Anti-diagnosis of gender

In recent years, there has been some debate about the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and specifically whether there are any good reasons to keep it in the books, or if there aren't many good reasons to keep it in the books. On the one hand, those in the LGBTQ community who want to keep it argue that it provides a justification for a condition and that it makes it possible to change it using a variety of medical and technological means. Also, insurance companies will cover some of the very high costs of sex change if they deem the change "medically necessary." For these reasons, it's important not to think of gender affirmation surgery or hormone use as "voluntary surgery." While some might argue that it is a choice, even an exciting and well-reasoned choice, the question of who is paying for the insurance requires that the choice be a medical one. What exactly is a medical choice? This question is certainly a subject for some thought, but for the purposes of my argument, I think it's important to distinguish between two things; a choice that is diagnostically determined and a choice that is not diagnostically determined. In the latter case, the choice to change includes some or all of the following: choosing to live as the other sex, undergoing hormone therapy, finding and announcing a new name, establishing a new legal status for one's sex, and undergoing surgery. If the psychologist or medical practitioner confirms that the transition is necessary, that is, if they believe that the absence of the transition will result in distress, maladjustment, and other forms of suffering, then it seems that the choice to change can be supported and excused by medical practitioners, who are always concerned about people's health and well-being. This "diagnosis" can work in a number of ways, but one way it can and has worked (especially in the hands of transphobic people) is as a tool of pathologization.

To be diagnosed with Gender Identity Disorder (GID) is to be considered sick, disgusting, wrong, against public order and morality, perverted, and as a consequence of the diagnosis, the "patient" will be subjected to a certain contempt. Therefore, some radical psychiatrists and transgender people have proposed that this diagnosis should be abolished altogether, because transgenderism is not a mental disorder, it should not be considered a mental disorder, and transgender people should be considered as practicing self-determination, a practice of autonomy. Therefore, on the one hand, this diagnosis is still considered valuable because it helps people transition in an economically viable way; on the other hand, this diagnostic approach is strongly opposed because it continues to treat what should be seen as one of many possibilities for people to self-determine their gender as a mental disorder.

From the brief sketch above, we can see that there is a tension in this debate between those who are trying to win rights and financial aid (which is the purpose of their debate) and those who are trying to root transgender practice in a sense of autonomy. We might hesitate for a moment and ask whether these two views are really opposed. After all, one could say—and indeed some have said—that this diagnosis helps to secure insurance benefits, medical care, and legal status, which in fact serves the concept of what we call "trans autonomy." After all, if I want to change, I can certainly use the help of this diagnosis to achieve my goals, and the achievement of this goal is an exercise of my autonomy. Indeed, we can argue that no one can achieve autonomy without the help or support of a group, especially if the person is making a difficult decision such as gender transition that requires courage. But if this is the case, we must ask whether this diagnosis is definitely part of the "support" that an individual needs in order to exercise self-determination of gender. After all, the diagnosis makes many assumptions that are counterproductive to the exercise of autonomy. It takes the form of a psychological assessment that assumes that the person being diagnosed is influenced by forces that they do not understand, that they have delusions and anxieties. It assumes that certain gender norms are not being properly reflected, that there is a malfunction or failure. It makes assumptions about fathers, mothers, and what normal family life is and should be like. It assumes a language of correction, accommodation, and normalization. It insists on maintaining gender norms as they exist in the world and tends to pathologize any form of gender production that does not conform to existing norms (or to some dominant fantasy of what existing norms are). The diagnosis is imposed on people against their will, and it is done significantly against the will of many people, especially young queer and trans people.

So this debate seems extremely complex. And in some ways, those who want to keep the diagnosis want to do so because it helps them achieve their goals and therefore their autonomy. And those who want to get rid of the diagnosis want to do so because removing it might lead to a new world in which these people are no longer seen as pathological and therefore can greatly enhance their autonomy. I think what we can clearly see here is the limitations of any of these conceptions of autonomy that see individuals as existing alone, independent of social conditions and independent of various social tools. Autonomy is actually a way of living in the world within the constraints of social conditions, and these social tools such as the diagnosis mentioned above can empower but also impose constraints, and in many cases, they play both functions at the same time.

On the surface, it seems that we have two different attitudes toward autonomy, but it should be noted that this is not just a philosophical question that can be answered in the abstract. To understand the difference between these views, we must ask how this diagnosis is treated in real life. What does it mean to treat it in real life? Does it mean that it helps some people's lives and helps them achieve a life that feels worthwhile? Does it mean that it hinders some people's lives, causes them to be humiliated, and, in some cases, leads to suicide? On the one hand, we should not underestimate the benefits of this diagnosis, especially for transgender people with limited means and without health insurance. For them, it would be impossible to achieve their goals without this diagnosis. On the other hand, we should not underestimate the coercion of this pathologized diagnosis, especially for young people who may lack the critical resources to resist this coercion. In these cases, the diagnosis is extremely lethal if not murderous. Sometimes it murders the soul, and sometimes it becomes a factor in suicide. Therefore, this discussion is crucial and it is ultimately a matter of life and death. Diagnosis means life to some and death to others; it is a tangled blessing to some and a contradictory curse to others.

To understand how these two positions, which we all understand, came about, let us first consider how this diagnosis was constructed in the United States, and secondly its history and current use. A diagnosis of gender identity disorder must meet the DSM-IV definition of gender identity disorder, which was last revised in 1994. However, in order to complete the diagnosis, in addition to psychological testing, a "letter" from the therapist providing the diagnosis is required to prove that the patient is able to live better with the new gender identity. The 1994 definition is the result of several revisions, and it is probably best understood by considering two things: in 1973, the American Psychiatric Association (APA) no longer diagnosed homosexuality as a disorder, and in 1987, the association decided to remove another relic of the earlier definition, "ego dystonic homosexuality." Some people believe that the GID diagnosis inherits some of the earlier homosexuality diagnosis and is therefore an indirect way of diagnosing homosexuality as a gender identity problem. In this way, the definition of GID continues the APA's homophobic tradition, but it is not as explicit. Indeed, conservative groups seeking to "correct" homosexuality, such as the National Association for Research & Therapy of Homosexuality, argue that if you can identify a child as having GID, you can expect with 75% certainty that the child will become a homosexual adult; to them, such an outcome is clearly perverse and unfortunate. Thus, the GID diagnosis is, in most cases, a diagnosis of homosexuality, and the disorder focus attached to it suggests that, for them, homosexuality remains a disorder.

The way in which some such groups conceptualize the relationship between GID and homosexuality is highly problematic. If we assume that GID depends on the persistence of opposite-sex sexual traits, i.e., "female" traits in boys and "male" traits in girls, then the assumption here is that boys' traits will lead to desire for women, and girls' traits will lead to desire for men. In both cases, the assumption is that heterosexual desire, the assumption that opposites attract. But this is almost like declaring that homosexuality should be understood as gender inversion, while it is heterosexual in terms of "sexual desire," albeit inverted. According to this conceptualization, it is rare for a boy with boy's traits to develop desire for other boys, and it is equally rare for a girl with girl's traits to develop desire for other girls. Therefore, 75% of people diagnosed with GID would only be considered homosexual if we understand homosexuality in terms of gender inversion and sexuality in terms of heterosexual desire. Boys still always desire girls, and girls still always desire boys. If 25% of those diagnosed with GID do not become homosexual, this would seem to imply that they do not fit the gender-inverting model. However, since the gender-inverting model can only understand sexuality as heterosexual, it would seem that the remaining 25% are homosexual, that is, those who do not fit the heterosexual model of homosexuality are homosexual. Thus, we have the somewhat amusing claim that 100% of those diagnosed with GID will become homosexual!

While this joke is irresistible to me simply because it would alarm the National Association for the Study and Therapy of Homosexuality, the point is that we need to think more seriously about how the picture of sex and gender is being mischaracterized by those who are in the thick of it. In fact, the relationship between gender identity and sexual orientation is murky at best: we cannot predict what gender identity a person will have, or what desires they will eventually pursue, based on their sex. Although John Money and other so-called transpositionists believe that sexual orientation follows gender identity, we are making a big mistake if we think that gender identity determines sexual orientation or that sexual orientation necessarily refers to a prior gender identity. As I have tried to point out, even if we think that "female" and "male" characteristics are unproblematic, this does not mean that "females" are attracted to "males" or "males" are attracted to "females." We can only reach such a conclusion if we adopt an exclusive heterosexual model of understanding desire. In fact, it is. That matrix distorts some queer transgressions in heterosexuality, such as when a feminine straight man wants a feminine woman so that the two can be like "girls together," or when masculine straight women want their boyfriends to be both boys and girls. The same queer transgressions occur in gay and lesbian life, such as when butch and butch combine to create a gay man in a unique lesbian mode. And, as I mentioned above, bisexuality cannot be simply seen as two heterosexual desires, the feminine side wanting a male object and the masculine side wanting a female object. Transgressions like that are as complex as anything that happens in heterosexuality or homosexuality, and these kinds of transgressions occur more frequently than is generally believed, and they make a mockery of the transpositionalist claim that gender identity is a barometer of sexual orientation. In fact, sometimes the split between gender identity and sexual orientation—the confusion of the transpositionalist model itself—is the sexiest and most exciting thing for some people.

The homophobic approach to disorders by researchers assumes that homosexuality is a lesion caused by sex change, but it is important to point out that this is not a disorder, that transgender life involves a variety of complex relationships, some of which involve cross-dressing, some of which may involve living as another gender, some of which may involve hormones and surgery, and more often, one or more of these. Sometimes this means a change in object choice, but sometimes it does not. One can be a trans male and desire men (i.e., become a gay man), or one can be a trans male and desire women (i.e., become a straight man), or one can be a trans male and undergo a series of changes in sexual orientation. These changes constitute a specific life history and narrative, a history that cannot be defined by a category, or that may only be defined temporarily by a category. Life history is a history of becoming, and categories sometimes act on the process of change, making it immobile. Changes in sexual beliefs may be in response to a particular partner, and people, trans or not, do not always present as coherently heterosexual or homosexual, and the meaning and experience of bisexuality can change over time, forming specific histories that reflect specific experiences.

The diagnosis of gender identity disorder requires that a person has been stereotyped for a certain number of years; gender can only be diagnosed after it has stood the test of time. You have to prove that you have a long-standing desire to live as a person of the other gender; it also requires that you have a practical plan to live as a person of the other gender for a long time. In this sense, the diagnosis is intended to treat gender as a relatively permanent phenomenon. For example, if you walk into a clinic and claim that you just realized what you want to do because you read Kate Bornstein's book, and you didn't really realize it before that - this will not be accepted. If your cultural life changes, and you see certain lifestyles as possible through written communication, activities and clubs, and your own possibilities are presented to you with more clarity than before, this diagnosis does not consider these changes as reasons for transgenderism. If you are trans, and you want to get support for this diagnosis, you can’t say that you think the norms that determine what is a viable life are fluid, that new cultural forces have broadened the scope of these norms in your life, so that someone like you can live well as a trans person in a supportive community, and that it is the changing public norms and this supportive community that makes you feel that transgender is possible and desirable. In this sense, you can’t directly support the view that changes in gender experience are the result of changing social norms. For to do so would violate Harry Benjamin’s normative rules for gender identity. In fact, like the GID diagnosis, these rules assume that we all more or less “know” what the norms of gender—“male” and “female”—are, and all we need to do is figure out whether they embody these norms in this or other examples. But what if these norms no longer describe our situation? What if they only clumsily describe the gender experience of others? And if the rules of this diagnosis assume that we are all eternally constituted in one way or another, what happens to gender as a mode of change? When we bend to the rules in order to gain the power we need and the status we want, are we frozen in time, becoming more compliant and more harmonious than we would like?

Although there are stronger critiques of this diagnosis to be made—some of which I will elaborate on when I get to the text of the diagnosis itself—calls for its removal are misguided if we do not first establish a way to ensure that sex reassignment surgery is affordable and legally secure; that is, if this diagnosis is a tool for gaining benefits and status in the present, it cannot be removed without first finding other durable ways to achieve the same results.

An obvious response to this dilemma is to insist that we should approach this diagnosis strategically, and then we can reject the truths that the diagnosis espouses, that is, its description of transgender, while at the same time using the diagnosis purely as a tool, a means to an end. We can then conform to the diagnosis ironically or playfully or half-heartedly, even though we think that trans desire or the determination to realize it has nothing to do with "pathology." But we must also ask whether conforming to the diagnosis will more or less consciously lead people to eventually internalize aspects of the diagnosis, to view themselves as mentally ill or insane, or both, even though we only want to use the diagnosis purely as a tool.

One point in favor of this latter view is particularly important and has great relevance to children and young people, for if we ask who is capable of maintaining a purely instrumental attitude toward this diagnosis, we find that it is mostly astute and perceptive adults who have other discourses to help them understand who they are and who they want to be. But are children and adolescents always capable of distancing themselves from this diagnosis so that they do not succumb to it?

Dr. Richard Isay cited the effect of the diagnosis on children as a primary reason to abolish it, writing that the diagnosis itself "may cause emotional damage to the self-esteem of a child who is not mentally ill." There is a belief that many young homosexual boys prefer so-called feminine behaviors in childhood, liking their mothers' clothes and refusing to participate in rough and violent activities. Isay accepted this view, but he also believed that the problem here was not the characteristics themselves but "the harmful effect that parents' warnings about these behaviors have on the boy's view of himself." His solution was to teach parents to support these behaviors, which he called "atypical gender characteristics." Isay's views were important in many ways, but one of the most obvious was that they rejected a language of pathologization and called for a re-conceptualization of the phenomenon: he refused to elevate typical gender characteristics to the standard of psychological normality or, in other words, he refused to regard atypical characteristics as abnormal. Instead, he replaced the language of normality with a language of typicality. Doctors who opposed Isay's views not only insisted that the disorder was a disorder, but also believed that the persistence of atypical gender characteristics in children was a "psychological pathology." They maintain this pathologization while also expressing a paternalistic concern for those who suffer, talking about how such a diagnosis is necessary for insurance benefits and other rights. Indeed, they exploit the clear and explicit demands of poor, working-class, and middle-class trans strong-willed people for health insurance and legal support, and use these demands not only to support the retention of the diagnosis on the books but also to support their view that it is an illness that must be corrected. Thus, even if the diagnosis is used as a tool to achieve trans ends, it can still (a) instill a sense of mental illness in those who receive it, (b) reinforce the power of the diagnosis to pathologize trans desire, and (c) may be used by well-funded research institutions as a rationale to confine trans desire to the realm of mental illness.

Other ways have been proposed to weaken the pathologizing effect of this diagnosis, to remove it from the control of the mental health professions altogether. Jacob Hale has proposed that such matters should not be the province of psychologists and psychiatrists. He argues that the question of how to get medical and technical help should be a matter between the client and the doctor. He argues that a person can go to a doctor and ask for various reconstructive surgeries or, in other cases, for the appropriate hormones; no one will ask you a bunch of questions about your early fantasies or what games you played in your childhood. We do not need to provide proof of mental stability when we ask for breast reduction surgery or hormone treatment for menopause. When a person wants to transition, he or she needs the help of a mental health professional, which imposes a patriarchal structure on the process and undermines the autonomy on which the claim of rights is based. In this case, there are specialist therapists who worry about whether you can psychologically participate in an established social world characterized by the majority of people conforming to accepted gender norms. But this therapist won’t ask whether you have the courage or community support to live your life as a transgender person, when the threat of violence and discrimination against you is at its most rampant. The therapist won’t ask whether this gender life will help create a less restrictive world, or whether you are capable of taking on such a responsibility. The therapist won’t predict whether your choice will lead to postoperative regret. Although the durability and tenacity of your desires are tested, little attention is paid to how these persistent and tenacious desires are affected by the social world and the diagnostic method itself, which denigrates these persistent and tenacious desires as mental disorders.

I suggested at the beginning of this chapter that the arguments one uses to support or oppose this diagnosis depend in part on how one views the conditions of autonomy. In Isay's theory, we see that his argument is that this diagnosis not only undermines children's autonomy but also misinterprets their autonomy as pathological. In Hale's argument, we see that when this diagnosis is no longer used by mental health professionals, it has a different meaning. However, we are still faced with the old question of whether medical practitioners without special training in mental health will use mental health criteria to make similar decisions as mental health professionals. But if Hale is saying that it is necessary to turn to general practitioners in order to redefine this diagnosis so that it no longer includes any mental health criteria, then he is advocating a diagnosis or no diagnosis at all, because the DSM-IV cannot be formulated without mental health criteria. To answer whether switching to general practitioners is a good thing, we must question whether medical practitioners in general are able to take on such responsibilities, or whether the world of progressive therapists can give us more hope of diagnosing on a humane and successful path. Although I do not have a sociological answer to this question, I think it is something we must consider before we judge whether Hale's suggestion is reasonable. The greatest benefit of his view is that it regards patients as clients who exercise consumer autonomy within the medical field. This autonomy is assumed and is also the ultimate goal and meaning of the transition process itself.

But this raises new questions: how should we conceive of autonomy in this debate? Could a revision of the diagnosis itself offer a way around the impasse between those who want to eliminate it and those who want to keep it for its instrumental value, especially those with financial difficulties? There are two different conceptions of autonomy in this debate. Those who are completely opposed to the diagnosis are likely to be individualists if not libertarians, while those who favor keeping it tend to recognize that the exercise of freedom requires material conditions. Those who worry that the diagnosis may be internalized or that it is harmful believe that the psychological environment for autonomy is undermined by the diagnosis, that such damage has already been done, and that the risk of compromised and damaged sense of self is higher among young people.

Autonomy, liberty, and freedom are all interrelated concepts that imply certain kinds of legal protections and rights. After all, the U.S. Constitution guarantees the pursuit of liberty. It can be argued that restricting transgender individuals from exercising their freedom to exercise this identity and practice is discriminatory. Paradoxically, when insurance companies distinguish between “medically necessary” and “elective” mastectomies, they actually devalue the concept of liberty. The former is seen as surgery that is not actively chosen by a person, but rather required by a medical condition, most commonly cancer. But even this statement does not properly describe the wide range of choices that an informed patient can make about how to deal with cancer. For, sometimes, available treatment options may include radiation, chemotherapy, Arimidex, excision, and partial or full mastectomy. Women may make different choices about treatment based on how they feel about their breasts, how they feel about the progression of cancer, and the range of treatment options. Some women may be willing to keep their breasts at all costs, while others may not have much difficulty giving them up. Some may choose reconstructive surgery and make certain choices about the intended breast, while others may not make similar choices.

Recently, a very butch lesbian in San Francisco developed cancer in one breast. After consulting with her doctor, she decided to have a complete mastectomy. She thought it would be a good idea to remove the other breast because she hoped that this would minimize the chances of recurrence. This choice was not difficult for her because she did not have a strong emotional attachment to her breast: it did not play a central role in her self-understanding of gender and sexuality. Her insurance company agreed to pay for the removal of one breast, but they were concerned that the removal of the other was an “elective procedure” and that if they paid for it, it would set a precedent for insurance coverage of elective gender-affirming surgery. The insurance company wanted to both limit the customer’s autonomy in medical decisions (by treating the woman as if she wanted to remove her other breast for medical reasons) and disregard the fundamental role of autonomy in gender-affirming surgery (by treating the woman as transgender). Meanwhile, a friend of mine who was recovering from a mastectomy was trying to understand her reconstructive options. Her doctor referred her to some transgender clients because they could educate her about the various techniques and the aesthetic benefits of these approaches. While I don’t know if there is an alliance between breast cancer survivors and transgender people, I sense that a movement could easily emerge with the main demand being that insurance companies recognize the role of autonomy in the creation and maintenance of primary and secondary sex characteristics. I would like to point out that this all seems less difficult to understand if we view cosmetic surgery as part of the culturally and socially conditioned human practice of maintaining and nurturing primary and secondary sex characteristics. I don’t think that men who want to increase the size of their penises and women who want to have breast augmentation or reduction do not need to go to a psychiatrist to get a certificate. Of course, it is interesting to think about this in light of existing gender norms: why would a woman who wants to have breast reductions not need a psychological certificate, while a man who wants to have his penis reduced would? We don’t assume that women who use hormones and men who use Viagra are mentally abnormal. I suspect that this is because these practices are normative, because they seek to enhance what is “natural,” adjust to accepted norms, and sometimes even confirm and reinforce traditional gender norms.

The butch, who was almost transgender, wanted to have both her cancerous and noncancerous breasts removed; she understood that the only way to have a mastectomy was to have cancer in the other breast or to have her gender desires reviewed by medical and psychiatric care. Although she did not identify as transgender, she knew that if she presented as transgender, she could receive a GID diagnosis and thus qualify for insurance benefits. Insurance companies can sometimes pay for reconstructive breast surgery, even if the surgery is self-selected. However, mastectomies are not among the elective surgeries that insurance companies cover. In the insurance world, if a woman wants smaller breasts, it is understandable, but if she doesn't want breasts, it is considered unreasonable. The idea of ​​not wanting breasts calls into question whether she still wants to be a woman. It seems that the butch's desire to have her breasts removed is not a health concern unless it is a symptom of gender identity disorder or some other emergency medical condition.

But why do we treat these choices as choices, regardless of how we view their social significance? Society does not consider itself to have the right to prevent a woman from enlarging or reducing her breasts, and we do not consider penis enlargement a problem unless the operation is performed by an illegal practitioner and botched. If a person announces that he or she is going to cut or grow his or her hair, or adopt a certain diet, he or she will not be sent to a psychiatrist unless the person is at risk of anorexia. However, if we understand secondary sex characteristics as various physical indicators related to gender, then these practices are actually daily habits that cultivate secondary sex characteristics. If these physical characteristics "indicate" gender, then gender is not the same as the means of indicating it. Gender is understood through these symbols that indicate how gender should be read or understood. These physical indicators are the cultural means of interpreting the gendered body. They are themselves physical, yet they function as symbols, and therefore it is not easy to distinguish what is the "material" truth about the body from what is its "cultural truth." I am not saying that purely cultural symbols create the material body, but only that the body would be difficult to read in sexual terms without these symbols, and these symbols are both cultural and material and cannot be simplified.

So what claims about autonomy do these various views of the DSM diagnosis of gender identity disorder employ? How do we conceive of autonomy in order to find a way around the debate over whether to keep or eliminate this diagnosis? While it is clear that not all people diagnosed with gender identity disorder will or wish to be transgender, they are nonetheless affected by the use of this diagnosis for transition purposes, because its use actually reinforces its status as a useful tool. This is not a reason not to use it anymore, but it does illustrate the risks and implications. A diagnosis that is emphasized may have effects that are undesirable or unforgivable to its users. And while it may serve an important need for an individual and provide identity and financial support for transition, it may also be used by the medical and psychiatric establishment to extend its pathologizing influence on transgender people and lesbian, gay, and bisexual people. From an individual perspective, this diagnosis can be seen as a means of enhancing personal expression and decision making. Indeed, it can be considered one of the basic mechanisms that a person needs to make changes for the better in their life, and it provides the basis for the flourishing of a person as an embodied subject. On the other hand, this approach also has a life of its own, and it can make life more difficult for those who suffer from pathologization and those who lose certain rights and freedoms (such as custody of children, work, housing) because of the stigma attached to the diagnosis, or more precisely, because of the stigma that is emphasized by the diagnosis. Although it would be best to live in a world without such stigma and diagnosis, the world we live in is not so beautiful. Moreover, a deep suspicion of the mental health of people who transgress gender norms structurally affects most psychological discourse and institutions, medical approaches to gender, and legal and economic institutions that determine one's identity and access to financial assistance and medical benefits.

However, from the perspective of freedom, we need to make an important point: it is important to remember that the specific form that freedom takes depends on the social conditions and social institutions that govern human choice. Some people claim that transgenderism is, or should be, a matter of choice, an exercise of freedom. These people are certainly right, and they are also right to point out that the barriers erected by the psychological and psychiatric professions are forms of paternalistic power through which a fundamental human freedom is suppressed. Underlying these views is a liberal claim to gender transition. Richard Green, president of the Harry Benjamin International Gender Dysphoria Association, is a strong supporter of transgender rights, including the rights of transgender people as parents. He believes on this issue: This is a matter of personal freedom and privacy. He cites John Stuart Mill, who “argued forcefully that adults should be able to do what they like with their own bodies, as long as it does not harm others.” Therefore, if a third gender, transgender person, or person about to undergo amputation can continue to have social responsibilities after the operation, then their pursuit of surgery is no business of society. Although Green makes what he calls a “philosophical” argument, he also notes that we should also consider who should pay and whether society has an obligation to pay for a surgery that is considered an exercise of personal freedom.

I found that there wasn't a lot of research going on in this area, except from the Christian Right. The Christian Right says we should embrace gender identity disorder wholeheartedly, saying, "Don't take this diagnosis away from me! Please label me as ill!" Of course, there are many psychiatrists and psychologists who insist on gender identity disorder as a disorder. George Rekers, a prolific and well-funded professor of neuropsychiatry and behavioral sciences at the University of South Carolina, combines vitriolic political conservatism with efforts to strengthen and extend the use of this diagnosis. He seems to be focusing primarily on boys, boys who are becoming men, and men who are becoming strong fathers in heterosexual marriages. He also attributes the emergence of gender identity disorder to the breakdown of the family, the loss of a strong father figure in boys, and the subsequent "insecurity" that this allegedly causes. His concern about homosexuality in boys is evident in his discussion of the work: he cites the 1994 DSM conclusion that 75 percent of young people with gender identity disorder will become homosexual as adults. Rekers has published a number of studies that are filled with "data" from empirical research. Although quite controversial, he sees himself as a scientist, an empiricist, and he characterizes his opponents as ideologically biased. He writes, "A generation has been mesmerized by radical ideologies about male and female roles. What is needed is real research on men and women: good examples of men and women who have an established male or female identity." The purpose of his "real research" is to demonstrate the benefits of clearly distinguishing between gender norms and deviations from these norms "for family life and the larger culture." Similarly, Rekers points out that "preliminary findings have been published showing the positive effects of religious conversion on the cure of transsexualism... and the positive effects of the church on repentant homosexuals." "He seemed relatively unconcerned about girls, which to me reflects his extreme concern for patriarchy and his inability to see the threat that various women might pose to his assumptions about patriarchy. The fate of masculinity attracts the attention of this study because, as a fragile and easily broken construct, masculinity needs the social support of marriage and stable families to find its way. Indeed, in his view, masculinity itself is not stable but needs to be nurtured and supported by various social forces, which means that the functioning of masculinity itself depends on these forms of social organization and has no connotation beyond them. In any case, there are always people like Rekers who are stubborn and mean-spirited and who want not only to preserve this diagnosis but to strengthen it, and their political reasons for strengthening this diagnosis are extremely conservative, in order to strengthen the structures that support normalcy.

Ironically, it is these very structures that support normalcy that have created the need for this diagnosis in the first place, including its benefits for those who need it to transition.

The irony, then, is that those who suffer from this diagnosis also find themselves unable to leave it. The fact is that, under current conditions, one has reason to fear that removing the diagnosis would remove the benefits that would come from it, with potentially disastrous consequences. Rich people may be able to pay tens of thousands of dollars for a female-to-male transition (with a double mastectomy and penis reconstruction), but most people, especially poor working-class trans people, will not be able to pay for it. Socialized medicine in the United States is viewed as a fundamentally communist thing. At least in the United States, it is difficult to get the government or insurance companies to pay for these procedures without first establishing that there are serious, well-tested medical and psychiatric reasons for transitioning. To do so requires establishing that there is conflict. Establishing that there is great pain, that there is a persistent desire to be another gender. And that person must first experiment with cross-dressing all day to see if it is predictable that the person will adjust to a transitioned life, and undergo a series of sessions and correspondence to prove that the person is mentally coherent. In other words, as Foucault says, one must submit to a machine of control in order to make the exercise of freedom possible; one must submit to labels and names; to violations, to intrusions; one must be subject to standards of normalcy; one must pass tests. Sometimes this means that one needs to become familiar with these standards, to know how to present oneself in order to be a credible candidate. Sometimes therapists find themselves in a dilemma. They are asked to provide a letter to the person they want to help, but at the same time they hate that they have to write this letter in the language of diagnosis in order to help their client create the life he wants.

In a sense, the normative discourse surrounding this diagnosis has taken on a new life: it may not describe the client who uses this language to achieve his or her own ends; it may not reflect the beliefs of the therapist who signs the diagnosis and releases it. Dealing strategically with this diagnosis involves a series of individuals who use language that does not represent reality and do not fully believe what they say. The price of using this diagnosis to achieve one's ends is that one cannot use language to say what one truly believes to be true. One pays for freedom by sacrificing one's right to use language that one believes to be true, that is, one gives up one freedom while achieving another.

Perhaps this brings us closer to understanding the difficulty of autonomy that this diagnosis poses, how freedom is seen as determined and expressed in a particular social way. There is only one way to gain the means by which this transformation can begin, and that is to learn how to describe yourself in a language that is not yours, a language that effaces you in your self-representation, a language that you really want to use to describe who you are, how you came to be, and what you want from life. In denying all of this, this language offers a promise (if not blackmail) that if you agree to falsify yourself, you will have the opportunity to have the life, body, and gender you want. In the process, you actually support and authorize the power of this diagnosis to be imposed on more people in the future. If someone supports the right to choose and opposes this diagnosis, then this person must deal with the huge economic consequences of his or her decision for those who cannot afford the existing medical resources. Their insurance (if they have such insurance) will not support this choice within elective treatment. Even if local ordinances were passed making insurance available to city workers seeking such treatment (as is now the case in San Francisco), people would still have to undergo diagnostic testing, so choice certainly comes at a price, and sometimes that price is truth itself.

In light of this, if we want to support the poor and uninsured in this regard, it seems that we must support efforts to extend insurance coverage to the diagnostic categories endorsed by the AMA and APA and codified in the DSM-IV. The call to depathologize everything related to gender identity and to cover elective surgery and hormone therapy as a set of legal elective procedures seems doomed to failure, simply because most medical, insurance, and legal practitioners will support the use of sex change technologies only if what we are talking about is a disorder. It has proven futile to insist that people have a strong, legal claim. There are claims that make sense in theory and that can be made to insurance companies: that the transformation will enable a person to realize certain human possibilities that will allow life to flourish, or that it will move a person out of fear, shame, and paralysis into a state of increased self-esteem and the ability to form strong bonds with others, or that the transformation will help alleviate great suffering or help fulfill the basic human desire to have a body form that expresses a fundamental sense of self. Yet some gender identity clinics, such as the one at the University of Minnesota directed by Dr. Walter Bockting, do make this point and offer therapeutic support to people who are willing to make choices on the issue—whether living as transgender or transsexual, becoming a third gender, or considering a transition process that has no clear or guaranteed results—but even this clinic has to provide DSM-IV compliance materials to insurance companies.

The exercise of freedom through the strategic use of the diagnosis also creates a degree of unfreedom, because the diagnosis itself devalues ​​the self-determination of those it diagnoses. But paradoxically, it sometimes also enhances their self-determination. When the diagnosis is used strategically, when it implicitly overturns its assumption that the person being diagnosed is trapped in a state of inability to make choices, the use of the diagnosis can subvert the purpose of the diagnosis. On the other hand, in order to pass the test, one must submit to the language of the diagnosis. Although the stated purpose of the diagnosis is to know whether one can successfully live in accordance with the norms of the other gender, it seems that the real test proposed by gender identity disorder is whether one can submit to the language of the diagnosis. That is, it may not be whether you can live in accordance with the norms of the other gender, but whether you can comply with the psychological discourse that stipulates what these norms are.

Let’s look at the language. The DSM section on gender identity disorder makes it clear at the outset that there are two components to this diagnosis: “The first is that there must be a strong, persistent transgender identity.” I suppose this is not easy to determine, because identity does not always manifest itself in this way: there may remain some aspects of hidden fantasy, part of a dream, or an unformed structure of behavior. However, the DSM asks us to be a little more positivist in our study of identity, arguing that we can tell what identities are going on in a particular person’s mental life through the interpretation of behavior. Transgender identity is defined as a “desire” to be another gender, or a “persistence in identifying oneself as another gender.” The “or” in this sentence is worth noting, because it means that a person may have the potential to be another gender. The desire for one gender—let’s not go into what the “other gender” is for the moment. And by the way, in my opinion, there is no clear answer to this question—while not necessarily insisting on being that gender. These are two separate criteria. They don’t have to go together. So. If there is any way to conclude that someone has this “desire to be,” even if they don’t insist on it, this will provide reliable evidence for concluding that gender identification is occurring. And if there is an “insistence” to be the other gender, then this can serve as a separate criterion, which, when met, is sufficient to conclude that trans-gender identification is occurring. In the second case, there is a requirement for a verbal act of insisting on being the other gender; this insistence Holding onto something is seen as a way of verbalizing a claim to the other gender, to claiming that gender as one’s own. Certain expressions of this “wanting to be” or “insisting that I am” are therefore excluded as evidence of this claim. “This desire must not simply be due to the cultural benefits of being the other gender.” Now, let’s pause for a moment, because this diagnostic assumes that we can experience gender without considering what cultural benefits are to be gained from being a certain gender. Is this even possible? If our experience of gender takes place within a cultural matrix of meanings, if the meaning of gender is relative to a wider social world, then can we connect the experience of “gender” with its social meanings – including the power within those meanings? How can we separate the ways in which sex operates within the cultural matrix? Gender is a term that applies universally to people, so it is difficult to think of my gender as something extremely specific. If so, then the question is not simply about "my gender" or "your gender" but about how the category of "gender" transcends the individual's use of it. It seems impossible, then, to feel sexuality outside of this cultural matrix and to understand it outside of the benefits it may provide. Indeed, when we think about cultural advantages, whether we act for such advantages or not, we must ask whether what we do is good for me; that is, whether it advances or satisfies my desires and pursuits.

Some vulgar analyses suggest that trans men have emerged simply because it is easier to be a man than a woman in society. But these analyses do not ask whether being trans is easier than living as a perceived biological sex, that is, a sex that “matches” the sex assigned at birth. If social advantage dictates this choice decision unilaterally, then the forces of social conformity may win out. On the other hand, there are those who assert that if you want to wear a flashy red scarf and a tight skirt on the street at night, it is more advantageous to be a woman. This is certainly true in some parts of the world, although biological women, cross-dressers, and trans women all share certain risks on the street, especially if any of them are mistaken for prostitutes. Similarly, one might say that, in general, being a man is culturally advantageous if you want to be taken seriously in a philosophy seminar. But some men have no advantage if they cannot join the discussion. That is, being a man is not a sufficient condition for one to join the discussion. So I wonder if it's possible to want to be a certain gender without considering the advantages that might come from doing so, because the cultural advantages that come with it would also be the advantages that it brings to someone with certain desires and certain people who want to be able to take advantage of certain cultural moments.

If the diagnosis of gender identity disorder insists that the desire to be or adhere to another gender must be assessed without regard to cultural advantage, it may be that this approach misunderstands some of the cultural forces involved in creating and maintaining such desires. The diagnosis of gender identity disorder, then, must respond to the epistemological question of whether we can perceive gender outside of a cultural matrix of power relations, of which relative advantages and disadvantages are only part.

This diagnosis also requires the presence of a "persistent discomfort" with one's assigned gender; it is at this point that the claim that "something is not right" comes in, the assumption being that one can and does have a sense of appropriateness: a sense that this gender is right for me. At the same time, I can and do have a sense of comfort, and can have this comfort if it is the right norm. Importantly, the assumption in this diagnosis is that gender norms are relatively fixed, and the problem is making sure you find the right one that makes you feel comfortable and at ease with your gender. There must be evidence of "distress" in the diagnosis - yes, pain. And if there is no "distress", then there should be "impairment". It is natural to ask here where these claims come from: pain and impairment, the inability to function in the workplace, the inability to do certain daily chores. The diagnosis assumes that the reason a person feels distress, discomfort, and discomfort is because the person is the wrong gender, and that if it were possible for the person to conform to another gender norm, he or she would feel much better. But this diagnosis does not ask whether the gender norms it sees as fixed are problematic, whether they create pain and discomfort, whether they hinder a person’s ability to work, or whether they are a source of suffering for some or many people. Nor does it explore under what conditions they can provide a sense of comfort, belonging, or even a place where some human possibilities for a future, life, and happiness can be realized.

This diagnosis attempts to establish a set of criteria for identifying transgender people, but in its formulation of these criteria, it is extremely rigid about gender. Here is its description of gender norms in very simple terms: "In boys, transgender identification is manifested in a marked fascination with traditionally female activities. They may have a preference for wearing girls' or women's clothing, or may improvise similar items using materials available when materials are scarce. Towels, aprons, and scarves are often used to represent long hair or skirts." This description seems to be based on a history of collecting and summarizing observations; someone saw a boy do this and reported it. Others did it, too, and the reports were collected, and summaries were made based on these observations. But who was observing and how the observations were made? We are not clear. Moreover, although we are told that this identification in boys is marked by a fascination with "traditional female activities," we are not told what exactly this marking consists of. But it seems important, because this "marking" will determine what observations are selected as evidence for the argument.

Indeed, everything that follows from this account seems to work against the account itself, for according to it what these boys do is a series of substitutions and improvisations. We are told that they may have a preference for wearing girls' or women's clothes, but we do not know whether this preference is manifested in actual cross-dressing. All we have is a vague notion of a "preference" which may simply describe an assumed mental state or inner tendency, or it may be inferred from practice. The latter point seems open to a variety of interpretations. We are told that one of their practices is improvisation, taking things at hand and turning them into women's clothes. Women's clothes are called "real clothes," which leads us to conclude that the materials with which these boys improvise are not real enough or related to real women's clothes, if not unreal or "fake." "Towels, skirts, and scarves are often used to represent long hair or skirts." So there is a kind of imaginative play here, and an ability to transform one thing into another through improvisation and substitution. In other words, there is an artistic practice here that is difficult to name as a simple act of conforming to a norm. Something is made, something is made from something else, something is tested, and if it is an improvisation, it is not fully choreographed.

Although the account further insists that the boys are obsessed with “stereotypically female Barbies”—in this case, “Barbie”—and “female fantasy characters,” we are not told what place Barbie and fantasy occupy in conceptions of gender identity. For a particular gender to become a site of fantasy, or for a stereotype to become a source of fantasy, several relationships to that stereotype may be involved. It is possible that the stereotype is obsessed because it is multifactorial; that is, it becomes the site of contradictory desires. The DSM assumes that the Barbie you play with is the object of your desire to be, but perhaps you simply want to be her friend, her rival, or her lover. Perhaps you want to be all of these at the same time. Perhaps you have made some kind of switch with her. Perhaps playing with the doll is an improvisational behavioral scenario that expresses a complex set of tendencies. Perhaps there is something going on in this play beyond simply following a norm. Perhaps the norm itself is being played with, explored, or even broken. If we want to raise and explore these questions, we need to treat play as a more complex phenomenon than the DSM.

According to the DSM-IV, you can tell whether girls have a transgender identity by the arguments they have with their parents about what clothes to wear. They clearly prefer boys' clothes and short hair, their friends are mainly boys, they express a desire to be boys, and, strangely, "they are often mistaken for boys by strangers." What I'm trying to figure out here is how evidence of a person's transgender identity can be established by a stranger identifying them as a boy. It's as if casual social designation is taken as evidence, as if the stranger knows the girl's psychological makeup, or as if the girl has solicited questioning from the stranger. The DSM goes on to say that the girl "may ask to be called by a boy's name." But even so, it's as if she was first called a boy and only then wanted a name that would confirm the correctness of the name. Once again, the language provided by the DSM contradicts its own assertion because it wants to label transgender identity as part of gender identity disorder and as a psychological problem that can be cured. In its imagination, each person has a relationship with their "assigned sex," and this relationship is either an uncomfortable, painful one or a comfortable, peaceful one. But even the concept of "assigned sex"—the sex "assigned" at birth—implies that gender is socially produced and mediated, that it comes to us not simply as a private view of ourselves but as a social category assigned to us. This social category transcends us in its pervasiveness and power, but also exemplifies itself in the site of our bodies. It is revealing that the DSM attempts to establish gender as a set of more or less fixed and conventional norms, even as it constantly gives us evidence to the contrary, even as if it were working against its own will. Just as the boys who engage in improvisational, alternative activities do things that do not conform to established norms, the girls seem to understand something about social assignments, about what it means to be called a boy. What happens when she calls out, and what this makes possible. I’m not sure that the girl, in grasping this disorienting but apt inquiry, is providing evidence for some pre-established “barrier.” Rather, it is simply pointing to the ways in which gender is constituted through assignment, opening up possibilities for reassignment, and this stimulates her sense of agency, play, and possibility. The boys play with the scarf as if it were something else; they are already familiar with this world of props and improvisation. Like them, the girls grasp the possibility of being called by another name, exploring the possibility of naming themselves in the context of the social world. They are not simply providing evidence for internal psychological states, but are performing certain behaviors, even practices, that are crucial to the creation of gender itself.

As many psychiatrists do, the DSM offers a discourse on sympathy, suggesting that living with the disorder produces pain and unhappiness. The DSM has its own version of the topic: “In young children, the pain is expressed in unhappiness with their assigned sex.” Here, it seems, the only unhappiness is caused by an internal desire, not by the fact that such children lack social support, that the adults to whom they confide their unhappiness diagnose and pathologize them, or that gender norms set the conversation in which unhappiness is expressed. The DSM sees itself as diagnosing a pain that needs to be relieved, while at the same time it argues that “social pressure” can lead to “extreme isolation in such children.” The DSM does not talk about suicide, even though we know that peer pressure on transgender youth can lead to suicide. The DSM does not talk about the risk of death or murder, which happened just a few miles from my home in California in 2002, when transgender Gwen Araujo wore a dress to a youth party. Her body was found in the Sierra Hills, beaten and asphyxiated.

We live in a world where violent death and suicide are still real problems, and the suffering caused by them is not apparently part of the diagnosis of gender identity disorder. After briefly discussing what is euphemistically called "teasing and rejection by peers," the DSM comments that "children may refuse to go to school because of teasing or because of the pressure to wear clothing consistent with their assigned sex." Here, the language of the text seems to assume that the pressure of social norms may undermine daily behavior. But in the next sentence, it claims that it is the person's own obsession with transgender desires that "interferes with daily activities" and that it is this obsession that leads to social alienation; this puts the responsibility for the suffering caused by social norms on the individual. In a sense, we find that social violence against transgender youth is euphemistically called teasing and pressure, and the suffering caused by this is recast as an internal problem, a sign of obsession, self-destruction; that is, it is all seen as the result of these desires themselves. Is the "alienation" mentioned here real? Are the groups that provide support far away from observation? And is the emergence of alienation a sign of pathology? Or is it, for some, the price of openly expressing certain desires?

Most worrying, however, is how the diagnosis itself functions as a form of social pressure to induce distress, to pathologize desires, and to reinforce the management and control of those who express them in public. Indeed, one has to ask whether the diagnosis of transgender youth functions as peer pressure, as an escalated form of teasing, as a euphemism for social violence. If we conclude that the diagnosis does, how do we get back to the thorny question of what the diagnosis actually offers us? If part of the contribution of the diagnosis is a form of social recognition, if this is the form that social recognition takes, and if only through this social recognition can third parties (including health insurance) voluntarily pay for medical and technological changes, is it possible to completely eliminate the diagnosis? In a way. The dilemma we ultimately face has to do with the conditions that limit social recognition. For even if we are tempted by a folk liberal position to understand it as an individual right, the fact is that individual rights can only be protected and enforced through social and political means. To assert a right is not the same as being able to exercise it, and in this case the only right recognized is “the right to be treated as a disorder and to have access to medical and legal help that can correct it.” One exercises this right simply by submitting to a pathologizing discourse, and in submitting to this discourse one acquires a certain power, a certain freedom.

We can and should argue that this diagnosis brings relief; at the same time, we can and should argue that this diagnosis exacerbates the very pain that is being relieved. Under current social conditions, gender norms are still expressed in conventional ways, and deviations from them are viewed as suspicious: autonomy can only be a paradox. The state pays for sex reassignment surgeries, a wider group provides “trans funds” to help those who cannot afford the expensive costs, and individuals are given “funds” to pay for “cosmetic surgeries.” The movement to allow trans people to become their own therapists and diagnosticians has and will continue to help. These are all ways around the dilemma until it disappears. But if the dilemma eventually disappears, then the norms that determine how we understand the relationship between gender identity and mental health will change dramatically, so that the economic and legal systems recognize how important being a certain gender is to one’s sense of personhood, well-being, and the possibility of flourishing as a bodily being. Not only do individuals need the social world to exist in a certain way in order to have rights over what they have, but what they have is always dependent from the outset on things that are not theirs, on social conditions that strangely deprive and dissolve their autonomy.

In this sense, in order to be ourselves, we must first dissolve ourselves, we must become part of a larger social structure of “being” in order to create ourselves. This is, of course, the paradox of autonomy, which is exacerbated when gender norms begin to paralyze gender agency at different levels. Before these social conditions change dramatically, freedom often requires unfreedom, and autonomy is entangled with submission. If the social world - which is a symbol of our fundamental lack of autonomy - must change for the possibility of autonomy, then individual choice is shown to be dependent on conditions that are not arbitrarily set by any of us in the first place. And no one can make choices outside of a radically changed social world. This change comes from the increase of collective or decentralized behavior that does not belong to any single subject: but one of the results of these changes is that it becomes possible to act like a subject.

Judith Butler, "Undiagnosing Gender", in Undoing Gender (Routledge, August 17, 2004)