Presented by: Stacee L. Reicherzer, PhD, LPC, NCC

1. “Why Does ‘He’ Want to be Called ‘Jill’?”: An Introduction to the History and Politics of the Gender Identity Disorder Diagnosis Presented by: Stacee L. Reicherzer, PhD, LPC, NCC Member- World Professional Association of Transgender Health (WPATH) Faculty- MS in Mental Health Counseling program, Walden University

2. Overview • Definitions and Continua • A brief history of gender diversity • The historical development toward standardized care for transgenders • Understanding the GID Diagnosis and HBIGDA Standards of Care • A hierarchy of ethical decision making • Transgenders name their experiences of mental health care • Transgender subjectivity redefines care guidelines • Ethical vignettes

3. Continua of Sex and Gender • Birth Assigned Gender- a person’s apparent biological sex as assigned at birth. In the U.S., birth-assignment is traditionally made by the doctor or midwife who performs delivery. Male __ Female __ • Sex- The genitalia a person has. This may be male, female, or a blending of the two. It is demonstrated as a continuum of bodily possibilities. Male I-------------------------------------------I Female Adapted from Whalley (2005)

4. Continua of Sex and Gender • Gender Identity- A person’s core sense of being male, female, or a place in-between. Male I-------------------------------------------I Female • Gender Expression- External characteristics and behaviors that are socially constructed as either male or female: clothing style, demeanor, speech patterns, etc. Masculine I------------------------------------I Feminine Developed by Shane Whalley, LMSW

5. Gender as a Dual Continua • An alternate way of understanding gender identity and expression: Non-Mutually Exclusive Gender, expressed as a Dual Continuum. Maleness and masculinity is not treated as opposite from femaleness or femininity. Rather these appear as equal possibilities that can be experienced in a fuller range of gender possibilities, in which an individual identifies multiple characteristics of each gender; or alternatively, few characteristics. Male/Masculine 0--------------------------I Female/Feminine 0--------------------------I

6. Continua • Sexual orientation- The sex or sexes to whom a person tends to be sexually and otherwise relationally attracted. I----------------------------------------------------I Male Attracted Female Attracted

7. Socially Constructed Terminology Transgender- A range of behaviors, expressions, and identifications that challenge the pervasive binary gender system in a given culture. It is an umbrella term that used to describe any of a variety of gender identities and expressions. Transsexual-. A person actively pursuing a gender transition, which may include hormonal and surgical interventions to change personal appearance and sex characteristics. Transsexuals are described as either male to female (MTF) or female to male (FTM).

8. Socially Constructed Terminology • Gender Queer/Bigendered/Genderless- Any of a number of identifiers that denote an experience of gender blending, or sense of being without gender. This may include use of third-gender pronouns (“sie” or “ze” instead of he or she; “hir” instead of “him” or “her”). • Intersex- People born with some combination of vaginal and testicular tissue, or who later develop secondary sex characteristics that differ from those of their birth-assigned gender.

9. Socially Constructed Terminology • Gender Binarism- The socially constructed notion that “female” and “male” are separate and discrete categories, each with its own rules and laws that dictate permissible behaviors. • Gender Straitjacketing/Sextyping- Cultural mandates to adhere to socially constructed gender norms, enforced through punishment, estrangement, and other tools of social opprobrium.

10. Social Pain/Pain Overlap Theory • Social pain is experienced in the same part of the brain as physical pain (Anterior Cingulate Cortex) • Neuroimaging study: ACC more active during exclusion than inclusion, correlated positively with self-reported distress at being excluded (r=.88) • Social pain leads to social withdrawal (avoidance of pain) • Perceptions of social rejection are a key feature in suicide • Eisenberger, N. I. & Lieberman, M. D. (2004). Why it hurts to be left out: The neurcognitive overlap between physical and social pain. Trends in Cognitive Sciences, 8, 294-300. • Eisenberger, N. I., Lieberman, M. D., Williams, K. D. (2003). Does rejection hurt? An FMRI study of social exclusion. Science,302, 290-292. Retrieved August 18, 2005 from: http://www.ncbi.nlm.nih.gov

11. Social Reinforcements of Gender Binarism- Dominant U.S. Culture • Strict reinforcement, rewarding of socially sanctioned behaviors for “correct” ways of being male or female • Rules about sex (sexually active men are never called “skanks”) • Expectations about parenting • Rules about emotions: “boys don’t cry” and “nice girls don’t get angry” • Notions about Men from Mars and Women from Venus

12. History of Gender Diversity- The West • Classical Greece: Euripedes’ The Bacchae, Sophocles’ character Tiresias in Oedipus Rex • Roman Emperor Elagabalus (ruled 218-222) • Legend of 13th century Pope John Angligus- Pope Joan • Joan of Arc (1400s) • Captain Alice Clark (grain riot of 1531) • Rebecca’s Daughters (1839) • Actors Stella (Ernest) Boulton and Fanny (Frederick) Park- late 19th century

13. History of Gender Diversity- Eastern and Tribal Cultures • Native American “two spirits”- Zuni, Navajo, Lakota, Hopi, and others • Zulu Shamans • Hijra of India • Kathoey of Thailand

14. European World Conquest • Colonialism • Forced adherence of tribal cultures to dominant European ideologies, including system of binarism • Eradication of native cultures

15. The historical development toward standardized care for transgenders • 1920s: first SRS’s performed in London on 2 “transvestite homosexuals.” • 1920s to 30s: Magnus Hirschfield’s Institute of Sexual Science in Berlin • 1947: David Cauldwell coins term “transsexual” • 1952: George Jorgensen becomes Christine

16. The historical development toward standardized care for transgenders • 1962- UCLA opens the Gender Identity Research Clinic- endeavored to teach gender conformity to children • 1966- Harry Benjamin published The Transsexual Phenomenon • 1966- Johns Hopkins University began providing SRS, first of many gender clinics to do so (each with its own standards)

17. The historical development toward standardized care for transgenders • 1968- The DSM II is published to include “Transvestism” and “Sexual Orientation Disturbance [Homosexuality]” • 1979- Harry Benjamin organized first HBIGDA • 1980- DSM III includes in “Psychosexual Disorders” a section of “Gender Identity Disorders”

18. The historical development toward standardized care for transgenders • 1987- DSM III-R, Gender Identity Disorders are now in a category called “Disorders Usually First Evident in Infancy, Childhood, or Adolescence” • 1970s to 80s- many private surgeons begin providing SRS. • 1994- DSM IV removes predisposing factors, several differential diagnoses

19. The historical development toward standardized care for transgenders • 2000- DSM-IV-TR modifies language once more, terms “autogynephilia” in describing MTF sexual preoccupation • From the 80+ years that the mental health profession has talked about transgenders, Dr. Reicherzer found only one (Poxon, 2000) study that asked transgenders about their experiences in mental health

20. Gender Identity Disorder-DSM-IV-TR Diagnosis -“Strong and persistent cross-gender identification” -“Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex” • Does not include physical intersex condition • “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”

21. Understanding WPATH Standards of Care • Purpose of Standards of Care • Epidemiological Considerations • Diagnostic nomenclature, which now uses DSM-IV-TR language • The mental health professional • Work with children and adolescents • Work with Adults

22. Understanding WPATH Standards of Care • Requirements for hormones • Effects of hormones • The real-life experience • Surgery • Genital Surgery • Breast Surgery • Post- Transition Follow-up