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Theory in Action, Vol. 11, No. 4, October (© 2018)
DOI:10.3798/tia.1937-0237.1826
74
Pathologising trans people:
Exploring the roles of patients and medical personnel
Kinnon Ross MacKinnon1
Despite the 2013 decision to replace the diagnostic labelling of
gender identity disorder with gender dysphoria, there remains wide
consensus amongst scholars that transgender identities are
pathologised. Yet the claim that trans identity has been pathologised
has yet to be rigorously substantiated. Adapting a model for verifying
the credibility of medicalisation claims, this inquiry confirms that the
human phenomenon of gender-variance has underwent
pathologisation to embed trans identity within a medical model by (1)
historicising how trans identity became viewed as a medical
condition; (2) highlighting that medical explanations for trans identity
are adopted by trans people and the culture at large; and (3) showing
that medical theory for trans identity gains traction over any other
explanation. [Article copies available for a fee from The Transformative
Studies Institute. E-mail address: journal@transformativestudies.org
Website: http://www.transformativestudies.org ©2018 by The
Transformative Studies Institute. All rights reserved.]
KEYWORDS: Transgender, Trans, Gender Dysphoria, Medicalisation,
Pathologisation.
INTRODUCTION
In contemporary Western nations most people identify and express their
gender in ways that culturally match their birth sex. These people can be
described as cisgender and are contentiously understood to represent the
baseline of ‘healthy’ or ‘normal’ gender identity and expression, despite
significant rejection of these labels from transgender health research and
advocacy (Davis et al. 2016; Schilt & Westbrook 2009). On the other
hand transgender and other gender-variant (trans) people experience a
1 Kinnon Ross MacKinnon, MSW, is a PhD candidate in public health at the University
of Toronto and a fellow with the Wilson Centre at University Health Network. Address
correspondence to: Kinnon Ross MacKinnon, University of Toronto, Dalla Lana School
of Public Health, 155 College Street, Toronto M5T3M7, Canada; e-mail:
k.mackinnon@mail.utoronto.ca.
1937-0229 ©2018 Transformative Studies Institute
Theory in Action
75
diverse range of life experiences, gender identities, and behaviours that
are atypical of their birth-assigned sex, including cross-sex identification
and/or the use of medical technologies to transform their bodies. In
addition to their shared status as trans people, individuals within this
group will find many of their unique life experiences listed as diagnostic
criteria for the psychiatric condition currently listed as ‘gender
dysphoria’ (GD) in the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM) (APA 2013). This condition was
listed as ‘gender identity disorder’ (GID) in previous editions of the
DSM. The tenth edition of the International Statistical Classification of
Diseases lists GID as a psychiatric diagnosis (WHO 1992), however this
is anticipated to change with the release of the eleventh edition in 2018
(Inch 2016). Measured against cisgender (non-trans) identities, those
whose gender does not adhere to biological sex are a outliers according
to this medical model. Reflecting what Foucault (1994) describes as
medicine’s ‘healthy/morbid opposition’ (p. 35), cisgender gender
identities are implicitly ‘healthy’ and ‘normal’, whereas trans gender
identities are rendered as pathological deviations.
Embedding the human phenomena of gender-variance within a
medical model is a relatively recent Western development of the mid-
twentieth century. For this reason, literature from the theoretical domain
of trans studies and empirical trans health research takes for granted that
trans identities have underwent medicalisation and pathologisation
(Conrad 1992; Davis et al. 2016; Johnson 2015; Lev 2013; Vipond
2015), and that processes of medicalisation and pathologisation are
phenomena that have been done to trans people by clinicians and
researchers (Butler 2001; Davis et al. 2016; Eckhert 2016). However, the
explicit claim that trans identity has been pathologised has yet to be
rigorously substantiated. Adapting Sadler and colleagues’ (2009) three-
pronged model for verifying the credibility of medicalisation claims, this
novel inquiry streamlines Sadler et al.’s (2009) approach by (1)
historicizing how trans identity became viewed as a medical condition;
highlighting that (2) medical explanations for trans identity are adopted
by trans people and the culture at large; and showing that (3) medical
theory for trans identity gains traction over any other explanation. Using
this rubric, the goals of this inquiry are two-fold: First, this article seeks
to confirm the credibility of claims that trans identity has undergone
pathologisation. And as a tertiary goal, the relational ways that both trans
people and medical providers leverage the medical model of trans
identity are explored, taking a departure from understanding
Kinnon Ross MacKinnon
76
pathologisation as an event that trans people have been exclusively
passive recipients of.
This article begins with a brief refresher on the field of medicalisation
and its sibling concept, pathologisation. Next, literature related to the
pathologisation of trans identity is discussed to provide evidence of
scholars’ explicit discussions surrounding the phenomenon. The
substantive section that follows centres Sadler and colleagues’ (2009)
model for the purpose of understanding the social and historical
processes through which trans identity has come to be viewed as a
mental health condition. Finally, limitations of this project are discussed
and future directions are offered.
MEDICALISATION
Conceptualizing medicalisation
Medicalisation emerged as a theoretical concept from scholarship
within the sociology of health and illness in the 1960s-1970s. Critiques
of the medical institution began in the 1960s in concert with the social
constructionist paradigm shift. Without being explicitly named
medicalisation, Parsons’ (1951) analysis of ‘the sick role’ may have been
the first to advance the notion that medicine exists as a tool for social
control (Conrad 1992). Conrad (1979) also established three ways in
which the medical institution contributed to social control: medical
ideology (imposing a dominant medical model); collaboration (doctors as
gatekeepers and agents of the medical institution); and technology (the
use of drugs, surgery, and genetics for social control). During this period
Freidson (1970) untangled the social experiences of illness from
biological realities, asking ‘how signs or symptoms get to be labeled or
diagnosed as an illness in the first place?’ (p. 212). Largely based on
structuralism, constructionist critiques of the medical institution formed
the foundational knowledge to deploy the theory of medicalisation.
Later, it was Conrad’s seminal studies (1975; 1992) that explicitly
developed medicalisation as a conceptual tool to understand the social
control of deviancy. Medical sociologists (Conrad & Schneider 1992;
Zola 1972) additionally studied how and why certain human behaviours
are controlled by medical means. French historian and philosopher,
Foucault (1970; 2003; 2006), for instance, was interested in power
relations between macro-level medical structures and micro-level
interactions between doctors and patients that gave rise to the expansion
and authority of medical knowledge, and the subsequent creation of
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disease categories. Foucault (2003) writes that ‘the hospital doctor going
from bed to bed was one of the major agents of contagion… the role of
the hospital space and the doctor’s knowledge was to produce the
‘critical’ truth of the disease’ (p. 337). The powerful role that patient-
provider interactions within the medical institution play in the discovery
and creation of disease categories is illustrated here.
Psychiatry was the first discipline to hold medical sociologists’
attention in terms of the connection between medicine, deviancy, social
control, and the rise of pharmaceutical treatments and biomedical
interventions (Conrad 1975; 1992). In the 1970s social scientists were
critically attuned to the proliferation of psychiatry and processes that
contributed to making deviancy and delinquency a medical issue (Conrad
1975; Friedson 1970; Zola 1972). For instance, medicalisation has been
used by scholars to explore how homosexuality was added and then
removed from the DSM (Conrad 2007), trans peoples’ interactions with
the medical system (Conrad 1992; Davis et al. 2016; Johnson 2015;
Reicherzer 2015) and how the medical model shapes trans people’s legal
rights (Johnson 2015; Vipond 2015).
A conglomerate of Zola (1983) Conrad (1992), and Sadler et al’s
(2009) theorizing on medicalisation is given primacy in this
investigation. Zola (1983) explains that medicalisation is a ‘process
whereby more and more of everyday life has come under medical
domination, influence, and supervision’ (p. 295). Conrad (1992)
describes medicalisation as ‘a process by which nonmedical problems
become defined and treated as medical problems, usually in terms of
illness or disorders’ (p. 209, italics added). In direct response to Conrad’s
definition, bioethicists Sadler and colleagues (2009) instead strike
‘nonmedical problems’ from their interpretation of medicalisation
because this wording connotes that some human problems may be
unquestionably nonmedical. Rather than investigate what constitutes
authentic and inauthentic medical conditions, Sadler et al (2009) instead
launch a bioethical question of the value of medicalisation suggesting
‘medicalisation, as a social practice, may represent a broad range of
interests and values, as well as serve one or more social purposes or
functions’ (p. 414). Their three-step rubric for verifying when a human
experience has indeed undergone medicalisation will be more
extensively explored later.
Kinnon Ross MacKinnon
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Pathologisation:the connection between processes of normalisation
and gatekeeping
Theoretical and empirical research projects in the areas of trans
identity are heavily peppered by both of the terms medicalisation and
pathologisation. Jacob and others (2014), however, caution researchers to
distinguish between medicalisation and pathologisation, noting that a
phenomenon must first be defined medically and then used in clinical
practice to label individuals as abnormal. This is an important distinction
given the prevalence of these terms within literature related to trans
identities. Pathologisation calls upon normative standards in order to
calculate deviations from a baseline, such as the case with cisgender
versus trans experiences, with the latter group’s characteristics
taxonomized as mental disorder complete with biomedical treatments.
According to scholars within the field of medicalisation,
‘normalisation’ refers to actions surrounding the use of medical
interventions that align the body into a cultural expectation of what is a
more ‘normal’ or socially desirable aesthetic (Conrad 2007).
Normalisation occurs, for instance, when parents of short children
request human growth hormone in hopes the child will reach ‘normal’
height, or when women’s small breasts are labelled as ‘micromastia’ and
surgically enhanced (Jacobson 2000). Scholars have similarly argued that
the medicalisation of gender-variance and corresponding hormone
replacement therapies (HRT) and gender-confirming surgeries, also
termed sex reassignment surgeries (SRS), contributes to the
normalisation of non-normative expressions of sex and gender (Butler
2001; Vipond 2015). This argument has been applied to the case of trans
adults and gender-independent children who medically transition sexes
(Pyne 2014), and in circumstances in which parents and doctors make
decisions on behalf of intersex babies (Davis et al. 2016; Holmes 2002;
Repo 2013). Similarly, the argument has been made that SRS may exist
to normalise gendered bodies that are misaligned with anatomical sex,
and to render deviant bodies into a normative gender binary system
(Repo 2013).
Gatekeeping of transition-related treatments such as HRT and SRS
contributes to the pathologisation of trans identity. This is in part due to
medical providers exclusively holding the power to define trans
experiences as mental illness, while guarding and sometimes obstructing
access to transition-related care. Conrad (2010) and Conrad and Bergey
(2014) importantly draw attention to the role that clinicians play in the
medical profession, calling medical professionals ‘gatekeepers’ in the
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context of increased power of pharmaceuticals and biomedicine.
Interestingly though, whereas in the context of the seminal
medicalisation literature ‘gatekeeping’ refers to the shrinking power that
health care providers carry, yet for trans health researchers ‘gatekeeping’
is decidedly used to underscore the power that physicians hold as the
protectors of transition-related medical interventions (Bouman et al.
2014; Collazo 2013; Vipond 2015). Physicians (often psychiatrists) are
typically solely responsible for conducting the mandatory psycho-social
assessments that verify the authenticity of a trans patient’s diagnosis
prior to being granted access to HRT and/or SRS. But on the other hand,
Eckhert (2016) observes the fraught role that trans patients play in this
interaction, rehearsing and recycling the narratives necessary to pass
through this clinical gateway, espousing what Butler (2001) calls the
‘truth’ of transsexuality. In other words, trans people present medical
providers with the imagined life stories that are necessary to gain access
to HRT and SRS, which is what Cohen-Kettenis and Pfafflin (2010) refer
to as a search for an authentic or truthful transsexual. Yet for trans people
this may be a pragmatic approach to accessing services, as research
indicates that some clinicians continue to conduct assessments based on a
normative trans narrative and gender expression, rather than the
dysphoria and distress that patients describe (Serano 2007; Moleiro &
Pinto 2015). Conrad and Bergey (2014) similarly draw attention to the
role that patient advocacy groups play in assisting others in being
knowledgeable of diagnostic criteria in order to receive necessary
treatments.
Pathologisation of trans identity and transnormative medical narratives
Due in part to processes related to pathologisation, it is well
documented within academic and grey literature that the relationship
between trans people and medical providers is strained (Cheng Thom
2015; Kosenko et al. 2013; Snelgrove et al. 2012). For instance, some
health care professionals express barriers to delivering care to trans
individuals, and some explain that treating trans people ought to remain
within the domain of psychiatry (Snelgrove et al. 2012), which may
contribute further to the pathologisation of trans identity (Inch 2016).
From the perspectives of trans studies scholars, however, clinicians’
exclusive authority to verify, scrutinize, and diagnose the authenticity of
trans identities ultimately protracts the pathologisation and stigmatization
of gender-variance (Butler 2001; Davy 2015; Inch 2016; Johnson 2015;
Reicherzer 2008; Vipond 2015).
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Vipond (2015) reflects on the normalisation of some trans people
through processes of medicalisation using a construct called
‘transnormativity’. Dominant narratives of transnormativity, such as
being ‘born this way’, having an awareness of one’s trans identity from a
young age, being ‘trapped in the wrong body’, and desiring to surgically
and hormonally transform one’s body to the opposite sex, among others,
do a number of important actions in relation to medicalisation and
pathologisation (Eckhert 2016; Vipond 2015). These narratives 1) form
the basis of diagnostic criteria to assess the authenticity of a patient’s
gender dysphoria; 2) reinforce the notion that there are only two genders;
and 4) affect how medical personnel interact with trans-identified clients.
According to Dewey and colleagues (2016), these dominant
transnormative narratives also position gender as biologically
determined. In Vipond’s (2015) analysis, gender conforming trans
persons (those who access transition-related medical interventions to
physically transform their bodies. I.E. – transsexuals, trans men, trans
women, people with a history of transitioning) are privileged and
legitimized by medical discourses over those who are gender non-
conforming (those who have not yet transitioned medically, or do not
wish to. E.g. - genderqueer, non-binary) (italics added). Meanwhile in a
clinical context, patients who disclose transnormative narratives are
rendered intelligible to clinicians and are seen as ‘sick enough’ to access
transition-related medicine, and post-medical transition may be seen as
‘no-longer-sick’ (Vipond 2015 p. 29). Inch (2016) extends a similar
conversation about trans people who must say the ‘right’ things to
clinicians in order to meet criteria for diagnosis and treatment, ‘perhaps
overemphasizing their distress’ (p. 197). Conversely, gender non-
conforming trans-identified individuals who do not adhere to medical
narratives become unintelligible in the face of transnormative medical
narratives and risk being seen as too deviant, or even incurable from the
perspective of medical providers who are also influenced by these
dominant transnormative medical narratives. This is not to suggest that
trans people who present clinicians with transnormative medical
narratives in order to access transition services are morally bankrupt or to
be blamed for the discrepancies experienced by gender non-conforming
trans people - regardless of whether those life stories are authentic or
embellished. Parens (2013) and Purdy (2001) underscore that many
people choose to use medical technologies to enhance their quality of
life. Indeed for many trans people who want to transition, gaining access
to medical technologies is associated with improved mental health
outcomes (Mizock 2017). Yet these choices for trans people are often
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limited based on the constraints of transnormative narratives and the
ways in which clinicians act as the gatekeepers of mental health care
services.
Toward depathologisation
Given the current debates within trans research surrounding shifting
diagnostic terminology and advocacy in support of removing GID and
GD from psychiatric manuals (see Davy 2015; Drescher 2010; Eckhert
2016; Inch 2016; Johnson 2015), it is also pertinent to consider the
concept of ‘demedicalisation’. Demedicalisation references conditions
that were once considered medical issues, and then cease to be defined
according to medical terms - with medical treatments being no longer
seen as appropriate treatments (Conrad 2007). Contemporary research
related to the interactions between trans people and health care providers
has delineated the over-pathologisation of expressions of gender-
variance and called for the depathologisation of trans identity namely
through the removal of GD from the DSM and GID from the ICD (Inch
2016; Kosenko 2013; MacKinnon et al. 2016; Snelgrove et al. 2012).
While Dewey et al (2016) recognize that many medical personnel aim to
depathologise trans identity through providing biological explanations
for the emergence of gender-variance, trans people cannot be understood
as healthy under a framework that views this phenomenon as a
pathology. In fact Inch (2016) suggests that it may be unethical to
withhold medical treatments that have been proven to improve trans
people’s quality of life unless patients are willing to be diagnosed with a
psychiatric illness. For this reason, the complete removal of GD from the
DSM and GID from the ICD is argued to be the best path to
depathologisation (Inch 2016).
Transitioning from labelling GID to GD is not unlike the rationale
provided for the DSM’s 1980 shift from labelling homosexuality as a de
facto illness to a focus on the ‘symptomatic’ distress experienced by gays
and lesbians. Conrad (1992; 2007) spends considerable attention to
studying the processes through which homosexuality first became
pathologised and then later depathologised, drawing attention to the
potential bi-directionality of the medicalisation of a human phenomenon.
For instance, in the early to mid-twentieth century physicians and
psychiatrists considered same-sex sexual behaviour and attraction to be
pathological and thus much energy was focused on curative conversion
therapies (Moleiro & Pinto 2015). In 1952, the first edition of the DSM
labelled homosexuality as a ‘sociopathic personality disturbance’, but by
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1968 the DSM-II reclassified the phenomenon as a ‘sexual deviation’
(Moleiro & Pinto 2015 p. 2). Conrad (1992) offers homosexuality as
perhaps the sole instance of depathologisation through its removal from
the DSM-II in 1973. However, scepticism remains concerning the
persistent pathologisation of gender and sexuality because in 1980 the
DSM-III launched a new category for sexuality disturbances called ‘ego-
dystonic homosexuality’, which remained there until 1987. Rather than
disordering homosexuality per se, ego-dystonic homosexuality
pathologised the impairments and discomfort that individuals
experienced as a result of homosexuality, while at the same time
legitimizing conversion therapy practices for those who desired to
change their sexual orientation (Moleiro & Pinto 2015). Yet there are
opponents of the demedicalised homosexuality claim as same-sex
sexualities may remain medicalised through HIV and other LGBTQ
research and clinical services (Conrad, 1992; 2007; Eckhert, 2016), and
pathologised through the current gender dysphoria diagnosis (Conrad
2007; Drescher 2010). Oddly similar to the homosexuality diagnosis, the
change in nomenclature from GID to GD discussed extensively by Beek
and colleagues (2016) and Lev (2013), limits psychiatric diagnosis to the
period of a trans person’s life in which they are distressed about an
incongruent gender identity (Drescher 2013).
To summarise, the scholarship surrounding medicalisation and its
sibling concepts - normalisation, pathologisation, and depathologisation -
laid the groundwork for theorists and empirical researchers to identify
and critique practices related to the disordering of gender-variance and
pathologising trans identities. Critical works within the domain of trans
studies illustrates how access to transition-related medicine is predicated
on certain medical transnormative narratives, extending the
pathologisation of trans experiences. Meanwhile, this literature also
provides ample evidence of the ubiquity of assumptions that trans
identity has undergone pathologisation. In the next section, Sadler and
colleagues’ (2009) model for verifying the credibility of medicalisation
claims is applied using literature that straddles trans studies,
medicalisation, and neuroscience research in order to substantiate the
claim that trans identity has indeed underwent pathologisation. Before
proclaiming that a condition has been medicalised, Sadler and colleagues
(2009) caution that researchers should conduct a robust evaluation. As
described briefly earlier, this process urges critical scholars to (1) situate
the phenomenon in a recent historical context to ensure it is a recent
medical development; (2) identify that medical rationales and theories
are voiced by society at large or populations within that society; and
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verify (3) medicalisation claims by establishing the dominance of
medical explanations. While the wording of their approach has been
amended slightly to enhance clarity, the integrity of the process is
maintained.
CONFIRMING THE PATHOLOGISATION OF TRANS
IDENTITY: A THREE-PRONGED APPROACH
1. Historicise how trans identity became viewed as a medical
condition
The human phenomenon of gender-variance is not a recent occurrence.
Indeed, gender-variance has been present across many cultures globally
throughout history (Bartlett & Vasey 2006; Medicine 2002; Stryker
2008). However, viewing gender-variance as a medical condition in
concert with specific medical treatments is a relatively recent twentieth
century development. Medical work with gender-variant people
originated in Western Europe in the 1920s-1930s, creating the
contemporary psycho-medical categories of GID/GD. In London,
England the first documented vaginoplasties were completed in the
1920s on two biological males who were referred to as ‘transvestite
homosexuals’ (Abraham 1997). These surgeries were done out of fear
the patients would otherwise self-castrate (Reicherzer 2008). During this
time period in Berlin, Germany, SRS experimentation was conducted at
the Magnus Hirshfield Institute for Sexual Science where Dr. Magnus
Hirschfield studied gender-variance and individuals who desired to
change their sex (Reicherzer 2008). Hirschfield ostensibly studied these
phenomena out of a personal interest, as he was described as a
‘transvestite and effeminate homosexual’ (Rector 1981 p. 25).
Following the Nazi’s destruction of Hirschfield’s institute prior to the
Second World War, American sexologist Dr. David Cauldwell was
influenced to study and classify persons who were determined to live as
the opposite sex as ‘psychopathic transsexual’. Cauldwell may have been
the first American physician to use the term transsexual, and wrote that:
Transsexuality, although individuals do not thus define it, occurs in
a far greater number of people than the surveys have revealed. It
would seem that here is a fertile field for research which has been
neglected because sexologists, taxonomists, statisticians and others
have been looking for such departures from sex codes as those
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diversions of the sex instinct known as homosexualism,
bisexualism, etc. (Cauldwell 1950 29)
Being uncomfortable with making ethical judgments surrounding human
sexual behaviours and desires, however, Cauldwell saw cross-dressing as
nothing more than a ‘quirk’, and in complicating the notion that the
medical institution was exclusively pathologizing toward gender-variant
people, he argued that just like heterosexuals, transsexuals could be
mentally healthy or unhealthy (Ekins & King 2001). Yet it may have
been Dr. Harry Benjamin’s research, writing, and public speaking that
popularized the term transsexual. Benjamin credits himself for using the
medical description of ‘transsexualism’ for the first time in a public
lecture in 1953, although he also references Cauldwell’s earlier research
that described a girl who desired being male as ‘psychopathia
transsexualis’ (Ekins & King 2001). And Hirschfield similarly used the
descriptor ‘psychic transsexualism’ (Ekins & King 2001). Ostensibly, the
first taxonomising and medical labelling of gender-variant identities and
behaviours can be historically traced to these primary pioneering
physician-researchers in the 1920s-1950s.
The early period of the medicalisation of trans identity began not
exclusively as a venture of cisgender medical authorities pathologizing
gender-variance. Rather this process began with early SRS patient
advocacy by and for gender-variant people, and a nuanced understanding
that trans people’s behaviours and desires could, according to Cauldwell,
fall along the continuum of mentally healthy or not (not unlike
heterosexuals). Interestingly, it was not until later that trans identity was
added to diagnostic manuals of mental disorders, due in part to the
‘trapped in the wrong body’ transnormative medical narratives
publicized by trans people. In fact, it was an 1967 autobiography
authored by American trans woman Christine Jorgensen who detailed her
transition from male-to-female (MTF), describing many of the
transnormative medical narratives that remain with us today (i.e. being
‘trapped’ in the wrong body; and having a trans awareness from an early
age). This autobiography was endorsed by her physician, Dr. Harry
Benjamin, and was highly influential in developing medical narratives
for diagnostic criteria. With Benjamin writing a compelling forward to
Jorgensen’s autobiography, he provided a medical authority which
legitimized that she indeed was once sick, but following HRT and SRS
she became a ‘normal’ and ‘healthy’ woman (Reicherzer 2008). Hence,
both trans patients and medical providers played distinct roles in the
medicalisation and pathologisation of trans identity in terms of
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describing which life experiences went on to form the basis of the gender
dysphoria diagnosis, and whose authority held the power to endorse
these unique character traits as a pathological condition.
Beginning in the late 1970s and early 1980s, interventions to treat
gender-variance underwent further pathologisation in terms of moving
toward a focus on ‘curing’ gender-variant bodies with biomedical
technologies such as SRS and HRT. On par with the discipline of
psychiatry in the 1920s-1960s, sexologists’ studies of gender-variance
were laced with psychoanalytic and health psychology theory, arguing
that gender-variant expressions could be treated with behavioural
rehabilitation, including conversion therapy. This is not surprising given
that prior to the growth of the pharmaceutical industry approaches to
broad mental health concerns were grounded in psychoanalysis and
theories of the subconscious (Smith 2014). In the 1950s to 1980s,
prescribed treatments for psychological suffering were typically talk-
based rather than biomedical or pharmaceutical. In fact, a late 1960s
study named the ‘Sissy Boy Syndrome’, funded by the National
Institution of Mental Health in the United States, was heavily influenced
by psychoanalytic development theories. Findings from this controversial
study eventually informed the DSM-III’s first-ever inclusion of GID in
1980 (Reicherzer 2008). But in 1979 Benjamin made a pivotal move
creating the Harry Benjamin International Gender Dysphoria
Association, urging the medical community to discontinue the use of
psychotherapy to cure transsexualism, while citing that biomedical
transition technologies, such as SRS and HRT, were superior treatments
(Reicherzer 2008). This transfer from psychoanalytic development
theories and psychotherapy over to biomedical interventions and
pharmaceutical treatments highlights the relatively recent shift in the
culture of medical explanations and treatments in connection to the
medicalisation and pathologisation of trans identity.
2. Medical explanations for trans identity are adopted by trans
people and the culture at large
Today, trans people and their allies may be the loudest force in
advocating for increased access to transition-related medical treatments
and for adding mandatory trans-specific units to medical education
programs (see Collazo et al. 2013; MacKinnon et al. 2016). Along with
institutions like the Harry Benjamin International Gender Dysphoria
Association, which later became known as the World Professional
Association for Transgender Health, trans people and empirical trans
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86
health researchers consistently argue that access to transition-related
medicine is vital for the health and well-being of the population, citing
that transitioning improves mental health and lowers risk of suicidality
(Bailey et al. 2014; Dhejne et al. 2015). These trends within the broader
population, and especially amongst trans human rights advocates,
indicate that trans experiences are becoming further integrated within a
medical model. Yet Johnson (2015) cautions that the DSM’s heavy focus
on medically transitioning sexes as a necessary action to relieve gender
dysphoria tends to obscure some trans experiences, as HRT and/or SRS
interventions are not the solution for many trans people, particularly non-
binary individuals.
The ways in which trans people embody transnormative medical
narratives provides evidence that trans people do voice medical theories.
Relying heavily on Benjamin’s 1966 book, The Transsexual
Phenomenon, clinical assessment standards for the diagnosis and
treatment of transsexualism [sic] focused on individuals’ dissatisfaction
and lack of sexual pleasure associated with their genitalia prior to SRS,
same-sex sexual desire prior to transitioning, and a convincing
performance of the ‘opposite sex’ (Eckert 2016). Given these
constraining and heteronormative clinical assessment tools working
alongside the ‘born in the wrong body’ transnormative devices, trans
people quickly learned and performed these rituals. In this way both trans
people and clinicians discursively shaped and perhaps even permanently
altered the trans identity category (Eckhert 2016).
Importantly, the recycling of transnormative medical narratives by
trans people in clinical interactions is not explicitly an error on the part
of those who desire to medically transition sexes. Rather it may be more
of a reflection of the constraints of the psychiatric care system, and the
limitations of a ‘healthy/morbid’ dichotomy (Foucault 1994). Trans
people feel that in order to meet their goal of accessing treatment and/or
being seen as a legitimate sick person, they ought to say the ‘right’ thing
to clinicians (Inch 2016). Yet a body of critical theoretical literature
delineates the underlying complexities of trans peoples’ active
participation in processes surrounding medicalisation and pathologisation
(Butler 2001; Johnson 2015; Vipond 2015). This scholarship underscores
the interactionist roles that both trans people and medical personnel play
in leveraging transnormative narratives within the growing field of
normative discourses of trans identity for the purpose of advancing
authentic diagnostic criteria, assessment, and treatment protocol. When
trans people locate their gender identity narrative in childhood, using for
instance the discursive notion of being ‘born this way’, it may have the
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unintended consequence of re-positioning gender as biologically
determined (Davis et al. 2016). In fact, Butler (2004) refers to the
courtship between trans patients and providers as an ‘instrument of
pathologisation’, highlighting transnormative medical narratives within
clinical procedures surrounding diagnoses of GID/GD. However, Butler
(2004) also cautions that the inclusion of these diagnoses in medical
manuals, and the diagnostic dances performed by patient and providers
constructs trans people as ‘ill, sick, wrong, out of order, abnormal…’ and
reifies the stigmatization of gender-variance (p. 76). With that said
however, earlier research into the dynamics of the trans community from
the 1990s (Gagne & Tewksbury 1998; Gagne et al. 1997; Schrock 1996)
indicates that at the micro-level, trans people conducted ‘accountability
practices that were deeply reliant on the medical model of transgender
identity and experience’ (Johnson 2015 p. 807). Practices of community
accountability created a culture in which the medical model of trans
identity was strictly enforced by trans people through processes of intra-
group surveillance, and those who did not subscribe to the medical
transsexual narrative (transnormativity) were scrutinized and deemed
‘not trans enough’ (Mog & Swarr 2008). But on the other hand, Butler
(2001) poignantly observes the role that trans patients play in coaching
other trans people in rehearsing the narratives necessary to espouse the
‘truth’ of transsexuality to pass through this clinical gateway. This is not
unlike Conrad and Bergey’s (2014) discussion on the role of patient
advocacy groups in assisting others in being knowledgeable of diagnostic
criteria in order to receive necessary diagnosis and treatments.
3. Medical theory for trans identity gains traction over any other
explanation
The final stage of verifying the pathologisation of trans identity is
relatively uncomplicated. Given that there are no explanations for the
existence of trans people that lie outside of the psycho-medical domain
that the author is aware of, it can be stated that medical theory provides
us with the strongest explanation for the trans phenomenon. This has
arisen in a few notable ways, but particularly through the medical
community’s exclusive focus on treating or even ‘curing’ gender
dysphoria with biomedical and pharmaceutical interventions such as
HRT and SRS, and through the emergence of neuroscientific research
studies that search for distinct trans brains.
The existence of neuropsychology research, including neuroimaging
technologies such as magnetic resonance imaging (MRI), operates in
Kinnon Ross MacKinnon
88
concert with the medicalisation and pathologisation of trans identity.
Asking whether the brain phenotype of a trans person more closely
resembles that of their natal sex or that of their gender identity group,
neuropsychologists delve into brain imaging studies (see Kreukels &
Guillamon, 2016). For instance Hahn and colleagues (2015) found that
pre-HRT MTF and FTM trans subjects’ have unique structural
connectivity in comparison to female and male ‘healthy’ controls. In fact,
a number of similar studies have found that trans subjects’ brains more
closely matched those of their same gender identity ‘healthy’ controls
than to those of their same biological sex in terms of neurons and
subcortal nuclei (Zhou et al. 1995; Garcia-Falgueras & Swaab 2008), and
structural distinctions of gray (Simon et al. 2013) and white matter
microstructure (Rametti et al. 2011a; Rametti et al. 2011b). For example,
it has been shown that the size and number neurons found in the striata
terminalis and the anterior hypothalamus of MTF trans people was
typical to that of females (Zhou et al. 1995). In all of these studies, MRI,
diffusion tensor imaging, or voxel based morphometry data is used to
compare images of trans people’s brains prior to, or following, HRT
treatments in order to draw boundaries around the brain of people who
experience gender dysphoria and identify as trans. Simon and colleagues
(2013) summarise neuroscience research related to gender dysphoria.
They explain:
A recent review about sexual differentiation of the human brain,
transsexualism [sic] might be the result of the fact that the
development of the sexual organs in the fetal life occurs well before
the sexual differentiation in the brain… The disturbance of the
testosterone surge that masculinize the fetal brain might be at the
background of GID in certain cases (p. 1).
However interesting these findings are, this area of research contributes
to the development of biomedical scientific knowledge that seeks to
study, quantify, taxonomise, and provide medical explanations for
abnormalities, underscoring Foucault’s (1994) healthy/morbid
dichotomy. As there continues to be skepticism toward research that
searches for a ‘gay gene’ (see Servick, 2014), neuroscience researchers
examining images of trans people’s brains in order to discover
differences in regional brain alterations and structural networks should
proceed with much caution and hesitation. Echoing research that aims to
discover a gay gene, brain scans attempting to map the brains of trans
people is at best a feeble attempt to make sense of a complex schema of
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human behaviours, and at worst, may hold the potential of creating a
range of future ethical issues such as verifying whose brains are
authentically trans and worthy of health insurance funded treatments, or
perhaps even selective abortion practices.
Despite much controversy psychiatric researchers and clinicians
working in the area of gender dysphoria continue to label trans identities
as a mental health condition, as evidenced in the DSM-5 (APA, 2013).
Opponents of psychiatric medial theory remind us, however, that trans
identities are not expressions of ill health, but merely deviations of social
norms, and ‘diagnosis of gender incongruence should not, therefore,
imply pathology (Walsh 2017 p. 98). In fact Parens (2013) identifies
psychiatric geneticists that state that variations in species is normal and
conditions that are thought of as ‘mental illness’ are nothing more than
the quantitative extreme of a normal distribution of traits. Even still,
some researchers argue that the association of trans identity with mental
illness is spuriously predicated on an anachronistic belief in binary
gender roles and the power of Western psychiatry to define what is
normal or deviant (Inch 2016; Walsh & Krabbendam 2017).
In sum, by using Sadler and colleague’s rubric, it has been shown that
trans identity was pathologised through various clinical interactions
between trans patients and medical personnel, advocacy on the part of
trans individuals, and the creation of discipline-specific clinical
knowledge by physicians and researchers. This confirms the ubiquitous
claims within academic and grey literature that trans identity has been
pathologised. The article now concludes with a discussion of the
limitations of this research and future directions below.
Limitations of this work and future directions
While this article substantiated the claim that trans identity has
undergone pathologisation, there are many limitations to discuss. First, a
scan and summary of the relevant scholarly literature was conducted to
illustrate the social processes that enabled the pathologisation of trans
identity. However, a full scoping or systematic review is warranted in
order to evaluate the rigor of included studies on the basis of application
of theory, data analysis, and in some cases, statistical validity.
Admittedly, this inquiry included only English-language articles that
discuss the Western European, American, and Canadian context. To fill
this gap, future work in the area of the medicalisation and
pathologisation of trans identity could look at the applicability of this
article’s argument in non-Western contexts, and perhaps even examine
Kinnon Ross MacKinnon
90
the association between globalisation and the expansion of the GID/GD
diagnosis in international contexts.
This conceptual project lacks the empirical validation that is necessary
to generate a more robust analysis of how these processes culminate in
pathologisation. In particular, future directions should prioritise
harnessing the experiences of both trans patients and medical providers
who provide health services to trans people. While the few empirical
studies discussed in this article do include researchers’ speculations on
how pathologisation shapes the clinical relationships between trans
patients and providers, the voices of those who directly contribute to the
pathologisation of trans identity is largely absent. Hence, future studies
may consider conducting qualitative interviews or focus groups with
trans and non-binary folks on themes related to medicisation and
pathologisation. Given that the vast majority of qualitative research in
the area of trans health solely engages the experiences of trans people, it
is crucial to balance these perspectives by hearing from medical
professionals. For instance, empirically collecting the insights of medical
professionals who are critical of the medical model of gender-variance
and the pathologisation of trans identity, and for whom inclusion of
GID/GD in diagnostic manuals ought not to be a precondition of
transition-related health care. Capturing these counter-viewpoints and
publishing these ideas in high-impact medical and other applied
healthcare journals is likely to influence the belief systems of physicians
and other professional health providers (MacKinnon et al. 2016). And
given the positive correlations between trans-related stigma and poor
mental health outcomes, quantitative researchers may instead take up an
exploration of rates of stigma and mental health conditions in
jurisdictions undergoing depatholigisation - where assessments for SRS
and HRT are transitioning from the domain of psychiatry to primary
care.
Lastly, in recognizing the literature’s consensus that the inclusion of
GD in the DSM and GID in the ICD contributes to the pathologisation of
trans identity and subsequent stigma faced by trans people,
complementary research could investigate the impact that clinical texts
have on trans patients and medical providers. For his unpublished
master’s thesis Rowe (2009) conducted an institutional ethnography into
trans men’s experiences accessing health care services in Ontario,
Canada. However, there are no known published studies that analyze the
ways in which these clinical texts shape, constrain, and rule the clinical
relationships between trans service users and service providers.
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CONCLUDING REMARKS
Through this conceptual exploration the ubiquitous claim that trans
identity was pathologised has been rigorously verified. Yet the status quo
assertions that pathologisation was something done to trans people by
agents of the medical institution was jettisoned in favour of a critical
inquiry into the interactionist and relational roles played by both trans
patients and medical personnel that contributed to this phenomenon.
Using a three-pronged conceptual model developed by Sadler and
colleagues (2009), it was shown that trans identity was embedded within
a medical model and underwent pathologisation through social and
clinical processes beginning in the mid-twentieth century. The
recommended next steps of this project include conducting an enhanced
systematic or scoping review, empirically studying the associations
between trans-related stigma, pathologisation/depathologisation, and
mental health outcomes, and investigating the ways in which clinical
texts such as the DSM and the ICD shape the provision of mental health
services for trans people and clinicians.
REFERENCES
American Psychiatric Association (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596.
Bailey, L., Sonja, E. J., and McNeil, J. (2014). Suicide risk in the uk
trans population and the role of gender transition in decreasing suicidal
ideation and suicide attempt. Mental Health Review Journal 19(4),
209-220. https://doi.org/10.1108/MHRJ-05-2014-0015.
Bartlett, N. H. and Vasey, P. L. (2006). A retrospective study of
childhood gender-atypical behavior in samoan fa’afafine. Archives of
Sexual Behavior 35(6), 659-666. https://doi.org/10.1007/s10508-006-
9055-1.
Beek, T. F., Cohen-Kettenis, P. T., and Kreukels, B. P. C. (2016).
Gender incongruence/gender dysphoria and its classification history.
International Review of Psychiatry 28(1), 5-12.
https://doi.org/10.3109/09540261.2015.1091293.
Benjamin H, (1966). The transsexual phenomenon. New York: The
Julian Press.
Kinnon Ross MacKinnon
92
Bouman, W. P., Richards, C., Addinall, R. M., Arango de Montis, I.,
Arcelus, J… and D., Wilson. (2014). Yes and yes again: Are standards
of care which require two referrals for genital reconstructive surgery
ethical? Sexual and Relationship Therapy 29(4), 377-389.
https://doi.org/10.1080/14681994.2014.954993.
Butler, J. (2001). Doing justice to someone: Sex reassignment and
allegories of transsexuality. GLQ: A Journal of Lesbian and Gay
Studies 7(4): 621-636.
Butler, J. (2004). Undoing gender. New York: Routledge.
Cauldwell, D. O. (1949). Psychopathia transexualis. Sexology 16, 274-
280.
Cauldwell, D. O. (1950). Questions and answers on the sex life and
sexual problems of trans-sexuals. Girard: Kansas: Halderman-Julius
Publications.
Cheng Thom, K. (2015, October 27). 6 ways the healthcare industry
needs to stop abusing trans people. Everyday Feminism. Accessed
May 10, 2017 http://everydayfeminism.com/2015/10/healthcare-
abusing-trans-folks/.
Collazo, A., Austin, A., and Craig, S. L. (2013). Facilitating transition
among transgender clients: Components of effective clinical practice.
Clinical Social Work Journal 41 (3), 228-237.
https://doi.org/10.1007/s10615-013-0436-3.
Conrad, P. (1975). The discovery of hyperkinesis: notes on the
medicalisation of deviant behaviour. Social Problems 23(1): 12-21.
https://doi.org/10.2307/799624.
Conrad, P. (1979). Types of medical social control. Sociology of Health
& Illness 1(1), 1-11. https://doi.org/10.1111/1467-9566.ep11006751.
Conrad, P. (1992). Medicalisation and social control. Annual Review of
Sociology 18, 209-32. https://doi.org/10.1146/annurev.so.18.080192.001233.
Conrad, P. (2005). The shifting engines of medicalisation. Journal of
Health & Social Behavior 46(1), 3-14.
https://doi.org/10.1177/002214650504600102.
Conrad, P. (2007). The medicalisation of society: On the transformation
of human conditions into treatable disorders. Baltimore: John Hopkins
University Press.
Conrad, P., and Barker, K. K. (2010). The social construction of illness:
Key insights and policy implications. Journal of Health and Social
Behaviour 5(1), S67-79. https://doi.org/10.1177/0022146510383495.
Theory in Action
93
Conrad, P., and Bergey, M. R. (2014). The impending globalization of
ADHD: Notes on the expansion and growth of a medicalized disorder.
Social Science & Medicine 122, 31-43.
https://doi.org/10.1016/j.socscimed.2014.10.019.
Conrad, P. and Schneider, J. W. (1992). Deviance and medicalisation:
From baldness to sickness. Philadelphia, PA: Temple University Press.
Cohen-Kettenis, P. T., and Pfafflin, F. (2010). The dsm diagnostic
criteria for gender identity disorder in adolescents and adults. Archive
of Sexual Behaviour 39, 499-513. https://doi.org/10.1007/s10508-009-
9562-y.
DeCuypere, G. D., Knudson, G. and Bockting, W. (2010). Response of
the world professional association for transgender health to the
proposed dsm 5 criteria for gender incongruence. International
Journal of Transgenderism 12, 119-123.
https://doi.org/10.1080/15532739.2010.509214.
Davis, G., Dewey, J. M., and Murphy, E. L. (2016) Giving sex:
Deconstructing intersex and trans medicalisation practices. Gender &
Society 30 (3), 490-514. https://doi.org/10.1177/0891243215602102.
Dhejne, C. Van Vlerken, R., Heylens, G., and Arcelus, J. (2016). Mental
health and gender dysphoria: A review of the literature. International
Review of Psychiatry 28(1), 44-57.
https://doi.org/10.3109/09540261.2015.1115753.
Drescher, J. (2013). Controversies in gender diagnoses. LGBT Health 1:
10-14. https://doi.org/10.1089/lgbt.2013.1500.
Eckhert, E. (2016) A case for the demedicalisation of queer bodies. Yale
Journal of Biology and Medicine 89(2), 239-246.
Ekins, R., and King, D. (2001). Pioneers of transgendering: The popular
sexology of david o. cauldwell. The International Journal of
Transgenderism 5(2), https://www.atria.nl/ezines/web/IJT/97-
03/numbers/symposion/cauldwell_01.htm.
Foucault, M. (1994). The birth of the clinic: An archaeology of medical
perception. New York: Vintage Books.
Friedson, E. (1970). Profession of medicine: A study of the sociology of
applied knowledge. New York: Harper and Row.
Gagne, P. and Tewksbury, R. (1998). Conformity pressures and gender
resistance among transgender individuals. Social Problems 45(1), 81-
101. https://doi.org/10.1525/sp.1998.45.1.03x0158b
Gagne, P., Tewksbury, R., and McGaughney, D. (1997). Coming out and
crossing over: Identity formation and proclamation in a transgender
community. Gender & Society 11(4), 478-508.
https://doi.org/10.1177/089124397011004006.
Kinnon Ross MacKinnon
94
Holmes, M. (2002). Rethinking the meaning and management of
intersexuality. Sexualities 5(2), 159-179.
https://doi.org/10.1177/1363460702005002002.
Inch, E. (2016). Changing minds: The psycho-pathologization of trans
people. International Journal of Mental Health 45(3), 193-204.
https://doi.org/10.1080/00207411.2016.1204822.
Jacob, J. D., Gagnon, M., McCabe, J. (2014). From distress to illness: A
critical analysis of medicalisation and its effects in clinical practice.
Journal of Psychiatric and Mental Health Nursing 21, 257-263.
https://doi.org/10.1111/jpm.12078.
Johnson, A. H. (2015). Normative accountability: How the medical
model influences transgender identities and experiences. Sociology
Compass 9(9), 803-813. https://doi.org/10.1111/soc4.12297.
Kosenko, K., Rintamaki, L., Raney, S., and Maness, K. (2013).
Transgender patient perceptions of stigma in health care contexts.
Medical Care 51(9), 819-22.
https://doi.org/10.1097/MLR.0b013e31829fa90d.
Kreukels, B. P. C., and Guillamon, A. (2016). Neuroimaging studies in
people with gender incongruence. International Review of Psychiatry
28(1), 120-128. https://doi.org/10.3109/09540261.2015.1113163.
Lev, A. I. (2013). Gender dysphoria: Two steps forward, one step back.
Clinical Social Work Journal 41, 288-296.
https://doi.org/10.1007/s10615-013-0447-0.
MacKinnon, K. R., Tarasoff, L. A., and Kia, H. (2016). Predisposing,
reinforcing, and enabling factors of trans-positive clinical behavior
change: A summary of the literature. International Journal of
Transgenderism 17(2), 83-92.
https://doi.org/10.1080/15532739.2016.1179156.
Medicine, B. (2002). Directions in gender research in american indian
societies: Two spirits and other categories. Online Readings in
Psychology and Culture, Unit 3. Retreived from
http://scholarworksgvsu.edu/orpc/vol3/iss1/2. https://doi.org/10.9707/2307-
0919.1024.
Mizock, L. (2017). Transgender and gender diverse clients with mental
disorders: Treatment issues and challenges. Psychiatric Clinics of
North America 40, 29-39. https://doi.org/10.1016/j.psc.2016.10.008.
Mog, A. and A. L. Swarr. (2008). Threads of commonality in
transgender and disability studies. Disability Studies Quarterly 28(4).
Accessed May 10, 2017 http://dsq-sds.org/article/view/152/152.
https://doi.org/10.18061/dsq.v28i4.152.
Theory in Action
95
Parens, E. (2013). On good and bad forms of medicalisation. Bioethics
27(1), 28-35. https://doi.org/10.1111/j.1467-8519.2011.01885.x.
Parsons, T. (1951). The Social System. Glencoe, IL: The Free Press.
Purdy, L. (2001). Medicalisation, medical necessity, and feminist
medicine. Bioethics 15(3), 284-261. https://doi.org/10.1111/1467-
8519.00235.
Pyne, J. (2014). The governance of gender non-conforming children: A
dangerous enclosure. Annual Review of Critical Psychology 11, 79-96.
Rametti G., Carillo, B. Gomez-Gil, E. Junque, C., Sergovia, S. and
Guillamon, A. (2011a). White matter microstructure in female to male
transsexuals before cross-sex hormonal treatment. A diffusion tensor
imagining study. Journal of Psychiatric Research 45(2), 199-204.
https://doi.org/10.1016/j.jpsychires.2010.05.006.
Rametti G., Carillo, B. Gomez-Gil, E. Junque, C., Sergovia, S., … and
Guillamon, A. (2011b). The microstructure of white matter in male to
female transsexuals before cross-sex hormonal treatment. A DTI
study. Journal of Psychiatric Research 45(7), 949-954.
https://doi.org/10.1016/j.jpsychires.2010.11.007.
Rector, F. (1981) The nazi extermination of homosexuals. New York:
Stein and Day.
Reicherzer, S. (2008). Evolving language and understanding in the
historical development of the gender identity disorder diagnosis.
Journal of LGBT Issues in Counseling 24 (4), 326-347.
https://doi.org/10.1080/15538600802502035.
Rowe, W. (2009). Auditioning for care: Transsexual men accessing
health care (Unpublished master’s thesis). McMaster University,
Hamilton, ON.
Sadler, J. Z., Jotterand, F., Craddock Lee, S. and Inrig, S. (2009). Can
medicalisation be good? Situating medicalisation within bioethics.
Theoretical Medical and Bioethics 30, 411-425.
https://doi.org/10.1007/s11017-009-9122-4.
Schwalbe, M. and Shrock, D. (1996). Identity work as group process.
Advances in group process 13, 113-147.
Schilt, K. & Westbook, L. (2009). Doing gender, doing
heteronormativity: “gender normal,” transgender people, and the social
maintenance of heterosexuality. Gender & Society 23(4), 440-464.
https://doi.org/10.1177/0891243209340034.
Schrock, D. (1996). Transsexuals’ narrative construction of the ‘true
self’. Social Psychology Quarterly 59, 176-192.
https://doi.org/10.2307/2787018.
Kinnon Ross MacKinnon
96
Servick, K. (2014). New support for ‘gay gene’. Science 346 (6212),
902. https://doi.org/10.1126/science.346.6212.902.
Shipherd, J.C., Green, K.E., and Abramovitz, S. (2010). Transgender
clients: Identifying and minimizing barriers to mental health treatment.
Journal of Gay & Lesbian Mental Health 14, 94-108.
https://doi.org/10.1080/19359701003622875
Simon, L., Kozak, L. R., Simon, V., Czobor, P., Unoka, Z., … Csukly,
G. (2013). Regional grey matter structure differences between
transsexuals and healthy controls – a voxel based morphometry study.
PLOS One 8(12), 1-10. https://doi.org/10.1371/journal.pone.0083947.
Smith, D. T. (2014). The diminished resistance to medicalisation in
psychiatry: Psychoanalysis meets the medical model of mental illness.
Society & Mental Health 4(2), 75-91.
https://doi.org/10.1177/2156869313512211.
Snelgrove, J. W., Jasudavisius, A. M., Rowe, B. W., Head, E. M., and
Bauer, G. R. (2012) “Completely Out-At-Sea with Two-Gender
Medicine”: A qualitative analysis of physician-Side barriers to
providing healthcare for transgender patients.” BMC Health Services
Research 12(110), 1-13. https://doi.org/10.1186/1472-6963-12-110.
Stryker, S. (2008). Transgender history. Berkeley, CA: Seal Press.
Vipond, E. (2015). Resisting transnormativity: Challenging the
medicalisation and regulation of trans bodies. Theory in Action 8(2),
21-44. https://doi.org/10.3798/tia.1937-0237.15008.
Walsh, R. and Krabbendam, L. (2017). How social norms affect
psychiatric approaches to gender incongruence. The Lancet 4(2), 98.
World Health Organization. (1992). The ICD-10 classification of mental
and behavioral disorders: Clinical descriptions and diagnostic
guidelines. Geneva; World Health Organization.
Zhou J.N., Hofman, M.A., Gooren, L. J., and Swaab D. F. (1995). A sex
difference in the brain and its relation to transsexuality. Nature 378,
68-70. https://doi.org/10.1038/378068a0.
Zola, I. K. (1972). Medicine as an institution of social ontrol. Sociology
Review 20, 487-504. https://doi.org/10.1111/j.1467-
954X.1972.tb00220.x
Zola, I. K. (1983). Socio-medical inquiries. Philadelphia: Temple
University Press.
