right out of the water; because certain things are
   directly a result of hormonal constitution.... A lot of my MTF
   clients who were formerly under the predominance of testosterone,
   [when] they shift to an estrogen based constitution ... all of a
   sudden they're crying at the stupidest diaper commercials....
   They're in the driveway and they can't decide, "do I
want to go to
   Denny's or Shari's?" 


Karen describes her clinical practice as the "perfect experiment" because, from her perspective, the only thing that is changing from session to session is her clients' "hormonal constitution." Like Terrance, Karen sees the agency of hormones as unmediated by cultural interpretation, which is why she thinks it "blasts feminists right out of the water."

Karen goes on to explain how estrogen and testosterone produce two distinct and incompatible gender experiences.
    Estrogen is a very connecting hormone; it connects the world; it
   connects generations; it's cooperative; it's
communication....
   Testosterone increases [one's] very laser-like focus, solving
   problems, building a bridge.... Testosterone is the reason why
   people came west.... Hormones are the life blood of our system,
   they are the oil and the gas in the car, it's like putting
diesel
   in a gas car or gas in a diesel engine; it's just wrong.
It's not
   that they're bad hormones, they're just wrong. 


From this essentialist perspective, individuals only have one gender destiny for which our hormone receptors are the blueprint. In Karen's opinion, the biological drive of hormones is so powerful that they can account for larger social trends such as westward expansion.

In an interesting twist of their own causal logic, practitioners explain that clients discover whether they are truly transgender or not once they begin the process of taking hormones. Linda Lairs, a licensed clinical social worker from San Francisco who specializes in gender transition explains,
    [Hormone therapy] is another way of figuring out if transitioning
   is the right thing or not.... Are they having more of a sense of
   peace, more joy, more happiness, more sense of balance? Or are they
   feeling more anxious? 


Similarly, Terrance Vaughn suggests to his clients whose "identities are not so clear cut" to try a low dose of hormones to help clarify their gender identity. Portland therapist Diane Lane puts it this way: "the proof is in the pudding." Such practitioners seem to agree upon the utility of hormones in "treating" their transgender clients. They use a low dose of hormones as a diagnostic tool to weed out what they see as the mentally ill or temporarily confused from the authentically transgendered. From their essentialist perspective, evidence for the agency of hormones is found in practice: their trans clients feel peace and joy because hormones realign them with their biologically given gender identity.

In sum, the hard essentialists see hormones and their receptors as primary agents in the construction of gender identity. They adhere to an authenticity model of gender identity that assumes that humans have a stable, fixed, and binary gender identity. According to this model, the power of hormones is direct, binary, and unmediated by culture. Complex social norms that define and regulate appropriate emotional responses for women and men are reduced to chemical reactions. As Terrance Vaughn explains, FTMS report that they can no longer cry when they begin taking testosterone, and Karen Davis points to MTFS who begin hormone therapy and subsequently report crying at diaper commercials. Vaughn and Davis offer their clinical experience as evidence against "feminist social constructionism," but confuse cultural interpretation with individual expressions of gender identity. They imbue hormones with gendered qualities--for example when they associate women, and thereby estrogen, with indecision and erratic emotions. For hard essentialists, the culturally unmediated nature of hormones means that at the level of clinical practice hormone therapy has a diagnostic function as well. Operating as prophets of gender identity by reading the clues left by their clients' interpretation of the impact of hormone therapy, essentialist practitioners can feel more confident that their clients have the correct "gas" (hormone) in their "engine" (brain).

"WE GAVE THE LANGUAGE": SOFT ESSENTIALIST MODELS

A number of practitioners (n=8) who extensively discussed the role of hormones in the construction of gender identity also acknowledged social aspects of gender that can impact, yet not fundamentally alter, one's gendered sense of self. In this softer version of essentialism, hormones and their receptors are the primary foundations for gender identity, but the behaviors they produce are socially mediated. Like the hard essentialists, even those who express a more watered-down version of gender essentialism tend to believe that hormone therapy can reveal one's innate gender. Akin to the form of soft essentialism Messner discovered in the realm of youth sports--namely that so-called natural differences between men and women "exist alongside relativized and noncategorical views"--soft essentialists believe that culture influences the impact of hormones, but they maintain a view of the gendered self as biologically fixed before birth. (35)

In a fashion typical of soft essentialists, Kara Butte, a counselor with a private practice in Portland, believes that hormones are the foundation for gender identity, but she also thinks that the meanings of hormonal reactions are socially interpreted. When asked how one acquires a gender identity, she remarked,
    A fair amount [is] biological and hormonal--estrogen,
   testosterone--but it is also what society says is male and female.
   We gave the language to how people feel and behave when they have a
   lot of estrogen, and we called it female. So, you have this balance
   of hormones in the womb, and then you come out and then society
   tells you about what's okay when it comes to long hair, dress,
   emotional expression, occupations, and everything. 


Interviewer: So hormonal levels or genetic makeup could determine how someone would want to have their hair or it could determine how someone would want to dress?

Butte: [Nodding] Because maybe they feel feminine or soft, an expression of that is long hair and flowy clothes. Maybe somebody has hormones that make them feel practical, analytical, and scientific, and maybe they choose a profession that is an expression of that, [or] they choose clothes that express that.

Here Kara describes gender acquisition as a mix of biological and social factors, yet Kara sees hormones as powerful gender agents that not only direct behavior and occupation choice, but also aesthetic tastes. For Kara, hormones create the impulse, and society offers possible options for expressing these chemical reactions.

Similarly, Cindy Hope, a licensed clinical social worker from Portland with a number of trans clients, believes that humans are born with a gender identity, probably determined by "hormone baths in utero," but expressions of femininity and masculinity are socially constructed. She explains,
    What we define as feminine is ... being concerned about clothes,
   decorating, high voiced, and afraid of spiders [laughs]. You could
   be physically a male and have all those traits, and we would label
   them as feminine. But maybe they're just your traits. Maybe
you're
   just a guy who's afraid of spiders and likes pink. Who's
calling
   them female? The world is calling them female. So that's where
the
   social construct comes in. 


Like Kara, Cindy believes that gender is constructed by a mix of biological and social factors. In the final analysis, however, Cindy believes that one is born with a core gender identity that cannot be altered by society.
    I think the way we divide it into either male or female and ascribe
   roles to it is a social construct, but I think that definitely
   people come equipped with a certain sense of who they are. The
   latest research seems to suggest that it has to do with wash of
   hormones in the uterus as the embryo is developing. That may well
   be, but I don't know that for a fact. It makes as much sense as
   anything else. Certainly I know that you don't get your sense of
   gender by what somebody else tells you, or what your mother does or
   what your father does. 


Finding herself unconvinced by developmental psychological models of gender acquisition, Cindy places her bet on hormones as the primary agent of gender identity and reduces social forces in the construction of identity to parental influences.

For Lauren Lairs, who straddles the line between hard and soft essentialism, hormones and their receptors are likely the main agents of gender identity for most people, but she also believes that some exceptional individuals have biological blueprints for gender fluidity.
    I think for most people gender is biological ... and fixed at
   birth. But, there are certain people who have the potential, and
   maybe they're born with that potential, to have their gender or
   their sexual orientation more fluid. It is hard to explain, but I
   definitely feel like gender is most likely biological but there are
   aspects of it that can be socially constructed. I think people can
   self-construct their gender too. 


In this formulation of soft essentialism, Lauren tries to explain how people can have a fluid sense of gender over their life course if, in fact, gender is innate. Rather than assuming this fluidity is evidence for the social construction of gender identity, Lauren projects that there are some people who are born with the potential to "self-construct" a more fluid gender identity. In this way, Lauren expresses a form of bioreductivism that rejects a binary categorical view of gender; gender identity can be fixed and innate at the same time it is fluid, because some individuals are born with a uniquely flexible gender identity.

The soft essentialist approach expressed by practitioners like Kara, Cindy, and Lauren is indistinguishable from the hard essentialist approach in clinical practice. Because soft essentialists believe that hormones are the likely foundation for gender identity, they also see hormones as diagnostic tools. As Katheryn McFarr, a counselor in Seattle, notes, hormones can indicate if the client is on the "right path." While Katheryn will not write a letter for hormones unless she is confident in the client's gender dysphoria, she also believes hormones have the power to foretell the truth of one's gender identity.
    Usually hormones are somewhat of a test.... If they start feeling
   better then they're probably on the right path. But you
don't just
   start someone on hormones right away because there are side
   effects, and it [hormone therapy] changes you. 


Far from questioning the diagnostic efficacy of hormones, Katheryn questions this method in practice, because she has worries about irreversible physical and emotional changes.

It is important to note that two practitioners who expressed soft essentialist views also described hormones as agents of heterosexual desire, as if testosterone chemically fuels the body's desire for sex with women; this is a conflation that Jordan-Young found in her review of brain organization/activation theories. (36) For example, Jan Fields, a clinical practitioner in the Seattle area, states that hormones influence the body as well as the mind, and she has personally seen clients (FTMS) experience increase in sexual drive, physical attractiveness, and protective behaviors. She comments that she thought that these traits were just stereotypes of men, but that her clients undergoing hormone therapy have experienced the occurrence of such traits.
    He [an FTM client] was really surprised to find himself
   changing.... He felt much more sexually driven than before, and he
   had already had really high sexual drive before more testosterone
   was added. But he talked about being much more, well maybe it can
   start to be stereotypical, but visually drawn to any woman. And
   before, when he identified as lesbian, that wasn't his
experience. 


Even though she prefaces her own comment by saying it is "stereotypical," Jan nonetheless notes that this client experienced a heightened sex drive as a result of testosterone, reflecting the Victorian gendered expectation that women are meant to tame sexuality, as men naturally have unbridled sexual desires for women.

What Jan leaves unexplained is the interpretive process essential to the agency of hormones; the belief that men are more sexual can actually become reality through the process of interpreting what hormones do. The chemical reaction clients experience when taking hormones can be "real" but their meanings are symbolically constructed; the hormones work within a heteronormative sociosemiotic context. (37) In other words, social expectations about gender can actually function as self-fulfilling prophecies, as Jordan-Young notes.

Soft essentialists see culture as a force in constructed gender expectations and as offering symbolic options for gender expressions. However, like hard essentialists, they believe gender identity is stable and fixed and mostly hardwired. In terms of practice, both hard and soft essentialists see hormone therapy as a diagnostic tool that can reveal the client's "authentic" gender identity.

"IT'S WHO IS DOING THE LOOKING": CONSTRUCTIONIST MODELS

Five of the practitioners in our sample who spoke of hormones as agents of gender identity and expression were suspicious of or unequivocally rejected the essentialist models described in the previous sections. According to this minority of practitioners, the agency of hormones is fundamentally mediated by society and thus the utility of hormone therapy for their clients' well-being depends on their use of social cues. Although only a small number of practitioners rejected the essentialist model, their perspective is important because it speaks to alternative ways of understanding hormones as social agents whose chemical process is intertwined with the work of cultural interpretation.

Kandi Campbell, a marriage and family therapist in Seattle who is new to her profession, believes that gender identity is fundamentally "culturally defined and culturally proscribed." When asked what she thought about brain organization theories, she stressed the importance of cultural interpretation: "I'm sure that different brains look different under different scans but there's also this cultural lens saying, 'I'm going to put you into a category,' because people like categories. It's how culture works.... It's who is doing the looking." Unlike the hard and soft essentialists who tend to reduce social influences to the process of socialization, or "what your parents tell you," Kandi argues that gender categories themselves are a cultural construction; she feels "strongly that there are at least four genders, if not five or more." In this way, Kandi is neither essentialist nor binary in her understanding of gender; moreover, the hormonal expressions noted by Karen (crying at diaper commercials, having a difficult time choosing a restaurant) are not an unmediated biological stimulus, but part of culturally constructed expectations for femininity.

Morgan Shallow, a clinical psychologist from Portland who works mostly with post-op clients, doesn't point to a specific number of genders, but she deconstructs the link between gender and hormones: "The reality is that females have many of the same hormones as males. Just because you may have more testosterone doesn't mean that all of a sudden you're a male. You may be a female with testosterone or vice versa." Instead, Morgan believes that people have more will in constructing a sense of their gender identity. As she puts it, "Who cares what your plumbing is or what your hormones say? It's who you believe you are and how you want to live your life." Even though Morgan's views of gender identity sound more voluntaristic than socially constructed, she explicitly refutes the formulation that hormones are sexed by nature.

Both Morgan and Kandi believe gender is constructed; however, they do not completely disregard brain organization research. Rather, they believe it is one aspect, or as Morgan says "only one piece," of a complex process that many people find uncomfortable because it is hard to define. Kandi finds brain research "fascinating," and can understand the allure of the essentialist approach. Echoing Lancaster's warning about bioreductivism, she states,
    As a culture we want that biological answer because it seems more
   real, and sometimes those nebulous cultural answers are too hard to
   sit with. You invite too many questions, and it's too much of a
   struggle to make sense of. People want to write it off. 


People become convinced of biologically essentialist theories because they simplify the world in a way that provides comfort and clarity.

Lori Brown, who works primarily with trans youth in Portland, expresses an opinion similar to that of Kandi and Morgan, in which the brain is only a piece of the gender puzzle. "Whatever we do to change the way the body produces hormones is still occurring after it's had experience with them.... We know that the way nerves develop is affected by things that happen to us environmentally." Lori expands on Kandi's and Morgan's understanding of brain organization research by speculating that the brain chemistry piece is only activated in an environmental context.

However, not all constructivists accept brain organization research as a valid puzzle piece in understanding gender identity. Nicole Anchors, a very experienced social worker in Portland, when asked her thoughts about the view that gender is a product of a neurochemical process, remarked,
    I don't know. That always freaks me out a little bit. The same
way
   that they say queerness is a biological thing, because someone's
   going to want to fix it. "If I find out that my kid is
   [transgender] then I get to fix it because life is going to be so
   hard," or, "this is a quality that we don't
necessarily celebrate."
   I get a little worried about that.... It seems like something that
   could be fixed. Trans folks are already discriminated against
   enough right now. 


Nicole is unsure about the veracity of biochemical explanations for gender identity and deeply suspicious about the political implications.

When it comes to the level of practice, the constructionists are more likely to view the agency of hormones as social cues in a social psychological construction of gender identity. Essentially, the client's psychological state is inseparable from how they are perceived in social interaction and, as Lori Brown demonstrates, hormones create a sense of balance and stability:
    I see people wanting to be clearly seen and visible. They want
people to
   respond to them as the people they believe and know themselves to be.
   They want their bodies to match the person that they are, so ... when
   other people speak to them, they speak to them and not to a body that
   feels foreign. 


For constructionists, the agency of hormones is mediated by a larger mirroring process that includes multiple levels of symbolic interpretation; one can only "feel comfortable" when others can interpret bodily cues in a way that accurately reflects the client's gender identity. Nicole Anchors describes this process of interpretation as a match between the inward and outward presentation, and hormones are one tool for her clients to be perceived as their true gender. In this formulation, the agency of hormones is mediated by social interaction; the physiological changes that come with hormone therapy act as social cues. Unlike the right "gas" for the right "engine," this model refuses a binary logic and leaves room for more flexibility and options for gender/sex embodiment.

Diane Couch, who has worked with trans clients for over twenty-five years and sits on the board of directors for the World Professional Association for Transgender Health, is unsure of any potential biological or hormonal basis for gender identity, but like Nicole, she knows from clinical experience that proper "mirroring" is the key to the psychological health of her trans clients.
    If you have an inner sense of yourself one way and the world sees
you
   differently based on gender, you're never mirrored appropriately
... and
   that can raise psychological issues such as shyness, depression,
anxiety,
   all kinds of things, because we need to be seen as ourselves. 


The mirroring model described by Lori, Nicole, and Diane essentially describes or at least acknowledges the interpretive process that mediates the relationship between hormonal changes and one's sense of self. In sum, the constructivist approach in clinical practice assumes that hormones can act as semiotic agents in the process of gender transition.

While it is clear that practitioners who take a constructionist approach reject the theory that gender is biologically based, some see gender identity as binary and relatively stable throughout the life course. There are, however, a handful of constructionists who explicitly reject the gender binary. Kandi, as previously stated, believes there can be "five or more" genders. She states, "Working with trans folk has made it very clear to me ... there's such tremendous range in human behavior that these two determining defining categories [male/female] are not very helpful ... they do not capture the complexity of life." Unlike the soft constructionist Lauren Lairs, who views gender variation as a biological characteristic of some special individuals, Kandi thinks binary gender classifications themselves are too restrictive to capture human behavior in general.

Shirley Lovejoy, a clinical practitioner in Seattle, like Kandi, finds that gender cannot be restricted to the male/female dichotomy, but can even exist in the ambiguous state. She has had clients who ask her for (and she grants) lower doses of hormones, in order to present themselves as androgynous; a trend she has noted with younger clients.
    I let people kind of tell me who they are, and how they want to be
   seen in the world. [People say] "We don't have to take
hormones; we
   don't have to do surgery, plastic surgery; we can just be who we
   want to be."... If that works for them, fine. 


For Lovejoy, and other practitioners who reject the gender binary model, hormones can be tools for identity expression in general rather than a way to align the body with a biologically predetermined gender, as was the case with essentialist practitioners.

CONCLUSION

The mental health practitioners with whom we spoke are charged with the impossible task of deciphering a client's authentic gender identity in order to help them forge a path toward a more healthy and congruent life. Not all mental health practitioners subscribe to the "authenticity model" of trans embodiment, but those who do embrace a form of gender essentialism cling to some objective certainty to ground their decisions. Subsequently, hormones and their receptors are ideological agents that diffuse and mask the symbolic and interpretive work inherent in the diagnostic and treatment processes. Placing this diagnostic agency in the hands of hormones ignores the scientific research that has long questioned this sex dimorphic model. Mental health practitioners remain committed to the dimorphic model in spite of evidence that testosterone, androgen, and estrogen are not sexed by nature. (38) This is partially because such research is not common knowledge in the field of mental health and also because prescientific gender ideology is a continually available interpretive framework reproduced and materialized in clinical practice. Moreover, the larger US cultural context of bioreductivism and the specific institutional structure of accountability that leaves mental health professionals responsible for opening the gate to medical body modifications make the certitudes of essentialist narratives more appealing. As Kandi explained in our interview, "nebulous cultural answers ... invite too many questions"; whereas medical clinicians are looking for confidence and clarity before prescribing hormones that have potentially irreversible impacts and possible side effects. At the same time, lingering reparative therapy models that would have the same trans clients realign their gender identities (rather than their sexed bodies) with dominant gender ideologies would only be strengthened by acknowledging the socially malleable constitution of gendered selves.

The minority of practitioners who articulate more constructionist narratives, on the other hand, see the power of hormones in the context of cultural interpretation by understanding their role in creating social cues that aid in the process of mirroring. Both models have specific implications for understanding hormones in their proper social and cultural context and uncovering prospects for resisting the dominant gender regime that produces and enforces essentialist and binary models of gender identity and experience.

What do we learn about sex hormones as material, cultural agents of gender identity? In the "proof is in the pudding" model (hard and soft essentialism), hormones have the power to reorient the body toward its biologically predestined gender identity. Hormones do not create one's gender identity; they simply provide, as Karen puts it, the appropriate gas for the engine type. It is important to note that this model locates gender identity in the brain and generally assumes one's "brain gender" is binary, precultural, and fixed at birth. Drawing from experiences with their clients, practitioners who subscribe to this model see hormones as a type of diagnostic test as well as medical treatment. If the hormones make the client feel better, then they must be using the right "gas." Moreover, the effectiveness of hormone therapy further convinces the practitioners of this essentialist model. The unique characteristic of hormones as mobile messengers with indelible qualities allows the semiotic reversal that Hird describes--wherein gender is mistaken as the product rather than the agent of sex--to persist despite the "lies" told by "untouched" bodies. (39) In other words, the sex of the body can fail to signify one's true gender but still maintain its credibility as an instrument of gender identity when hormones and their receptors, rather than gonads or genes, are constructed as primary sex-determining agents. In this way, hormones are not only agents that "perform their messaging activity within cultures," but, as our work indicates, they also act as nonreflexive actors that social agents ask to foretell the truth of what they see as naturally given gender identities. (40)

Is there another way to explain the effectiveness or agency of "sex hormones" without reproducing binary essentialist assumptions? The minority of practitioners who reject essentialist models and see gender identity as a social construction also routinely recommend clients for hormone therapy, as they too see the power of hormones to improve the lives of their clients. Unlike psychological socialization models, or what Terrance Vaughn and Karen Davis see as feminist nurture perspectives from the 1970s, these practitioners see sex and gender classifications (male and female; masculine and feminine) as cultural and potentially fluid. Consistent with the work of Fausto-Sterling and Jordan-Young, constructionist practitioners such as Morgan Shallow deconstruct the relationship between sex, gender, and hormones. According to the logic of this model, hormone therapy works because hormones produce social cues, or expressions and meanings that become interpreted according to culturally constructed gender classifications. These practitioners do not deny the "real" impacts of hormone therapy on their clients' everyday experience. Here it is useful to keep in mind Vance's point that socially constructed does not mean inauthentic or false. As Jordan-Young's revitalization of the Thomas dictum implies, the constructionist "mirroring" perspective ultimately places the power of hormones in the context of cultural interpretation: hormones provide a social cue for the self and outsiders, and these cues are then reflected back to the self, creating a congruence between how you see yourself and how the world sees you.

Along with providing a different understanding of the power of sex hormones, these models also imply two different logics for resisting the dominant Western gender/sex ideology that subordinates trans experience as well as gender and sex variation in general. The hard and soft essentialist models reject the assumption that all "normal" selves are born with a consistent sex and gender constitution that is either male or female and naturally aligned with masculinity or femininity. Because gender identity is prewired and naturally constituted, it is unethical and ineffective to try to reprogram gendered selves; instead, the solution is to bring the body back into chemical alignment through the prescription of sex hormones. This logic provides a space for trans clients to gain access to hormone therapy, but only within the ideological construct of biological essentialism. So what is the danger in this? Our data cannot definitively confirm that this essentialist approach works at "the expense of human freedom." (41) But if we think of the authenticity psychological model and the practice of gatekeeping that restricts access to hormones based on clients' adherence to a clear gender narrative, then the way that biological essentialism plays out in practitioners' approaches to gender-variant clients who do not fit the assumptions of bioessentialism is troubling. (42) Moreover, if hormone therapy does not work for clients, essentialists such as Linda Lairs tend to interpret this as a diagnostic sign that the client is not trans, rather than evidence that might call brain activation/organization theory into question. In other words, the onus for change is placed on individual bodies, rather than on the social and cultural construction of sex and gender.

What are we to make of constructionist models that refuse the bioreductive narratives, yet continue to recommend hormone therapy for their trans clients? They appear to provide a "third way" that rejects essentialist and reparative assumptions by evoking hormone therapy as a type of somatic-semiotic agent that is a part of a larger, complex interrelationship between the body and society. This path is consistent with the Mobius strip model as it acknowledges both the generative impact of binary and heteronormative ideologies on the chemical functioning of the body and the materiality of bodily processes that cannot be reduced to their symbolic functions. The constructionist path thus reveals possible frameworks within the psychological/medical model that are neither based on authenticity claims nor on maintaining hegemonic gender ideology. (43)

While the constructionist clinical path resists the binary and essentialist logics that entrench and legitimate dominant gender ideologies, as a clinical practice it is designed to help individuals, not deconstruct destructive cultural ideologies. Refusing to understand this distinction leads to reducing the importance of individual trans lives to the looming social problems produced by dominant gender ideologies that create selves and bodies from the male/female and masculine/feminine binaries. At the same time, cultural ideologies, both in the form of expert scientific narratives (such as brain activation theory) and popular culture (think of Eric's citing of Scientific American Mind) clearly influence clinical practice. Our work confirms the importance of deconstructing bioreductive narratives at the cultural level, both in terms of research and development and popular discourse. More importantly, our sample of constructionist practitioners reminds us that deconstructing the binary essentialist hormone discourse need not pose a threat, but might actually improve access and equity in trans medical treatment.

(1.) For an example of a hybrid popular-scientific account of the power of sex hormones to destabilize economic structures, see Jon Coates and Joe Herbert, "Endogenous Steroids and Financial Risk Taking on a London Trading Floor," Proceedings of the National Academy of Sciences 105, no. 16 (April 2008): 6167-72.

(2.) "Gender transition" is a controversial phrase, as it implies that transgendered individuals who receive hormone therapy are changing identities. We are only using it for lack of clear alternative phrasing, not because we believe body modifications change gender identities.

(3.) See Anne Fausto-Sterling, Sexing the Body: Gender Politics and the Construction of Sexuality (New York: Basic Books, 2000); Rebecca Jordan-Young, Brainstorm: The Flaws in the Science of Sex Differences (Cambridge, MA: Harvard University Press, 2010); and Nelly Oudshoorn, Beyond the Natural Body: An Archeology of Sex Hormones (New York: Routledge, 1994).

(4.) Fausto-Sterling, Sexing the Body, 193-94.

(5.) Fausto-Sterling, Sexing the Body.

(6.) Ibid., 232.

(7.) Fausto-Sterling, Sexing the Body, Elizabeth Grosz, Volatile Bodies: Toward a Corporeal Feminism (Bloomington: Indiana University Press, 1994).

(8.) Jordan-Young, Brainstorm, 263.

(9.) Oudshoorn, Beyond the Natural Body.

(10.) Celia Roberts, Messengers of Sex: Hormones, Biomedicine, and Feminism (New York: Cambridge University Press, 2007).

(11.) See Donna Haraway, Simians, Cyborgs, and Women: The Reinvention of Nature (New York: Routledge, 1991).

(12.) Roberts, Messengers of Sex, 22.

(13.) See Jaye Cee Whitehead, Jennifer Thomas, Brad Forkner, and Dana LaMonica, "Reluctant Gatekeepers: 'Trans-Positive' Practitioners and the Social Construction of Sex and Gender," Journal of Gender Studies 21, no. 4 (2012): 387-400.

(14.) Roger Lancaster, The Trouble with Nature: Sex in Science and Popular Culture (Berkeley: University of California Press, 2003); Roger Lancaster, "Sex, Science, and Pseudoscience in the Public Sphere," Identities 13, no. 1 (2006): 101-138.

(15.) Roger Lancaster, The Trouble with Nature, 24.

(16.) Michael Messner, "Gender Ideologies, Youth Sports, and the Production of Soft Essentialism," Sociology of Sport Journal 28 (2011): 151-70.

(17.) See, for example, Dwight Billings and Thomas Urban, "The Socio-Medical Construction of Transsexuality: An Interpretation and Critique," Social Problems 29, no. 3 (1982): 266-82; Richard Ekins and Dave King, The Transgender Phenomenon (London: Sage Publications, 2006); Myra Hird, "For a Sociology of Transsexualism," Sociology 36, no. 3 (2002): 577-95; Myra Hird, Sex, Gender, and Science, (New York: Palgrave, 2004); and Joanne Meyerowitz, How Sex Changed: A History of Transsexuality in the United States (Cambridge, MA: Harvard University Press, 2004).

(18.) Myra Hird, "For a Sociology of Transsexualism."

(19.) Ekins and King, The Transgender Phenomenon; Hird, Sex, Gender, and Science, 9; and Hird, "For a Sociology of Transsexualism," 580.

(20.) World Professional Association for Transgender Health (WPATH), Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th ed. (WPATH, 2012), 33, 34.

(21.) Ibid., 5.

(22.) See Whitehead, et ah, "Reluctant Gatekeepers."

(23.) See, for example, Sandy Stone, "The Empire Strikes Back: A Post-transsexual Manifesto," in Body Guards: The Cultural Politics of Gender Ambiguity, ed. Julia Epstein and Kristina Straub (New York: Routledge, 1991), 280-304; and Susan Stryker, "(De)Subjugated Knowledges: An Introduction to Transgender Studies," in The Transgender Studies Reader, ed. Susan Stryker and Stephen Whittle (New York: Routledge, 2006), 1-17.

(24.) See Viviane Namaste, Invisible Lives: The Erasure of Transsexual and Transgendered People (Chicago: University of Chicago Press, 2000); and Michelle O'Brien, "Tracing This Body: Transsexuality, Pharmaceuticals, and Capitalism," in The Transgender Studies Reader 2, ed. Susan Stryker and Aren Z. Aizura (New York: Routledge, 2013), 56-65.

(25.) Eli Clare, "Body Shame, Body Pride: Lessons from the Disability Rights Movement," in The Transgender Studies Reader 2, 261-65.

(26.) O'Brien, "Tracing This Body.'

(27.) For the "authenticity model," see Hird, "For a Sociology of Transsexualism."

(28.) Two research assistants coded each interview using a common coding index collectively constructed during the process of data collection to achieve intercoder reliability. The primary investigator independently coded each interview and any coding discrepancies were discussed and settled by the research team.

(29.) Messner, "Gender Ideologies."

(30.) See Thomas Laqueur, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, MA: Harvard University Press, 1990).

(31.) Carole Vance, "Social Construction Theory: Problems in the History of Sexuality" in Which Homosexuality, ed. M. Van Kerkhof (London: Gay Men's Press, 1989), 13-34

(32.) See Fausto-Sterling, Sexing the Body, and Emily Martin, "The Egg and the Sperm: How Science Has Constructed a Romance Based on Stereotypical Male-Female Roles," Signs 16, no. 3 (1991): 485-501.

(33.) See Lancaster, The Trouble with Nature, and Lancaster, "Sex, Science, and Pseudoscience."

(34.) See Vance, "Social Construction Theory."

(35.) Messner, "Gender Ideologies," 166.

(36.) See Jordan-Young, Brainstorm.

(37.) See Roberts, Messengers of Sex.

(38.) Oudshoorn, Beyond the Natural Body.

(39.) Hird, "For a Sociology of Transsexualism."

(40.) Roberts, Messengers of Sex: Hormones, 23.

(41.) Lancaster, The Trouble with Nature, 24.

(42.) See Hird, "For a Sociology of Transsexualism"; and Whitehead et al., "Reluctant Gatekeepers."

(43.) Billings and Urban, "The Socio-Medical Construction of Transsexuality."

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