Pathologizing Gender

Posted: Wed, Apr 2, 2025

Diagnostic and Statistical Manual of Mental Disorders, 5th ed., Text Revision (DSM-5-TR) (2022)

Previously: gender identity disorder (DSM-4); transsexualism (DSM-3).

(F64.0) Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
  • A strong desire for the primary and/or secondary sex characteristics of the other gender.
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(F65.0) Fetishistic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator).

Ray Blanchard’s typology of trans women

  • “Homosexual transsexuals” (true, classic archetype): fetishizes their “biological sex” -> confused -> naturally feminine/“attractive,” strictly attracted to men, no “fetishism”/attraction toward women
  • “Autogynephilic transsexuals”: fetishizes femaleness -> confused -> cross-dressing, paraphilia directed toward having a female body

What’s in important part at stake here is access to medical care.

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th ver. (SOC 7) (2012)

Criteria for initiating hormone therapy

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to give consent for treatment;
  3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
  4. If significant medical or mental concerns are present, they must be reasonably well controlled.

Also required: one letter & 3 continuous months of “real-life experience” (ambiguous under SOC 7; removed in SOC 8).

Criteria for bottom surgery

  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to give consent for treatment;
  3. Age of majority in a given country;
  4. If significant medical or mental health concerns are present, they must be well controlled;
  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).
  6. For genital reconstructive surgery: 12 continuous months of living in a gender role that is congruent with their gender identity.

Also required: two letters.

In-class activity

  • Recall both the documentary and the readings assigned for today: What would you say is the relationship between the medical community and trans people?
  • What was the significance of Agnes’ case for this relationship?

The gatekeeping model of trans healthcare

  • As a mental disorder: trans people are fundamentally confused.
  • Agenes’ case: trans people are manipulative, and will do anything to get medical care.
  • Goal is maintenance of the dominant gender/sexuality system:
    • Attractive/passing (racialized): if you don’t show up to your appointment wearing a dress and looking pretty, are you even serious about being a woman?
    • Heterosexual par excellence: for trans women, no interest whatsoever in masturbation or sex with women, only heterosexual penetration from a man.
    • Perfect performance of gender: “role appropriateness.”
    • Plausibility & invisibility: forced fabrication of non-trans personal history.
  • Gatekeeping: access to medical care is used as both carrot and stick.
    • By requiring trans patients to be assessed and referred for gender dysphoria, doctors play the role of gatekeepers, whose job is to determine whether a patient is really trans and should be allowed to access gender-affirming medical care.
    • Trans people’s response: playing into doctors’ expectations in order to access medical care.
  • Weird, masculinized playing God in the surgeon’s power to create manhood/womanhood itself.

Florence Ashley’s arguments against the gatekeeping model

Jigsaw: Your group will be the expert on one of Ashley’s three arguments against the gatekeeping model (what’s the argument? what do you think of it?); I’ll then ask you to explain the argument to your classmates.

  1. Argument from epistemic authority
  2. Argument from diversity of trans embodiment
  3. Argument from double standards

Informed consent: An alternative model of trans healthcare which has been practiced by a growing number of hormone providers in North America, especially university and large-volume clinics.

  • Under the informed consent model, no psychiatric assessment is required for access to gender-affirming hormones; instead, the patient’s informed consent is taken to be sufficient.
  • In general, the informed consent model is not extended to gender-affirming surgeries.

Argument from epistemic authority

The usual version: We are epistemic authorities with respect to our own genders. -> A relevant kind of deference is owed.

  • Challenge: Are we epistemic authorities with respect to our own genders?

Ashley’s version: Even if we are not, we still have epistemic authority over psychological experiences of gender dysphoria.

  • Still fallible?
  • Incompatible with their second argument?

Argument from diversity of trans embodiment

The idea here is that many trans people seek transition-related care not to alleviate gender dysphoria, but for gender euphoria and gender creativity.

  • “Creative transfiguration sees the body as a gendered art piece that can be made ours through transition-related interventions.”
  • Trivializes/misdiagnoses the harm of gatekeeping?

Argument from double standards

Abortion and trans care are both “frequently justified by reference to personal autonomy and are frequently but not always motivated by distress, and yet neither pregnancy nor being trans is illness. I invite physicians to answer this question for themselves and inquire into how double standards in clinical practices may reflect an unconscious hostility towards trans lives and experiences” (481–82).

  • Leveling up vs. leveling down?