Paradigm and power shifts in the gender clinic

Trans1 people seek access to surgical, hormonal and psychotherapeutic treatments, but seek to avoid pathologisation and stigmatisation – this is a defining characteristic, perhaps the central dilemma, of their relationship with clinicians. This tension underlies contention around different approaches to clinical practice and gender variance. In medicine generally, relationships between clinicians and their clients have changed dramatically over the last 50 years in Western societies, as have sociological conceptions of those relationships. In the 1950s, the dominant model was Parsons’ ‘sick role’ – the patient passively accepting medical authority. Now the emphasis is on autonomous clients or ‘consumers’ who actively organise their health, and the medical clinician is only one source of information, albeit with regulated powers to prescribe medical interventions (Rogers and Pilgrim 2005). There is much at stake for psychiatric professionals whose work concernsgender variance. They defend psychiatry’s professional dominance over treatment of gender variance from incursions by other professions and by trans clients. Their defence necessarily centres on maintaining the mental illness diagnosis. In knowledge production about aetiology, psychiatry is defending its approach against neurology and the claims of trans clients. Psychiatry deploys diagnostic categories to control and contain its clients, creating order out of a chaotic, multi-dimensional field of behaviour. However, this way of managing difference is increasingly resisted by clients. This is not unique to gender variance – there is similar resistance as psychiatry seeks to extend psycho-pathologisation to many previously ‘normal’ emotional states such as sadness (Horwitz and Wakefield 2007). These general changes in power relations between health professionals andtheir clients contribute to an ongoing paradigm shift in treatment of trans people from the gate-keeping or mainstream model to the collaborative or gender variance model (Lev 2004). In gate-keeping, the clinician’s role is to restrict access to the package of surgical and hormonal treatment known as Sex Reassignment Surgery (SRS)2 only to those people who meet the diagnostic criteria for pathology. In collaboration, the clinician and client together determine the most appropriate gender outcome.3 These models rely onconceptions of trans that arise from different knowledge bases. While psychiatry sees psycho-pathology that can sometimes be ameliorated by SRS, social disciplines see an atypical variation in lived experience and subjection to social exclusion and discrimination. Knowledge construction about aetiology and treatment is based on the interaction of trans people’s narratives and activism, clinician-researchers’ work in a range of disciplines, and a narrow set of biological and neurological research. As there are few researchers and no largescale comparative studies, there is not a strong empirical basis for either consensus on aetiology, or a move to an evidence-based medicine approach to treatment. The shift in treatment models is compatible with, and partially informed by,a shift in aetiological paradigms from trans as a disorder of psychosocial origin to trans as a healthy variation, whether of psychosocial, biological or biopsychosocial origin. Nurture/nature debates in the past have pitted social researchers against biological researchers and have divided trans people. However, I argue that agreement on variance of sex, gender and sexuality as healthy creates possibilities for interdisciplinary collaboration with trans people around a biopsychosocial model of diversity. The shifting aetiological and treatment paradigms lead many trans people and some clinicians to argue for moving trans people’s health care out of psychiatry’s domain – focused on removing or reforming the Gender Identity Disorder (GID) diagnosis in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM). This paradigm shift is developing largely through inter-and intra-professional struggles, with trans people applying pressure upon professional institutions – resisted by some significant leaders. These movements align closely with shifts in other medical domains. Voices within mental health professions have strongly challenged the dominance of diagnosis (Boyle 2007). Patient movements have organised against the stigma of diagnoses, especially mental health ones, and other health and social movements such as those around HIV/AIDS have significantly influenced clinical research and scientific knowledge construction. The potential shift in power relations away from psychiatry and towardstrans people is illustrated by the impact of trans activism on treatment modalities and aetiological research, in a complex process involving coexisting, competing networks of trans people, clinicians and researchers. To structure discussion, I simplify this field by framing these as contending forces.4 On one side are advocates for a biological aetiology for trans and advocates for a queer idea of gender as fluid, who both argue for depathologisation and recognition of gender diversity. On the other side are highly influential clinicians who maintain a psychological disorder model of trans and a dichotomous, normative view of gender. In between are clinicians and others who seek a compromise that reforms the psychiatric diagnosis to reduce negative impacts of pathologisation and stigmatisation. By analysing published work and interview material, I developed heuristic positions to describe these groupings. Activistsand researchers who work in a neurological paradigm form the healthy biological variation (HBV) position. Activists, clinicians and social theorists working in a social research paradigm form the transgender activism-social research (TA-SR) position. The middle-ground clinicians (MGC) balance between psychiatry, biological and social research and trans people’s self-identification. Clinicians who strongly maintain the psychiatric emphasis on diagnosis form the psychological disorder (PD) position. These constructed positions are intended to assist analysis, not to substitute reified description for social reality. Outside of this framing, other forces oppose any surgical or hormonal treatment (the anti-SRS position) or leave all decisions up to consumer choice. This chapter is based on doctoral research examining the social and politicalimpacts of the ‘brain sex’ theory of trans. Below, I draw on semi-structured qualitative interviews with biological researchers, psychiatric and other clinician-researchers, social scientists and trans advocates. When I quote from an interview, I provide the person’s name and use single quote marks for those participants who preferred to be identified by a pseudonym.5 In the following analysis of clinical approaches to gender and identity, I am motivated by broad questions. How do clinicians and trans people act on knowledge to manage the trans body? How do battles over aetiological theory affect clinical practice and power relations? The questions I can actually address are more narrow, aiming to illuminate the strategic possibilities for trans people in this complex field. How have clinicians acted on the mainstream model of clinical practice for ‘treating’ trans people? How is that model and those practices changing? What are the implications for the availability of treatments for a wider range of trans people? How do the aetiological paradigms and disciplinary frameworks impact on a shift to a less stigmatising and pathologising approach, in particular proposals to reform or drop the DSM diagnosis of GID? These lead back to an overarching question – how central are the struggles over knowledge claims to social actors?