The Medicalization of Transgenderism

The early 1900s brought about the initial discussions of transexualism within the scope of the medical community. With the establishment of the Scientific Humanitarian Committee in 1897 - the first organization entirely devoted to social reform on behalf of sexual minorities - Magnus Hirschfeld commenced this discussion. Hirschfield held the belief that variations in gender and sexuality were primarily rooted in biology. He and his colleagues were among the first to study the morphological effects of sex hormones, and to conduct successful sex reassignment surgery.

In the wake of such developments, transgenderism began to undergo increased medical regulation. Increasingly more transgender individuals began to present themselves as in need of psychiatric and medical attention. Medicine became a powerful tool for social regulation, providing medical practitioners the power to determine what was and was not pathological. This enabled the development of social hierarchies based upon gender norms and individual compliance.

Medical interventions, including hormonal and surgical treatments, began to appear in the United States, with Harry Benjamin as its leading medical authority. Such treatments offered transgender individuals the possibility of alteration to their birth-given sex characteristics. However, access to medical intervention was in the hands of the medical community, and directly tied to their power in defining the condition. Access to such services was dependant on the pathologization of transexualism, and its construction as a mental illness. Pathologization was considered a necessary endeavor as increasingly more transgender individuals began to seek medical intervention. Medical practitioners reasoned that, since illness legitimizes medical intervention, transgender individuals must be considered to have a pathological condition in order to undergo medical treatment. Access to medical services became dependant on the construction of transgenderism as a mental illness to legitimize medical intervention. Such notions perpetuated the idea that transgenderism is psychologically damaging, and that it is something that should be corrected.

In the mid-1960s, Benjamin published The Transexual Phenomenon - a text which applies his research on transgender patients to the treatments previously executed by Hirshfield. He posed the argument that gender identity was a fixed aspect of the human condition. He claimed that it is the doctor’s responsibility to enable transgender patients to live in the gender they internally identified with. Months after its publication, the first sex change program in the U.S. was established at John Hopkins University Medical School (Stryker, 2008). 

Similar programs became established throughout the country as interest in transexualism grew within the trangender community. As interest grew, so did the influence of the medical community in defining and regulating transgenderism. Those seeking treatment became subject to the medical community's interpretation of the culturally appropriate sex and gender dyad. In their attempts at subverting societal notions of sex and gender, individuals seeking treatment have been subjected to medicalized perceptions of their bodies and identities. Though the options made available to transgender individuals allowed them to feel more comfortable with their bodies, and to find a place within the socially regulated sphere, their bodies became rigorously controlled by medical professionals. In seeking medical alterations to their physical bodies, transgender individuals become subject to the scrutiny of the medical community in the regulation of their bodies. 

Professional treatment of transgender individuals provides several options, all of which are subject to the medical communities’ enforcement of specific regulations and criteria for sex reassignment (Barnes, 2001). In order to receive any financial assistance for transitional procedures, one must comply with the strict regulations set forth by medical institutions. Even access non-surgical transition options, such as hormonal treatments, are highly regulated by medical personnel. Most clinics have adopted the Standards of Care, restricting access to hormonal and surgical treatment to those involved in long-term psychiatric therapy. 

The DSM-IV’s classification of Gender Identity Disorder as “a strong and persistent cross-gender identification” with “evidence of persistent discomfort over one’s assigned sex” necessitated psychiatric therapy and continued to pathologized transgenderism. In 2013, alterations were made to the DSM-V, replacing the disorder with Gender Dysphoria in order to decrease stigmatization. Gender dysphoria refers to the distress caused by the incongruence one’s of gender identity and assigned sex. Despite the removal of the terms “disease” and “disorder” from transgender discourse, stigmatization persists, and transgenderism remains highly pathologized. 

In order to receive insurance coverage for transitional procedures, one must be diagnosed as gender dysphoric. Diagnosis works to “legitimize” one’s transgenderism, and to facilitate medical treatment. One must establish that transition is medically necessitated in order for insurance companies to reduce the otherwise infeasible cost of treatment. Treatment must be considered a medically sanctioned choice for insurance purposes. However, even for those who’ve undergone diagnosis, facial reconstruction and other bodily alterations are not insured. If gender dysphoria must be included into the DSM in order for patients to receive treatment, shouldn’t then patients be insured full coverage? 

Even those outside of the medical profession rely heavily upon medicalization, in providing certain benefits and protections to transgender individuals. Most state administrative agencies rely on the medicalization of transgenderism in order to provide IDs that express desired gender and name changes, and in order to ensure protection under anti-discrimination laws. In 2006, the Employment Non Discrimination Act included both homosexual and transgender inclusion clauses. Thanks to openly-gay congressman Barney Frank and political lobbyist group, The Human Rights Campaign, transgender inclusion was actively undermined. Through some states have since adopted transgender anti-discrimination laws ensuring certain rights, the passage of federal legislation is an imperative in providing overarching rights to transgender individuals. 

Federal law distinctly excludes transgender people from protection under disability legislation. This has been the source of much controversy over the past several years. Those who oppose their protection under disability legislation argue that inclusion might perpetuate a reliance on medicalization to protect the rights of transgender individuals. Its classification as a “disability” would place emphasis on the physical and mental “abnormalities” which constitute the transgender condition. Others argue that gender dysphoria fits under the American Disabilities Act’s broad definition of disability as “an impairment which limits one or more major life activities”, and should be protected under it. (Chung, 2011). 

Though diagnosis can operate to grant access to medical services and legal protection, it also serves to pathologize transgenderism. Diagnosis with gender dysphoria suggests that the patient suffers from a certain stigmatization caused by their “abnormality”. It assumes that gender norms have not been properly embodied by those diagnosed, resulting in a sense of failure and dysphoria. Diagnosis pathologizes that which deviates from the norms, and any failure to conform to the social expectations of one’s birth-defined gender. 

Many activists suggest diagnosis be eliminated altogether. They believe that transsexuality is not a disordered condition, but rather a practice of autonomy and self-determination. By pathologizing derivations from sex-determined gender, we are essentially stripping the individual of their agency to determine their own gender identity. In her essay titled “Undiagnosing Gender”, Judith Butler proposes alternative approaches to medicalization. She suggests a strategic approach which rejects the disordered claims associated with diagnosis, using diagnosis solely as a vehicle for providing treatment. However, she points out that those utilizing this method remain at risk of internalizing their diagnosis. She expresses particular concern over childhood diagnosis, questioning whether children have the capability of recognizing the flawed pathologization of diagnosis, or the ability to avoid internalizing these claims. Children also run the risk of emotional damage resulting from their understanding of themselves as disordered (Butler, 2004). Many propose we reduce the pathological perceptions of transgenderism by taking it out of the hands of the mental health profession by provide access to treatment through medical doctors. 

Though I acknowledge the pathologizing effects of diagnosis, I find it necessary for individuals to undergo some form of psychological evaluation prior to treatment. It would be somewhat reckless to eliminate psychological evaluations from the transition process entirely. Mental health professionals play a significant role in helping transgender individuals understand their experiences, and in evaluating which methods of treatment to pursue. Therapy is often an ongoing process, which provides the patient ample opportunity to evaluate their situation. Removing this step of the process, and leaving it up to general physicians to provide treatment may pose problems to patients’ understandings of their condition and how to treat their specific situation. 

Though gender dysphoria is a term far less pathologizing than the disorder it replaced, the removal of any term regarding gender identity would serve to de-pathologize transgenderism. In my opinion, transgender individuals should not have to undergo diagnosis, but should be required to see a mental health professional throughout their transition process. To eliminate psychologist would not de-pathologize transgenderism, but rather further medicalize it by placing it directly into the hands of physicians.