Want Your Rights? Take Off Your Pants

This article will focus on the two areas of reform.  The first is the diagnostic category of "Gender Identity Disorder" (GID), which includes a broad array of gender variant adults and children who may or may not be transsexual and may or may not be distressed or impaired. GID literally implies a "disordered" gender identity.  The second troublesome category of diagnosis is "Transvestic Fetishism" (TF), which labels cross-dressing by heterosexual males as a sexual fetish and paraphilia.

As transgender activist Leslie Feinburg wrote: "Gender is self expression, not anatomy." Sex is being taken from biological science and placed into a social science context as gender. Why are we still stuck in medical medieval times?  The very misleading term of "Gender Identity Disorder," implies that questioning your own gender identity is disordered or deficient.  Are men who wear a dress mentally ill?  Current definitions of sickness encourage gender-conversion therapies, intended to change or shame one's gender identity or expression.

Medical practitioners, historically and today, tend to enforce rigid gender roles.  As Dr. Barbara Hammond notes, "At the heart of the current medical policy is a presumption of gender essentialism, perpetuating the doctrine of two sexes, immutable, and determined by genitalia. The growing body of literature that considers gender a social construction, not a biological imperative has been inexplicably disregarded."

Transgenderism and cross-dressing are not new cultural developments.  The history and celebration of multiple gender identities can be seen in the inclusive of two spirited people in native cultures, the Hijras of India, the ­tranvesti of Brazil.  The DSM focus of pathology based on the nonconformity to assigned birth sex is in complete disregard to the definition of mental disorder, which comprises of distress and impairment.

Many transgender advocates and care providers hope for the inclusion of clinical approaches described by Dr. Diane Ehrensaft, "If we allow people to unfold and give them the freedom to be who they really are, we engender health. And if we try and constrict it, or bend the twig, we engender poor mental health."  The current diagnostic categories of Gender Identity Disorder and Transvestic Fetishism have long raised concern within the transgender community. Those who are distressed by their physical sex characteristics or ascribed social gender roles need diagnostic tools that support the legitimacy of transition and access to medically necessary treatment. The DSM should not be a cultural weapon that imposes the stigma of mental illness or sexual deviance on femininity, masculinity or gender diversity. The language should respect the gender identity and expression of gender variant children, adolescents and adults. 

Medicine and the law are entwined in the case of gender.  The ability to self identify your own gender is extremely limited.  In Ontario, the government interpretation of the Vital Statistics Act requires a medical letter and sex reassignment surgery before allowing a change in the birth certificate. Government policies for other documentation vary across provinces, but there is a requirement of medical proof that the individual is transsexual rather than accept self-identification. There have even been reported instances of custody disputes where the transsexual parent was required to undergo medical assessment to confirm the person's gender identity.  It is astonishing that a transgendered person before the courts and under current laws must undergo a process of physical transformation to have the right to be themselves.

The legal 'medicalisation' of gender means that a transgendered person must receive 'official' recognition from a gender identity clinic, which is not always accessible, in order to receive appropriate service or treatment from the health care system and other organizations that they may come in contact with. The Ontario Human Rights Commission reports that often general practitioners lack the resources or expertise needed to provide services to transgendered patients. As a result, there are many transgendered individuals who self-medicate with hormone therapy, which subsequently puts their health at risk.  A large number of transsexuals in Ontario seek sex reassignment surgery but due to recent changes in government policy, and economic and medical barriers, they cannot access it. A growing number of people who are transgendered no longer consider sex reassignment surgery as a suitable option for them either due to cost, medical risks, medical barriers, or on principle.

The law and medicine then collude to make gender identity based on outside physical appearance. Our society's rigid bifurcated standards of sex and gender congruence are put into legalese.  There is an assumption that if you are a woman (for example) you must meet certain physical standards.  A person can get a nose job, breast implants, or facial sculpting without asking the permission of society, but sexual reassignment surgery requires rigorous 'proof' from the medical establishment.  Problems arise when the medical profession is responsible for all aspects of gender identification rather than allowing self-identification. When the tool for diagnosing gender identification is flawed then the legal system exacerbates the problem.  As the Ontario Human Rights Commission writes: "The law, in its enforcement and administration, allows for only a minimal capacity to self-declare as transgendered. Thus when dealing with official institutions (i.e. court system, corrections system) even if a person self identifies as transgendered they have no access to medical documentation to support their felt gender identity so that they can be dealt with in the appropriate manner."

There is a dangerous precedent set in giving medical caregivers this much power over legal personhood.  There is inherent inequity in transsexual psychotherapy -- a therapist serves as a gatekeeper to the availability of surgical or hormonal treatment and holds absolute power over a transgendered client. This undermines the therapeutic relationship, leaves the client with little motivation for honest expression, and creates a distorted view of transgenderism by psychiatric caregivers reflected in the current medical policy. The transgender community has expressed growing concern that the work group for Sexual and Gender Identity Disorders, in the DSM-V Task Force of the American Psychiatric Association, is not sufficiently representative of newer, respectful attitudes toward gender diversity that are widely held by practitioners who work with gender variant adults and youth today.

Joan of Arc

The category of Transvestic Fetishism does not acknowledge the existence of healthy, well-adjusted male-identified cross-dressers. Many have expressed concern that Transvestic Fetishism serves no constructive therapeutic purpose in the DSM. The inclusion is puzzling and brings to mind the transvestism of Joan of Arc, who was charged with this crime during the Inquisition.  Joan asserted "For nothing in the world will I swear not to arm myself and put on a man's dress." Joan of Arc was burned at the stake after once again donning male attire and telling the court that she preferred a man's dress to a woman's.  Court records show that Joan's male attire, so deeply rooted in pagan cross dressing and her own identity, was morally repugnant.  The same standards of moral 'normalcy' are found in the DSM. The diagnostic category of Transvestic Fetishism in the Paraphilias section of the DSM, equates cross-dressing -- and the expression of femininity by biological males -- with sexual fetishism and imposes unfair social stigma of perversion.

The treatment and diagnosis of youth and children is particularly flawed.  Symptoms of Gender Identity Disorder in the DSM describe at length the childhood participation in stereotypically gender inappropriate behaviour. 'Disordered' boys enjoy playing house, drawing pictures of girls and princesses, avoid competitive sports, and playing with toy trucks, while 'disordered' girls prefer short hair, sports, and rough and tumble play.  These medical examples which define 'sickness,' are what we would label a child on the playground as a tomboy or a sissy.  This deviating invention of categorizing gender is used to force conformity. As a result this 'ill' behaviour needs to be resisted or cured.  Critic Dean Spade wrote that the diagnostic criteria of Gender Identity Disorder, "produces a fiction of natural gender . . . This story isn't believable, but because medicine produces it not through a description of the norm, but through a generalized account of transgression, and instructs the doctor/parent/teacher to focus on transgressive behaviour, it establishes a surveillance and regulation effective for keeping both non-transsexuals and transsexuals in adherence to their roles."

Policing appropriate gender behaviour is a scary.  In a day and age where the general concensus is that the sexes are equal and young women deny they are feminists, it seems strange that we are expecting our children, and later adults, to conform so strickly.  It is crazy that genitals make up so much of society's expectations for a person.  It is crazy that declaring your gender outside the norm is considered a medical illness.  Hiding from doctors to escape gender regulation isn't new.  Before transgendered pioneer Deborah Sampson came out in later life, he spent most of his life dressing and acting as a man. As a male soldier in the American War of Independence he was shot.  To avoid detection as a biological female he performed self surgery and pulled the bullet out of his own thigh to avoid discovery.  The DSM needs to take the fear out of these archaic definitions and categories, and instead embrace new ways to help people.  If eshewing surgery and pulling a bullet out of your thigh can be viewed as the most logical course of action in the 18th century, and little has changed in over 200 years, perhaps a shift in soicetal thinking is a long time coming.

For more information:

http://www.ohrc.on.ca/en/resources/discussion_consultation/genderidentity?page=dfhh-Current.html

http://www.transgender.org/gidr/

http://gidreform.wordpress.com/2009/04/22/transvestic-disorder-and-policy-dysfunction-in-the-dsm-v/

http://emedicine.medscape.com/article/293890-overview

http://www.gidreform.org/dsm5.html