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

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Presentation on theme: "The DSM 5 and the politics of diagnosing transpeople Dr Zowie Davy School of Health and Social Care."— Presentation transcript:

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

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

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: (1)genomic imprimatur that marks Gender Dysphoria as a Disorder of Sex Development (DSD), moving from the mind to the body (2)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.

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

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

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

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)

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).

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.

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).

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)

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).

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).

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?

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.

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).

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).

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).

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).

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.

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.

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).

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).

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


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