From Gender Identity Disorder To Gender Dysphoria

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Pop culture and news outlets misconstrue transgender (trans), non-binary and gender non-conforming (GNC) identities as a new phenomenon, when it is documented that trans, non-binary and GNC people have existed for long before (CITE). Due to this misrepresentation, it is often understood that inclusion of these identities is “progressive” or “revolutionary,” which is problematic because it fetishizes and tokenizes people’s bodies and experiences. Although these notions have been heavily critiqued by Queer Studies and Women and Gender Studies (WGS) scholars, the field of psychology has historically pathologized and invalidated trans, non-binary and GNC experiences. This paper will provide a historical overview of the Diagnostic Statistical Manual’s (DSM) categorization of Gender Identity Disorder (GID) and Gender Dysphoria (GD) as well as perspectives of Queer Studies and WGS scholars that professionals in the field of psychology could benefit from incorporating in their clinical and research work.

Reactions to the American Psychological Association’s (APA) 1980 announcement of a GID diagnosis in DSM III are important to explore because of the variety of people and groups who opposed this decision. Even though the DSM is mostly used only in the field of psychology to define how mental health concerns are determined and diagnosed, it impacts how people see themselves and see each other. The theoretical purpose of such diagnostic terms is to enable care and access to mental health insurance coverage, but at the same time, these terms can have a stigmatizing effect. Several activists voiced this opinion in response to APA’s announcement, claiming that it is immoral of health care providers to deem expressions of gender variance as “symptoms of a mental disorder” as this would only further stigmatize and cause harm to communities which are already highly vulnerable and stigmatized (Drescher, 2010). People also wondered whether the decision to remove “homosexuality” as a disorder which was made back in 1973 would be overturned due to the reintroduction of pathologized gender identities in the DSM update. Because non-normative gender expressions are common in the histories of queer men and women, it is not surprising that the categorization of gender variance in the DSM was tied to pathologizing non-normative sexualities (Mathy & Drescher, 2009). Sexual orientation and gender identity have had a long history of getting conflated with one other. Therefore, it is important to examine the history of the categorization of sexual orientation in the DSM to fully understand that of gender identity in the DSM.

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Rhetoric around non-normative sexualities, or queerness, has been tied to cultural values throughout history. Therefore, a lot of the earlier official proclamations regarding queer behaviors primarily came from the Western realm of religions, many of which considered queerness to be “sinful.” This changed during the 19th century with the Western cultural shift from religious to secularism, resulting in queer bodies receiving increased inquiry within the fields of law, medicine, psychiatry, sexology, and human rights activism. Karoli Maria Kertbeny, a Hungarian journalist, coined the terms ‘‘homosexual’’ and ‘‘homosexuality’’ in 1869 in a political piece against Paragraph 143, a Prussian law later codified in Germany’s Paragraph 175 that forbade male homosexual behavior (Katz, 1995). Kertbeny’s theory claimed that ‘homosexuality’ was innate, unalterable and a normal variation, to counter the attitudes that led to the passage of sodomy laws. Another prominent view at the time held by German psychiatrist Richard von Krafft-Ebing, regarded homosexuality as a ‘‘degenerative’’ disorder (Drescher, 2010). Krafft-Ebing’s 1965 Psychopathia Sexualis interestingly adopted Kertbeny’s vocabulary but not his normalizing views. This text classified all non-normative sexual behaviors as genetic psychopathology and in need of medical scrutiny (Meyer-Bahlburg, 2010). On the other hand, Freud (1953) believed that everyone was born with bisexual inclinations; therefore, the expression of homosexuality can be a normal phase of heterosexual development. His belief in innate bisexuality led him to write several papers attributing the homosexuality of patients and historic figures to family dynamics. Rado (1969), who had an important influence on the American psychiatric and psychoanalytic thought in the mid-twentieth century built on these ideas and claimed that there was no such thing as either innate bisexuality or normal homosexuality. “Heterosexuality was the only biological norm and homosexuality a phobic avoidance of the other sex was caused by inadequate parenting (Drescher, 2010).” This gave birth to psychoanalytic “cures” for homosexuality.

While psychiatrists, physicians, and psychologists were trying to cure and change queer bodies, sex researchers of the mid-twentieth century were expanding their research on gay and lesbian identities to a wider sample of individuals that included non-patient populations. Alfred Kinsey’s seminal works titled Sexual Behavior in the Human Male (Kinsey, Pomeroy & Martin, 1948) and Sexual Behavior in the Human Female (Kinsey, Pomeroy, Martin & Gebhard, 1953) were groundbreaking. Kinsey’s work surveyed thousands of people and found a higher percentage of gay and lesbians in the general population than was generally believed, which immediately contested the psychiatric claims of the time that these identities were extremely rare. Another important study by psychologist Evelyn Hooker in the late 1950s, failed to find more signs of psychological troubles in a group of non-patient gay men compared to non-patient heterosexual men (Drescher, 2010). Although this side of the field was producing astonishing, groundbreaking results, they were mostly being ignored by the mainstream psychiatric and psychological movement. This was evident by the 1952 controversial release of APA’s DSM-I that classified “homosexuality” as a “sociopathic personality disturbance.” Published in 1968, DSM-II reclassified “homosexuality” as a ‘‘sexual deviation.’’ However, by 1970, the scientific research arguing for a non-pathological view of homosexuality was dramatically brought to APA’s attention by gay and trans activists (Bayer, 1987), which led to the 1980 publication of DSM-III that did not contain an entry for “homosexuality.”

The same DSM-III that was the first to not have an entry for “homosexuality” was the first that did have a new diagnosis of Gender Identity Disorder, with the following subcategories: Transsexualism, GID of Childhood, and Atypical GID. These were placed in the group of Psychosexual Disorders due to the continuous conflation of these distinct identities. Magnus Hirschfeld is known for being the first person to differentiate sexual orientation from gender identity (Mathy & Drescher, 2008). In the United States pop culture, the sensationalized focus on trans people’s bodies began when Christine Jorgensen medically transitioned with gender-affirming hormones and surgery in Denmark and returned to the U.S. in 1952. Regardless of the success of this case and several others that were reported on, for the next three decades, many psychiatrists, and particularly psychoanalytic practitioners, remained critical of gender-affirming medical procedures for trans and GNC people. This led to a variety of academics theorizing about gender and gender identity during 1960s and 1970s, including John Money, Harry Benjamin, Robert Stoller and Richard Green. Although this academic work led to the opening of some of the first medical school-based gender clinics and preparation of standards of care for providers engaging with trans and GNC patients, their work was extremely problematic. These academics were still working from a binary, medical model that assumed all trans and GNC people followed a binary model of gender, identifying as either male or female, man or woman, masculine or feminine, with “true transsexuals” reporting that they had been born in the wrong body, requiring a medical transition as complete as possible, to turn them into a heterosexual woman or man after transition (dickey, Hendricks & Bockting, 2016). Trans and GNC people who did not fit this singular narrative were typically not eligible for gender-affirming hormones or surgery and instead were encouraged to contain or compartmentalize their gender-variant identities and expressions.

The 1980 release of DSM III was an obvious example of leveraging gender variance for the “progressive” goals of lesbian and gay inclusion. Queer theorist Eve Sedgewick (1991) critiques this revisionist psychology that conflates gender expression with sexual orientation and defines a “healthy” gay man only as grown up and masculine. She highlights how the removal of “homosexuality” from the DSM was only accomplished under strong pressure from gay and lesbian activists outside the profession and was celebrated widely, but only minimal attention was given to the addition of GID in the manual which was not even considered to be part of the same conceptual shift. In this way, “a depathologization of an atypical sexual object-choice [has been] yoked to the new pathologization of an atypical gender identification” which is rooted in “effeminophobia” (Sedgewick, 1991).

Currently, with the introduction the diagnosis of Gender Dysphoria in DSM V in 2013, the field can be looked at as ‘having come so far,’ since the acknowledgment of the most marginalized people in our society is seen as ‘progress.’ The shift from a “disorder” to “dysphoria” was aimed at depathologizing trans folks experiencing stressors and issues relating to their specific positionalities; however, different people have different relationships with the idea of dysphoria, which doesn’t necessitate the DSM definition of dysphoria that has particular connotations of anxiety and depression. These associations are further pathologizing, which indeed goes against the “purpose” of the renaming. Additionally, the GD diagnosis continues to perpetuate the binary model of gender with the underlying concept entailing a ‘switch’ from one gender to another, without any critique of the gender binary at all. Not only does this largely exclude non-binary people from the conversation and medical access, but it also gives rise to gender essentialism in the medical field as well as in popular culture that is toxic. This is where an adoption of queer theory methodology could benefit the field of psychology due to ways in which gender is conceptualized and talked about.

For example, when researching for this paper, I found out about the controversial involvement of Kenneth Zucker, who works at the Toronto Centre for Addiction and Mental Health (CAMH) and is a big name in trans mental health care and GID. Trans activists have accused him of practicing reparative therapy on trans youth as young as 3 years old for years now. Since the mid-1970s, he has treated about 500 preadolescent gender-variant children to force them to accept the gender identity they are assigned at birth until they are at an age that he believes they may determine their own gender identity (Tosh, 2011). Despite his controversial and problematic involvement within the field, he continues to be treated as a distinguished researcher by national and international psychological bodies. For example, he was appointed the chair of the Work Group on Sexual and Gender Identity Disorders (WGSGID) for the review process for DSM V (Drescher, 2010), and was also invited to be the keynote speaker at the annual conference hosted by the Division of Clinical Psychology (DCP) of the British Psychological Society (BPS), amongst other laurels. Jemma Tosh (2011) writes an account of the latter as she attended the conference as one of the protestors allowed to attend Zucker’s keynote to ask him questions about his work. Several participants attended specifically to ask him questions about his work, and many of them came up to Jemma Tosh later to find out more about the protestors’ critiques of Zucker’s work. More recently, CAMH had to shut down their Gender Identity Clinic headed by Zucker since it was found to practice conversion therapy on young trans individuals. The fact that Zucker was the chair of the working group that came up with the diagnoses of Gender Identity Dysphoria speaks volumes about that amount of work still left to be done in the field.

Researching for this historical paper also highlighted for me the importance of the work that places like Lurie Children’s Hospital are doing and the long histories of work that they are building on. Acknowledging the brutalities of the history (and the present) of the field and the generational trauma that has been caused due to that needs to be at the forefront of practitioners’ work. As folks invested in this field, and as young entrants into this field, it becomes our work to constantly challenge and question the larger structures that have already been in place since before our time. These are some of the things that I will be keeping in mind as I start my work in the field of trans mental health care.   

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