Depathologization. Sounds complicated: it’s not. For behind the fancy ideological word lies a stark reality. This is a campaign about power, and control and respect.
Who, in the end, will dictate the futures that trans people may choose for themselves? Will support for the transgender community always to be predicated on the basic, insulting premise that, at some level, we’re all a little bit mad? Or will, finally, the medical profession wake up to the fact the world has moved on – and it is no longer up to them to define and limit the trans experience?
On the one side this is about professional self-interest: a group of mainly white, male, middle-aged, middle-class psych professionals who claim that no-one but they can fully understand trans-ness – and therefore it is up to them to decide who shall receive ‘treatment’, who shall be cast into the outer darkness. On the other, like the perennial underdogs in a Hollywood movie are a growing number of trans folk who have looked around, seen what the medics are offering and declared ‘we’re not going to take this any more’.
Hence today’s campaign, as well as a longer running, slower burning argument over the Diagnostic Standards Manual, the ‘bible’ of the American Psychiatric Association (APA), now in the process of formulating its fifth addition, in the teeth of fierce opposition from a trans community sick and tired of having their condition labeled a ‘disorder’.
The issue has its origins in the dim and distant past – not long after the psychiatric community decided that female masturbation was not a disorder after all, but some decades before they accorded the same courtesy to homosexuality. This was the point when the world first became aware that not everyone was happy with their gender presentation and advances in surgical techniques were, for the first time, allowing the possibility that something could be done about this.
But of course, the idea these individuals simply had a condition that could be overcome through help and support from the medical community was unthinkable. After all: allow patients to choose for themselves the best way to receive help and the next thing you know you’ll have women claiming that pregnancy is not a medical condition!
So trans-ness got dragged under the medical umbrella. The profession was not slow to kick off with a wide variety of wild and often contradictory theories about what trans was. Repressed homosexuality was one favourite. An obsession with the female form another.
Alongside the pathologization came the logical corollary. If it was a medical condition, requiring professional types to diagnose it, then only they could decide how best it should be treated. So began the weary drive towards protocols and process and rules and hurdles and gate-keepers, which has the net effect of slowing access to any sort of gender treatment as well as introducing scope for all manner of disrespect into the system.
If you’re female and 40-something and would like HRT to stave off the effects of the menopause, a single visit to your GP will usually suffice. If, on the other hand, you would like hormone treatment for gender dysphoria, the chances are that you will need to wait three to six months minimum: and that is only after you’ve managed to talk to a specialist, which could add a further year to your wait time, and after you’ve jumped through a series of hoops that include your gender presentation matching what they consider appropriate.
No wonder that levels of depression and attempted suicide within the trans community are high.
At the same time, the degree of anger on the part of many who have been forced through the medical system is palpable, as is contempt for a psych community, feathering its nest at the expense of trans men and women.
Of course, it is not that simple. It never is. Somewhere behind all this is the ‘charmed circle’ of sexuality, first described by Dr Gayle Reuben. This is the observation that psychiatry is essentially conservative when it comes to sex. Heteronormative to the nth degree. So, from Freud onward, psychiatry has a history of supporting a certain form of sex – mostly straight, non-kinky, non-commercial, ‘lights on’ stuff – and considering as disordered anything that fell outside those limits.
It may just be happy co-incidence for the profession that this ability to divide the world into sexual sheep and goats is good for their bank balances.
There is, too, a darker side to medicalization. For many of those who are movers and shakers in the APA in the field of gender dysphoria are also – now or in the past – active exponents of the idea that gender dysphoria is something that can be cured. That, too, is a pretty natural consequence of regarding it as ‘illness’. That, too, has added to suicide rates.
With all this questioning, it is no surprise that those most wedded to the idea of pathologization have begun to change their tune. The APA in particular have lately talked of listening and of engaging with the trans community. For some reason, few in the trans community trust this supposed olive branch, which has also many, many detractors in the wider academic world.
No. The broad thrust in medicine nowadays is toward understanding that many things that require ‘treatment’ are not illness, are not pathological. They are conditions which call for support and assistance. No more. Being trans is one of those.
Asking for transgender depathologization is as basic as asking that the medical profession begin to listen, begin to respect and, perhaps for the first time, begin to accept trans individuals as equal partners in their own treatment.