Doctors Who? The Radical History of DIY Transition

FIFTY YEARS AGO, a small group of women of color boarded a bus in Southern California bound for Tijuana, Mexico. They may or may not have stuck out in the crowd of Americans who crossed the border daily for the cheaper rates on goods and services. Once in Mexico, these women, who had journeyed all the way from San Francisco, walked into a pharmacy, bought out its entire stock of estrogen, and then carefully hid it inside their luggage. Back home, they made straight for the Tenderloin.

These women were trans—poor, many unhoused, and most sex workers who faced unending street harassment from the police, clients, and other Tenderloin residents. They were also the self-appointed doctors of their community. In hotel rooms, shared apartments, and sometimes the back bathrooms of quiet bars, they resold and administered the estrogen to their friends—other trans women who could pay in cash for injections. At the turn of the 1970s, this group of ad hoc smugglers and lay doctors were part of a vast and informal market in hormones that stretched along most of the West Coast. Similar networks no doubt spanned other regions of the country, though few left obvious traces behind.

Decades later, the story reads a little like something out of a heist film. What’s not obvious from today’s perspective on trans health care is that smuggling and reselling hormones was once quite normal, verging on unremarkable. Now, in an era of moral panic and shallow journalistic punditry dramatizing trans people as exceptional and mysterious, transition is conventionally narrated as an individual journey into the medical establishment. This form of institutionalized care is also under threat. In April, Alabama became the first state to successfully enact a ban on gender-affirming care for trans people under the age of nineteen. The law was soon challenged in federal court. Yet only a few months later, after the Supreme Court overturned Roe v. Wade, Alabama updated its legal reasoning in the case. If there is no constitutional right to abortion in the United States, then by analogy the state reserves the right to stop anyone it pleases from transitioning. “No one,” argued state Attorney General Steve Marshall, parroting Justice Alito in Dobbs v. Jackson, “has a right to transitioning treatments” because such a right is not “deeply rooted in our Nation’s history and tradition.” The political winds are fast blowing in this direction: Alabama’s law is one of over one hundred anti-trans bills that have been introduced across the country this year.

There is, however, a long history of medical transition in the United States—though it mostly unfolded outside the confines of the medical establishment. There was either no doctor to visit, or the gender clinic was a place that only the white middle class could successfully navigate. Instead, trans people—like the women in the Tenderloin in the 1970s—provided care to and for themselves. This kind of DIY, or do-it-yourself, transition sits at the heart of trans history, though you wouldn’t know it from reading today’s headlines in so-called papers of record. As the liberal principles of bodily autonomy and the right to privacy are eviscerated, the history of DIY transition offers one path out of the quagmire of zero-sum legal arguments and toward what might come after, or in the place of, state-sanctioned care.

Institutional trans health care came about in the late 1950s and early 1960s, when a cohort of endocrinologists, psychiatrists, surgeons, and social scientists in the United States and Europe united around the diagnostic term transsexuality to describe those asking for hormones and surgeries to transition. Although trans people were hardly new, and neither were the medical procedures they were requesting, they faced almost universal hostility for asserting themselves. The medical establishment, unwilling to fathom why people without any medical conditions would want to transition, viewed them as sexual deviants—in the words of endocrinologist Harry Benjamin, “among the most miserable people I have ever met.” Doctors thus styled the provision of care as a paternalistic errand of mercy.

The diagnosis of transsexuality came with a particularly cruel twist: it was explicitly designed to restrict access to transition. By establishing extremely narrow diagnostic criteria, doctors were able to reject the vast majority of potential patients from their clinics: either they did not perfectly “pass” as generic women or men; they were not heterosexual enough; they did not dress in a conservative fashion; or they weren’t white, didn’t have blue- or white-collar jobs, and were therefore broadly undeserving. While clinicians pretended outwardly that their self-appointed role was to make sure no one who wasn’t really trans made a decision they might later regret, in private they admitted to one another that there was no test that could determine who was or wasn’t trans. By making transsexuality an exceptionally difficult diagnosis to qualify for, Benjamin and his cohort were protecting themselves from patients who might regret the poor quality of their care, particularly when it came to surgery. This regime of medical gatekeeping made transition through official means inaccessible to most and miserable for the few willing to attempt it.