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Finding natural variation: assembling underdetermined evidence of gender dysphoria, doing trans therapeutics

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Abstract

Trans medicine has historically naturalized a heterosexual binary model of gender by treating variation as aberrant. Gender dysphoria, the current psychiatric diagnosis that often facilitates trans medicine, is represented by mental health experts and LGBTQ groups as a superficial semantic shift in this tradition. Based on in-depth interviews with experts who crafted gender dysphoria for the fifth edition of the Diagnostic and Statistical Manual (DSM-5) in 2013 and archival study of the experts’ research process, I find far more than semantics at stake. Because experts had an imperative for evidence-based revisions to the DSM-5 and an underdetermined research based on gender identity development, their revision affirms gender variation as natural and non-pathological. Gender dysphoria is maintained as a mental disorder because experts insist on its importance for the institutional legitimation of trans people, not because gender variation is understood to be pathological. This move toward treating gender variation as a flexible spectrum of illness and wellness required a new scientific interpretation of evidence. This interpretation (1) finds underdetermined research to be credible evidence of natural variation and (2) applies this variation simultaneously to traits (like gender) and also to health status. Consequently, natural variation becomes a scientific finding.

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Notes

  1. “Trans” is how I refer to a broad group or community of people with non-normative gender identities and experiences. I use the term “gender-variant” to more accurately reflect the clinical language of experts when discussing the subjects of their work.

  2. “Gender dysphoria” is introduced here in quotes to indicate that I am referring to the psychiatric diagnosis which may or may not be the actual experience of dysphoria that many trans people have. In this article, gender dysphoria will refer to the diagnosis rather than the experience unless specified otherwise and will not appear in quotes.

References

  • American Psychiatric Association. 1980. Diagnostic and statistical manual of mental disorders, 3rd ed. Washington: American Psychiatric Association.

    Google Scholar 

  • American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders, 4th ed. Washington: American Psychiatric Association.

    Google Scholar 

  • American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders, 5th ed. Washington: American Psychiatric Association.

    Google Scholar 

  • Bayer, R. 1981. Homosexuality and American Psychiatry: The politics of diagnosis. New York: Basic Books.

    Google Scholar 

  • Berg, M., and S. Timmermans. 2003. The gold standard: The challenge of evidence-based medicine. Philadelphia: Temple University Press.

    Google Scholar 

  • Bryant, K. 2006. Making gender identity disorder of childhood: Historical lessons for contemporary debates. Sexuality Research & Social Policy 3 (3): 23–39.

    Google Scholar 

  • Cambrosio, A., P. Keating, T. Schlich, and G. Weisz. 2006. Regulatory objectivity and the generation and management of evidence in medicine. Social Science and Medicine 63 (1): 189–199.

    Google Scholar 

  • Clarke, A., J. Shim, L. Mamo, J. Fosket, and J. Fishman. 2003. Biomedicalization: Technoscientific transformations of health, illness, and U.S. biomedicine. American Sociological Review 68 (2): 161–194.

    Google Scholar 

  • Cohen-Kettenis, P., and F. Pfäfflin. 2010. The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior 39 (2): 499–513.

    Google Scholar 

  • Conrad, P. 1992. Medicalization and social control. Annual Review of Sociology 18: 209–232.

    Google Scholar 

  • Daley, A., and N. Mulé. 2009. LGBTQs and the DSM-5: A critical queer response. Journal of Homosexuality 61 (9): 1288–1312.

    Google Scholar 

  • Davis, G. 2015. Contesting Intersex: The Dubious Diagnosis. New York: New York University Press.

  • Dean, M. 2010. Power at the heart of the present: Exception, risk, and sovereignty. European Journal of Cultural Studies 13 (4): 459–475.

  • Decoteau, C.L. 2013. Exclusionary inclusion and the normalization of biomedical culture. JAmerican Journal of Cultural Sociology 1 (3): 403–430.

    Google Scholar 

  • Deogracias, J., L. Johnson, H. Meyer-Bahlburg, S. Kessler, J. Schober, and K. Zucker. 2007. The gender identity/gender dysphoria questionnaire for adolescents and adults. Journal of Sex Research 44 (4): 370–379.

    Google Scholar 

  • Diamond, L., and M. Butterworth. 2008. Questioning gender and sexual identity: Dynamic links over time. Sex Roles 59: 365–376.

    Google Scholar 

  • Drescher, J. 2010. Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior 39 (2): 427–460.

    Google Scholar 

  • Drescher, J., and W. Byne. 2012. Gender dysphoric/gender variant (GD/GV) children and adolescents: Summarizing what we know and what we have yet to learn. Journal of Homosexuality 59 (3): 501–510.

    Google Scholar 

  • Eder, S. 1950s. The volatility of sex: Intersexuality, gender, and clinical practice in the 1950s. Gender & History 22 (3): 692–707.

    Google Scholar 

  • Epstein, S. 1995. The construction of lay expertise: AIDS activism and the forging of credibility in the reform of clinical trials. Science, Technology, & Human Values 20 (4): 408–437.

    Google Scholar 

  • Eyal, G. 2013. For a sociology of expertise: The social origins of the autism epidemic. American Journal of Sociology 118 (4): 863–907.

    Google Scholar 

  • Fausto-Sterling, A. 2000. Sexing the body: Gender politics and the construction of sexuality. New York: Basic Books.

    Google Scholar 

  • Frances, A. 2014. Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: HarperCollins.

    Google Scholar 

  • Foucault, M. 1978. History of sexuality: An introduction, vol. 1. New York: Vintage Books.

    Google Scholar 

  • Gill-Peterson, J. 2014. The technical capacities of the body: Assembling race, technology, and transgender. Transgender Studies Quarterly 1 (3): 402–418.

    Google Scholar 

  • Greenberg, G. 2013. The book of Woe: The DSM and the unmaking of psychiatry. New York: Plume.

    Google Scholar 

  • Grossman, J., and F.J. MacKenzie. 2005. The randomized clinical trial: Gold standard, or merely standard? Perspectives in Biology and Medicine 48 (4): 516–534.

    Google Scholar 

  • Haraway, D. 2016 [1991]. A cyborg manifesto: science, technology, and socialist feminism in the late twentieth century. In: Manifestly haraway, ed. Wolfe, C, 5–90. Minneapolis: University of Minnesota Press.

  • Hennessy, E. 2018. The politics of a natural laboratory: Claiming territory and governing life in the Galápagos Islands. Social Studies of Science 48 (4): 483–506.

    Google Scholar 

  • Heyes, C., and J.R. Latham. 2018. Trans surgeries and cosmetic surgeries: The politics of analogy. Transgender Studies Quarterly 5 (2): 174–189.

    Google Scholar 

  • Horwitz, A. 2002. Creating mental illness. Chicago: University of Chicago Press.

    Google Scholar 

  • Howard Brown Health. 2019. Revised THInC protocol. https://howardbrown.org/programs-services/transgender-health/revised-thinc-protocol/. Accessed 23 March 2019.

  • Igoe, J., K. Neves, and D. Brockington. 2010. A spectacular eco-tour around the historic bloc: Theorising the convergence of biodiversity conservation and capitalist expansion. Antipode 42 (3): 486–512.

    Google Scholar 

  • Johnson, A.H. 2019. Rejecting, reframing, and reintroducing: Trans people’s strategic engagement with the medicalisation of gender dysphoria. Sociology of Health & Illness 41 (3): 517–532.

    Google Scholar 

  • Knaapen, L. 2013. Being ‘evidence-based’ in the absence of evidence: The management of non evidence in guideline development. Social Studies of Science 43 (5): 681–706.

    Google Scholar 

  • Lane, C. 2007. Shyness: How normal behavior became a sickness. New Haven, CT: Yale University Press.

    Google Scholar 

  • Lane, R. 2009. Trans as bodily becoming: Rethinking biology as diversity, not dichotomy. Hypatia 24 (3): 136–157.

    Google Scholar 

  • Lev, A.I. 2013. Gender dysphoria: Two steps forward, one step back. Clinical Social Work 41: 288–296.

    Google Scholar 

  • Meyer-Bahlburg, H. 2010. From mental disorder to iatrogenic hypoganodism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior 39 (2): 461–476.

    Google Scholar 

  • Meyerowitz, J. 2002. How sex changed: A history of transsexuality in the united States. Cambridge: Harvard University Press.

    Google Scholar 

  • Money, J., and J.G. Brennan. 1970. Homosexual vs. homosexual attitudes: Male partners’ perception of the feminine image of male transsexuals. Journal of Sex Research 6: 193–209.

    Google Scholar 

  • Money, J., and P. Tucker. 1975. Sexual signatures: On being a man or a woman. Boston: Little, Brown.

    Google Scholar 

  • Moreira, T. 2007. Entangled evidence: Knowledge making in systematic reviews in healthcare. Sociology of Heath & Illness 29 (2): 180–197.

    Google Scholar 

  • Nguyen, V. 2009. The republic of therapy: Triage and sovereignty in West Africa’s time of AIDS. Durham: Duke University Press.

    Google Scholar 

  • Norton, A.T. 2013. Surveying risk subjects: Public health surveys as instruments of biomedicalization. BioSocieties 8 (3): 265–288.

    Google Scholar 

  • Petryna, A. 2004. Biological citizenship: The science and governance of Chernobyl-exposed populations. Osiris 2 (19): 250–265.

    Google Scholar 

  • Pickersgill, M. 2011. ‘Promising’ therapies: Neuroscience, clinical practice, and the treatment of psychopathy. Sociology of Health & Illness 33 (3): 448–464.

    Google Scholar 

  • Pitts-Taylor, V. 2016. Brain’s body: Neuroscience and corporeal politics. Durham: Duke University Press.

    Google Scholar 

  • Pitts-Taylor, V. 2019. Neurobiologically poor? Brain phenotypes, inequality, and biosocial determinism. Science, Technology, & Human Values 44 (4): 660–685.

    Google Scholar 

  • Plemons, E. 2014. Descriptions of sex difference as prescription for sex change: On the origins of facial feminization surgery. Social Studies of Science 44 (5): 657–679.

    Google Scholar 

  • Plemons, E. 2017. The look of a woman: Facial feminization surgery and the aims of trans-medicine. Durham: Duke University Press.

    Google Scholar 

  • Preciado, P.B. 2013. Testo junkie: Sex, drugs, and biopolitics in the pharmacopornographic era. New York: The Feminist Press.

    Google Scholar 

  • Rose, N. 2007. The politics of life itself: Biomedicine, power, and subjectivity in the twenty first century. Princeton: Princeton University Press.

    Google Scholar 

  • Singh, D., J. Deogracias, L. Johnson, S. Brandley, S. Kibblewhite, A. Owen-Anderson, M. Peterson-Badali, H. Meyer-Bahlburg, and K. Zucker. 2010. The Gender identity/gender dysphoria questionnaire for adolescents and adults: Further validity evidence. Journal of Sex Research 47 (1): 49–58.

    Google Scholar 

  • Spade, D. 2011. Normal life: Administrative violence, critical trans politics, and the limits of law. Brooklyn: South End Press.

    Google Scholar 

  • Steensma, T., R. Biemond, F. de Boer, and P. Cohen-Kettenis. 2010. Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry 16 (4): 499–516.

    Google Scholar 

  • Stone, S. 2007. The empire strikes back: a posttranssexual manifesto. In Transgender studies reader, ed. S. Stryker and S. Whittle, 221–235. New York: Routledge.

    Google Scholar 

  • Sullivan, N. 2015. Reorienting transsexualism: from brain organization theory to phenomenology. In Fuckology: Critical essays on John money’s diagnostic concepts, ed. L. Downing, I. Morland, and N. Sullivan. Chicago: University of Chicago Press.

    Google Scholar 

  • Sweet, P.L., and C.L. Decoteau. 2018. Contesting normal: The DSM-5 and psychiatric subjectivation. BioSocieties 13 (1): 103–122.

    Google Scholar 

  • Thornton, J., J. Zher, and M. Loose. 2009. Effects of prenatal androgens on rhesus monkeys: A model system to explore the organizational hypothesis in primates. Hormones and Behavior 55 (5): 633–644.

    Google Scholar 

  • Timmermans, S. 2011. The joy of science: Finding success in a “failed” randomized clinical trial. Science, Technology, & Human Values 36 (4): 549–572.

    Google Scholar 

  • Vance, S., P. Cohen-Kettenis, J. Drescher, H. Meyer-Bahlburg, F. Pfäfflin, and K. Zucker. 2010. Opinions about the DSM gender identity disorder diagnosis: Results from an international survey administered to organizations concerned with the welfare of transgender people. International Journal of Transgenderism 12 (1): 1–14.

    Google Scholar 

  • Whooley, O. 2016. Measuring mental disorders: The failed commensuration project of the DSM-5. Social Science & Medicine 166: 33–40.

    Google Scholar 

  • Zucker, K., and R. Duchinsky. 2015. Dilemmas encountered by the sexual and gender identity disorders workgroup for DSM-5: An interview with Kenneth J. Zucker. Psychology & Sexuality 7 (1): 23–33.

    Google Scholar 

  • Zucker, K., and R. Spitzer. 2005. Was the gender identity disorder of childhood diagnosis introduced in DSM-III as a backdoor maneuver to replace homosexuality? A historical note. Journal of Sex and Marital Therapy 31 (1): 31–42.

    Google Scholar 

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  1. Department of Sociology, University of Illinois at Chicago, 1007 West Harrison Street (MC 132), Behavioral Science Building, Chicago, IL, 60607-7150, USA

    Cal Lee Garrett

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Garrett, C.L. Finding natural variation: assembling underdetermined evidence of gender dysphoria, doing trans therapeutics. BioSocieties 17, 28–52 (2022). https://doi.org/10.1057/s41292-020-00201-9

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