Degree Date

5-2016

Degree

Doctor of Philosophy (PhD)

Department

Social Work and Social Research

Abstract

Background: From 1980 to 2013, the American Psychiatric Association (APA) published the diagnoses Gender Identity Disorder (GID, originally “Transsexualism”) and Gender Identity Disorder of Childhood (GID-C) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). When applied to adults, the Transsexualism and GID diagnoses represented individuals as suffering from treatable forms of psychiatric disturbance and distress. This representation allowed physicians to employ surgical and endocrine technologies that helped some who sought to change their gender/sex embodiment to achieve that goal. When applied to children, the GIDC diagnosis authorized psychological interventions on gender/sex nonconforming children and their families, ostensibly to avert a lifetime of psychiatric disturbance, deviance, and distress. Method: I interviewed stakeholders in the debate over deleting or revising these diagnoses in the DSM-5. I described areas of agreement among participants, and analyzed competing lines of reasoning critiquing or defending retention of the diagnosis. I also considered their arguments in the context of both historical medical constructions of gender/sex norms and the practical management of deviance from those norms. Findings: Collectively, interview participants provisionally endorsed retention of the diagnosis, largely because GID had become logistically useful in establishing the “medical necessity” of surgical and endocrine services. This claim of necessity facilitated insurance payments, making physical transition affordable for some consumers. However, participants also argued that the GID and GID-C diagnoses: 1. Reinforce etic (expert) over emic (insider) representations of the transgender experience. The outsider representations emphasize distress over aspiration; identity over performance; and practitioner liability over consumer autonomy. These representations portray transgender people as mentally ill and as incompetent decision makers, in need of psychological and medical management and repair. 2. Legitimize professional practices of bullying gender/sex nonconforming children into compliance by recruiting their family members to enforce stereotypes. 3. Intensify prejudice against trans people, increasing the adoption of discriminatory policies and practices internationally. Furthermore, participants argued that appropriate, affordable, and high quality care can be provided to gender/sex nonconforming people even without a diagnosis. Indeed, this already occurs in some settings.

Interpretation: Analysis of these claims, in the context of the history of popular scientific and medical constructions of deviance from gender/sex norms, shows that sexology and psychiatry have been central in producing and regulating these norms. Specifically, diagnoses including Homosexuality, Disorders of Sexual Development (intersex conditions), and Transsexualism have been instrumental in defining the purportedly “natural” order and in defining and controlling deviance. The GID diagnosis reinforces, as if scientific, the erroneous binary narrative of normative gender/sex correspondences across development (from genetic sex, hormones, and morphology to identity, attraction, and role performance). Implications: This report raises questions about the ethical use of power by psychiatry in formulating expert knowledge which systematically marginalizes the voices of trans and queer people. It challenges professional psychiatry to increase transparency about the sociality of diagnostic constructions. The report also challenges activists to be wary of tactically useful discourses, lest they inadvertently participate in the circulation of problematic discourses to the detriment of the very classes of people they intend to support. Contact: michael@mpfeiffer.com

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