1. The DSM 5 and the politics of diagnosing transpeople
Dr Zowie Davy
School of Health and Social Care

2. INTRODUCTION In the DSM
From Gender Identity Disorder to Gender Dysphoria
Psychological abnormality that manifests in trans-gendering practices–play and social behaviors
Nation States (esp. United States) allow psychiatrists using the DSM the power to (dis)allow referral for treatments, such as hormones and surgical technologies, if so sought, for non-conforming individuals on behalf of society
In the American Psychiatric Association’s (APA) DSM 5, the authors have changed the diagnosis for transpeople of all ages from Gender Identity Disorder (GID) to Gender Dysphoria. In part, this change functions to realign the ‘pathology’–dysphoria–of trans-gendering to psychiatry and addresses the sex role identity formation alignment problem apparent in the previous manuals. However, if we delve deeper Gender Dysphoria in the DSM 5 continues to depict a psychological abnormality that manifests from trans-gendering practices–play and social behaviors–and the supposed distress this causes. This new formulation continues to provide psychiatrists the enduring power to (dis)allow referral for treatments, such as hormones and surgical technologies, if so sought, for non-conforming individuals on behalf of society.

3. INTRODUCTION
The Workgroup on Sexual and Gender Disorders, Chaired by Kenneth Zucker, was employed to assess the available evidence surrounding gender and sexual disorders
According to pre-publication reports the new diagnosis should also attend de-stigmatization of transpeople
and
Consider a diagnosis that third party funders will accept for issuing payments for transitioning
The Workgroup on Sexual and Gender Disorders, Chaired by Kenneth Zucker, was employed to assess the available evidence surrounding gender and sexual disorders. According to pre-publication reports and commentaries leading up to the new diagnosis, members of the Workgroup promoted the group as attending to the de-stigmatization of transpeople, whilst considering a diagnosis that third party funders will accept for issuing payments for transitioning treatments.

4. MY ARGUMENTS I will argue
that the semantic change from GID to Gender Dysphoria in DSM 5 attends less to the harms done by psychiatric pathologisation and related stigmatization and continues to pathologize gendered expressions
Beyond psychiatrists’ offices political representational work by trans advocates are countering the stigma attached to trans embodiment by casting narratives with:
genomic imprimatur that marks Gender Dysphoria as a Disorder of Sex Development (DSD), moving from the mind to the body
Within a self-determination frame that marks an anti-pathologisation stance that see the future of care pathways for transpeople beyond the influence of psychiatry.
I will argue that the semantic change from GID to Gender Dysphoria in DSM 5 attends less to the perceived harms done by psychiatric pathologisation and related stigmatization and continues to pathologize gendered expressions, which has little to do with whether one identifies as a particular gender. I will illustrate how some transpeople are negotiating psychiatric care to attain transitioning technologies and their thoughts about using these services. I will then turn to some of the representational work that trans advocates are instituting, attempting to counter the negativity attached to trans embodiment in contemporary societies. Representations have been made public, most notably on websites, wherein transgender identities are cast with genomic imprimatur. Particularly, I will attend to the claims that mark Gender Dysphoria as a Disorder of Sex Development (DSD). I will then turn to more progressive jurisdictions beyond the North American borders and the claims made by trans advocates in the anti-pathologisation movement and review their claims for future care pathways for transpeople beyond the influence of psychiatry as a fundamental human right.

5. DIAGNOSTIC AND POLITICAL SHIFTS
1974 DSM II Removal of ‘Homosexuality’ (except ego-dystonic homosexuality-A psychosexual disorder in which an individual has persistent distress associated with same-sex preference)
1980 DSM III Introduction of Transsexualism
1994 DSM IV Transsexualism to Gender Identity Disorder (GID)
2013 DSM 5 GID to Gender Dysphoria
Since the introduction of transsexualism as a disorder in the Diagnostic and Statistical Manual of Mental Disorders Version 3, through to its later manifestation Gender identity disorder (GID) and now Gender Dysphoria, the politics surrounding the diagnostic developments have manifest in numerous ways. In July 1974, in the seventh printing of the DSM II and, notwithstanding ‘dystonic homosexuality’ remaining, the removal of ‘homosexuality’ as a diagnostic category was accomplished. This was despite vexatious claims and complaints from psychiatrists and psychoanalysts that this removal will slow scientific progress in the area of human sexuality. Non-clinical critics accuse the manual’s authors of replacing the void that ‘homosexuality’ left with transsexualism in the 1980 DSM IV version of the manual. Since, many avenues of sexuality studies have developed, including retrospective and prospective research linking ‘trans gendering’ in childhood to future non-heterosexual sexualities. Most of this research situates children’s behavior as essentially masculine or feminine–in line with stereotypical notions of play–and when playing becomes ‘inverted’ this can act as an indicative precursor to bisexuality, homosexuality, and only occasionally, gender transition later in life. This theory is maintained in later research, which is visibly linked to the diagnosis of Gender Dysphoria for children and adolescents in the DSM 5.

6. Harry Benjamin Trans continuum True transsexual-transvestite-male
post-surgically trans women will embrace unquestioningly a ‘female’ vaginal heterosexual orientation
DSM IV GID sub-divided: sexually attracted to men, women, both, neither or unspecified
In the 1960s Harry Benjamin initiated a trans continuum and differentiated the true male to female transsexual from transvestism and homosexuality. Benjamin depicts a rejection by trans women of their original genitalia and once transitioned they will assume a heterosexual sexuality. We can deduce from Benjamin’s (1966) case studies described in The Transsexual Phenomenon that he assumes that post-surgically trans women will embrace unquestioningly a ‘female’ vaginal heterosexual orientation. At this time there was little said about trans men’s genitalia and surgical and sexual orientations because they were rarely seen in the clinician’s office.
The term ‘transsexualism’ became clinically invalid due to the failure of Benjamin’s ‘true transsexual’ conceptualization. The ‘true transsexual’ model was widely rehearsed by transpeople and widely used to gain transitioning interventions. The clinical use of the model was said to be designed for gender dysphoric people who have decided to pursue their transitioning needs through hormonal and surgical interventions. Therefore, extending the diagnostic idiom in the DSM IV to GID was perhaps required to detect other ‘gender deviant’ identities who did not necessarily pursue technological interventions. In this version, GID subtypes were included and described as being sexually attracted to men, women, both, neither or unspecified, which clearly linked trans gender expressions and its development with sexual object choice.
According to some clinicians, the development from ‘transsexualism’ to GID in the 1994 version of the DSM enabled clinicians to use ‘reparative therapy’, in union with parental wishes, to avert non-heterosexual sexuality and trans gendering practices in childhood, adolescence and later in adulthood.

7. EARLY CRITICS OF DIAGNOSING TRANSPEOPLE
Transsexualism replaced by a diagnosis able to absorb many gender non-conforming individuals
GID as a diagnosis maintains the clinical monopoly on additional forms of less or more permanent gender transitioning practices
DSM is caught up in the continuities and temporalities of hegemonic and stereotypical cultural designations of male/female, masculinity/femininity, heterosexual/homosexual
Whereas, critics have argued that the shift from rather narrow characterizations of the ‘transsexual’ transitioning was replaced by a diagnosis able to absorb many more gender non-conforming individuals, who may experience some form of distress. In a more negative tone, existing research has claimed that diagnoses of multiple ‘gender disorders’ under one overarching GID identity maintains the clinical monopoly on additional forms of less or more permanent gender transitioning practices. The theoretical framework in the DSM 5 for all transpeople continues to be underpinned by essentialist, hetero-normative assumptions that situate binary sexes–male and female–with corresponding genitalia as the anchor from which these ‘gender problems’ are judged. Put simply, psychological gender that does not match the birth assigned sex, signals a psychiatric disorder. These judgments are facilitated through processes of theoretical deductions derived from stereotypes applied in the clinics serving transpeople, rather than empirically developed from masculine and feminine variables. The reason being is that masculine and feminine variables are fictional and ephemerally distributed statements that vary through time and with different intensities on both similar and different bodies. (Trans) people have never been autonomous subjects of a masculine or feminine type. The constructs masculine and feminine serve to persuade people that they possess these particular characteristics rather than them producing them within certain discursive systems. To understand pursuing gender transition within psychiatry today we must recognize the way that the DSM authors are caught up in the continuities and temporalities of hegemonic and stereotypical cultural designations of male/female, masculinity/femininity, heterosexual/homosexual–if one does not play or function according to one’s original genitals and display the accompanying ‘distress’ surrounding them–dysphoria–you will not fit the model that may steer you then to the transitioning care pathways. This is in spite of behavioral and social scientists arguing that there are no pathological sexual deviations, only alternative designations, and if viewed through liberationist politics scholarship, that these ‘conditions’ are merely social designations that are non-determinable whilst being either acceptable or condemned by (psychiatrists and) society.

8. ‘Sexual Science’ or ‘Sexual Politics’?
hyper-sexualization of two sub-types of male to female transsexuals
‘homosexual male transsexuals’
Autogynephiliacs
Blanchard (1989, 1991) Lawrence (2004)
Transpeople’s ‘atypical’ gender expressions and requests for medical interventions continue to be diagnosed as some manifestation of inverted masculinity or femininity and consequently sexuality. Researchers who have clearly influenced the construction of the DSM have linked GID to either a previous homosexual orientation or a sexualized cross-dressing fetish. This is perhaps best illustrated in Blanchard’s vontested work on the hyper-sexualization of two sub-types of male to female transsexuals: Autogynephilliacs and Homosexual Transsexuals. According to this research, some trans women are ‘homosexual male transsexuals’ who have a ‘homosexual career’ prior to transitioning and transition to make themselves sexually attractive to heterosexual men. Autogynephilliacs usually have a sexualized ‘transvestite career’ prior to transitioning. Researchers analyzing trans phenomena from this perspective conclude that the Autogynephiliac’s eroticism is directed towards themselves as ‘women’; in other words, since they fantasize and become aroused when they think of themselves having sex as women, these feelings motivate them to physically embody the woman they love through a narcissistic gender transition. The self-proclaimed Autogynephiliac, Anne Lawrence argues that this type of transperson is in fact a man who desires to be a woman and not the commonly found reference in the trans community of transpeople being trapped by their original anatomy. It is unclear whether Lawrence used the Autogynephiliac narrative to attain his transitioning technologies with psychiatrists or whether he used the common narrative I have outlined above. Evidence suggests that by entering a psychiatrist’s office claiming an unofficially sanctioned narrative would impede the desired ‘migrating journey’. This is thought especially so if transpeople divulge any non-normative form of sexuality, such as Autogynephilia, desiring (trans)people of varying body morphology, sadomasochist practices, for androgyny and genderqueer.

9. ‘Sexual Science’ or ‘Sexual Politics’?
The changes in the psychiatric model in the DSM 5 was not founded on this wider social science characterizations of transpeople
The new diagnosis of Gender Dysphoria has been pitched as a democratized version incumbent of wider voices and knowledges (Zucker, 2013).
We have come only a short way from Benjamin’s treatise in sexological research, if not into an incredibly political domain that has been facilitated by the internet. However, researchers from a broad range of disciplines are offering new approaches to the trans phenomena. Relatively new biological knowledge, contemporary philosophical and social scientific scholarship and an emerging generation of out and proud transgender and genderqueer individuals and their allies are offering new research and empirically informed conceptualizations. The changes in the psychiatric model in the DSM 5 was not founded on this wider social science characterizations of transpeople. Perhaps understandably, the Workgroup disregards the plethora of studies challenging the sexological status quo. In the pre publication reports, the Workgroup seem to have only considered the views and evidence derived from sexological research. Many of the considered texts were letters to the Workgroup offering opinion rather than empirically based research. Nonetheless, this seems to have been included as a form of ‘expert consensus.’ As such, the review process has been curtailed, rather than being a complex combination of sexological and psychosocial work illustrating the phenomenological diversity of ‘gender incongruence’ evidenced in other disciplines. I suggest that the latest DSM 5 manual transpires from so called expert sexological consensus rather than a systematic synthesis of biogenetic, psychosocial, or wider scientific evidence even though the new diagnosis of Gender Dysphoria has been pitched as the Chair of the Working group Zucker did as a democratized version incumbent of wider voices and knowledges.

10. Aims of research
1. In what ways does changing the GID to Gender Dysphoria taxonomy in the DSM 5 lessen the already stigmatized position of transpeople?
2. How does the trans anti-pathologisation movement challenge DSM 5 recognition?
The first set of data is derived from 21 semi-structured interviews conducted in with pre, post and non-operative transmen and women (n = 7 and n = 14) at varying stages of transition, and 1 person who had decided to live ‘beyond’ the binary, following sex reassignment surgery from male to female.
a content analysis from Transgender Community Organizations websites, forums and blogs. From these sources I explore the narratives of transpeople and the groups who offer details of their political praxes.
To make my points in this study I have drawn examples from two sets of data collected between 2006 and The first set of data is derived from 21 semi-structured interviews conducted in with pre, post and non-operative transmen and women (n = 7 and n = 14) at varying stages of transition, and 1 person who had decided to live beyond the binary, following sex reassignment surgery from male to female. Whilst these interviews were facilitated 7-8 years prior to the publication of the DSM 5, the analysis provides insights about accessing medical and psychiatric services in the UK. The qualitative interviews lasted 1 to 3 hours; I interjected questions to clarify points, to explore and extend avenues within the narratives to understand what I term the politics of trans embodiment qua the medico-legal system. Most participants had accessed, or were accessing psychiatric services for referrals for their medical transition and/or receive confirmation of their transition to change their legal status in the UK. Three participants were considering ways to approach psychiatrists for their transitioning needs. I will explore the narratives of transpeople who offer intimate details of their encounters with psychiatry or their understanding of what the processes may be if they had not so far sought services. The second set of arguments is derived from a content analysis from Transgender Community Organizations websites, forums and blogs, which are by nature international in their scope. From these sources I explore the narratives of transpeople and the groups who offer details of their political praxes. These illustrations show how advocates are utilizing science and knowledge to create discourses about trans embodiment and the contemporary contestations surrounding psychiatric practices. I will pay close attention to the contestations of the DSM made by the trans anti-pathologisation movement. I wish to post a methodological caveat. It is obvious that I may not have reached all the internet sources available and cannot; therefore, claim that this section of the study has reliability or is exhaustive. Indeed it is not my intention to do so. As Zucker (2013) suggested for those researchers who have a life, it would be almost impossible to access the entire number of available internet sources. I suggest; if it is fine for Zucker and the American Psychiatric Association’s Gender and Sexual Disorder Workgroup during deliberations for the new diagnoses for the DSM 5, then it must be fine for other researchers to do the same. Notwithstanding these limitations, I suggest that the internet source analysis reaches conceptual validity in relation to contestations surrounding the newly formed diagnosis in the DSM 5.

11. REHEARSING THE CLINIC NARRATIVE
not all transpeople wish for all the technologies available
whilst therapy is potentially advisable for some who need such life changing interventions, retrospectives are guided by a required ‘correct’ narrative
Outside of these clinical encounters there is no single ‘nature’; however, inside there are certain clinical culture norms that are aspired to by clients.
‘no continuity of psychic life, […] no stability of sexual identity, no position for women (or for men) which is ever simply achieved’ (Rose, 1986: 90).
For over 60 years a minority of sexologists/psychiatrists have monopolized representations of transgender people through networks of ‘expert knowledge.’ Expert knowledge is most notably built through data from the gender identity clinics, referring to case studies of people attending them. These experts have used their case studies to validate a deductive pre-conceived model of what constitutes normal development in relation to bodily aesthetics and desires surrounding gender role performance. The insistence of lengthy clinical encounters by psychiatrists prior to referring those transpeople wishing to modify their bodies–not all transpeople wish for all the technologies available–whilst potentially advisable for some who need such life changing interventions, retrospectives are guided by a required ‘correct’ narrative, otherwise the journey will be rife with difficulties. Outside of these clinical encounters there is no single ‘nature’; however, inside there are certain clinical culture norms that are aspired to by clients. Jacqueline Rose (1986) asserts that norms are cultural and not natural and should not function as baseline indicators of pathology. According to Rose, there is ‘no continuity of psychic life, […] no stability of sexual identity, no position for women (or for men) which is ever simply achieved’ (Rose, 1986: 90). The sex lives of many transpeople are subjected to normalizing parameters as a diagnostic tool. For example, transpeople understand that to disclose enjoying one’s penis or vagina alone or with another, while claiming a feminine or masculine gender identity, is considered dysfunctional by psychiatrists. Transpeople feel that if they admit to this that this could lead to disqualification from any form of treatment. The section (F64.9) Unspecified Gender Dysphoria in the DSM 5 can potentially be “used in situations in which the clinician chooses not to specify the reason that the criteria are not met”, which may encourage clinicians who are unfamiliar with wider characterizations of gender variant people and their life trajectories to halt or even misrecognize the phenomenological diversity of people wishing to transition.

12. REHEARSING THE CLINIC NARRATIVE
“All men have a feminine side, but I did not dare show that to the psychiatrist. […] The positives are that you get what you need from them. The negatives were […] very generalized and out of date questioning, which resulted in standard answers.” (Benjamin, trans man)
“look more physically trans and less female” (Oscar, trans man)
For instance, both Oscar and Benjamin’s narratives were curtailed, because they understood that psychiatrists have the power to stop the transitioning process.
“All men have a feminine side, but I did not dare show that to the psychiatrist. […] The positives are that you get what you need from them. The negatives were […] very generalized and out of date questioning, which resulted in standard answers.” (Benjamin, trans man)
Oscar considered how his narrative could be tailored to suit his transition plans. At this time he did not wish to be part of the NHS route because of the problems he had with the “reliance on certain medicalized narratives,” which he found politically and personally problematic. Oscar suggested that the narratives he was expected to tell reinforce what he sees as a false understanding of what a ‘true,’ ‘real’ and the ‘authentic’ transperson is. He wanted to take hormones at this stage to “look more physically trans and less female” (Oscar, trans man). Thus, norms constructed in the clinic guiding the attainment of transitioning technologies become embedded in transpeople’s discursive practices in the clinic, not because of some natural turn of events, but because the authorized psychiatric model constrains the discourses available to transpeople who want to pursue medical transitions. This may weaken the relevance of the data derived from research whose samples are derived from the clinics. In part, this potentially diminishes the significance of Gender Dysphoria as a diagnosis for all clients.

13. REHEARSING THE CLINIC NARRATIVE
Psychiatry only recognizes certain hetero/gender normative subjects as having rational minds and orderly bodies. The truth and importance of the original (natal) body becomes key in the diagnostic process rather than the contemporaneous mind (Cohen-Kettenis & Pfäfflin, 2010).
“In adolescents and adults incongruence between experienced gender and somatic sex is a central feature of the diagnosis [of Gender Dysphoria]” (APA, 2013: 455).
The DSM 5 has not changed drastically from the DSM IV in relation to the ‘Diagnostic Features’. Sexual difference, as proclaimed by the on-looking doctor at birth, becomes the location from which normal (psychic) development must evolve and guides this psychiatric model. Psychiatry only recognizes certain hetero/gender normative subjects as having rational minds and orderly bodies. In these binary models, then, the truth and importance of the original (natal) body becomes key in the diagnostic process rather than the contemporaneous mind. As the manual states: “In adolescents and adults incongruence between experienced gender and somatic sex is a central feature of the diagnosis [of Gender Dysphoria]”. This development model is coupled with particular naturalized sex dimorphic behaviors. This is perhaps best seen in the literature that provides data about children, adolescents, and adults meeting the DSM criteria for Gender Dysphoria. In Zucker et al. there is much reference to children being referred to clinics whose ‘gender confusion’ is compared to ‘normal children’ and who are evaluated by assessing their preferred behaviors. The assessments include the child’s and parents’ retrospective observations about these behaviors. In adults, gender issues are assessed in relation to childhood, adolescent and ongoing behaviors and judged against the behavior they ‘ought’ to be performing based on their natal bodily aesthetic and sex assignment. An instance is in sexologists’ continued insistence on the lack of ‘rough and tumble play’ for trans girls and women.

14. REHEARSING THE CLINIC NARRATIVE
“My being a woman is whether I look good, bad or indifferent. I can be under the sink trying to unblock the sink covered in grease but I still am who I am. That is the important thing as I don’t have to justify myself in those terms, like no woman has to do […] but then I am a feminist [and] riding very large motorcycles, believe it or not. I am afraid the love of the larger motorcycles has never left me but the being hairy has. Yes my bike was a Harley Davidson” (Anne, trans woman).
“[m]any of the Transgenders I have talked with have similar early childhood memories clomping around in mother’s high heels, hiding in her closet, and feeling the soft fabric of her dresses [...] Perhaps many little boys hide in mom’s closet and put on girls’ clothes sometimes; [these retrospectives] subsequently seems more significant to Transgenders” (Lerner, 2006: 151).
Beyond the clinic however, transpeople are freer to disclose their leisure pursuits to other researchers:
“My being a woman is whether I look good, bad or indifferent. I can be under the sink trying to unblock the sink covered in grease but I still am who I am. That is the important thing as I don’t have to justify myself in those terms, like no woman has to do […] but then I am a feminist [and] riding very large motorcycles, believe it or not. I am afraid the love of the larger motorcycles has never left me but the being hairy has. Yes my bike was a Harley Davidson” (Anne, trans woman).
It is clear from much feminist research that behaviors are not intrinsically masculine or feminine but both socially and epistemologically transient. Nonetheless, retrospective understandings of childhood and adolescent play and contemporary behaviors are utilized by transpeople seeking therapy, and their narratives are interspersed with expected binary gender inflections. However, this seems inevitable if the narratives that transpeople recount are constrained by the diagnostic models, especially if they are seeking transitioning interventions. As Elaine Lerner suggests:
“[m]any of the Transgenders I have talked with have similar early childhood memories clomping around in mother’s high heels, hiding in her closet, and feeling the soft fabric of her dresses [...] Perhaps many little boys hide in mom’s closet and put on girls’ clothes sometimes; [these retrospectives] subsequently seems more significant to Transgenders”.
The models used to understand Gender Dysphoria only help us determine whether someone is experiencing dysphoria about incongruence with the deductive model of gender norms, which has very little to do with gender identity. Accordingly, transpeople must express ‘dysphoria’ about their ‘natural’ body and incongruent behavior and dis-orientations from the gender norms applied to their assigned sex at birth, even though these behavioral differences are becoming more unrealistic in today’s societies. Gender role performance and gender identity are not the same thing. Much research has illustrated that these so-called sex dimorphic behaviors are performative, where genders and sexualities are socially and clinically interpellated and produced by, what Judith Butler calls the ‘heterosexual matrix’ in which gender roles are ‘naturalized’ through “a parody of the idea of the natural and original.”

15. REHEARSING THE CLINIC NARRATIVE
“[most psychiatrists] adhere to gender identity as both ‘real’ and fixed. This adherence then facilitates the continued use of highly stereotyped notions of gender to provide the framework for assessing and treating transsex […] individuals” (Hird, 2003: 183).
why boys should be more aggressive, play at rough and tumble and only have male friends, and why girls should only play at house, and dress in skirts and dresses?
why are the majority of female psychiatrists in the room wearing trousers, with minimal use of make-up and no high heels?
The clinically expected expressions do not correspond well to gender role play or leisure pursuits apparent in contemporary society. Myra Hird (2003) has previously questioned the model used in the DSM IV, by exposing that the bodily aesthetics and behaviors that transpeople are expected to perform in clinical encounters are different to how actual life practices of the psychiatrists evaluating transpeople are. Hird (2003: 183) argues that
“[most psychiatrists] adhere to gender identity as both ‘real’ and fixed. This adherence then facilitates the continued use of highly stereotyped notions of gender to provide the framework for assessing and treating transsex […] individuals.”
At a conference workshop Hird asked: why boys should be more aggressive, play at rough and tumble and only have male friends, and why girls should only play at house, and dress in skirts and dresses. Hird then asked, why are the majority of female psychiatrists in the room wearing trousers, with minimal use of make-up and no high heels? What Hird is implying here is that therapeutic models are based on both stereotypical aesthetics and behavior that are less apparent in Western societies today. We could suggest that women and girls playing rugby, martial arts, boxing, climbing or those learning to fight in combat situations are somehow non conformist to their true natural gender, but because there is no distress about these behaviors, they will not approach a psychiatric office to pursue therapy for dysphoric feelings. In effect, psychiatrists’ demands of transpeople’s intentionality reveal how transpeople ‘ought’ to be because of their ‘new’ gender identity. As such, there is a myth of linguistic cohesion surrounding gender identity and its gender role characterizations in the DSM model with which transpeople must live with, but under whose procedures they must succumb and suffer.

16. NON-DYSPHORIC CLIENTS
Dysphoria is a sense of unease or distress, which may better reflect the experiences that some transpeople feel about their gender expression and who actually experience clinically significant distress related to their gender incongruence prior to transitioning.
It is important not to undermine the distress that people sometimes feel in relation to their sense of gender incongruence, because this will serve only to silence these voices.
However, the current Gender Dysphoria diagnosis universalizes a personal intra -psychical understanding of dysphoria for all transpeople, which may or may not be the case.
Operationally the model’s gender norms have wider cultural consequences. Some public and healthcare perceptions surrounding people with a diagnosis of GID, now Gender Dysphoria, it is just that, a disorder. What Gender Dysphoria in the DSM 5 reflects now are various degrees of personal dissatisfaction with sexual identity, body characteristics, and perceived gender roles. Gender Dysphoric transpeople are characterized as psychically dissatisfied with their (truthful) sexed body, which causes a psychic disorder in the form of Gender Dysphoria. Irrationality and distress must be present in order to receive a diagnosis. Dysphoria is a sense of unease or distress, which may better reflect the experiences that some transpeople feel about their gender expression and who actually experience clinically significant distress related to their gender incongruence prior to transitioning. This change may permit a shift from a ‘gender identity’ position to situational and experiential concerns better aligned to psychiatric practice. It is important not to undermine the distress that people sometimes feel in relation to their sense of gender incongruence, because this will serve only to silence these voices. However, the current Gender Dysphoria diagnosis universalizes a personal intra -psychical understanding of dysphoria for all transpeople, which may or may not be the case.

17. NON-DYSPHORIC CLIENTS
“My mum was a senior nurse so she was within the medical profession and she took me to a lot of people because she knew I was not developing properly. My sexuality was not what, what one would hope because at the end of the day the successes of the mother goes through what their children become, this was especially in the past […] That sort of attitude in a family can be quite limiting. My family would turn to the medical profession to cure you […] When I was a kid I used to want to be in the RAF, be an engineer, but I couldn’t do that. ‘You can’t do that, you’re a girl.’ I had a major breakdown when I was fifteen and a half [years old] because of all the pressure” (trans man Jonathan).
A problem psychiatrists face is when they have to determine whether the client ‘has’ Gender Dysphoria or whether distress manifests for other reasons. As such, the sorts of stress narratives psychiatrists see in their patients need to be teased out more to illustrate the gap between the performative functions of the Gender Dysphoria diagnosis and other stress related conditions. Social alienation and other external factors, such as negative social relations, rejection, maltreatment, and victimization, are reasons given by trans youth for their suicide ideation and are fundamental to their experience of distress, for instance. It is unclear how psychiatrists can differentiate internal gender distress or external factors that are contributory to stressful situations the two except when the client is not expressing the restrictive narratives explored above. Other psychiatric impairments accordingly may not be detected. As Zucker et al. (2002) suggest the vast majority of children and adolescents would not qualify for ‘gender dysphoria on this basis in his clinical observations, because it is not clear to what extent psychiatric impairments are a consequence of “chronic Gender Dysphoria”. and warrants the question then: on what grounds is diagnosing Gender Dysphoria justified given its shortcomings. This is a somewhat problematic situation that has not been explained by Zucker (2009). Jonathan illustrates a scenario, which shows the disparity between familial and medical concerns and his aspirations:
“My mum was a senior nurse so she was within the medical profession and she took me to a lot of people because she knew I was not developing properly. My sexuality was not what, what one would hope because at the end of the day the successes of the mother goes through what their children become, this was especially in the past […] That sort of attitude in a family can be quite limiting. My family would turn to the medical profession to cure you […] When I was a kid I used to want to be in the RAF, be an engineer, but I couldn’t do that. ‘You can’t do that, you’re a girl.’ I had a major breakdown when I was fifteen and a half [years old] because of all the pressure” (trans man Jonathan). This quotation represents family members and psychiatric concerns about how Jonathan’s behavior ought to be, which was in stark contrast to his desires. Jonathan’s distress was situated in wider medical and familial condemnations of his aspirations rather than in his desire to become a boy/man. Thus, if we incorporate understandings about where the distress emanates, we may come to a different sociological conclusion about what underpins his distress.

18. NON-DYSPHORIC CLIENTS
“the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available” (WPATH, 2012: 6 emphasis added)
“I went to see [psychiatrist] and I thought I was going to be grilled because I had heard of this guy, and he said ‘so, how can I help you?’ I said ‘well I think you should be treating my father not me and it should be my father sitting here.’ And of course he didn’t like that at all and got his back up immediately because of that. At the end of the day I turned around to him and said ‘I don’t give a shit about what you have to say because you are not going to make me anymore male than I am or anymore female than I am, all you can do is make this journey a smidgen less difficult than it already is” (trans man Richard).
There are no concessions in the DSM model of Gender Dysphoria that transitioning is about rational choice and agency. What about those people who wish to transition but do not experience Dysphoria? It is unclear how psychiatrists referring clients for hormone therapies and surgeries are implicated with these clients, unlike in the latest widely recognized version of the World Professional Association of Transgender Health’s (WPATH) Standards of Care (2012). In the Standards of Care it states that: “the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available” (WPATH, 2012: 6 emphasis added). According to this guidance, Dysphoria need not be present. Being transsexual, transgender, or gender nonconforming Is a matter of diversity and not pathology. Peter was one of those transpeople who felt that he was not dysphoric but his father had wanted him to see a particular psychiatrist linked to the gender identity clinic, and whose research had underpinned the manifestation of ‘reparative therapy.’ “I went to see [psychiatrist] and I thought I was going to be grilled because I had heard of this guy, and he said ‘so, how can I help you?’ I said ‘well I think you should be treating my father not me and it should be my father sitting here.’ And of course he didn’t like that at all and got his back up immediately because of that. At the end of the day I turned around to him and said ‘I don’t give a shit about what you have to say because you are not going to make me anymore male than I am or anymore female than I am, all you can do is make this journey a smidgen less difficult than it already is” (trans man Richard).
For some of the research participants, who suggested that they felt to be in a ‘wrong body’ but had rational minds and no dysphoria, to utilize the trope of ‘wrong body’ with psychiatrists would put them at odds with the normative psychiatric modes of correct development–an original body with a corresponding mind–and places the transperson in a paradoxical situation. By ‘non-gender dysphorics’ engaging with this model it inadvertently confirms their own pathology. Moreover, receiving surgery or hormones to relieve the ‘dysphoria’ does not relinquish pathologisation because one’s natal sex and gender identity is always incongruent. Whilst the DSM does not offer any indication about how to relieve Gender Dysphoria, it is inferred that technological interventions are available to alleviate this ‘disorder.’ A psychiatric diagnosis has possibly offered some transpeople in some developed countries the hope or expectation of subsidized state and insurance funded health care and surgery. Drescher (2013) has argued that the retention of a psychiatric diagnosis on the one hand, is in part to allow transpeople to access treatment, but difficult to find any de-stigmatizing language because any financial access is based on being pathologised. Without this depiction of pathology insurance companies are less like to provide the transitioning interventions needed by transpeople. Of course, the outcomes of these clinical encounters are never guaranteed, because it continues to be about safeguarding a narrative that may not account for all who need to transition medically and legally and does not include those that do not demonstrate dysphoria.

19. CLAIMING A DISORDER OF SEX DEVELOPMENT
“Many transgender people have believed for the longest time that biology had been the cause. I myself believe this as my earliest memories were that of wanting to be a girl even before I learnt to spell. Hopefully further studies like this will prove beyond a shadow of doubt that the phenomenon is a natural occurrence, leading to social acceptance of transgender people” (SameSame, 2008).
The anti-pathologisation movement has suggested alternative ways to approach this dilemma, which leads me to my second question: how does the trans anti-pathologisation movement challenge DSM 5 recognition? For the first time in the DSM manual Disorder of Sex Development (DSD)–previously known as intersex–has been aligned to the diagnosis of Gender Dysphoria. This is an interesting inclusion, because some trans advocates’ are utilizing a DSD narrative in an attempt to subvert psychological categories for biogenetic categories in a bid to challenge the psychiatric understanding of Gender Dysphoria. Political advocates previously defined inverted gender identities within a ‘wrong body’ narrative but have now started to refine this and adopt a ‘biogenetic’ narrative. Trans advocates’ claims are often in the form of a cerebral DSD condition. Drawing on biological research, advocates often suggest that their gender identities are a product of dispositions, caused by hormonal influences in fetus, which has affected their desire to transition. As one website illustrated: “Many transgender people have believed for the longest time that biology had been the cause. I myself believe this as my earliest memories were that of wanting to be a girl even before I learnt to spell. Hopefully further studies like this will prove beyond a shadow of doubt that the phenomenon is a natural occurrence, leading to social acceptance of transgender people” (SameSame, 2008). Societal stigmatization of transpeople is frequently couched in sexual predator discourses. Transpeople battle against depictions of their need to change gender being aligned to mentally unstable pedophiles and sexual deviant. Therefore, it is not known if the biogenetic claims of being someone with a DSD will or will not lessen the stigma surrounding Gender Dysphoria. There is little understanding of the political implications of these subversions.

20. CLAIMING A DISORDER OF SEX DEVELOPMENT
many prenatally testosterone-exposed individuals raised as girls continue to have an adult female gender identity, and that masculine gender role behaviors in DSD female raised children should not be mistaken for a male gender identity (Cohen-Kettenis, 2010).
It is important to distinguish between ‘gender identity’ and ‘gender role’ when considering DSD
“given the choice of male, female or intersex I would unhesitatingly select intersex. But society does not give me that option” (Macdonald cited in Phillips, 2001: 41).
The biogenetic position; however, may prove to be problematic in a number of other ways. For instance, the claims to a biogenetic disposition i.e. DSD embodiment and a particular gender identity simultaneously are untenable because they are underpinned by two different logics. The notion that people with a DSD are inherently one gender or the other and compelled to transition because of an underlying biogenetic position is too simplistic. Existing research into multiple forms of DSD illustrate that there is more variability to gender identity outcomes than was previously assumed. For example, research has suggested that many prenatally testosterone-exposed individuals raised as girls continue to have an adult female gender identity, and that masculine gender role behaviors in DSD female raised children should not be mistaken for a male gender identity. Cohen-Kettenis (2010) argues that it is important to distinguish between ‘gender identity’ and ‘gender role’ when considering DSD. Gender identity is characterized in much of the DSD literature as a sense of oneself as male, female or indeterminate, whereas gender role is characterized as behaviors, personality traits and interests that society applies to these aspects and the way that people (are) measure(d) against these stereotypical attributes. Gender Dysphoria aligned to DSD position would have to presuppose that ‘DSD people’ would, like many of the trans advocates utilizing this discourse, need ‘right bodies’ that ‘matches’ their inherent gender identities. Whilst there is some evidence to suggest that ‘DSD people’ do identify with a particular gender identity and do wish for normative bodies, the evidence suggests that we cannot discount psychosocial development as irrelevant for them. This DSD position corresponding to a particular gender identity is not always evidenced in the literature. As we have seen above, roles and identities can be considerably modified by psychological, social, and cultural factors. Zucker and Bradley (1995) too believe that behaviors can be modified with their treatment of gender non-conforming children. Moreover, there is contrary evidence about connecting DSD and a particular binary gender identity. Some ‘DSD people’ want to live beyond a binary system of gender roles, gender identities, and embodiment. Mairi Macdonald from the UK Intersex Association states that “given the choice of male, female or intersex I would unhesitatingly select intersex. But society does not give me that option”.

21. CLAIMING A DISORDER OF SEX DEVELOPMENT
these biological assignments often conceal the relationship between the transperson and a gendered world.
in the sexological literature and essentialist arm of trans advocacy conceal the multiple ways that transpeople live their social lives.
The diverse phenomenology of transpeople becomes both asocial and epistemologically intransient.
The websites reveal poor and misleading representations of the science.
Essentialist claims are made in order to subvert any medicolegal opposition to transitioning technologies for ‘DSD transpeople.’ The causal story of Gender Dysphoria seems to appeal to some trans advocates, because biogenetic scientists are socially legitimated experts. Given the relative power that the biogenetic narrative maintains in society and particularly in medicine, it seems like a wise appropriation of essentialism. However, the trans web based materials depicting a ‘DSD embodiment’ and the desire to transition to a particular gender tend to mirror the simplistic dualisms in the biological research: that gender–masculinity and femininity–are ‘natures.’ These websites take for granted that scientists, who have the power to judge gendered behavior, have assigned unbiased meanings to the ‘biological’ features used in their studies. These assignments; critics have suggested, far exceed, in a sociological sense, anything warranted by biology. Moreover, these biological assignments often conceal the relationship between the transperson and a gendered world. Accordingly, in the sexological literature and essentialist arm of trans advocacy there is widespread concealing of the multiple ways that transpeople live their social lives and as such maintain problematic and contestable dualisms. As a result, the diverse phenomenology of transpeople becomes both asocial and epistemologically intransient. In the many websites, the ‘biogenetic’ claims and scientists’ expertise is praised for finding the ‘true cause’ of their Gender Dysphoria. For example, there are a number of un-cited depictions of the binary sexed brain, but the study that was cited most was Hare et al’s study (2009) that argued that there was significant association between transsexualism and the AR allele gene (androgen receptor). This study argues that the AR allele gene may cause feminization or ‘undermasculinization,’ with transwomen and that gender identity might be partly mediated by it. Hare et al’s study actually found a very weak association and contradicted the study that it tried to replicate, and has since failed replication in another study. This evidence casts some doubt on the claims made on the websites. Accordingly, the websites are revealing poor and misleading representations of the science. I will now turn to the ways that other transpeople in the anti-pathologisation movement approach a sense of collective identity upon which claims of recognition, technological interventions, and care pathways can be sought.

22. SELF-DETERMINATION AS POLITICAL PRAXES
Trans advocates have argued that it is erroneous for psychiatrists and other mental health professionals to label variations of gender expression as symptoms of a mental disorder (TGEU, 2012).
The only conceivable way of eventually removing the stigma surrounding transpeople’s transitioning is by removing the connection between psychiatry and the care pathways altogether.
Should be seen as an agentic human right within a health framework.
Whilst there is evidence on some of the trans advocates websites confirming Vance et al’s suggestions that trans welfare organizations wanted a change in taxonomy, diagnostic criteria and language use in the DSM 5 for trans related issues in order to lessen the stigma surrounding transgender. Vance et al., in a DSM 5 prepublication report, argue that some advocates also wanted the diagnosis to remain because of the insurance payments to health care providers continuing for transpeople in North American contexts. Whilst the DSM is a US centric manual, the authors, nonetheless, have much influence beyond the American borders, for instance in the recent NHS England and The Royal College of Psychiatry reports and guidance for psychiatrists respectively, have both adopted the term Gender Dysphoria. Nonetheless, following the announcement that the DSM was to be revised controversies emanated from both clinical and trans advocacy quarters providing other voices to the debate about the inclusion of transpeople in the DSM 5 diagnostic criteria. Some trans advocates have argued that it is erroneous for psychiatrists and other mental health professionals to label variations of gender expression as symptoms of a mental disorder (TGEU, 2012). According to some trans advocates, the only conceivable way of eventually removing the stigma surrounding transpeople’s transitioning is by removing the connection between psychiatry and the care pathways altogether. These advocates suggest that the need to change gender (markers) is a form of rational self-determination. Because of an inner self desiring such a transition, transitioning is situated in a phenomenological experiential framework underpinned by self-determination. As such, transitioning should be seen as an agentic human right within a health framework. The phenomenological experience is accounted for in numerous sociological and anthropological studies that have illustrated the agentic practices of transpeople living a gender that suits them better, whether that be within the binary or beyond it.

23. SELF-DETERMINATION AS POLITICAL PRAXES
The data emphasizes that every transperson has a right to actualize their transition, as far as they wish it should go.
The Argentinian law will “not only […] give you the right to self- identify, but for those who want medical intervention, [it] require[s] public and private providers to cover procedures for self- actualization.” (Katrina Karkazis cited in Schmall, 2012: no page number).
The strategic move of suggesting that transpeople do not require a psychiatric diagnosis to engender the transitioning process, if so desired, has been attempted and has succeeded in France, Denmark and Argentina, which I will return to below. Self-determination, according to some trans advocates, is way of making recognition claims for those wanting technological interventions to change gendered characteristics beyond a psychiatric frame. For instance, Denmark has introduce what they call 1) The declaration model where a person may apply for legal gender change by providing a declaration that he or she feels to be of the opposite gender. Transgender Europe situates this type of self-determination model within a human rights discourse. The data available emphasizes that every transperson has a right to actualize their transition, as far as they wish it should go. The weight of this approach is becoming more and more visible, perhaps because of governments, such as the one’s mention and the Argentinean government that recently legislated on, arguably, the most progressive trans recognition law in the world. The law allows people to alter their gender on official documents without first having to receive a psychiatric diagnosis or surgery. In the New York Times online, Katrina Karkazis, a Stanford University professor of bioethics said that Argentina’s new law will: “Not only […] give you the right to self-identify, but for those who want medical intervention, [it] require[s] public and private providers to cover procedures for self-actualization.”

24. SELF-DETERMINATION AS POLITICAL PRAXES
Sandy Stone (1991) observed that a liberal transsexual politics may direct its energies towards the human rights of transsexuals rather than, for example, at psychomedical constructions of transsexuality.
transpeople should not be psychiatrically classified because “difference is not disease, nonconformity is not pathology, and uniqueness is not illness” (GID Reform Advocates, 2010: no page number).
The self-determination frame challenges healthcare professionals to work towards supporting transpeople’s health interventions by reducing the psychopathological framework. In effect, these claims remove the need for the psychiatric diagnosis of Gender Dysphoria. In 1991 Sandy Stone (1991) observed that a liberal transsexual politics may direct its energies towards the human rights of transsexuals rather than, for example, at psychomedical constructions of transsexuality. In 2013 we can witness that human rights groups have refocused their energies towards ‘transsexuality’ and other transpeople by showing that expressions of gender are “expressions of sexual diversity” . As one prominent group argues: attempting to diagnose diversity is, they say, “a pointless exercise” (TGEU, 2012). According to one website, transpeople should not be psychiatrically classified because “difference is not disease, nonconformity is not pathology, and uniqueness is not illness” (GID Reform Advocates, 2010: no page number). The enactment of the Argentinean legislation is underpinned by a human rights and self determination model and derived from the reframing of transpeople by anti-pathologisation advocates. The legislation is an illustration of the way that advocates have started to erode the power of psychiatry over trans bodies without implying the dualist notions of body and mind, and the conflation of gender role and gender identity, unlike the DSD discourse advocates. From a self-determination position, advocates are redressing the notion of pathology and questioning the role that dysphoria has in the lives of all transpeople and trans politics. Advocates are insisting that people can actualize their embodied needs rationally, euphorically perhaps and in whatever ways they desire, without the need for psychiatric gate keeping in the form of Gender Dysphoria.

25. Concluding remarks
The guidance in the DSM for psychiatrists has; nonetheless, been underpinned by much political wrangling.
Psychiatric recognition of transpeople has been used to access and provide transitioning treatments in many jurisdictions
The narratives expressed in psychiatric consultations is fashioned in line with the dominant discourses of binary sexed identities.
Perceived harms done through psychiatric pathologisation and the power that psychiatrists have over trans bodies is being contested.
Transpeople are being recognized despite psychiatry being uncoupled from transpeople’s care pathways
The DSM 5 diagnosis of Gender Dysphoria is too new yet to understand if it will indeed lessen the stigma surrounding transpeople and too new to see how it will affect the narratives of transpeople’s when they need technological interventions to change their bodies. The guidance in the DSM for psychiatrists has; nonetheless, been underpinned by much political wrangling. Whilst psychiatric recognition of transpeople has undoubtedly been used to access and provide transitioning treatments in many jurisdictions, the narratives that need to be expressed in psychiatric consultations is fashioned in line with the dominant discourses of binary sexed identities. The shift of emphasis from binary sexed identities to psychological distress has been wrought with contestations about psychiatric power over the bodies of those who wish to transition medically and/or legally to another gender. The semantic change from GID to Gender Dysphoria in DSM 5 maybe an attempt to rectify the mismatch between Gender Identity Disorder and the distress that may manifest from being trans; however, the perceived harms done through psychiatric pathologisation and the power that psychiatrists have over trans bodies is being contested. Some trans advocates suggest insisting on care pathways and legal assistance for those people who need to have a body different to their natal morphology and/or gender assignment beyond a psychiatric frame. They argue that if we look to other jurisdictions this can be accomplished. Transpeople are being recognized despite psychiatry being uncoupled from transpeople care path ways and in spite of offering a non-dualist, agentic, self-determination model of gender variance.