Paper presented at the 1st Annual Qualitative Methods Conference: "A spanner in the works of the factory of truth"
20 October 1995, University of the Witwatersrand, South Africa

Gender Dysphoria: Stereotypes, Psychiatry & the Law
Agnes Clarke
Angela has talked about the sort of experiences that transsexuals go through while changing their gender and sex. I will be focusing on how the medical profession has constructed transsexuals and how this relates to the treatment of transsexuals socially and legally.

The stereotype of transsexuals states that we clearly want to change our sex from the age of six (at the latest), that we have a continual urge to cross-dress, that we are desperately unhappy with activities "appropriate" to our given gender, that we hate our pre-operative bodies, that the operation is the most significant change in a transsexual's life and that transsexuals can expect to be generally rejected and mocked. The press continually return to the theme that transsexuals are people with the wrong gender for their bodies ("a woman trapped in a man's body").

The reality is much more flexible. Some transsexuals do not become aware of their feelings before adulthood. There is no urge to cross-dress; it is an easily kept secret and transsexuals can have gaps of decades in which no cross-dressing takes place. Some transsexuals never "cross-dress" until they start changing their public role. Transsexuals do not necessarily even feel uncomfortable with their initial genitals. We live in a culture which frowns on nakedness and which goes to great lengths to hide the human body, so the sex-change operation does not make a significant difference in the outward life of transsexuals. Most importantly, most transsexuals find support and acceptance. Most transsexuals work for at least some time during their transition in a knowing and accepting environment.

Psychiatrists play a gatekeeper role in transsexuals' lives. They are the people who determine whether transsexuals may have access to surgery and whether they can obtain legal recognition of their chosen status. The question that psychiatrist are expected to answer is whether their patient is gender dysphoric or otherwise. Gender dysphoria - meaning unhappiness with one's gender - is the technical term for transsexuality and is accepted as meaning a persistent desire to belong to the "opposite" sex, hatred of one's current body, and impulses to cross-dress and otherwise express one's preference for a different gender.

There are some obvious similarities between gender dysphoria and the widespread stereotype I talked about above. They also share the assumption that if one has the "wrong" gender for one's body one will be unhappy. I do not think there is any reason why feminine men or masculine women should be unhappy. But the assumption is that the situation would feel like a square peg in a round hole, as though one's body has an innate tendency towards a particular way of behaviour that is painful because this is not in accordance with one's mind.

Thus unhappiness is located by the gender dysphoria model in the appropriateness of extremely limited gender-roles rather than in the social expectations, interactions and frustrations around those roles. We are asked to believe in effect that transsexuals are unhappy because men are not supposed to bake cookies, and not because transsexuals get rejected and isolated. It should be asked why there is no research into the "dysphoria" of gender dysphoria. Furthermore, as the patients are in therapy to change their bodies, why is the condition labelled gender dysphoria and not sexual dysphoria? In summary, the condition reflects a different focus and aim to that of the people it is foisted on.

Psychiatrists start from a position of perceiving transsexuality as a pathology, and thus a patient's statements regarding their desires for a different body are invalidated. Indirect testing that attempts to exclude the patient's overt expressions of preference are thus used. The kinds of tests used on transsexuals include so-called sex-role inventories, informal evaluation of the patient's gender-role performance in therapy, and a number of specific issues that tend to disturb therapists.

Sex-role inventories attempt to determine a "psychological sex" for the patient by correlating the patient to a number of behaviours deemed to be masculine or feminine. The conformity of the transsexual to the gender behaviours associated with their chosen sex is an indication that the patient may be suitable for surgery. Kando's Masculinity-Femininity Scale is indicative of the crudity of these supposedly scientific tests, evaluating patients on such criteria as:
I (would) love to have children.
I am the primary supporter of my family.
In general I would submit to my spouse's decisions.
Engagement and wedding rings are very important to me.
The informal evaluation of transsexual's gender-role performance (conformity) is a natural extension of the above tests. The clothing a transsexual chooses to wear to therapy, possession of skills such as knitting or carpentry, one's voice and physical appearance, all weigh more heavily in the mind of the psychiatrist than anything the patient may actually say or feel. It is routine, for example, that male-to-female transsexuals will be made to feel very uncomfortable should they wear pants instead of skirts to their session.

Consequent to this attitude are a number of particular issues that may delay a transsexual's operation for years, or even prevent it entirely. The sexual orientation of transsexuals is expected to conform to heterosexual standards - for example lesbian male-to-female transsexuals are regarded as unsuitable for surgery by many psychiatrists. (A disturbing aside is that these psychiatrists seem to feel much more comfortable with transsexuals who motivate their need for surgery by reference to "homosexual" desires). It is also common for psychiatrists to resist a patient's requests for surgery or other treatments by objecting that the patient is too tall or short, has feet that are too