Amy Rodgers discusses the pathologising harm of a “gender dysphoria” diagnosis
In 1973, “homosexuality” was removed from the list of mental disorders in its Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association, essentially uncoupling being gay from being crazy. Same-sex desire was no longer a medical condition, but instead an identity or orientation. This move is now viewed as a key historical event that has helped the increasing acceptance of gay people in society. Similar steps must now be taken when it comes gender variation. At the moment, much of society views trans identities in a way that is comparable to how homosexuals were viewed pre-1970s. Being trans is considered to be something undesirable; something one is both burdened with and suffers from. This conception of being transgender is reflected in law and in medicine.
The current process to legally change your gender in Scotland is through the Gender Recognition Act 2004. It is a long and laborious process which involves intrusive and often humiliating psychological analysis. There are a number of hoops that applicants need to jump through to be granted the legal change they need and desire, one of which is the attainment of a diagnosis of “gender dysphoria” from two health professionals. Basically, trans people need to “prove” that they are an “authentic” trans person.
Gender dysphoria is a mental health diagnosis and it is associated with experiencing feelings of discomfort or distress because there is a mismatch between one’s biological sex and gender identity. The issue with this is that by requiring a gender dysphoria diagnosis, Scottish law is perpetuating the idea that having transgender desire makes someone mentally ill, and establishes trans wishes as abnormal and pathological.
To understand how this happens let us look closer at what the diagnosis actually asks for. The definition is not contained in the Gender Recognition Act itself but guidance on its meaning can be found in a few places. The medical practitioner who is responsible for diagnosing a trans individual will use either the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5) or the World Health Organisation’s International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), and further guidance can also be found on the NHS website. Suffering is clearly a core aspect of gender dysphoria; the words “distress” and “discomfort” are used in both the DSM manual and the NHS definition of the condition. The use of these words strips trans people of any autonomy over their identification and makes the identification itself something that is undesirable and in need of authentication.
The Act uses the phrase “gender dysphoria”, as opposed to “gender identity disorder” (which is how it was previously defined in the DSM-II up until 2013), and so in some respect, the change in language is an improvement. But the use of a mental health diagnosis (whatever the exact wording) still positions being trans as something that is in need of treatment to alleviate the psychological suffering. The result: those who identify as a member of the sex other than the sex they were assigned at birth are not considered to natural gender variance but rather abnormal gender variance. Evidence of the abnormality or pathology that society attaches to any sort of gender or sex variation is clear when you look at the statistics: Stonewall found that two in five trans people have experienced a hate crime or incident because of their gender identity in the last 12 months. And sadly, this stigmatisation is often internalised; self harm, suicide rates and poor mental health are prevalent among trans folk, especially young people. To be clear, it isn't being gay or trans that puts kids at risk of suicide, but the hostility of society.
A gender dysphoria diagnosis identifies trans desire as a problem that is in the mind or the body of the trans person, instead of in the way society has constructed what it means to be “normal” and “healthy”. To put it another way, “gender dysphoria” puts the responsibility on trans people for their suffering, and not on the moral and social environment that stigmatises and pathologises them. Treating gender variation as a deviation from the norm helps the gender binary (the idea that there are only two sexes) maintain its position of prominence in society (just as the historical positioning of homosexuality as abnormal allowed heterosexuality to be seen as the natural default). When faced with the reality of trans people, many cis people react with suspicion, ridicule or hostility. Why? People are heavily invested in the idea of gender and sex as stable binary concepts. Not to mention the inherent gendered privilege that many people are not ready to give up. But the supposed natural gender and sex binary has been proven to be a lie on both a social and biological level. And importantly, it is harmful to everyone. It is in everyone’s best interests - trans or cis - to dismantle it.
At the moment, the diagnosis currently facilitates access to healthcare for trans people under the NHS. Steps will need to be taken to rearrange the healthcare system before the diagnosis route is eliminated, to ensure that people are still able to get the treatment they need and desire. But there is no reason that trans-specific health care should require a diagnosis. Having a disease or a mental disorder is not a necessary condition of being afforded health care. Seeing gender variation as a problematic disease strips people of agency and power over their bodies, minds and lives. We need to move beyond a disease model. A similar trend is happening in the way we look at addiction, with psychologists and neuroscientists challenging whether the disease model is in fact helpful for addicts.
We have (thankfully and wisely) moved on from thinking about sexual attraction in binary terms and now recognise that there are many overlapping and fluid types of sexuality, all of which are normal and positive variations of human sexuality. It is time to do the same for gender and sex.
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