My last post, about my dissatisfaction with the inclusion of 'Autogynephilia' as a diagnostic category in DSM-V has caused some controversy on Twitter, which I feel I should address here. What I specifically want to address is the accusation that I don't believe Autogynephilia is 'real'.
The reality, of course, is more complex than that. The thing about psychiatric diagnoses is that they are harder to arrive at than biological ones. Klinefelter's Syndrome is comparatively easy to diagnose: either your karyotype indicates you have an extra X chromosome or it doesn't. Gender Identity Disorder - soon, gods and goddesses willing, to be reclassified as Gender Incongruence - is a more nuanced diagnosis to make, depends on a lot of factors, and can be experienced differently by different people.
The reason for this is that psychiatrists and psychologists, in classifying mental disorders, are dealing not so much with specific viruses or bacteria, but more nebulous collections of symptoms. Many of the symptoms occur together and often react well to certain forms of clinical intervention. Where this happens it is usual to apply a diagnostic label to the collection of symptoms in order to aid the treatment of individuals who present with them in the future. But the labels we apply to these collections of symptoms are always subject to change, as are the symptoms which fall under a certain label. For example, schizophrenia as we know it has developed over a curious course of diagnostic evolution from its original classification as 'dementia praecox' to the clinical definition we know today. Currently, moves are afoot to eliminate Asperger's Syndrome as a separate condition and merge it with the other Autism Spectrum Disorders, on the grounds that it fits in better on that spectrum than as a separate entity. All this is as it should be: research modifies our understanding of a condition, which in turn modifies the way we categorise it, which in turn leads to improvements in the ways we treat or help people deal with these conditions.
In a perfect world this is how it would always work, but this world is far from perfect, and, despite vast efforts to build in a system of checks, balances and controls, psychologists and psychiatrists are at least as likely as people in the general population to have prejudices and biases, and these biases can and do creep into the disciplines themselves. This is one reason why periodic revision of the DSM is a good idea: it allows for reevaluation of the previously accepted psychological norms.
'The normal' itself is, of course, one of the biggest biases that can creep into diagnosis. I mentioned in my previous piece that, for a long time, homosexuality was considered a psychiatric 'disorder' because it was regarded as 'abnormal.' Thankfully, these days it is accepted that this isn't the case. But psychiatry persists in categorising some sexualities as normal and others as not so. The device used for this purpose is the idea of 'paraphilia' or, in layman's terms, sexual fetishism.
Paraphilia, as a diagnosis, has its uses, in that it provides a useful framework for considering the sexual desires of people whose behaviour is genuinely harmful, such as paedophiles and sex murderers. You'll note that the DSM-IV definition talks of non-normative sexual behaviours which 'may cause distress or serious problems for the paraphiliac or other persons associated with him or her'. But, notice the may. Something doesn't have to be causing anyone harm to be considered a paraphilia. Your kink might be pretty innocuous - maybe you have a thing for being shagged on formica tables, or you like to masturbate while listening to Vaughan Williams' Fantasia on a Theme of Thomas Tallis. You're not harming anyone (unless you go to a concert hall to pleasure yourself), but it doesn't matter. You have a paraphilia. You have a disorder. You are, as they say, in the system.
Look: I've known some kinky people. Hell, I'm pretty kinky myself (you don't want to know what I want Girl Obelix to do to me), and none of the kinky people I've met seemed mentally ill. Some had other mental illnesses, such as depression, but no more than in the general population, by my reckoning. And where there did seem to be a link between their particular pastime and some level of, say, depression or alcoholism, this could always be understood as a reaction to their marginalised status, and the prejudice they suffered from people with more privileged 'normal' sexualities.
I'm coming to understand that the social construction of mental disorders, which seemed like a purely theoretical idea when I first studied psychology, is a reality. To say disorders are socially constructed does not mean they aren't 'real.' Rather, it's the case that when people fall outside social norms, the response of people in society to their behaviour actively constructs their disorder. Consider the paradigm that has recently emerged in the field of disability activism: people are not disabled in themselves, they are disabled by a society which creates obstacles to their effective functioning, to the benefit of the privileged. Without wanting to come across as entirely RD Laing, I don't think it's too much of a leap to say that many people we class as 'disordered' actually reflect the disordered state of society.
Gender Incongruence is a real thing which people experience, and which can be treated with a variety of methods, up to and including gender reassignment surgery. But it only becomes a disorder because it conflicts with the social expectations a society places on someone because of their birth gender, and failing to meet those expectations causes feelings of trauma and guilt. Most sexual fetishes only become disorders when the treatment of people who happen to enjoy such fetishes leads to their experiencing feelings of marginalisation and low self-worth.
This applies even to those disorders considered to have a strong physiological basis. Depression seems to be the result of chemical imbalances in the brain (given that it often responds to treatment using chemicals which correct said imbalances). However, depression as a disorder, rather than a normal, acceptable and managable part of human diversity, is constructed by a society which unduly rewards self-confidence and bonhomie over actual achievement (there'll be more on this in my next post, which will consider the issue of privilege and self-esteem in greater depth).
So, to return to Autogynephilia, here we have a definition of something which could easily be classed as Gender Incongruence, but isn't because some cis male psychologists have decided that the only real gender incongruence is heterosexual in nature. If you're a trans woman and you want to fuck men, Roberta's your auntie. But if you're male assigned at birth, feel gender incongruence, but want to get it on with other ladies...that's not real Gender Incongruence. That's just a paraphilia. That's just sexual deviancy (don't worry if you're a trans man who wants to fuck other fellas, though. Ray Blanchard doesn't consider gay trans men in his definition of Autogynephilia. Perhaps, like Queen Victoria on lesbians, he doesn't think they really exist).
I cannot see the logic in this distinction. As far as I can work it out, Gender Incongruence is the same regardless of who you want to bump uglies with, because, well, Gender Congruence is the same, regardless of who you want to bump uglies with. So 'Autogynephilia' can only be a socially constructed 'disorder' based on the heteronormative, cissupremacist prejudices of our society. But it isn't just a bad diagnosis. It's actively harmful.
Many transphobes today persist in regarding being trans as a 'lifestyle choice'. By creating a false division which says one type of Gender Incongruence is real, but one is just a 'perversion', the deployment of Autogynephilia as a diagnostic category legitimises this perception. It makes psychologists and psychiatrists complicit in the marginalisation of people who are already heavily marginalised by society. This is a deep betrayal of psychology's basis as a science, and psychiatry's basis as a branch of medicine. The purpose of science is to describe reality objectively, free from the biases and prejudice of phenomenologically lazier forms of discourse. The purpose of medicine is to heal those who are hurting, without harming them further.
'Autogynephilia' does not meet either of these requirements. It is scientifically unnecessary: everything it involves could easily be described in terms of Gender Incongruence. And it is medically abhorrent, as it leaves people who form a normal, healthy part of the gender spectrum with the idea that they are somehow 'wrong', with no possibility of cure, and causes them further harm by legitimising the prejudiced views that they're all just perverts.
None of this means that there are not birth-gendered men who identify as female in a primarily sexual context. For some of these people it is just a fetish, either cross-dressing or enforced feminization. That's fine. For some it goes deeper. There are also, of course, trans women who aren't very sexual. And there are trans women who are very sexual, and trans men of all kinds too. The gender spectrum is just that, a spectrum, on which there are many varieties of experience. This is a concept bourne out by the experiences of people in the trans community and their cis allies every day, but it's a concept which still meets with resistance from the more bigoted sectors of the population. The job of psychologists is to break down this bigotry by revealing the truth about the human psyche. The job of psychiatrists is to help those who are harmed by such bigotry. So the message to the people compiling the DSM-V should be clear: focus on a more inclusive, but still robust, definition of Gender Incongruence, chuck 'Autogynephilia' on the scrap heap with dementia praecox and sexual inversion, and do your bloody jobs. It's what you're there for.