Text of talk given via video at the "Who's Afraid Of Depathologization" conference in Turin Italy
Video available on YouTube.com
Anne Vitale Ph.D.
March 31, 2012
I want to thank Christian Ballerin and the others at Circolo LGBTQ Maurice for inviting me to address this gathering.
I'm Dr Anne Vitale...a psychologist in private practice in the San Francisco, California Bay area where I have been specializing in gender issues since 1978.
I have been asked to answer three questions:
Why is transsexuality considered a pathology?
Are there other --less stigmatizing and perhaps more accurate words we can use to define the issue?
How can depathologization of gender issues change transpersons life's?
This is a very important and timely topic. One can write a book on these three questions alone. Since I only have ten minutes, I will do the best I can.
clarify how I view the terms pathology and de-pathologization when used in the context of transsexualism.
When it comes to transsexualism, nothing is ever black and white or conforms to any of the norms in the cisgendered world. Transsexuals live in a world where everything comes in shades of grey. Labeling transsexuality a pathology --especially as a mental disorder--is clearly an overstatement. On the other hand calling it a pathology for people seeking help for their medical needs is, I believe appropriate.
Please keep in mind -
extreme gender variance is unlikely to ever be viewed as normal or freely accepted by parents, society, or even the transpersons themselves because it's outside normative expected binary gender role presentation. Especially when on factor in the unjustly related but ever present psychosexual stigma.
Then there's the practical side. . .if people are going to be helped with medical procedures and medical interventions, and if professionals and insurance is to be involved, it will be in today's terms, a pathology.
Since there is no "in between" or "modified" definition of pathology, our only recourse is to modify the wording of gender issues so that the stigmatization and emotional connotation is reduced to a more helpful terminology while all the time being careful as to leave the individual open access to medical care.
Looking at question No 1... the reason transsexuality is considered a pathology
--and this may sound like I am being too obvious but it's because gender issues are treated primarily by mental and medical health providers. To aid them in classifying their work, these providers have books and Journals that contain list and lists of ailments that they consider real and treatable. If the symptoms -in this case gender dysphoria-- are in the book, it is considered a real disorder that deserves to be treated. For transsexuality the book it is most commonly listed in is the Diagnostics and Statistical Manual of Mental Disorders or as it is more commonly known, the DSM.
I believe all here would agree that transsexualism lies outside the norm in our binary sexing society. So when a group of psychiatrists describes the variation from the norm as a "persistent sense of discomfort or inappropriateness about one's anatomic sex and a persistent wish to be the other sex"- --and then decides to put the abnormality in a book of mental disorders…. the connotation attached to the abnormality becomes a pathology in the minds of professionals, lay people and even to some degree the transsexuals themselves.
This brings us to question number 2--Are there other --less stigmatizing and perhaps more accurate words we can use to define the issue? My answer is, Yes.
On my first reading of the DSM IV back in 1994, I was immediately put off by seeing that Transsexualism as it was described in the previous edition of the DSM was now being replaced by Gender Identity Disorder.
I had always thought the term "Transsexual" just described individuals who were experiencing a variation on one's sense of being male or female. Gender related for sure-- but nothing at all to do with identity. All of a sudden what I had been dealing with over the last decade as a psychotherapist was being considered a serious pathology that I and other psychotherapist were supposed to cure with talk therapy.
A more problematical issue was that GID had been placed in the area of the DSM reserved for Sexological Disorders --right next to the paraphilias such as pedophilia, exhibitionism, voyeurism and a host of cross dressing and sexual fetishes. What in the world were the authors thinking?...unless, of course, they really thought gender variation was some sort of perverse sexual problem.
The term, Gender Identity Disorder so bothered me on first hearing that, I knew I had to give it a different name-- even if it was for my own use. It was not long before I simply started calling it Gender Expression Deprivation Anxiety Disorder or G.E.D.A.D. I came up with the term because that was what I treated.
Essentially, with this new terminology, I was hoping to move the issue from an identity disorder --a concept that I did not believe in-- to what it was that my gender issues clients were struggling with. For me, what I saw was anxiety and I had a good idea what caused that anxiety and knew how to treat it.
Back in 1994 when I first introduced the term Gender expression deprivation into the scientific literature I saw the anxiety as being a combination of inadvertent physiological and sociological maladaptations. I believe the anxiety is caused, first by certain individual's inability to produce the cross sex hormones their gender variant brain needs for psychological comfort --this is evident in that when cross sex hormones are introduced to gender dysphoric individuals there is an almost immediate improvement in their sense of well being. If you give the same cross sex hormones to a cisgendered individual, that individual experiences an increase in anxiety. That has become such a truism that the administration of cross sex hormones or anti-androgens is now the primary diagnostic tool used to determine how far the client should take any possible full or partial gender role transition.
The second and equally important element involved in Gender expression deprivation anxiety is the sociological aspect...or the granting of permission to express openly new gender role behaviors. This latter aspect is, of course, where the individual runs afoul of society. We are all painfully aware that family, friends, employers, religious institutions and the legal system struggle mightily to maintain a binary ordering system of males and females.
There are some -- undoubtedly even some of you here-- who would prefer to see all reference to gender identify removed from the DSM. These well meaning individuals usually evoke the history of homosexuality having been successfully petitioned and then removed from a previous editions of the DSM... never to reappear. I am against that notion because unlike homosexuality many people with gender identify issues need access to medical care. For individuals who desire complete gender role transition, access to therapists, endocrinologist and surgeons are the only way for them to get their needs met. With no diagnosis, National Health Care systems and insurance companies would not be required to cover even the smallest amount of the cost. In some countries they pay for much of the necessary hormones and expensive surgical procedures.
Regarding question number 3...How can de-pathologization of gender issues change transpersons life's? The first and most important way is psychological.
There are socially acceptable pathologies and there are socially stigmatizing pathologies. Depression and anxiety-- terrible and as problematic as they are--are common and socially acceptable while anything that has to do with sexual behavior, gender identity and gender expression are for a large part of society considered weird and perverted.
As a consequence, too many of my clients come into see me suffering from fear of discovery, difficulty functioning in their daily lives and with very damaged sense of self worth...caused by years of living in the shadows racked with guilt and shame. Afraid or too ashamed to talk to anyone about their gender issues, far too many either go into denial about their situation or try to tough it out...often for decades. Who could blame them when they know that some mental health professionals think they are suffering from a psychosexual disorder.
Another area of a transperson's life that can be aided by de-pathologization is in the public policy area. As long as government entities consider transpersons sick and lets face it, that is what pathology means to most people, there is going to be a natural hesitation toward accommodating us in areas of providing updated identity papers, access to medical care, laws that protect us from work place discrimination, child custody rights and the ability to marry the person we love without bias.
To sum this up, keep in mind that Transsexuality is a phenomenon of its own, demanding further discussion as to how we rephrase the pathologizing/de-pathologizing question.
After almost 30 years of working with hundreds of transpersons going one way or the other, I have come to the conclusion that we should redirect our attention from thinking in strictly male/female terms. We should--instead-- as professionals and lay people alike simply consider it an expression deprivation anxiety disorder treatable by a combined physical and sociological adjustment. Thereby bypassing entirely any special psychosexual or overly negative mental health pathology connotation.
Thank you once again for giving me this opportunity to address this forum. Enjoy the rest of your program.
Copyright 2006 Anne Vitale Ph.D. All Rights reserved.
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