Psychology and Gender Dysphoria

Feminist and Transgender Perspectives

Jemma Tosh

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317745990
• Edition: 1
• Topic: Psychology
• Subtopic: Social Psychology
• Index: Psychology

Psychiatry and psychology have a long and highly debated history in relation to gender. In particular, they have attracted criticism for policing the boundaries of 'normal' gender expression through gender identity diagnoses, such as transvestism, transsexualism, gender identity disorder and gender dysphoria.

Drawing on discursive psychology, this book traces the historical development of psychiatric constructions of 'normal' and 'abnormal' gender expression. It contextualizes the recent reconstruction of gender in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its criteria for gender dysphoria. This latest diagnosis illustrates the continued disagreement and debate within the profession surrounding gender identity as 'disordered'. It also provides an opportunity to reflect on the conflicted history between feminist and transgender communities in the changing context of a more trans-positive feminism, and the implications of these diagnoses for these distinct but linked communities.

Psychology and Gender Dysphoria examines debates and controversies surrounding psychiatric diagnoses and theories related to gender and gender nonconformity by exploring recent research, examples of collaborative perspectives, and existing feminist and trans texts. As such, the book is relevant for postgraduate and postdoctoral researchers of gender, feminism, and critical psychology as well as historical issues within psychiatry.

Chapter 1

Introduction

Gender Dysphoria . . . a marked incongruence between one’s experienced/expressed gender and assigned gender.

(American Psychiatric Association [APA], 2013, p. 452)

The definition of gender dysphoria provided by the American Psychiatric Association is from the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is a diagnosis that can be applied to those who do not conform to Western gender ‘norms’ (see Chapter 3). Currently in its fifth edition, the DSM is meant to represent a consensus of diagnostic terms and criteria for psychology and psychiatry to use for clinical and research purposes. It provides a universal language for those working in therapeutic contexts to describe and diagnose people experiencing emotional distress. To ascertain what kind of distress, professionals need only consult this comprehensive ‘Bible’ of psychiatry (Kutchins & Kirk, 2003), to see which term best describes the presenting ‘symptoms’. However, the DSM has also represented an intersection of competing perspectives, being the target of much criticism since its inception in 1952 (Boyle, 2007; Caplan, 1996; Cooper, 2004; Crowe, 2000; Frances, 2013; Gornall, 2013; Kutchins & Kirk, 2003; Wakefield, 1997; Zur & Nordmarken, 2008). This has been in relation to its conceptualization of homosexuality, bisexuality, asexuality, gender identity, femininity, hearing voices and ‘race’ (Barker, 2007; Conrad & Angell, 2004; Kim, 2014; Phoenix, 1994; Sedgwick, 1991; Ussher, 2011; Winters, 2009; Wise, 2004), to name a few examples.

Psychiatry and psychology, then, are highly contested areas. They define ‘normality’ and label all that fall outside of this narrowly assigned category as ‘mentally ill’. The diagnosis of gender dysphoria is no exception. It is a contentious concept as those who try to define and diagnose come up against counter-narratives and concepts based on lived experience, activism and research focused on social justice (Ansara & Hegarty, 2012; Hill, 2012; Meyer & Sansfacon, 2014; Tosh, 2011c; Winters, 2009). Debates regarding gender have an equally conflicted history within feminist and transgender studies (see Chapters 4 and 5) that often run parallel to psychological and psychiatric perspectives. Consequently, the diagnosis of gender dysphoria is at a cataclysm of numerous debates and disagreements – it is at the epicentre of long-standing arguments originating from many different directions. The purpose of this book is to navigate this complex terrain, to examine the tensions between and within these discourses, and consider how these relate to lived experiences of an embodied gender-related distress.

The tendency to focus on abstract concepts means that the very people being talked about can be left behind in these debates (Hill, 2012; Namaste, 2000). Often considered an opportunity to develop gender theory, or a new population for study, the high rates of suicide attempts, hate crime, murder and rape of gender nonconforming people (Clements-Nolle, Marx, & Katz, 2006; Goldblum et al., 2012; Grant et al., 2010; Jauk, 2013; Lee & Kwan, 2014; Stotzer, 2008; Turner, Whittle, & Combs, 2009) fall to the side while psychiatrists debate which treatment is best for ‘the prevention of transsexualism’ (Zucker et al., 2012) and some feminists argue whether it is safe to use public toilets (e.g. Jeffreys, 2014). More time is spent talking about gender nonconformists as being a threat, than talking about the threats they face from a society that positions conformity as the ‘norm’. Responses to the perceived threat of gender nonconformity have included online and offline harassment, the deliberate ‘outing’ of trans people, which puts them at risk of violence, discrimination and suicide (Molloy, 2014; Moore, 2014), and the promotion of legislation that stops access to medical and social services (Stryker, 2009). Moreover, this sole focus on the pathologization and victimization of trans people can overlook their celebration, success and happiness. From protests and petitions, to threats of violence, the debates regarding gender dysphoria have well surpassed academic discussion (Tosh, 2011a, 2011c; Woolbert, 2014).

With this volatile context in mind, I will describe the role psychology and psychiatry have played in defining gender ‘normality’ and ‘abnormality’, as well as the responses and challenges posed by those more likely to be positioned in the latter category: women (cisgender and transgender) and those with gender identities and bodies that exist outside of the binaries of man/woman, male/female. I do this with an appreciation of the historical and changing contexts in which these perspectives occurred. I echo the aim of many who have positioned the ‘psy’ disciplines as the subject of study and analysis (Foucault, 1975; Rose, 1979). I provide a genealogical tracing as well as a critical questioning of present assumptions and misconceptions (Pilgrim, 1990). I show how long-standing problems within the psy professions impact on present discourses and experiences.

This can be a challenging endeavour, particularly if histories contradict current understandings of psychology and gender:

Revelations about Jung’s ‘collaboration’ with the Nazis (Masson, 1993) or Burt’s invented data, or the psychologist Cattell’s frank espousal of eugenic beliefs can be profoundly unsettling to psychotherapists and psychologists who have based their own careers, in good faith, on the work of these early pioneers.

(Newnes, 1999, p. 21)

The same can be said for feminism, where individuals join a movement with ambitions of contributing to social change, challenging oppression, helping women and ending sexism. It can be difficult to acknowledge the limitations of previous work that has had such positive implications for feminism in some areas, or of oppression perpetuated by some feminists, especially if one has been complicit in such actions on the assumption that it was for ‘the right reasons’.

Therefore, rather than outline a ‘traditional’ history that conveys psychology and psychiatry as progressing through its development of ‘science’ to its modern place of ‘expertise’, I provide a brief overview of how psychology and psychiatry have constructed, categorized and medicalized human experience and simultaneously positioned that knowledge as authoritative and ‘truth’ (Foucault, 1975; Scull, 1982; Shorter, 1998). I also highlight the role of violence, oppression and coercion in ‘treatment’ approaches, as this element is often lacking in historical accounts that convey psychology and psychiatry as ‘science’ (Szasz, 2007), and is key when looking at how different forms of oppression intersect.

Psychiatric classification

When someone experiences emotional distress, they may come into contact with a wide range of professionals, including psychologists, psychiatrists, psychoanalysts, psychotherapists and so on. There are many sub-disciplines within psychology and psychiatry, each emphasizing a different perspective on ‘mental illness’; from neuropsychology (the study of brain and behaviour) to parapsychology (the study of human experience and the paranormal), the possibilities for the study of human experience are vast. Psychology draws on sociology, philosophy, queer theory, business, history, education, feminism, animal behaviour, medicine and many more (Ayers & Visser, 2010; Brown & Stenner, 2009; Burman, 1997a; Clarke & Peel, 2007; Dickins & Donovan, 2012; Goto & Martin, 2009; Kaila, 2006; Kaluger, 1969; McInerney, 2013; Rogelberg, 2009; Suls, Davidson, & Kaplan, 2010). Despite this eclectic maze of (inter/dis)connected disciplines, medical and biological approaches to human experience and distress predominate. A wealth of criticism targeting the medical model of ‘mental illness’ and ‘mental health’ (Bentall, 2009; Boyle, 2007; Burstow, LeFrançois, & Diamond, 2014; Conrad, 1992; LeFrançois, Menzies, & Reaume, 2013; Mills, 2014; Newnes, Holmes, & Dunn, 1999; Rose, 2009; Szasz, 1960) has failed to bring an end to the dominance of medical diagnosis (Pilgrim, 2007).

Medical categorizations of human behaviour may seem necessary and enduring, but they are only one way that we have framed human diversity. Madness has been linked to the physical body since the classical period of ancient Greece (500–336 BC, Blundell, 1995) (Bentall, 2009), such as hysteria’s initial conceptualization as a ‘wandering womb’ (Wetzel, 1991). However, in the global North, the care of those considered ‘mad’ was within the realm of the layperson prior to the introduction of medical asylums (Boyle, 1990), the Church when people were thought to be possessed by a demon (Szasz, 2007), and law enforcement if their behaviour was framed as illegal (particularly in the case of criminalized sexualities, such as homosexuality) (Bullough, 1982; Robb, 2003). By the end of the seventeenth century, ‘trade in lunacy’ was ‘a flourishing new industry’ (Szasz, 2007) and a symptom-based classification system of madness was later introduced in the 18th century following similar moves in botany. François Boissier de Sauvages’s (1732, 1763) Nouvelles Classes de Maladies de Maladies dans un Ordre Semblable a Celui des Botanistes and Nosologie Méthodique listed ‘mental illnesses’ as ‘folies’, and was credited by William Cullen (1785) as the first successful attempt at the systematic classification of disease.¹ Vogel (1764) added to this with the publication of Definitiones Generum Morborum and Cullen (1784, 1785) produced a category of ‘neuroses’ that included ‘mania’ and ‘melancholia’ (Bynum, 1981). The last of these 18th-century ‘landmark works’ (Munsche & Whitaker, 2012) was Philippe Pinel’s Memoir of Madness published in 1794, outlining an argument for the need for humane treatment and asylums (Weiner, 1992).

However, it was not until the mid-19th century that psychiatry developed as a medical specialism (Bentall, 2009), due to the influence of Kraepelin’s (1883) empiricist approach to classification that continues to define the profession today (Pilgrim, 2007). Kraepelin (1883) produced Compendium der Psychiatrie, credited as including the first conceptualization of ‘dementia praecox’, meaning ‘senility of the young’ (Bentall, 2009) and later renamed ‘schizophrenia’ by Bleuler (1911).² Kraepelin’s influence was greater than the introduction of a new psychiatric category; he also promoted the theory that all mental ‘illnesses’ were a result of degeneracy – a biological inheritance of ‘abnormality’.

While research continues to look for evidence of the connection between genetics and ‘mental illness’ (Andreassen, Thompson & Dale, 2014; Flint & Kendler, 2014), the profession has admitted it has been unable to identify biologically based indicators related to the development of emotional distress, or ‘mental illness’ (Kupfer, 2013). Even so, the underlying medical naturalism of the approach remains influential. It assumes ‘that current medical terminology describing mental abnormality is valid and has global and trans-historical applicability’ (Pilgrim, 2007, p. 359). This is instead of the many different ways that unusual experiences, hearing voices and emotional distress can be understood from diverse perspectives from within and outside of psychology, and as a result, the very different possibilities for alleviating distress (Cromby, Harper & Reavey, 2007; Scott, 1997). An unfortunate consequence of the predominance of biomedical models of emotional distress is that it can often be assumed that for someone’s suffering to be considered ‘real’, it needs to have a biological basis. Those who research violence and abuse know this to be untrue.

During the early 20th century, organizations began collecting and analysing statistical data regarding the categories that had been produced earlier. The first edition of the International List of Causes of Death was initially published by the International Statistical Institute (1900), and was based on the work of a committee led by Jacques Bertillon and the earlier Bertillon Classifications of Causes of Death (American Public Health Association, 1899). Both included ‘insanity’ as a cause of death, with the latter listing a range of conditions under ‘mental alienation’ from the very familiar (e.g. ‘homesickness’ and ‘nostalgia’), to the long-standing and well-known (e.g. ‘melancholia’, ‘nymphomania’, ‘m...

Table of contents

• Cover Page
• Psychology and Gender Dysphoria
• Title
• Copyright
• Dedication
• Praise
• Contents
• Acknowledgements
• 1 Introduction
• 2 Psychiatric Constructions of Women and Femininity
• 3 Psychiatric Constructions of Transgender Identities and Gender Nonconformity
• 4 Feminist Constructions of Gender Dysphoria and Transgender People
• 5 Transgender Constructions of Psychiatry and Feminism
• 6 Conclusions
• Index