Yesterday, I ran across this essay on X(itter), and it annoyed me because the author makes all kinds of errors of both fact and reason. Since things on X have a nasty habit of disappearing at random, I will start with a bunch of screen captures of the essay itself. Then I will delve into the problems with the arguments being made.
Part I - The Original Essay
Part II - Let's Talk About It
To be kind, the points the author makes are more than a little bit scattershot. The author makes a large number of "Gender Dysphoria is just like X" comparisons, and then goes on to attack both the current diagnostic language in the DSM as well as Gender Affirming Care.
One thing I want to start off with point out is that the author provides us with no citations for many of the claims being made, but instead assumes that their characterization of things is accurate and relevant. I'm not going to nitpick and say "well, not exactly like that", because that would be missing the point.
Comparisons
The article starts off by listing a whole bunch of psychological phenomena that have occurred in the past, and makes some pretty wild inferences from them.
For example, the author makes a broad claim that Anorexia Nervosa (an eating disorder) in Hong Kong spiralled out of control after "western psychiatrists ran an information campaign in the 1990s". She makes similar claims about PTSD in Sri Lanka and depression in Japan. In all cases, she essentially argues that the spike in diagnoses that occurred was a result of a form of social contagion. Social contagion is a construct that Littman argued in her initial paper arguing for Rapid Onset Gender Dysphoria (ROGD) - I critique that paper in detail here.
I would argue that the author overlooks the very real probability that while the conditions mentioned were largely unrecognized previously that the spike in diagnoses is not a result of "social feedback loops" but rather reflective of what happens when people gain a framework within which to understand their feelings and experiences. The fact a condition was not formally recognized does not mean that it was not an issue for those who experienced it.
She also makes reference to "False Memory Syndrome", and the "Pricked by the Devil" nonsense from Salem during the Witch Trials era. The latter item is interesting more from a sociological perspective because it reflects the irrational panic we are seeing today regarding transgender people. Neither is reasonable, and both were based in misinformation. False Memory Syndrome is another matter entirely, and since it remains controversial within the mental health world, I will simply leave it at that.
Critiquing Gender Dysphoria and The DSM
All of this she uses to arrive at the following:
Currently the West is in the grip of an unprecedented medical scandal arising from a new entrant to the symptom pool, namely Gender Dysphoria.
Here is why from the perspective of being a nearly 30-year qualified clinical psychologist, I believe that Gender Dysphoria is a false construct. One that has caused, and if not stopped, will continue to cause immeasurable harm to innumerable numbers of people. (Emphasis Added)
Frankly, being a "30 year qualified clinical psychologist" doesn't really grant her a license to outright discard decades of research that was going on long before she was a psychologist. But, we'll come back to that.
For a moment, let's take the idea that "Gender Dysphoria" as a construct is incorrect. The author critiques it as follows:
But Gender Dysphoria itself is not real. It has no clinical or evidentiary basis. It is a false construct, created ex nihilo and first published in the Diagnostic and Statistical Manual for Mental Disorders (DSM), 5th edition, in October 2013. We psychologists should not be involved in any of it.
This is basically "it came out of nowhere in 2013" reasoning. Except this is simply factually and objectively wrong. The term itself dates back to at least the 1970s, and the current DSM 5 diagnostic category is an evolution of Transsexualism (DSM III), and Gender Identity Disorder (DSM IV). So to claim that it came out of nowhere ( ex nihilo ) is simply false. In fact, WPATH, when it was originally formed was named the "Harry Benjamin International Gender Dysphoria Association (HBIGDA)" - and that was formed in 1979 (although there were several years of meetings before the body was formal).
The argument that it has no "clinical or evidentiary basis" is also false. A key principle of psychology is that it is phenomenological in nature. That is to say that it is necessarily rooted in the observable phenomena. Cross-gender behaviour and expression is not new, we have evidence of it going back not merely years or decades, but in fact centuries. In terms of clinical literature, there is a significant body of work that dates back to the 1950s, so the claim that there is no clinical or evidentiary basis is also false.
A core part of a clinical psychologist’s skill set is psychometric assessment. Psycho/metric literally means ‘measuring the mind’. Psychologists can assess and quantify all manner of psychological properties, qualities and dysfunction occurring in humans. Anxiety, depression, trauma, resilience, suggestibility, marital health, life satisfaction. You name it, we can measure it.
Without going into huge depth here, psychometrics is far from a "precise science". At best, psychometrics provide a degree of "concreteness" to the evidence that a client provides in the form of narrative. If someone comes in and says "hey, I feel really depressed", I don't give them a couple of questionnaires and then diagnose them based on the answers. At best, those questionnaires are going to give me a baseline against which to measure things. It might confirm the client's initial statement, or it might not - clinically speaking it's just one piece of evidence in a larger picture.
Further, while there are "generally accepted" tools that we might use to measure things, broadly accepted and definitive are definitely not the same thing. For example, the Beck Depression Inventory (BDI) is widely hailed as the "gold standard" in assessing depression. However, because depression often occurs in context with anxiety and stress, the Depression, Anxiety, and Stress Scale (DASS) can be a more informative tool in some contexts. This is to say, psychometrics is definitely not a concrete and well defined discipline.
But here's the crux of the argument: The author is arguing that the lack of psychometric tools that allow for the objective diagnosis of gender dysphoria, that there's something wrong. Except this is an inaccurate criticism. Lots of diagnoses in the DSM lack "concrete" diagnostic tools. For example, Autism Spectrum Disorder is a very complex, broad disorder the assessment of which may require the application of various psychometric tools as well as observation and conversation with the individual.
None of this happens to obtain the spurious diagnosis of Gender Dysphoria. First, because standardised tests to accurately measure it simply do not exist, and second because the clinical features of Gender Dysphoria are not arrived at by the scientific method: ie formal testing, formulation, intervention, evaluation, and if necessary, reformulation.
I will agree that there is a lack of concrete tools for assessing Gender Dysphoria. This has been a long recognized problem, and there have been numerous attempts to resolve it over time. To the best of my knowledge, the underlying core issue is that we do not have a clear and coherent characterization of gender identity to begin with, much less a working model of its development over the course of life. So, yes, it's valid to say that there's a diagnostic challenge here. Creating and validating an assessment tool is a complex task. You need not only to assess the tool, but validate that it is in fact evaluating the construct you think it is.
BUT, and it's a big one - it's the fundamentally phenomenological aspect of psychology in general. In other words, one can evaluate through observation and conversation with the individual - which is really what goes on in a lot of assessments. The author here is being quite disingenuous about the nature of psychotherapy and diagnosis. To claim that this is "unscientific" is a failure to recognize that to this point in time, science has continually evolved and revealed new aspects of gender identity that were not previously understood.
This lack of any scientific rigour is reflected in the definition of Gender Dysphoria, which is full of stereotypes and circular reasoning:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender (or some alternative gender different from one’s designated gender)
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s designated gender)
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s designated gender)
The issue here is that the author is ignoring the evolution of the diagnostic criteria from its initial form in the DSM III. These criteria are extremely complex for clinicians to assess - in part because they ultimately rely on the clinician's ability to assess over time. As for the complexity, just ask yourself how you would describe gender identity - then try to come up with a coherent set of measures that actually describe that.
The author then goes on to complain about language like "marked" and "incongruent" because she doesn't know how to measure those factors. If you read through the actual DSM, language like "marked" shows up all over the place. That's up there with "impairment" - yes, it's imprecise language because diagnosis requires clinical judgment.
Furthermore, Gender Dysphoria is the ONLY clinical symptom in the DSM-5 whose treatment involves, (or even requires) surgical intervention!
First, gender dysphoria treatment might involve surgery, just as it might involve Gender Affirming Hormone Therapy (GAHT). It is unique in that treatment is in fact client driven and directed. Clients decide what interventions they want to pursue, not the therapist. Clearly this makes the article's author incredibly uncomfortable - apparently her perception of herself as a clinician depends on telling the rest of the world what they need.
Gender Dysphoria as a diagnosis also lacks what psychologists call ‘face validity’, namely is something measuring (in this case describing), what it appears to be describing? How can a six-year-old with precocious puberty, a 16-year-old autistic boy, a 30-year-old lesbian, and a 50-year-old married autogynephilic (AGP) man who secretly wears his wife’s knickers, who are all at different developmental stages and who have quite dissimilar psycho-social experiences, all be suffering from exactly the same clinical condition?
I would like to take a moment here to explain that gender identity is a construct that exists and evolves with us throughout our lifetimes. To argue that people at different stages of life do not have the same condition ignores the reality that it does evolve. The author further tips her hand as to her biases by deliberately conflating precocious puberty with gender dysphoria, and suggesting that a man who 'secretly wears his wife's knickers' is autogynephilic. Autogynephilia is an alternate diagnosis for gender dysphoria that a small number of people have been pushing since the 1980s - however it requires the clinician to ascribe motivations to a person for their actions - one of many reasons it has never been a diagnosis in any recognized sense.
Further, she also suggests that someone who is autistic can't possibly be transgender, while providing no reason for us to treat autism as a diagnosis which would exclude gender dysphoria. While much handwringing has been done over autism and gender dysphoria, to date nobody has shown that the two should be treated as mutually exclusive.
To illustrate the parlous, indeed criminal, state of affairs, I was contacted by a mother in California whose 16-year-old non-verbal autistic son was diagnosed with Gender Dysphoria on the strength of a 20-minute text chat with a ‘gender therapist’. A fortnight later he was on Oestrogen, sent to him through the post by the gender clinic. The mother felt it inevitable her son would progress to a penectomy, orchidectomy and eventually vaginoplasty. It appears that when it comes to gender issues, the mental capacity of the client themselves is completely ignored!
I hear about these kind of anonymized scenarios regularly, and they almost always are untraceable. If true, they could represent a significant ethical problem on the part of practitioners. But - and it's a big but - the argument that the capacity to consent isn't being assessed in these situations seems highly debatable. At the age of 16, that child is still technically a minor in California, so consent would have had to have been obtained from the parents before the youth was seen clinically. There is so much not being said in this kind of story as to make me suspect strongly it's significantly falsified.
We psychologists ought to know better. As a clinical psychologist for nearly 30 years I have encountered only ONE child with gender issues.
Since we have emerging numbers that suggest that the total transgender population ranges between 0.33% and 0.75% of the population, I am not surprised that the author has only seen one client with gender issues. That's probably true of a great many clinicians. That doesn't mean that the construct of gender dysphoria is wrong, or does not exist. Scarcity is something that makes it difficult to research and understand.
I posit instead that Gender Dysphoria belongs in the family of anxiety disorders and should be renamed ‘Body Anxiety Disorder’ (BAD). Psychologists are well able to treat anxiety disorders through talking therapy and behavioural modification. Treatment for BAD would be no different than standard psychotherapy for, say for depression, or anxiety, or relationship problems.
Uh yeah - nice try. Talk to actual transgender people about their experiences. The body isn't the entire issue - it is an issue connected to a myriad of social constructs as well. Transgender people have often spent much of a lifetime trying to cope "in the body they were given", and guess what? It's tortuous for them. People who have been studying this topic for more than 30 years learned a long time ago that this isn't the same thing as an anxiety disorder - and in fact it tends to be non-responsive to standard treatments for anxiety.
I'm going to leave it there for now. Suffice it to say, this is a case of a clinician who has formed an opinion without taking the time to fully understand the breadth and depth of the clinical literature and knowledge on the subject.
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