B.C. on Gender: Medicine and Transgender Politics

The Greatest Cure Ever!

From the time that DSM-II was published in 1968 until 1973, it listed homosexuality as one of the "sexual deviations." During 1973 the Nomenclature Committe of the American Psychiatric Association, under pressure from many professionals, and particularly from gay activist groups, recommended to the general membership the elimination of the category homosexuality [...]. The membership of the psychiatric association voted on the issue, in itself a comment on the conduct of science in the twentieth century. The change was approved, but not without vehement protests from a number of renowned psychiatrists who had for some time been identified with the traditional view that homosexuality reflects a fixation at an early stage of psychosexual development and is inherently abnormal.1

I wonder what it must have been like to have been a homosexual in the early seventies, regularly seeing a psychiatrist for years, only to be told, in 1973, that a vote had been taken, and that you were now normal. Speaking for myself, I'd be a little pissed off.

Actually, I am in an analagous situation, because as a transgendered person, I suffer from a "mental disorder", although no psychiatrist has ever diagnosed me. But after several years of reading about gender theory, I've come to the conclusion that modern psychiatry is wrong. I am not mentally ill; I am just different. I'm patiently awaiting the time when the American Psychiatric Association votes on me...

The Role of Medicine

Ekins and King suggest that "[i]n contemporary industrial societies, the institution of medicine has assumed or been given the task of maintaining" the 'reality' imagined by our normative senses.2 But in granting the medical community the authority to enforce a constructed reality, we have failed to question the validity of that reality.

By way of explanation, let me recount a story. Laura Masters, a Canadian TG once alleged to have called the office of Dr. John Money, whose early work on sex and gender heavily influenced medical perspectives of transgenderism. Laura allegedly said (I'm paraphrasing): "Dr. Money, how did you know that transsexualism was a disorder?" To which she was answered, "What else could it be?"

What else, indeed.

In the extreme, medical treatment of transgendered people requires absolute conformance to normative notions of gender. Catherine Millot, influenced by Janice Raymond, points out that part of the processes for handling M2F transsexuals includes evaluation of the patient in terms of compliance to gender-role norms:

the doctors, psychiatrists, endocrinologists and surgeons [...] gauge feminity in terms of the conformity of roles. [... T]hey construct scales of femininity, and measure [transsexuals] with batteries of tests. Permission to undergo sex-change surgery is contingent on the results of these tests, which also enable transsexuals to train for their future role, in accordance with the tried and tested methods behaviourism, which subjects them to a real conditioning process.3

What Millot suggests goes beyond normative senses being applied to TGs -- in fact, the tests of femininity can theoretically be applied to genetic females. The fundamental question that must be asked is this: "do these tests measure a 'natural' notion of femaleness?" For Millot and Raymond, the answer is "no". Drawing upon feminist critique, they argue that the measurable qualities of femaleness are nominal at best, and at worst they are "a purely masculine artefact, a typical male phantasy."4 Thus, they feel, medicine's ability to evaluate a TGs level of integration into the desired gender role is strictly nominal.

Millot, and Raymond especially, go on to argue against the legitamacy of transsexualism, using primarily essentialist arguments, and in those debates, I do not agree with their opinions (I'll talk about Janice Raymond more, later), but I think their implication of the institution of medicine in the perpetuation of societal norms is very interesting.

Depathologization of Transgenderism

I, personally, would like to see transgenderism removed from the domain of psychiatry, as homosexuality was in 1973. This is a very hot topic in TG circles, for many reasons, not the least of which is the fact that if transsexualism is depathologized, then major insurance companies would not have to reimburse the (high) cost of sex-reassignment surgery.

From the Horse's Mouth

I was recently interviewed as part of a Ph.D. thesis. Darryl, the interviewer, brought up the topic of medicine and transgenderism, and the following discussion took place between us:

DARRYL: There's a debate in some literature about whether or not transgenderedness should be a psychiatric disorder.

B.C.: Yeah, that's a very interesting debate.

DARRYL: It's coming up in some of my interviews

B.C.: [laughs]. Um, I'm... I really have a lot of questions about this. [...] I personally don't think that gender difference is a mental disorder. And I think that it would be a really good idea to stop trying to consider it a disorder and as something that needs to be fixed. You shouldn't have to fix somebody. But at the same time I also recognize that there are a lot of people for whom the fact that they are different causes them a great deal of distress, you know? And if I really believe that things like the medical requirements for the real life test and stuff like that provided some sort of social support framework for people, then, you know, whether or not it's really an illness or something that needs to be fixed is irrelevent. I think there are people -- people that I've met -- who really need to have some kind of support framework because they are very confused about what they are and their own gender identities and whatever. [Transgendered] people can say with some certainty, "I am a man...", or "I am a woman whatever my body happens to be", and I'm not saying that that's a confused idea. What the majority of people is saying [to TGs] puts them into a position where they're constantly doubting themselves. And part of me kind of says, you know, we should have a social institution (now maybe it's psychiatry, maybe it's psychology, or maybe it's medicine) that supports and helps these people perhaps by asking them interesting questions, asking them this all means to them, and perhaps even, you know, playing out a whole list of possibilities for them. But I think that the way transgenderism has been codified into the medical world is really limited. Like they're just [saying] "Let's make this person's body congruent with their gender".

DARRYL: Or if they're a kid, a child, and they're messing about with gender roles... they're fucked and let's get them going in the right direction.

B.C.: That's right. That's right. It's that whole tendancy not to ask questions but to provide answers that bugs me about the whole medical perspective on transgenderism. I mean it just irks the pants off me. It's unreal. [...]

DARRYL: [...] Part of what I'm doing, or part of what I hope to do with my research is to challenge what's going on in my profession. And some of the assumptions being made in my profession. And I'm sincere about that. I have no desire to further pathologize or characterize transgendered people in any negative light unless they are telling me that they're really messed up by this, and then that's sincere, but I think that's a different issue. I think, as you put it, you can't automatically assume just because somebody has a gender that is different from their biological sex, that they are going to be messed up or have any psychological problems, or that is in fact the psychological problem.


B.C.: Right, you know, people get themselves screwed up by things that are completely normal. It's just their reaction to them, or, the fact that their reaction is formed by a whole bunch of other crap in their lives.

DARRYL: Sure. People get really messed up by love relationships.

B.C.: Yup. That's an excellent example.

DARRYL: So messed up that they go around killing other people, just completely freaked out [...] but we don't say that falling in love is a pathological condition.5

Standards of Care and the Real Life Test

Transsexuality is the only condition for which the therapy is to lie.6

IMO, very few people live through transgendered teenager-hood without some really big emotional hang-ups, and the institution of psychiatry should be able to aid these people. But, as I made clear, above, the condition that should be treated is not Gender Dysphoria, but rather something comparable to "Transgender Anxiety" or "Ego-Dystonic Transgenderism"7 What remains questionable is whether or not certain processes such as Harry Benjamin's Standards of Care and/or the Real Life Test (RLT) should be part of the psychiatric treatment of these new treatments.

The Bejamin Standards of Care were set in place because hormone therapy causes major changes to the body, and further, SRS is an irreversible operation. Further, as Benjamin states:

Principle 3: Published and unpublished case histories are known in which the decision to undergo hormonal and surgical sex reassignment was, after the fact, regretted, and the final result of such procedures proved to be psychologically dehabilitating to the patient.8

As a consequence, Benjamin made the following statement:

Standard 1: Hormonal and/or surgical sex reassignment on demand (ie. justified simply because the patient has requested such procedures) is contraindicated. It is herein declared to be professionally improper to conduct, offer, administer, or perform hormonal sex reassignment and/or surgical sex reassignment without careful evaluation of the patient's reasons for requesting such services and evaluation of the beliefs and attitudes upon which such reasons are based.9

As a consequence, Bejamin recommended that the candidate for surgery literally live in the "other" gender role for a period of one year. This is known in TS circles as the Real Life Test (RLT). In Ontario, the Gender Identity Clinic of the Clarke Institute of Psychiatry requires the patient is expected to

live in society in the chosen gender role. This includes full-time employment, student status, or job retraining, and altering identification [...] After a full year in the cross-gender role, patients are re-evaluated and if progress has been made and the individual is emotionally stable, he or she is placed on the appropriate hormone therapy. [...] After a minimun of two years in the cross-gender role, patients are re-evaluated for possible surgical sex-reassignment [...].10

Thus, a pre-operative transsexual is expected to carry out a job in an "opposite" gender role for one full year without even the benefit of hormone therapy. As might reasonably be expected, the transition can "expose sex-change candidates to the high likelihood of reprisals from co-workers and, in many cases, from employers."11 Additionally, this type of requirement is unique amongst medical procedures; no other medical procedure require behaviour comparable to the real life test. Is transsexualism really so special as to deserve such a recipe for treatment?


1 Gerald C. Davidson and John M. Neale, Abnormal Psychology (4th Edition) John Wiley & Sons, 1982. p. 309.

2 Richard Ekins and David King, Body Guards, p. 75.

3 Catherine Millot, Horsexe, p. 14

4 ibid, p. 15.

5 Interview with Darryl Hill. I have editted the comments, removing annoying "uhms" and false starts to some sentences.

6 Kate Bornstein. Gender Outlaw. p.62.

7 In DSM III, the classification of homosexuality was removed, and replaced with a condition called Ego-Dystonic Homosexuality. This condition refers to a homosexual person who finds their sexuality to be a source of distress and wishes to become heterosexual.

8 Harry Benjamin, The Standards of Care for Transsexuals, 1979.

9 ibid.

10 "Gender Identity Clinic", a pamplet from the Clarke Institute of Psychiatry, as cited in "Extended Informed Consent" by Laura Masters.

11 Laura Masters. "Extended Informed Consent".

Copyright © 1996 by B.C. Holmes. Last updated December 30th, 1996
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