psychiatry

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New article: Transnormativity in the psy disciplines

Today sees the publication of the first full article from the Trans Pregnancy project team, in the journal American Psychologist:

Transnormativity in the psy disciplines: Constructing pathology in the Diagnostic and Statistical Manual of Mental Disorders and Standards of Care

[click here to read in American Psychologist]

[click here to read free open access version]

In this article we provide a brief history of how certain narratives and expectations around how trans people should behave and be treated have been constructed through the disciplines of psychology, psychiatry, psychotherapy, and psychoanalysis, especially in a US context.

It is part of a great new special issue on Histories of psychology after Stonewall, edited by Peter Hegarty and Alexandra Rutherford.

We examine how the interests of cisgender clinicians and transgender patients have variously been opposed and entwined, and contextualise this in relation to wider structures of racism, sexism, colonialism, and binary thinking around sex and gender. We focus especially on how guidance for diagnosing trans people and managing trans healthcare has been contested across various versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (the DSM) and the International Harry Benjamin Gender Dysphoria Association (HBIGDA, later WPATH) Standards of Care.

This article does not focus specifically on questions of fertility, pregnancy and childbirth (although we briefly touch very on this topic). Rather, it provides important historical background on the evolution of certain medical services which have help to shape how trans people are treated and percieved. We are also currently writing a number of articles that will report on specific research findings from the Trans Pregnancy project, and I am really looking forward to sharing them also when they are published!

 

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Some tips on opposing Kenneth Zucker’s new article on trans children

This morning it came to my attention that notorious child psychologist Kenneth Zucker has co-written a chapter on trans issues for the new (6th) edition of Rutter’s Child and Adolescent Psychiatry. The chapter, entitled “Gender dysphoria and paraphilic sexual disorders” effectively draws upon flawed and outdated research to promote reparative therapy for trans children. You can read most of it via Google Books here.

Cover of Rutter's Child and Adolescent Psychiatry

Abusing children – for science!

This is a big deal because Zucker draws upon harmful theories (including Ray Blanchard’s deeply reductive typology of transsexualism) to promote the idea that issues faced by gender variant children are due to a problem with the child, rather than societal gender norms. He therefore promotes a form of treatment that (to quote his new article) encourages parents to “set limits with regard to cross-gender behaviour, and encourage same-sex peer relations and gender-typical activities” in an attempt to cure them of difference. This is the kind of treatment that leads children to internalise the idea that non-normative gendered expression is shameful or wrong.

Rutter’s Child and Adolescent Psychiatry, meanwhile, is a widely-used textbook and can be found in university libraries and on reading lists in many countries.

I’m not sure what the best way is to stop this article from influencing practice. However, some ideas could include:

  • Write to professional organisations and ask them to explicitly oppose reparative therapy for trans youth
  • Write to University libraries and courses, asking them to consider sticking with the 5th edition of Rutter’s
  • Write to University departments and ask them to teach critical texts alongside the 6th edition of Rutter’s, and/or avoid putting the new edition on reading lists
  • Borrow the book from a local library if it becomes available, and write critical comments in the margins
  • Write to the book’s editors and/or publisher and question why Zucker has been given a platform for his outdated ideas
  • Comment on this post and/or join this new Facebook page to discuss possible ways forward.

The new edition isn’t yet widely available in libraries, so now is a good time to act.

If you’re writing letters or raising awareness of this as an issue, here is some useful information on opposing the article:

  • Zucker’s approach to treatment can seriously harm children
  • Zucker’s Gender Identity Service at the Toronto-based Centre for Addiction and Mental Health was recently suspended pending investigation in the wake of a large number of complaints – his approach to treatment is now also arguably illegal in the province of Ontario
  • Zucker’s new article represents poor academic practice. He cites himself 17 times, relies upon papers at least 20 years out-of-date to make many of his arguments, and also draws strong inferences from statistically insignificant quantitative findings
  • Zucker’s considerable academic position is based in part upon a small “invisible college” of academics who regularly peer-review and cite one another, thereby gaining many publications with a high profile whilst avoiding external criticism
  • There is a considerable evidence-based case to be made against Blanchard’s work. See for instance “The Case Against Autogynephilia“, a peer reviewed article by Julia Serano.

Thanks and respect to Peter Le C for raising awareness of this issue, and to oatc for suggested edits.

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Natacha Kennedy at TRED 2011

Natacha’s talk at TRED 2011. The bulk of this presentation is a witty response to Az Hakeem’s 2010 paper Deconstructing Gender in Trans-Gender Identities. Natacha herself deconstructs three central arguments present within the paper:

1) Trans people can be prevented from having genital reassignment surgery through group therapy.

2) Gender is becoming less rigid for cis people but more rigid for trans people.

3) Sex is “real” and scientifically verifiable, whereas gender is not.

The talk concludes with a brief reflection upon the work of Kenneth Zucker and the “normality” of trans and intersex phenomena.

 

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Lyndsey Moon at TRED 2011

Lyndsey’s talk at TRED 2011, which formed the introduction to an open discussion of numerous topics including psychology, pathologisation, and the place of gender variant voices in academia.

In the talk Lyndsey explores a number of issues centring around counselling and therapy, including:

  • the (lack of) training practitioners receive on gender issues.
  • the attitudes that many trainee and practising counsellors and therapists hold regarding trans people
  • experiences of teaching PhD candidates about gender and sexuality
  • the impact of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)
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Trans* Education and Determination: footage available from the event

A number of videos from the Trans* Education and Determination teach-in, kindly filmed by Natacha Kennedy, are now available on Vimeo.

There isn’t yet footage available for every speaker, but more videos are due to follow soon. I hope these will fulfil a key promise of the event: to reach beyond those able to attend on the day, and stimulate wider discussion.

It is in this spirit that I hope others might consider filming or writing responses and/or their own thoughts on the consequences of psychology, psychiatry, academia and feminism for trans people and trans rights.

Perhaps you could organise your own teach-in? TRED organisers and participants are already discussing possibilities for future events, but there’s no reason why any given group of people can’t put one together. Some notes for the future are available on the TRED blog.

On a slightly different note, I’m considering an event based upon the TRED videos at my own university. It shouldn’t be too hard to screen some of the footage from the even as a starting point for discussion.

Finally, I’ll be posting each presentation from the first TRED on this blog, along with a transcription. I hope you enjoy them as much as we did on the day!

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Trans* Education and Determination: a review

The Trans*Trans feminist symbol, designed by Helen G Education and Determination teach-in took place on Friday 20th May: the date on which a cancelled psychiatric event was intended to take place. It featured a number of talks, presentations and workshops exploring issues such as trans academia, counselling, psychiatric practice, and feminism.

The teach-in was a great success, and will hopefully lay the groundwork for future such events. This community effort – organised on the internet by a loose team of volunteers – was a powerful rebuke to the medical and psychiatric institutions that claim to speak for trans people whilst denying us a voice.

Trans* Education and Determination was originally envisaged as a response to the Royal College of Psychiatrists’ event Transgender: Time to Change, which was due to feature two transphobic speakers: Dr Az Hakeem and Julie Bindel. This event was cancelled following the announcement of a trans community protest and the withdrawal of support from Charing Cross Gender Identity Clinic. However, the decision was taken to go ahead with the teach-in.

Almost thirty people arrived at King’s College London for the launch of the teach-in on the Friday morning. This number gradually grew throughout the day as attendees freely came and went from the open event. Cheryl Morgan, Roz Kaveney and Juliet Jacques volunteered to act as chairs, taking turns to introduce speakers and facilitate questions and discussions.

PhD student Ruth Pearce informally opened the event during the introduction to her talk. She explored the theme of articulation, arguing that the teach-in offered a valuable opportunity to give voice to trans experiences and perspectives.

Ruth’s presentation offered some background on the evolution of trans academia and suggested that the internet has played a particularly powerful role in shaping the recent history of trans identity and community. She then provided some details of her planned research project, which will explore trans experiences of primary healthcare in the United Kingdom.

Attendees asked about Ruth’s research methods, which involve acquiring data from online communities. This led to a valuable discussion that explored the potential advantages, pitfalls and ethical implications of internet research.

Lunch was followed by a talk given by psychologist and sociologist Dr Lyndsey Moon. Lyndsey drew upon her experiences as a queer child, a practising counsellor and a teacher to critique the rigidity and contingency of psychiatric categorisation, particularly that found in the American Psychological Association’s Diagnostic and Statistical Manual (DSM). This talk illustrated the DSM’s failure to account for fluidity and complexity, and the danger this poses for professional understandings of gender and sexuality.

Lyndsey also explained how her own research had demonstrated that psychologists and psychiatrists receive practically no training on the impact of social phenomena such as gender, sexual orientation, disability, race and religion. She argued that psychology and psychiatry remain broadly white, middle-class and abled professions in the UK.

Attendees expressed their broad agreement with Lyndsey’s points and joked about artificiality of psychiatric classification. A number of individuals explained how they’d been treated poorly within academia because of the transphobic assumptions made about them.

Academic Natacha Kennedy provided an extended examination of Dr Az Hakeem’s 2010 paper “Deconstructing Gender in Trans-Gender Identities”. In this article, Hakeem argued that trans people reinforce gender norms, and advocated group therapy as an alternative to transition and stated.

Natacha questioned the logic of Hakeem’s claims, and demonstrated how he failed to provide evidence about many of his statements. Her frequently amusing deconstruction demonstrated how the paper relied greatly upon ideological statements rather than evidence-based study.

The presentation concluded with some background on the approach of Kenneth Zucker, a practitioner with somewhat more extreme views than Hakeem who is contributing to the next edition of the DSM. Natacha explained how her own research findings contradict some of Zucker’s claims during an anecdotal account of a previous trans protest.

NUS LGBT representative Kai Weston shared his perspective on the intersection of trans experiences and feminism. He provided a refutation of the radical feminist position held by Julie Bindel, drawing upon examples of gender variance from non-western societies and within trans communities to counter her argument that trans people reinforce binary gender norms.

Kai’s thoughts provided the introduction to an extended group discussion of intersectionality and the impact of feminist theory on trans lives. Attendees asserted the importance of countering sexism and misogyny whilst exploring the relative benefits and disadvantages of different feminist positions. Issues such as the invisibilisation of transmasculinity and the tensions between trans and intersex activism were also touched upon.

Journalist Jane Fae provided the final talk of the day, a deeply personal critique of psychiatry. She explained how Freud in particular relied upon deeply unrepresentative samples in order to justify his theory, suggesting that Freudian psychiatry therefore owes considerably more to abstract theorising than to empirical evidence. She provocatively claimed that the psychiatric profession and its accompanying academic literature is a psuedo-scientific scam.

Jane finished her talk with an emotional attack upon the psychiatric gatekeeping that requires trans patients to spend a considerable amount of time and/or money in order to pursue a physical transition.

The audience broadly welcomed the uncompromising central thrust of Jane’s argument, although there were some counter-examples illustrating benefits that psychiatry can bring. There was some confusion over the boundaries between psychiatry, psychology and psychotherapy, with a number of suggested solutions proposed.

Attendees broke away for individual discussions before the day finished with group feedback on the day, in which everyone present was offered the opportunity to share their thoughts and feelings. Positive criticism of the teach-in was shared with an eye towards similar events for the future.

Some felt that a less academic or “studenty” feel might help appeal to a wider audience. A number of individuals argued that any future events should remain free, although the possibility of a sliding scale entry fee was also suggested. Many agreed upon the idea of holding future trans teach-ins outside of London, hopefully within a somewhat more accessible, non-university building. It was also felt that more could be done to reach out to groups under-represented at the event, such as minority ethnic trans people.

Everyone welcomed the positive, productive atmosphere of the event, and thanks were offered to the many volunteers who worked hard to make the day a success.
Trans feminist symbol designed by Helen G.

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(Guest Post) Turn and Face the Strange

The following was written by Louis, who recently experienced an appointment with “Dr Jiff” that unfolded pretty much as outlined.


“But let me tell you, this gender thing is history. You’re looking at a guy who sat down with Margaret Thatcher across the table and talked about serious issues.”
– George H. W. Bush

One morning, as I awoke from anxious dreams, I discovered that in my bed I had been transformed into exactly the same body as I had been the night before.

Examination of my whole organic structure proved this to be true, and as my mother greeted me normally in the kitchen, my feeling of de-centralised horror was crystallised. Most people, upon waking to find themselves the same, would find reassurance in the stability of their own identity – unchanged by the nights stargazing. To the average man or woman, the roaming of a well-gendered mind at rest is a pleasure. I, however, on that morning, realised that my unprecedented disquiet was the beginning of something. I was right. I have not been quite at home with myself since.

Psychology today is a noble hobby, halfway between a humanity and a science. I tend to lean towards the side of art.

On the 9th December, 2010, I find myself sitting in the office of Dr Jiff in University Hospital Coventry. It’s the psychiatric clinic. I’ve spent half an hour waiting outside, before being beckoned, with a smile, into this room, where I am to give the performance of my life. My part: Myself, as the National Health Service wants to see me. The office is large and sparse, with high, grey windows and navy blue carpet. It’s warm, however, and my chair is comfortable. Not a couch, but a plain lavender seat by the doctor’s desk. Dr Jiff himself is something of a surprise. After all I’ve heard, here is a man in his twilight years: rotund, moustached, with yellow sweat patches under his arms. A fair tie, mind you – M&S perhaps.

He has an affable face, and is delightfully frank in all things… though as usual for a psychiatrist, his eyes are mirrored walls. This is our first meeting. As I write, I expect many more: my performance this day is a surprising success.

To begin to understand the nature of my madness, I would first have to explain what madness actually is, in a social context at least. I’m sure you have your own ideas on the matter, but here’s my take on the state of things. Madness is a state of mind which society as a whole (or perhaps the ideal that society projects of itself, and never seems to actually get to) finds to be outside the bounds of “normal”. Sometimes madness is considered genius. Sometimes geniuses go mad. More often than not, madness is considered a rather dangerous or undesirable thing to have around. The more cutting amongst you may have noticed that I didn’t define what “normal” is. That’s because I truly have no idea.

In Psychology and Psychiatry, different kinds of madness are categorised and given different names. The name for my particular type of madness is Gender Dysphoria. It has an average occurrence, according to the NHS, of about 1 in every 4000 people in the UK – though it is important to note that these are only those individuals seeking treatment. Estimates have been made suggesting that 1 in every 1000 people may experience gender dysphoric feelings, or even 1 in every 120. Some psychiatric organisations have suggested that there are perhaps 500,000 gender dysphoric people in the UK, and 10,000 who have successfully asked for, and received, treatment. Statistically speaking, you’ve probably met at least 3 people with some level of gender dysphoria within the last 5 years of your life. Whether or not you were aware is a moot point.

The treatment of my disorder is seen with some contempt by the general populace – it requires the breaking of ancient rules of civilisation. This sounds more exciting than it really is. In day to day life, I’m perpetually astonished by how seriously people take gender labels, and how violently they will react against those individuals who wish to put their hand up halfway through the lesson, and say “Excuse me, I think you got that bit wrong.”

On the 19th of August 1992, a gender dysphoric person was removed surgically from its mother’s stomach and placed (screaming, purple and bloody) into the world, possessing all the appearance of female genitalia. Because of this, a somewhat tenuous, but deeply historic and traditional, social categorisation was made, and it was assigned the gender role of “female”. However, the gender label which it now identifies with, if it has to at all (and that is a whole other debate), is “male”. Some people interpret this in the following way:

“She wants to be someone else” OR “She wants to be a man.”

A gender dysphoric person find this degrading and frustrating. As far as they are concerned, they have always been the same person, and will always be the same person, in one form or another. I summarise the following:

“He is a man, and if society wishes to hang so much meaning and status on gender pronouns – a figment of language no less – then it can at least have the decency to let people identify themselves, rather than thrusting identity upon them at a stage where they can’t argue back.”

Dr Jiff’s office, on the 9th of December, is a pleasant change from the usual hostility. To begin with, he has assured me that there are “unlikely” to be any problems in my referral. I explain the issues I have had when trying to achieve this in the past, and he shrugs off the ignorance of some in his profession with a simple:

“Some people just don’t go to enough conferences.”

Then:

“Do you masturbate?”

(Don’t tell me that wouldn’t knock you off balance a bit.)

“Yes.”

“Any particular fantasies?”

“Hmm.” I pull the face which I always pull when planning to politely lie. “No, just generic men.”

(Really, I have an imagination.)

“How do you identify – put into words?”

“Gay male, polyamorous.”

“Do you dream in colour or black and white?”

“Colour.”

“How do you place yourself within your dreams?”

(I want to say ‘the victim’, but I don’t.)

“Omnipresent.”

“And male or female?”

“I don’t see.”

“Any suicidal tendencies?”

“Nothing unusual. I saw a counsellor, it’s all in my notes and over with.”

And so on.

This stream of banal, sometimes cryptic, often probing questions, will determine the course of the rest of my life. In the end I “perform” so well that I achieve the referral and more: a fast track to a new clinic, with treatment as good as guaranteed in 3 months. The gatekeeper has been defeated. Apparently, the land of maleness is mine for the  exploration, chatting-up, styling, drawing, eating, sucking, dressing, drinking, writing, injecting, rubbing, wanking, fucking, and taking. And the clothes. I’ll be able to wear a pair of trousers on hips that aren’t just-too-wide, and a suit tailored to fit a new figure – simple pleasures hard won. Why choose soft curves when you can have hard lines? I know which I find easier to follow. But I digress.

“What do you know about the surgical options?” Doctor Jiff asks.

“First you have to ‘live the life’ for 2 years.”

“Yes that’s right, how long’s it been for you now?”

“2 months. Facebook proves it.”

“Good. And what were you considering?”

“Phalloplasty looks generally crap. I want top-surgery though.”

“Yes. The success rates for breast reduction and removal are excellent. How big are your boobs?”

(I can’t describe the impact of words like ‘boobs’ leaving this man’s lips.)

“Small.”

“Well it will be a question of finding the right surgeon, but I can help you.”

“Thanks.”

“Phalloplasty, though, is a tricky one. In 2 years time when you’re eligible, things may have changed completely, but at the moment it’s a poor sport. What you really want is to be able to feel and to experience, which as things stand in the field is not particularly attainable, so unless you suddenly become desperate for a penis, it’s worth avoiding for now. I mean, can you have a really good orgasm with what you’ve got?”

“…Yes.”

“Then that’s good, and anyway, there are things you can do with a strap-on, especially anally, that just can’t be done by natural men.”

(It’s only after I leave the room that it occurs to me to laugh and laugh.)

The question of my sexuality is only mentioned in passing. I have heard several, interesting viewpoints on it. My good friend L___ was rather surprised when I suggested that there was any problem. “But 80% of the female population are straight,” he argued, “So surely 80% of transmen are gay? It’s just logic.” I thanked him for this excellent piece of reasoning.

Others, however, have been less supportive. The first psychiatrist I saw to try and obtain a referral was quite obstinate in her belief that a transman couldn’t possibly be gay, because all transmen must surely be lesbians who just couldn’t face up to their sexuality. “I like anal sex,” I told her, just for the hell of it. She didn’t appreciate that. Of course, there lies another minefield of debate: my under-eighteens counsellor pointed out that with my total lack of sexual  experience of any kind, how could I possibly know what I was attracted to? This, to me, seems like a rather foolish question, and leads me to assert a rather controversial fact:

Nobody knows a person as well as they know themself.

That point made, it is interesting to note the breadth of reactions that a trans or gender dysphoric person may receive in their exploration of this idea. Imagine meeting someone you have known since infancy for coffee. The two of you make small talk and enjoy each other’s company, then out of the blue, your friend tells you that they have to say something important: they are not really brunette at all, they are actually blonde. To the evidence of your own eyes, this is ridiculous, and you say so. No, they explain, the brown is dye. I’ve been covering this up for my whole life.

Of course, hair colour is a somewhat less mind-bending issue than gender, but the premise is similar. Imagine the same conversation, but instead your friend reveals that they are homosexual. This is slightly more controversial. To   someone like me it doesn’t matter at all, but of course to many people, this is a genuinely world-altering piece of information. Now, imagine your friend putting down their coffee cup, and telling you that they are actually the opposite gender.

Imagine walking away with that information in your mind.

Surely you know them better than that? Don’t you?

If you need to stick a label on them to understand them, do you really know them at all?