De-pathologizing the Transgender Experience
This is another of the papers I wrote in my grad program. I’m posting it here because I learned a lot while writing it, and I hope you find it useful too. I completed it in early 2022, when anti-trans legislation was gearing up, but before it reached the tsunami-like proportions it has now in 2024.
Like all the papers I post, this one is limited by its conformation to APA style and the attendant colonial norms. Although this paper is written in a more detached style, I am trans, and I am also in one of the gatekeeping professions I list in the paper. This is deeply personal.
De-Pathologizing the Transgender Experience
For much of the past century in the western world, the experience of transgender and gender-diverse people has been pathologized, or treated as a form of illness with a medical cure rather than as a normal state (Vicente, 2021, and Stryker, 2009). Many of the options offered to trans people for gender affirmation are also medical, like hormones and surgeries, and indeed in many US states and in other countries these medical interventions (in some cases, including proof of sterilization) are required for a trans person to acquire updated identification documents, marry, or become acceptable to cisnormative society in a way that allows them to maintain employment, housing, relationships, and so forth (e.g. Gruenewald, 2020).
Likewise, a state of existence as transgender or gender-diverse is pathologized by the psychological professions. In the USA until very recently, the Diagnostic and Statistical Manual of Mental Disorders 4th ed (DSM-IV; American Psychiatric Association, 1994) categorized these people as having Gender Identity Disorder. Although this was changed less than a decade ago in the DSM-V to Gender Dysphoria (American Psychological Association, 2013) and is now only applied to those experiencing distress due to their identity, being trans or gender-diverse continues to this day to be pathologized: a disordered state, in contrast to the ordered state of being cisgender and gender-normative.
This mandatory pathology model presents transgender and gender-diverse people in the USA with a catch-22: in order to receive transition-related medical and psychological care, which is often essential and life-saving, trans people must submit to diagnosis. They must have their experience pathologized in order to have their needs met. Current best practice recommendations place psychotherapists, including LMFTs, LPCCS, LCSWs, psychologists, psychiatrists, and other credentialed counseling professions, in the position of gatekeepers to gender-affirmative care (Gruenewald, 2020). Psychotherapists and medical providers must pathologize and diagnose their trans clients for those clients to access those services which, in many cases, are openly offered to cisgender clients, such as breast augmentation, breast reduction, body or facial contouring, and hormone replacement therapy (HRT).
Compounding the problems inherent in a medicalized identity in the United States are the piecemeal laws protecting transgender rights in some states while removing them in others, as well as the mostly non-socialized American medical system, which places barriers between people and access to physical and mental health care based on income, class, career, location, citizenship status, and other factors.
A path forward advocated by many, both in the psychological professional community and the trans community, is a move towards informed consent and harm-reduction models and away from the triadic model proposed by the World Professional Association for Transgender Health, or WPATH (e.g. Gruenewald, 2020).
Scope and Limitations
A great deal of critique has already been leveled at the current system, and other systems have been proposed. This paper seeks not to reinvent the wheel, but to examine historical factors, explore alternatives, and offer suggestions. Change at many levels is needed, and even small incremental reforms may save or improve lives. Dismantling the system entirely, it must be noted, would also leave many people without access to necessary care under our current framework.
The scope of this paper is limited by the available research that I have remote access to, the page count, and by my inability to understand complex reference material in any language other than English. As such, I will primarily focus on the USA, with the acknowledgement that the current body of research here heavily favors white, middle to higher class, and binary transgender experiences rather than fully reflecting the variety of experiences present in this country.
A Note on Language
Throughout this paper, I will use the terms “transgender” and “trans” interchangeably, and use “transgender and gender-diverse” as an umbrella shorthand for people whose gender identity and/or expression differs in any way from the cisnormative expression of the gender assigned to them at birth, regardless of whether they wish to pursue medical or social transition, but this is profoundly inadequate language. For example, people may identify fully with their birth gender and still seek gender transition related care (e.g. butch lesbians seeking top surgery or testosterone, or femme gay men seeking estrogen or facial contouring). People may also identify as nonbinary or genderqueer rather than transgender (or as two or more of these) and may or may not seek gender transition care. Additionally, individuals may be intersex in addition to any (or all) of these identities and may or may not seek gender transition care (or may have received nonconsensual surgery). And, it must be noted, the ideas of gender in dominant US society are based in white European cultural concepts, and actively exclude or suppress the varieties of genders and gender concepts present in Indigenous societies and the rest of the world (Stryker, 2009).
Additionally, I will use terms like “trans-antagonism” and “queer-hostile” in place of “transphobia” or “homophobia.” It is unethical for me to diagnose a phobia in someone who is not an active client of mine, so I shall be calling these behaviors what they are instead of using an ableist euphemism.
Author’s Disclosure
My social location influences and limits my perspective. I am a white and Alaska Native, middle class, US citizen, nonbinary transgender person who was assigned female at birth and who chose to undergo binary medical and social transition beginning in 2012. My personal perspective is that transgender (and nonbinary, genderqueer, gender-diverse, and cultural genders outside the white male/female binary) identities are real and valid, and that gender affirming care (both medical and nonmedical) contribute to improved quality of life and constitute necessary, lifesaving care. I also believe that what care each person needs is individual, and that individuals are the experts on their own experiences and the best authorities on what they need and do not need in terms of transition-related care. I will not be entertaining arguments from writers who reject, seek to undermine the validity of, or pathologize trans identities or promote biological determinism, except as a discussion of why these are harmful or for historical context.
A Brief History of Being Trans in Western Society
It is impossible to understand where we are now without looking at how we got here. However, “how we got here” is an entire dissertation at the very least, so I will be brief and omit a great deal of detail.
Being what we now broadly call transgender or gender-diverse is part of natural human variety, and examples of gender diversity exist throughout the archaeological record and all over the globe (not to mention the performance and understanding of gender, binary or otherwise, is culture-specific and extremely diverse) (Ghisleni et al., 2016). Although the pathologization and othering of gender diversity now feels like the norm in much of western society, and has felt that way for living memory, it is a relatively recent cultural invention arising from white Victorian prudishness and tied to the rise of capitalism, eugenics, and fascism. Specific laws criminalizing “cross-dressing” proliferated in the USA in the mid-1800s, in reaction to the formation of nascent queer communities in urban centers as people migrated to cities from rural areas and immigrated from other countries (Stryker, 2009), codifying trans- and queer-hostility into the fabric of American law. Many of these laws remained fully in effect until very recently, such as a New York law criminalizing “female impersonation” by people perceived as male that was only overturned in 2011 (Public Broadcast Service, 2015).
The Medicalization of the Trans Experience
At the same time that this conservative crackdown on queerness and gender expression was metastasizing across the USA, gender medicine was in a process of modernization and innovation in Europe. In the early part of the 20th century, with the advent of anesthesia, aseptic technique, and antibiotics, surgery and hormonal treatments became viable options rather than virtual death sentences (Stryker, 2009). This was in many ways a godsend for many trans and gender-diverse people. Gender specialist surgeons and doctors began building small communities of tolerance, like sexologist Magnus Hirschfield and his surprisingly progressive Institute for Sexual Science where many transgender patents were sheltered, treated, and employed until the Nazis drove (Jewish and gay) Hirschfield out of Germany and destroyed his work (Vicente, 2021).
However, there is a saying that when all you have is a hammer, everything looks like a nail. This advent of medicalization of the trans experience created a hammer, and all trans and gender diverse people became nails. Surgery was widely seen as a form of correction for the condition of “inversion,” an idea popularized by eugenicist Havelock Ellis, “invert” being his catch-all term for any person who today might identify as queer, trans, gay, lesbian, etc. This theory postulated that gay people were “inverted” in both their sexual attraction and gender identity, and that surgical gender reassignment would “correct” this and allow inverts to live heternormative binary lives. Although this form of pathologization did in some ways serve to legitimize straight binary transgender identities (as an inborn “fault” rather than as a choice), it also meant racist and ableist eugenicist ideals and the pathology model were built into the foundation of gender medicine (Gruenewald, 2020).
In his aptly-named article, Society as Cause and Cure: The Norms of Transgender Social Medicine, Slagstad (2021) demonstrated that in Norway, even though groundbreaking advances were made towards the treatment and destigmatization of transgender people in the 1970s and 1980s, a cultural focus on upholding the gender binary was both a root cause of trans-antagonism and an impetus to socialize medical treatment of transgender people so that they could conform to binary standards. This was not limited to Norway, as similar cultural binds determined the course of transgender medicine in the USA and other western countries during this era as well. Psychiatrists and sexologists began to focus on the “successful” and “secure” development of sexual and gender identity, defined as heterosexual and cisgender, with trans, intersex, and queer people being defined as unsuccessful, insecure, or “unfinished.”
Trans people continued to be considered, definitionally, unwell and disordered. They also were placed at the mercy of the system that defined them so. Stryker (2009) puts it extremely well:
“But medical science has always been a two-edged sword— its representatives’ willingness to intervene has gone hand in hand with their power to define and judge. Far too often, access to medical services for transgender people has depended on constructing transgender phenomena as symptoms of a mental illness or physical malady, partly because ‘sickness’ is the condition that typically legitimizes medical intervention.” (pp. 36-37)
This willingness to pathologize is pervasive, and tied to cisnormative, capitalistic tendencies to other, shame, criminalize, or see as “wrong” any gender or gender expression not fully aligned with a binary white gender concept. When one is primed from birth to see deviation from the norm as “sick” or “threatening,” it feels like a logical step to view such behavior as pathological and in need of corrective treatment to become “healthy” or “safe.”
The Decriminalization to Medicalization Pipeline
The conversion of the trans experience from criminal to pathological continues to be a two-edged sword to this day. As anti-queer and anti-trans legislation is overturned and various Federal and State laws begin to protect and decriminalize the lives of transgender and gender-diverse people, medicalization has swooped in to catch them in a net that both provides a modicum of safety and binds their agency. If being trans isn’t a sickness or a social ill, then what responsibility would insurance companies, medical providers, social services, and legislators have to provide access to transition-related care? None whatsoever. And so, we continue to medicalize the transgender experience so that these treatments will be protected and provided.
How To Be Trans (Correctly) in 21st Century America
Today, many providers follow the so-called triadic model of care outlined by the World Professional Association for Transgender Health in their Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH SOC; 2011). Under this system, initial transition-related care access is either granted or denied by psychotherapists. Only after receiving psychotherapy and having been determined to meet sufficient criteria for a diagnosis of Gender Dysphoria, and sometimes after being required to transition socially, is a trans person allowed access to hormone therapy. After sufficient gender performance for the therapist and other medical professionals, the patient may then be allowed access to surgical options (WPATH, 2011, as cited in Gruenewald, 2020).
As one may readily see, this system, although widely touted as evidence-based and best-practice, places numerous barriers between the trans person and appropriate care. These barriers are arbitrary and dehumanizing, reminiscent of the hoops a performing animal must jump over on an agility course. The bar is set at a certain height. If the dog doesn’t jump high enough to clear the bar, it loses points and won’t win. Likewise, if a trans client does not perform “transness” to their therapist’s arbitrary personal standard guided vaguely by the DSM-V and WPATH SOC, the client will be denied access to transition care options and may even be gaslit and told they are not really trans. Their agency is gutted and their identity is stifled.
It is also important, always, to reiterate that in the USA, access to psychotherapy and transition-related medical care is extremely limited, even for people who have medical insurance, and is actively stigmatized. Gender specialists are few and far between, especially outside of urban areas in blue states, meaning some people may not have a single provider in their home town, or live hundreds of miles from the closest provider. In rural Alaska as an example, a trans person may only have access to a medical center or psychotherapist once or twice a year when they go to Anchorage for supplies (this can require a plane flight or multi-day road trip). Social, geographic, transportation, and financial barriers can stop a trans person before they even begin the very first step of the triadic model of care, let alone any of the other steps which may eventually amount to hundreds of thousands of dollars’ worth of stigmatized psychotherapeutic, medical, and surgical treatment. A model of care that places intentional barriers between trans people and access to what they need to survive and thrive is, quite simply, trans-hostile.
On a personal note, when I first began transitioning in 2012, I was required to jump over bars with criteria developed for binary trans people. “Non-binary” was not a word in common parlance at the time, and although I often used the term “third gender” or “genderqueer” to describe myself to close friends and in transgender spaces, I quickly recognized that deliberate conformation to a binary narrative, even though it was not my experience, allowed me access to treatment options I would have been denied had I been fully honest with my providers about my gender identity. This binary standard is still how many trans people are judged to this day, and any trans person who does not perform binary gender to the satisfaction of their therapist, doctor, or other provider can be denied access to life-saving care on that basis alone.
What Could We Be Doing Differently?
This is a big question, and the answers I can postulate here are limited by my imagination and optimism, or lack thereof. Obviously, we could burn it all down and start over (a possibility that feels simultaneously more enticing and more likely the further we get into the 2020s), but that would eliminate what few protection and support systems already exist, upon which many marginalized people rely for survival. Never burn anything down unless an alternate structure is already in place and ready to support the people who need it (anarchist pro-tip).
So, a more immediately useful question might be, how do we work within extant systems to change them while maintaining and increasing access and protections for trans people, prioritizing the most marginalized? This is also a big question, and I do not have room in this paper to fully address it, but I will go into what I feel is the key area for growth.
Harm Reduction and Informed Consent
Gruenewald (2020) advocates for the replacement of the triadic model with a combination of harm reduction and informed consent approaches.
Per Marlatt (1996, cited in Gruenewald 2020) harm reduction is a model with three key tenets: disentangle behaviors from ideas about their morality, accept alternatives that reduce harm if an ideal outcome is not achievable or reasonable, and any services offered must be both accessible to and informed by the people who will be using them.
Informed consent is a process by which a provider gives a patient the necessary information about risks, benefits, alternatives, and details to make their own decision about their care. This allows the decision to be collaborative and maintains the patient’s agency. It requires the patient to have sufficient understanding and competency to make an informed decision once provided with the appropriate education (Shah et al, 2021). This can be both an important boundary to prevent harm to someone who lacks the ability to fully understand the consequences of a medical procedure, but also a barrier if the patient has been pathologized or infantilized by a mental health professional and may have their rationality or decision-making ability questioned.
In the context of transition-related care, these two approaches give a significant level of agency back to trans people as complex, intelligent human beings who can collaborate with medical providers in their own care.
Who is Already Doing the Thing?
The best place to start in the search for better models is with organizations in the USA that have already implemented them, like Planned Parenthood. This organization began offering HRT in 2005, and currently at least some locations offer it on an informed consent basis to binary and nonbinary transgender people (Planned Parenthood, n. d.), meaning trans people may obtain prescriptions for hormones without first jumping through any hoops like seeing a psychotherapist or socially transitioning. As Planned Parenthood offers low-cost services, they effectively practice harm reduction by increasing access for low income, undocumented, uninsured, and other people with limited or no access to healthcare.
Although most people in the United States do not have access to socialized medicine, three programs do exist that essentially offer (in many cases substandard) socialized medicine to specific segments of the population: Medicare, the Indian Health Service, and the Veterans’ Administration. Various court cases have required these services to provide transgender care at no cost, although this care may be limited to HRT, and surgery coverage can be denied if certain conditions (generally diagnosis with Gender Dysphoria) are not met. All people in the USA deserve access to these treatments at no cost, and this could be provided if Medicare were expanded and the USA were to offer universal health care.
OK, But What Can I, an Individual, Do?
As individuals we do have some power. Any privilege one has access to can be leveraged to advocate for legislative changes at the local, state, and national level. As students, we can advocate for changes in the curriculum in our psychotherapy programs and speak up in classes. As trainees and associates, we can educate our peers and supervisors, listen to our trans clients and coworkers, and center marginalized voices in meetings and decision-making. As eventual licensed therapists, we can join working groups, teach informed consent and harm reduction to our peers, and pay trans and gender diverse speakers to come to our classes, workplaces, and events. Always and every day, we can approach concepts around gender with curiosity, humility, and a commitment to learn.
Conclusions
Trans people are now in a precarious position, and have been for much of modern history. Although laws have gradually been passed that provide certain protections and ensure certain kinds of access, most trans and gender-diverse people in the USA continue to be at the mercy of a non-socialized medical system informed by a history of eugenics, trans-antagonism, and white supremacist binary thinking. Until transness can be separated from illness, and until access to gender services can be simultaneously guaranteed without the need for a diagnosis of pathology, trans and gender-diverse people must continue to navigate this catch-22 system. It is imperative that psychological and medical professionals to continue advocating for, and centering the voices of, trans and gender diverse people. Educating peers and organizations on informed consent and harm reduction will be key strategies at the provider level, and listening to our trans patients with compassion and respect will always, always provide a clear north star.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Ghisleni, L., Jordan, A. M., & Fioccoprile, E. (2016). Introduction to “Binary binds”: Deconstructing sex and gender dichotomies in archaeological practice. Journal of Archaeological Method and Theory, 23(3), 765-787. https://doi.org/10.1007/s10816-016-9296-9
Gruenewald, A. F. (2020). Re-assessing the triadic model of care for trans patients using a harm-reduction approach. Health Care Analysis, 28(4), 415-423. https://doi.org/10.1007/s10728-020-00416-8
Planned Parenthood.Our history. https://www.plannedparenthood.org/
Public Broadcast Service. (2015). Arresting dress: A timeline of anti-cross-dressing laws in the united states. PBS News Weekend. https://www.pbs.org/newshour/nation/arresting-dress-timeline-anti-cross-dressing-laws-u-s
Shah, P., Thornton, I., Turrin, D. & Hipskind, J. (2021). Informed consent. National Library Of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK430827/
Slagstad, K. (2021). Society as cause and cure: The norms of transgender social medicine. Culture, Medicine, and Psychiatry, 45(3), 456-478. https://doi.org/10.1007/s11013-021-09727-4
Stryker, S. (2009). Transgender history. Seal Press.
Vicente, M. V. (2021). The medicalization of the transsexual: Patient-physician narratives in the first half of the twentieth century. Journal of the History of Medicine and Allied Sciences, 76(4), 392-416. https://doi.org/10.1093/jhmas/jrab037
World Professional Association for Transgender Health. (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people
