sign in sign up
<<
Home , Gender dysphoria, Sex change

UNIVERSITY OF HAWAI‘I AT HILO ◆ HOHONU 2020 ◆ VOL. 18

The Limitations of will express themselves by going back and forth : between the , expressing neither gender Examining the Language or being androgynous. While the trans commu- and Purpose of the DSM-5 nity has become more visible in recent years, they have also faced backlash. The backlash toward the Diagnosis community functions to maintain the Marisa Cortez validity of the (male/boy/ and 324 /girl/) as the main discourse of gen- der identity. The transgender community is both Abstract - “Transgender” is an umbrella term that encom- tion for invalidating their trans identity. Is gender passes the expression of gender- nonconformity in dysphoria in the DSM-5 a necessary diagnosis? I a variety of ways. While the trans community has intend to answer this question by examining the become more visible in recent years, they have also language of the criteria in the DSM-5 as well as faced backlash. The backlash toward the transgen- the purpose of the diagnosis of . der community functions to maintain the validity Gender Dysphoria in Theory of the gender binary (male/boy/man and female/ Gender dysphoria, previously named gender girl/woman) as the main discourse of gender iden- identity disorder, “refers to the distress that may tity. The transgender community is both patholo- accompany the incongruence between one’s ex- perienced or expressed gender and one’s assigned invalidating their trans identity. I argue that gender gender” (American Psychiatric Association, 2013, dysphoria should not be a diagnosis in the DSM-5 p. 451). The term gender dysphoria, as opposed to due to its limiting language and the reliance on it disorder (of the DSM-IV), focuses for access to transgender care in medical and le- on the distress and unease of the individual, rather - than focusing on the identity as disordered and eliminating the “pathologizing effects of the GID - diagnosis” (Davy & Toze, 2018, p. 160). Although tations and discrimination. the name change emphasizes the distress, the crite- Cis-gender is the term for a person whose ria continue to focus on the identity of the individ- birth-, labeled as male or female via the geni- ual. There are several criteria for distinguishing the talia, corresponds to their outward expression of incongruence of experienced and assigned gender boy/man or girl/woman, respectively. For those yet very little emphasis on the distress. Under the whose outward does not cor- “Diagnostic Features,” the DSM-5 states that the relate to birth-sex, there is the term transgender. marked incongruence “is the core component of Transgender is an umbrella term that encompasses the diagnosis” (American Psychiatric Association, the expression of gender- nonconformity in a vari- 2013, p. 453). Due to the language used in the ety of ways. There are varying degrees of outward DSM-5, it is unclear whether the discrepancy is expression. For example, a or woman socially based or biologically based. If the basis of may dress and behave as a gender not correlat- the diagnosis is social, then the diagnosis may not ing to their birth sex full-time and wholly identify be necessary. as that gender. Some may even take or The DSM-5 have surgery done to transform their birth-sex to pertain to sex and gender in order to make distinc- match their outward expression. There are also tions within the criteria for being gender dysphoric. people who identify as queens/kings (a label - under the transgender umbrella) who may only der, gender-assignment/natal gender, and gender express the gender that does not correlate to their - birth-sex part-time during performances or events. the DSM-5 clearly separates sex and gender: “Sex

41 UNIVERSITY OF HAWAI‘I AT HILO ◆ HOHONU 2020 ◆ VOL. 18 and sexual refers to the biological indicators of criteria, it is necessary to question the purpose of male and female (understood in the context of re- the diagnosis. productive capacity), such as in sex , Gender Dysphoria in Practice , sex hormones, and nonambiguous internal Transitioning is a process that many transgen- and external genitalia[...]gender is used to denote der individuals choose to undergo. The process in- the public (and usually legally recognized) lived volves social, medical, and/or legal changes that role as boy or girl, man or woman, but, in contrast allow the individual to express their desired gender to certain social constructionist theories, biologi- through clothing/accessories, hair, makeup, pro- cal factors are seen as contributing, in interaction noun usage, therapy, surgery, legal name with social and psychological factors, to gender - development” (American Psychiatric Association, cates and driver’s licenses. Compared to social 2013, p. 451). Sex indicates biology and uses the changes in outward appearance, medical and legal labels of male and female. Gender indicates so- changes are much more complex. Not only do the cial identity and uses the labels boy/man and girl/ changes involve accompanied social consequenc- woman. In order to connect sex and gender, the es, but they also involve navigating the medical DSM-5 introduces the term “gender-assignment” which “refers to the initial assignment as male or and regulations. Often times, stigmatizing prac- female. This usually occurs at birth and, thereby, tices are involved when having to navigate these yields the ‘natal gender’”(American Psychiatric systems. Association, 2013, p. 451). The term “gender-as- In order to access medical and legal services, transgender persons must be diagnosed with gen- sex, making the incongruence an issue of outward der dysphoria. As per the previous section of this expression and/or sex characteristics. This is not paper, the diagnosis of gender dysphoria is ambig- only apparent in the terminology, but in the crite- uous and limiting. The diagnosis can be given via ria of the diagnosis as well. The criteria required social and/or biological criteria, and it is written of children and adolescents/adults indicate that in binary terms of typically masculine and femi- one may have incongruence with primary and/or nine expressions of gender that limits transgender secondary sex characteristics, but it is not required people who want to transition yet do not express in order to be diagnosed as gender dysphoric, the themselves in terms of the gender binary. The use incongruence may only be in outward expression. of this diagnosis to grant access to gender transi- The incongruence and distress are necessary tion services has been widely criticized as being a ‘gatekeeping’ model, where the locus of power and gender, the source of the distress is unclear. lies with practitioners to make treatment decisions The DSM-5 states that distress must be clinically on behalf of transgender clients, often based on assumptions about gender that do not always ap- social functioning. The source of distress could be ply to the lived experience of transgender persons biologically or socially based. The source of the (Schulz, 2017, p. 72). distress can be from having the “wrong” genitalia, Not only is the diagnosis limiting in terms of which would indicate a basis in biology and the the binary, but it also operates under a distress nar- possible need for surgical or hormonal interven- rative. Though it is questionable whether the dis- tion. However, the distress can emerge from want- tress is a matter of an internal struggle or an exter- ing to express a gender other than the assigned nal one, the diagnosis assumes that one must be gender, rejection by family and friends, being so- distressed to want to make changes to themselves cially outcasted, or not being able to express the or that one who is not in distress must not want preferred gender. Each of these instances would or need to make changes to their body. According indicate a social basis that, short term, need inter- to two different studies that were consistent with vention at the psychological level and long-term, prior research, people in the transgender commu- signify the need for major societal changes regard- nity face discrimination that lead to self-harming ing sex and gender. Due to the ambiguity of the

42 UNIVERSITY OF HAWAI‘I AT HILO ◆ HOHONU 2020 ◆ VOL. 18

“The Social Costs of Gender Nonconformity for Transgender Adults,” stated that “consistent with - prior research, transgender people who face more er’s licenses] were proof of [sex reassignment sur- everyday and major discrimination are more likely gery] as well as letters from surgical and medical to engage in health-harming behaviors (i.e., at- aurtorities[...] These were privileged over other tempted suicide, drug/alcohol abuse, and smok- evidence of gender/sex transition, including letters ing)”; consequently, “gender nonconformity may from psychologists or therapists, documentation heighten trans people’s exposure to discrimina- of hormone therapy, or that the person was living tion and health-harming behaviors” (Miller & full-time as the requested gender/sex” (van Anders, Grollman, 2015, pp. 825-6). According to the study Caverly, & Johns, 2014, p. 178). Privileging sur- titled, “Suicidal Thoughts and Behaviors Among gery over other forms of gender expression puts up Transgender Adults in Relation to Education, barriers for those who do not wish to have surgery - yet wish to legally change their gender/sex, or for age rate of 46.55% lifetime and those who cannot get surgery due to ineligibility 27.19% attempts among transgender participants for the diagnosis of gender dysphoria. “The very are similar to those found in the author’s previ- existence of the diagnoses for trans individuals in ous study (56% ideation, 29% attempts) [...] The the Diagnostic and Statistical Manual [...] under- preponderance of evidence suggests that high scores the pathologization trans individuals face rates of [suicidal thoughts and behaviors] rather and how gender operates not merely to categorize, than being inherent to transgender individuals, but to regulate”(Funk, Funk, & Blaise Whelan, results from barriers to transitional care, stigma, 2019, p. 120). and discrimination” (Adams & Vincent, 2019, pp. Conclusion 237-8). While transgender people are more likely Due to the limiting language of the diagnosis to face discrimination due to their gender expres- and the reliance on it for access to transgender care in medical and legal services, gender dyspho- distress caused by external sources), it is possible ria should not be a diagnosis in the DSM-5. It cre- - teria of the DSM-5 to get the medical care that they wish to receive. without facing limitations and discrimination. For those unable to receive medical care, a large Rather, major changes to large societal institu- majority are unable to receive legal services in re- tions and general attitudes towards transgender gard to legal , depending on the state in people must take place in order for trans people to which they live. In the article, “Newborn Bio/logics be properly cared for and have the ability to func- and US Legal Requirements for Changing Gender/ tion healthily. “Transgender” is an umbrella term Sex Designations on State Identity Documents,” that encompasses a wide variety of gender expres- the authors’ goal was “to examine how gender and sions. It is possible proof of the variety of the hu- man condition that should be celebrated rather requirements about changing gender/sex on state- than suppressed. issued identity documents” (Van Anders, Caverly, & Johns, 2014, p. 173). The researchers exam- ined the requirements of the state governments to driver’s licenses. They gathered information from the state governments of the 50 federally recog- nized U.S. states plus Washington DC and New York City (New York City of which had its own - lected via agency websites, direct contact via tele- phone, and written policies. The researchers found

43 UNIVERSITY OF HAWAI‘I AT HILO ◆ HOHONU 2020 ◆ VOL. 18

References Adams, N. J., & Vincent, B. (2019). Suicidal Thoughts and Behaviors Among Transgender Adults in Relation to Education, Ethnicity, and Income: A Systematic Review. Transgender Health, 4(1), 226–246. doi: 10.1089/trgh.2019.0009 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Davy, Z., & Toze, M. (2018). What Is Gender Dysphoria? A Critical Systematic Narrative Review. Transgender Health, 3(1), 159–169. doi: 10.1089/trgh.2018.0014 Funk, J., Funk, S., & Blaise Whelan, S. (2019). Trans* and Representation and Pathologization: An Interdisciplinary Argument for Increased Medical Privacy. Berkley Journal of Gender, Law & Justice, 34(117). doi: 10.15779/Z380C4SK4F Miller, L. R., & Grollman, E. A. (2015). The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health. Sociological Forum, 30(3), 809–831. doi: 10.1111/socf.12193 Schulz, S. L. (2017). The Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. Journal of Humanistic Psychology, 58(1), 72–92. doi: 10.1177/0022167817745217 Van Anders, S. M., Caverly, N. L., & Johns, M. M. (2014). Newborn Bio/logics and US Legal Requirements for Changing Gender/Sex Designations on State Identity Documents. Feminism & Psychology, 24(2), 172–192. doi: 10.1177/0959353514526222

44