Wednesday, June 17, 2009

"Autogynephilia" and the Clinical Gaze

Starting last fall, when I wrote these posts on the American Psychiatric Association's ongoing project of drafting/revising the DSM-V, I've been kicking around a draft of a third post in that vein, this time concentrating on the doings of the Sexual and Gender Identity Disorders Work Group.

As you might infer from how long it's taken me to write said post, this entails opening up a huge can of worms.

I've also found I'm in way over my head with a lot of the issues involved, so I think I will intentionally avoid delving too deep into them; instead, I will point you to other people's writings that I've found illuminating.

Briefly, what's at stake is whether trans sexualities and gender identities will continue to be seen as "disordered" --- whether the category of Gender Identity Disorder* will be retained in the DSM-V. While the Gender Identity Disorders sub-workgroup is reportedly consulting trans advocacy organizations as part of its literature-review process, the makeup of the larger workgroup, and the prominence in leadership positions of two of its particularly worrisome members, introduces a strong bias towards viewing transgenderism and -sexuality as pathogies.

Here are some links that discuss the Sexual and Gender Identity Disorders Work Group --- and what its inclusion of Kenneth Zucker and Ray Blanchard means for trans people --- in greater detail:
Julia Serano, "Why feminists should be concerned with the impending revision of the DSM" (a guest post at Feministing.com)
Kelley Winters, "Transvestic Disorder and Policy Dysfunction in the DSM-V" (GID Reform Weblog)
Lena Dahlstrom, "Drafts from the DSM-V workgroup are out, and they're continuing to pathologize trans people" (Trans Group Blog)
Helen G, "APA Task Force reviews possible Gender Identity Disorder treatment guidelines" (Questioning Transphobia)

Now, I'd like to discuss one of the many trans-unfriendly ideas being brought to the DSM-V table: autogynephilia.

This nouveau-Greek concoction (meaning, I guess, "love of oneself as a woman") encapsulates Ray Blanchard's ideas about trans lesbians --- i.e., that they are straight men who fantasize about being women. (Blanchard also tends to refer to trans women as men: in his taxonomy, straight trans women are "homosexual transsexuals," while trans lesbians are "non-homosexual transsexuals." This can be quite confusing, apart from being just plain disrespectful to the people being talked about). Their femininity is thus taken for a sexual fetish rather than a component of their core identity.

Julia Serano has a lot to say on this topic --- not just about autogynephilia, but also about what she sees as the "sexualization" of MTF transgenderism by psychiatry.

Here's a summary of how she sees this sexualization play out (quoted from this description of a paper she presented at a 2007 conference for women in psychology, which became a chapter in her book, Whipping Girl):
The fact that MTF spectrum transgender people bear the brunt of our culture's fascination with, and demonization of, transgenderism, indicates that they are culturally marked, not for failing to conform to gender norms per se, but because they "choose" to be female and/or feminine. The notion that MTF transgender people are conceptualized within a traditionally sexist framework (i.e., one where femaleness/femininity are viewed as subordinate to maleness/masculinity) is perhaps most evident in the way that transsexual women (but not transsexual men) are hyper-sexualized in pornography and the media, wherein they are typically depicted as sex workers or as "sexual deceivers" who supposedly lure innocent straight men into sexual encounters. Implicit in all of these representations is a rigid, dualistic, heterosexual male-centered dichotomy in which only men can be viewed as legitimate sexual initiators and where womenare invariably viewed as sexual objects. In the context of this "predator/prey" dichotomy, transsexual women are consistently viewed as inviting their own sexualization by virtue of their feminine expressions and their physical transitions to female.

Understanding this predator/prey dichotomy allows us to make sense of psychological/psychiatric discourses of transgenderism, which have historically focused almost exclusively on MTF transgender individuals, while largely discounting female-to-male (FTM) transgenderism. For many decades, the diagnostic criteria devised for MTF transsexuals required them not only to be heterosexual and gender-conforming in the female role, but also to be sexually desirable in the eyes of heterosexual men. Those MTF spectrum transgender individuals who were unable or unwilling to meet all of the prerequisites for sexual object have typically been cast as sexual initiators and relegated to a distinct "paraphilic" category --- e.g., transvestic fetishism or autogynophilia. The positioning of this latter group (who are conceptualized as "men" who inappropriately fetishize female/feminine expressions in themselves) in opposition to "true" or "primary" MTF transsexuals (who are cast as willing objects of heterosexual male desire) reiterates the predator/prey dichotomy, thus preserving both the male/female and heterosexual/homosexual binaries. In this context, the invisibility and under-theorization of FTM transgenderism within psychology and psychiatry can be viewed as a direct result of the predator/prey dichotomy, which assumes that FTM spectrum individuals cannot be legitimate sexual initiators in their assigned sex (female), nor can their identified/preferred sex (male) be legitimately objectified.
Serano's thesis, in other words, is that the fear and hatred directed at trans women --- and the particular scrutiny the psychiatric profession directs at them --- derives from misogyny. If women are loathsome and inferior, then what kind of boy or man would choose to become a woman? The answer most commonly proposed by trans-misogynists is that such a man would have to be extremely, pathologically obsessed with sexuality (because, of course, women are sex!) of a particularly questionable stripe --- either the predatory sexuality of the transsexual "deceiver" of straight men, or the masturbatory and fundamentally narcissistic sexuality of the autogynephile.

Hopefully, you can now see where the "gaze" of my title comes in. The "autogynephilia" model does two things to the interaction between doctor and (trans lesbian) patient that skew it from a neutral, professional interaction to an exercise in sexualized power relations: first, it places the patient's sexuality on the clinical agenda, even when she has not made it an issue. Sexuality is seen as fundamental to her identity in a way that it would not be if she were cisgendered. Second, her sexuality is assumed to be wrong --- immature, paraphilic, disordered --- before anything is even said. She can therefore be silenced, or dismissed, or have her words twisted around, if what she says doesn't fit with the theory; because she is decided a priori to have deep-seated psychosexual issues, everything she says regarding her gender expression or sexuality can be considered suspect.

I think these two tendencies within this theoretical model constitute a pretty serious double standard --- the sexualities of trans women are probed and interrogated to a degree that no other sort of person's would be, unless that person had asked for help with a sexual problem. Thus, both because of a disproportionate rummaging through trans women's sexual quirks, and because of a selective attention to those trans women's own stories, the theory of autogynephilia as a cause of MtF transsexualism can't really be falsified. Nobody asks cis women if they find their own femaleness or femininity arousing, and Blanchard, Bailey and other "authorities" see no problem ignoring trans women who claim not to experience that.

*While the existence of GID as a category of mental illness perpetuates some seriously transphobic assumptions --- i.e., that trans people have something horribly wrong with them and need to be fixed, one way or another --- it also makes sex-reassignment surgery more accessible to those trans people who desire it, since by being the recommended "treatment" for the "disease" of GID, the surgery becomes much more justifiable in the eyes of insurance companies. I take this more as an indication that the U.S. health-care system sucks than a ringing endorsement by trans advocates of the medical model of transness, though.

3 comments:

shiva said...

I really need to post about the DSM. Had a meeting last week with some other autistic activists to try to get a statement together about it. Just seem to be having trouble stringing words together at the moment - but that guest post by Serano at Feministing is brilliant, i'll definitely have to work some of that stuff in and draw some parallels...

I agree completely with all of what you (and Serano) say here, but one point i would also like to make is... even if someone did want to transition to a female body out of "autogynephilia", that IMO would still be a perfectly valid reason for transitioning, because... well, you know, liberty and autonomy as fundamental ethical/political principles - people should have the right to do whatever they like to their own bodies, whatever their motivation is. If libertarian principles were followed, then hormones and SRS, like any other body modification, would be freely available on an informed consent basis, without any need for "gatekeeping" or pathologisation (ie, GID in the DSM) at all.

(Altho i do think that there is a current need for GID in the DSM, simply because attitudes in the medical profession are still paternalistic enough that surgeons aren't willing to provide SRS on an informed consent model, and because health insurance (in the US) or state healthcare systems (in most of the rest of the world) won't pay for things that are "not medically necessary", and the pathologisation of the DSM is necessary for that. There are, i think, parallels with many autism (and other disability)-related services here...)

(I'm also pleasantly surprised to see Serano posting at Feministing, because i had had the impression that the dominant point of view there was a fairly gender-essentialist and sometimes quite transphobic "radical feminism".)

Lindsay said...

"Had a meeting last week with some other autistic activists to try to get a statement together about [the DSM-V]."

Oh, neato! Do you think you will post this statement once you've all gotten the wording nailed down?

"...even if someone did want to transition to a female body out of 'autogynephilia,' that IMO would still be a perfectly valid reason for transitioning"

Oh, yes, I think so too. I also don't think there's anything wrong with autogynephilia; I just wanted to show how damaging the assumption that every trans woman must have that motivation. Part of it is the silencing --- that they're not given the chance to tell their own story if the doctor they end up seeing has already decided what that story is --- part of it is the sexualization Serano talks about, and another part of it stems from the fact that the "autogynephilia" theory revolves around sex, and sexual desire, which are not exactly value-neutral things in American culture.

That's kind of a weird, complicated idea that I'm not really able to explain better now. I just think that a major way to discredit or marginalize someone, throughout American history (and, probably, British history too) has been to imply that sexuality takes up a bigger portion of their life than it *should.* Especially when talking about women, sexual immoderation has been seen as a kind of monstrousness, and I think I might see this at work in this theory, too.

"There are, I think, parallels with many autism (and other disability)-related services here..."

Yes, I think so, too.

About Feministing, I've never gotten the impression it was a radfem site. I also don't remember any explicit anti-trans sentiment voiced there, though they are a pretty cis-centric site most of the time. And they can be amazingly classist, ableist and judgmental, especially in the comment threads.

shiva said...

"Do you think you will post this statement once you've all gotten the wording nailed down?"

Er, i hope/think so. Our (admittedly somewhat rambling and esoteric) conversation was recorded on a dictaphone by Laurentius, who i think is intending to write it up at some point...

"I just think that a major way to discredit or marginalize someone, throughout American history (and, probably, British history too) has been to imply that sexuality takes up a bigger portion of their life than it *should.* Especially when talking about women, sexual immoderation has been seen as a kind of monstrousness, and I think I might see this at work in this theory, too."

Yes, definitely agreed on that, and i think that's why sex-positive feminism and groups like CAAN - as well as the work in the disability field of people like Dave Hingsburger - are so important. Transphobia and homophobia are intricately linked with a more pervasive and generalised "sexphobia", IMO, which needs more writing about...