Protection or cruelty?

A dive into transmedicalism (among transfeminine people)

by Andrea Fogel


Editor’s note

I am grateful to Wester Hare for its contribution to my editing and pre-publication review of this article. —ICBM

It is difficult to find a tendency that generates more infighting among the trans community than transmedicalism (whose adherents self-describe as both “transmedicalists” and “truscum,” although this document exclusively uses the term “transmedicalists”): an ideology whose adherents assert “that gender dysphoria is necessary for being trans and that being trans is essentially a medical condition defined by dysphoria and the desire for ‘opposite’ sexed bodily characteristics” (Williams, 2019, p. 129). In order for the propositions associated with transmedicalism to be accepted as true, one would need to disregard not just the history of trans people in the West, but the non-Western identities that fall under the trans umbrella as well. It is a fundamentally ignorant, if not malicious, ideology.

Nonetheless, transmedicalism attracts a sizeable minority of the trans community by appearing to offer a straightforward approach in resolving trans people’s anguish surrounding the misidentification of our genders at birth (Dame, 2016, p. 24). Medical practitioners broadly regard dysphoria as a criterion that must be fulfilled for trans patients to access healthcare; therefore, these patients often “feel compelled” to misrepresent their dysphoria as being greater in intensity than it actually is in order to obtain said healthcare (Konnelly, 2021, p. 6). This process inherently homogenizes trans narratives by diminishing the differences in the intensity of dysphoria that said trans narratives reflect.

The medical establishment’s homogenization of trans narratives can result in trans people internalizing the transphobic treatment they receive and hence adopting the ideology of transmedicalism. Said internalization is then externalized onto the trans community at large: transmedicalist trans people enforce their ideology onto other trans people. The subversivist tendency within the trans community—defined by Julia Serano as “the practice of extolling certain gender and sexual expressions and identities simply because [italics mine] they are unconventional or non-conforming” (Serano, 2016, p. 346)—then inadvertently strengthens the fundamentally conservative ideology that is transmedicalism. I consider transmedicalism to be conservative, as it emulates the outdated classifications of the model of transsexualism of Harry Benjamin (1966/1999, p. 11): a medical model of transness dependent on medical gatekeeping, i.e., determining who is and who is not a “true [italics mine] transsexual” (op. cit., p. 19).

In order to better explain the problem of the subversivist tendency that has become mainstreamed within broad trans spaces over the past couple of decades, subversivism itself must be explained further. According to the subversivist framework, to choose to “blend in” is to choose to perform gender in a way that inherently uplifts cissexism, and therefore such gender expression is regarded negatively (Serano, 2016, p. 347).

However, Serano challenges this subversivist position. Serano is known for formalizing the concept of oppositional sexism: “the belief that male and female are rigid, mutually exclusive categories, each possessing a unique and nonoverlapping set of attributes, aptitudes, and desires” (Serano, 2016, p. 13). Serano argues that the subversivist framework — “the original oppositional sexist binary flipped upside down,” as she terms it (Serano, 2016, p. 349) — ultimately only serves to “reinforce [said binary] further” (ibid.).

Further, she notes that subversivism especially affects transfeminine people, stating:

In our culture, the meanings of “bold,” “rebellious,” and “dangerous” — adjectives that often come to mind when considering subversiveness — are practically built into our understanding of masculinity. In contrast, femininity conjures up antonyms like “timid,” “conventional,” and “safe,” which seem entirely incompatible with subversion. [. . .] Subversivism creates the impression that trans masculinities are inherently “subversive” and “transgressive,” while their trans feminine counterparts are “lame” and “conservative” in comparison.

Serano (2016), p. 348

Of course, to transgress the oppositional gender binary is no more virtuous than non-transgression, despite what those who hold the subversivist mindset believe. To assimilate on a personal level can even be an attempt at self-protection. Certainly, the theory behind the trans liberation movement presents a more permanent solution to the struggles associated with the trans demographic (Schrock et al., 2004, p. 62). However, some might conceive that to fight for this cause requires a greater amount of emotional investment than to transition in a manner that results in “blending in,” at least in the modern-day economically-developed world. Therefore, it is unreasonable to fault individual trans people simply for embarking upon the latter pathway as opposed to the former.

This is not to minimize the evident role that biopower — meaning power that deals “with living beings” and their bodies (Foucault, 1976/1990, p. 143) — plays in the medical system as it pertains to trans people, as gender is itself regulated by forces of biopower, “gendering practices” being “inextricably enmeshed with sexuality” (Stryker, 2014, p. 39). Transnormative constructs of what it means to be trans, i.e., those deeming “some trans people’s identifications as legitimate and prescriptive (e.g., those that adhere to a medical model) while others’ are marginalized, subordinated, or rendered invisible (e.g., those that do not adhere to a medical model),” are therefore rather prevalent, resulting in medical gatekeeping (Johnson, 2016, pp. 467–468). At the same time, trans people engaging, on a personal, individualized level, in modes of living that happen to be in accordance with the forms of being trans which outdated medical models have historically considered acceptable, is not, in and of itself, harmful.

Interestingly, though, trans women and transfeminine people are often expect to display traits of both assimilationist and subversivist tendencies. We are expected to be conventionally attractive — e.g., thin, white, and appearing to be cisgender women — yet we are still expected to retain penises as a distinguishing marker. We are expected not to disturb our cisgender peers by challenging their cissexist notions — to conform to the expectation of being submissive and docile which is imposed on women in general — yet we are expected to demonstrate pride in who we are, for hiding who we are is considered deception. And we are expected to work in so-called “respectable” fields, yet we are frequently relegated to marginalized occupations such as sex work. These are only a few examples of the societal double-bind.

Further, it is vital to note that a strongly assimilationist mindset has negative consequences of its own. To become an assimilationist — as it manifests in projecting one’s own medical relationship to being trans onto other trans people, coupled with policing of other trans people’s identities — is to become a conduit of biopower.

Transmedicalism and this tendency of strong assimilationism as described are closely related. Transmedicalism requires separatism because — despite historical evidence showing that, as Serano wrote, “activism requires alliances” (Serano, 2011, paras. 6–7) — transmedicalism entails the belief that trans people without gender dysphoria are in some way harmful to the larger trans community. Because of this belief and its consequences, transmedicalism inherently compels those who are suited best by transgressing the oppositional gender binary into denying their selfhoods as trans people.

The problem, ultimately, is not individual assimilation; the problem is assimilationism. Even so, I cannot say that assimilationism cannot be a compelling ideology. When one is severely dysphoric, it is not at all difficult, as a trans person, to look at other trans people — specifically those who experience no or minimal dysphoria, or alternatively do not experience it from being perceived as transgressing the binary — and wonder why one cannot be happy like they are. Grappling with gender dysphoria can be an extremely alienating experience, as no one chooses to experience it; it is difficult to imagine anyone wanting to feel such intense psychological anguish.

Consequently, the increasing diversity in the trans community in this regard — coupled with the tendency toward subversivism, as well as the pervasive transmisogyny in broad trans spaces by which that tendency is not-always-but-often accompanied — causes some trans people’s ontological security to become fragile. Since, as sociologist Anthony Giddens (1991, p. 54) states, “a person’s identity […] must continually integrate events which occur in the external world,” some trans people internalize the gatekeeping in the pathologization of trans identity, and then project their insecurities onto other trans people.

In doing so, they realize the adage: “hurt people hurt people.” When subjected to the immense amount of trauma that is, in some ways, inherent to being trans in a cissexist world, and to being a transfeminine person in a transmisogynistic world, it is not unrealistic for this to result in a disturbance in behaviors among trans people, especially transfeminine people. This creates a cycle, for, as philosopher Simone Weil wrote: “To put oneself in the place of someone whose soul is corroded by affliction, or in near danger of it, is to annihilate oneself. […] Therefore the afflicted are not listened to” (Weil, 1943/2005, p. 91).

This does not make transmedicalism acceptable. It does raise a question: How can society be restructured in order to be less traumatic for trans people, especially transfeminine people? The answer to that question is beyond the scope of this article. However, Weil continued:

Only by the supernatural working of grace can a soul pass through its own annihilation to the place where alone it can get the sort of attention which can attend to truth and to affliction. It is the same attention which listens to both of them. The name of this intense, pure, disinterested, gratuitous, generous attention is love.

Weil (op. cit.), pp. 91–92

About the author

Andrea Fogel (she/her/hers) is “a disabled/neurodivergent transsexual author who writes to capture the obscure emotions of the gutter in which she lives in order to elevate the low-brow into the high-brow”. You can visit her at


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