Paper presented at the 1st Annual Qualitative Methods Conference: "A spanner in the works of the factory of truth"
20 October 1995, University of the Witwatersrand, South Africa


Gender Dysphoria: Stereotypes, Psychiatry & the Law
Agnes Clarke
Angela has talked about the sort of experiences that transsexuals go through while changing their gender and sex. I will be focusing on how the medical profession has constructed transsexuals and how this relates to the treatment of transsexuals socially and legally.

The stereotype of transsexuals states that we clearly want to change our sex from the age of six (at the latest), that we have a continual urge to cross-dress, that we are desperately unhappy with activities "appropriate" to our given gender, that we hate our pre-operative bodies, that the operation is the most significant change in a transsexual's life and that transsexuals can expect to be generally rejected and mocked. The press continually return to the theme that transsexuals are people with the wrong gender for their bodies ("a woman trapped in a man's body").

The reality is much more flexible. Some transsexuals do not become aware of their feelings before adulthood. There is no urge to cross-dress; it is an easily kept secret and transsexuals can have gaps of decades in which no cross-dressing takes place. Some transsexuals never "cross-dress" until they start changing their public role. Transsexuals do not necessarily even feel uncomfortable with their initial genitals. We live in a culture which frowns on nakedness and which goes to great lengths to hide the human body, so the sex-change operation does not make a significant difference in the outward life of transsexuals. Most importantly, most transsexuals find support and acceptance. Most transsexuals work for at least some time during their transition in a knowing and accepting environment.

Psychiatrists play a gatekeeper role in transsexuals' lives. They are the people who determine whether transsexuals may have access to surgery and whether they can obtain legal recognition of their chosen status. The question that psychiatrist are expected to answer is whether their patient is gender dysphoric or otherwise. Gender dysphoria - meaning unhappiness with one's gender - is the technical term for transsexuality and is accepted as meaning a persistent desire to belong to the "opposite" sex, hatred of one's current body, and impulses to cross-dress and otherwise express one's preference for a different gender.

There are some obvious similarities between gender dysphoria and the widespread stereotype I talked about above. They also share the assumption that if one has the "wrong" gender for one's body one will be unhappy. I do not think there is any reason why feminine men or masculine women should be unhappy. But the assumption is that the situation would feel like a square peg in a round hole, as though one's body has an innate tendency towards a particular way of behaviour that is painful because this is not in accordance with one's mind.

Thus unhappiness is located by the gender dysphoria model in the appropriateness of extremely limited gender-roles rather than in the social expectations, interactions and frustrations around those roles. We are asked to believe in effect that transsexuals are unhappy because men are not supposed to bake cookies, and not because transsexuals get rejected and isolated. It should be asked why there is no research into the "dysphoria" of gender dysphoria. Furthermore, as the patients are in therapy to change their bodies, why is the condition labelled gender dysphoria and not sexual dysphoria? In summary, the condition reflects a different focus and aim to that of the people it is foisted on.

Psychiatrists start from a position of perceiving transsexuality as a pathology, and thus a patient's statements regarding their desires for a different body are invalidated. Indirect testing that attempts to exclude the patient's overt expressions of preference are thus used. The kinds of tests used on transsexuals include so-called sex-role inventories, informal evaluation of the patient's gender-role performance in therapy, and a number of specific issues that tend to disturb therapists.

Sex-role inventories attempt to determine a "psychological sex" for the patient by correlating the patient to a number of behaviours deemed to be masculine or feminine. The conformity of the transsexual to the gender behaviours associated with their chosen sex is an indication that the patient may be suitable for surgery. Kando's Masculinity-Femininity Scale is indicative of the crudity of these supposedly scientific tests, evaluating patients on such criteria as:
I (would) love to have children.
I am the primary supporter of my family.
In general I would submit to my spouse's decisions.
Engagement and wedding rings are very important to me.
The informal evaluation of transsexual's gender-role performance (conformity) is a natural extension of the above tests. The clothing a transsexual chooses to wear to therapy, possession of skills such as knitting or carpentry, one's voice and physical appearance, all weigh more heavily in the mind of the psychiatrist than anything the patient may actually say or feel. It is routine, for example, that male-to-female transsexuals will be made to feel very uncomfortable should they wear pants instead of skirts to their session.

Consequent to this attitude are a number of particular issues that may delay a transsexual's operation for years, or even prevent it entirely. The sexual orientation of transsexuals is expected to conform to heterosexual standards - for example lesbian male-to-female transsexuals are regarded as unsuitable for surgery by many psychiatrists. (A disturbing aside is that these psychiatrists seem to feel much more comfortable with transsexuals who motivate their need for surgery by reference to "homosexual" desires). It is also common for psychiatrists to resist a patient's requests for surgery or other treatments by objecting that the patient is too tall or short, has feet that are too large, is in an "inappropriate" profession, does not cause any feelings of sexual attraction in the psychiatrist, or the patient does not seem sufficiently unhappy with the existing body (i.e. if the transsexual admits to masturbating, or does not express disgust with their current genitalia the psychiatrist is likely to feel that transsexual desires are not strong).

It is quite obvious that such "tests" would not be used for persons not claiming to be transsexual. For example, sex-role inventories routinely find large proportions of men scoring extremely femininely and vice versa. Most psychiatrists acknowledge that no careers can be defined as exclusively masculine or feminine. They have even recently accepted that homosexual desires are not abnormal - yet their tests and expectations routinely exclude transsexuals for exactly these reasons. This difficulty is negotiated by claiming that it is the transsexuals who are slaves to stereotypes and not the psychiatrists. One psychiatrist summarised his perception of his patients by saying "they all want to be pom-pom girls!" Other researchers have also argued that "the position of maximum deviance (transsexuality) becomes paradoxically the position of greatest conformity..."

Their perceptions are based largely on the marvellous correspondence between their expectations and their patients' behaviour - in therapy. The test stereotypes are so obvious - especially to transsexuals who spend their lives consciously manipulating their gender - that it is not difficult to satisfy a therapist's expectations. Tests of post-operative transsexuals, who are not under pressure to satisfy their therapists, indicate no greater gender conformity among transsexuals than among control groups. Behaviours that remain hidden in "therapy" - such as non-conforming sexual preferences - become apparent in these follow-up studies. But these studies can be used to reinforce the reactionary position that many psychiatrists have chosen. A study of post-operative transsexual suicides indicated a much higher incidence of homosexuality amongst transsexuals who committed suicide than amongst a control group of pre-operative transsexuals. This was taken to indicate that homosexuality was indeed a legitimate cause for excluding gay transsexuals from surgery, conveniently ignoring the pressures transsexuals face during therapy to conform to social norms, which would be reflected in the stated sexual preferences of pre-operatives.

The identification of transsexuals as extreme gender-conformists has created numerous problems. The arrogance it creates in therapists (as can be seen from the above examples) is a barrier to any truly therapeutic relationship. It is hardly surprising that patients do not make themselves available for follow-up studies, and that transsexuals do not return to their therapists after surgery, often regardless of the difficulties they may be having in adjusting. Nor is it surprising that transsexuals are noted in clinical writings as difficult, resistant patients.

Another consequence is that transsexuals are pressured to adopt roles and behaviours that other members of their gender are attempting to rid themselves of. Transsexuals can have quite unrealistic perceptions of their life after changing their gender, and, rather than challenging such misconceptions, therapists actively encourage them.

The results of the current psychiatric approach to transsexuals are that:

  1. Many transsexuals do not qualify for treatment for arbitrary reasons, often no more significant than their physical size or their tone of voice.
  2. The psychiatric testing accepts as its basis that there are only two genders which are not flexible. This belief underlies the "normal" gender change procedure of "training" for the new gender in secret and finally making a sudden, all-encompassing change in public. An acceptance that gender is a fluid entity enables transsexuals to transform their gender at their own pace and to the extent they wish to. The difference between these approaches is that the first is an impersonal way of inventing a persona according to questionable norms, and the second challenges these norms and allows individual discovery and preference. It should be added that most transsexuals' transitions fall between these two poles.
  3. The assumption that there are only two genders encourages a denial of one's past - one's previous gender becomes inimical to one's new persona. Many transsexuals do deny their pasts, and go to great lengths to do so. I personally feel that such extreme secrecy is a tragedy, and that it serves no purpose except to divide transsexuals, isolate post-operatives, and perpetuate the myths about transsexuality that pervade our culture.

Psychiatrists see their role as restricting access to surgery, as though there was a great demand for radical, painful and only partly successful surgery. The arrogance and mistrust of this approach should be evident. Beyond determining the "suitability" of the candidate for surgery, no attempt is made to empower the patient to determine their own destiny. It seems that it is not regarded as good therapy to assist a person to be a transsexual. In fact, it seems it is thought correct to make the process as difficult as possible.

The medical profession's treatment of transsexuals has ramifications far wider than the individual patient. The input of doctors and psychiatrists is routinely sought when drafting new legislation to regulate transsexual surgery. The medical profession is seen by lawmakers as a neutral empathic body whose advice is naturally more valid than that of transsexuals. It is no surprise that legislation all over the world focuses on medical procedures and links change of legal sex to surgical reassignment. The economic consequences of this for surgeons are quite obvious.

The issue the laws attempt to resolve is the point at which a person's sex has changed. The internationally accepted standard is that legal sex may change at some point after surgery. This means that transsexuals undergoing their pre-operative "real-life test" (which may last several years) are put in a situation where they are technically continually breaking the law. South African law specifically outlaws impersonation of the "opposite" gender - which is what transsexuals are required to do before qualifying for surgery. Thus this period - in which the transsexual is attempting to construct a more normal integrated life - is made less viable for the transsexual, who justifiably feels forced towards surgery to resolve the legal impasse. It is ironic that psychiatrists require transsexuals to undergo a real-life test before surgery but when asked to make recommendations on laws relevant to transsexuals they never recommend the repealing or amendment of the laws that frustrate and invalidate this psychological requirement. Instead they join in the process of shoring up the legal separation of the sexes and the denial of the fluidities and ambiguities that do exist.

The medical realities of sex-changes are also swept under the carpet when it comes to making recommendations to lawmakers. Female-to-male transsexuals can expect to undergo ten or more major surgical procedures before having completed their reassignment procedure. At what point do they become male (some of the procedures have an incremental effect, so there is no clear before and after)? After completing a two-thirds majority of their operations? After completing them all? Many transsexuals feel that the state of surgery is so poor that they do not wish to undergo the existing procedures. Why should we be forced to undergo surgery that in our opinion is not worthwhile? Why should we be forced into surgery when it may be reasonable to await improvements in the standard of surgery?

Furthermore medical professionals seem to find it convenient or comforting to overlook the price of their services - legal recognition is ultimately dependent on expensive medical treatments not covered by medical aids. No recommendations are made to resolve the situation of transsexuals who cannot afford treatment and thus do not claim the attention of the health professionals.

In psychiatrists' own words....

"Marriage is the foremost ambition of a converted transsexual. This is easily understood when one realises that it is the most complete affirmation of femininity... [when marriage is not legally possible] Prostitution sometimes becomes a tempting substitute for marriage. There is no greater confirmation of femininity than that of having normal heterosexual men again and again accept her as a woman and even pay her for her sex services." Block and Tessler "Transsexualism and Surgical Procedures" in Surgery, Gynaecology and Obstetrics"
[quoted in the South African Law Commission's working paper "Examination of the Legal Consequences of Sexual Realignment and Other Matters," in motivation for the legalisation of transsexual marriages]

Kando, a leading "theorist" on transsexuals, divided up male-to-female transsexual careers into the following categories: housewife, show business woman, aspiring housewife, and career woman. He then suggested a numerical scale of respectability for the career categories: "One could assign a high respectability score to those transsexuals who play predominantly domestic roles and a low one to those who play professional roles..." Kando Sex Change

Kessler and McKenna report that one clinician they interviewed "said he was convinced of the femaleness of a male-to-female transsexual if she was particularly beautiful and was capable of evoking in him the feelings that beautiful women generally do. Another clinician told us he uses his own sexual interest as a criterion for deciding whether a transsexual is really the gender he/she claims." Kessler & McKenna Gender: An Ethnomethodological Approach.


Paper presented at the 1st Annual Qualitative Methods Conference: "A spanner in the works of the factory of truth"
20 October 1995, University of the Witwatersrand, South Africa
critical methods society - www.criticalmethods.org - info@criticalmethods.org