I Am Not A Disorder

At the end of the last episode, I was proposing to call this episode, “What’s Up, Doc?”, I know, terrible pun, but I felt justified as I was going to use an image of a certain bunny, from a Merrie Melody cartoon called, “What’s Opera, Doc?”.

I was reminded of this particular cartoon, from the Netflix 2020 documentary “Disclosure”, where Susan Stryker mentioned seeing it, and finding it in the sixties as the only positive transfeminine representation, which illustrates the power of animation, and the fact it was released in 1957, makes it all the more extraordinary.

And although off topic, I would like to recommend 1988’s, “Grave of the Fireflies”,

from Studio Ghibli, currently available on Netflix in the UK, which demonstrates the incredible power of animation, and all I will say about it is, a tissue or two might be handy.

However, back to Bugs, as the image was the copyright of Warner Bros. I contacted them to seek permission for its use, their reply, although very courteous, was a no, as they felt they where unable to grant permission.

So having to rethink the episode’s title, I also thought again about the subject I was planning to discuss, which was going to be psychotherapy, and decided instead to examine the standards of gender care for transgender and gender diverse people and how they have evolved, and a key figure of gender care.

Welcome to “Trans Wise Trans Strong”, I am Carolyne O’Reilly.

Episode thirteen, “I Am Not A Disorder”

The fallibility of memory, and mine in particular, resulted in me forgetting to mention in part three of my autobiographical trilogy, WPATH, which is the World Professional Association for Transgender Health.

WPATH produce an invaluable document, the Standards of Care, For the Health of Transgender and Gender Diverse people, with edition 8 released on the 15th of September 2022, being the latest.

At the time I was deciding to come out as a trans woman, edition 7 was current, and along with the various BBC documents for trans gender members of staff, proved invaluable in confirming my decision to come out.

As with any reference work that has existed for a period of time it has evolved, with some of the language and terminology changing to reflect new knowledge and understanding, and to include new areas, such as the inclusion in edition 8 of a chapter on non-binary gender identity.

But WPATH was not the original name of the organisation, it was in fact named after a key figure in transgender health care, Dr Harry Benjamin (1885 to 1986), and there is a very informative article on the National Library of Medicine’s website, about Dr Benjamin, “Harry Benjamin and the birth of transgender medicine”.

Dr Harry Benjamin was born in Berlin and studied medicine at the University of Tübingen, however in 1914 they were in the USA, and therefore became stranded there for the duration of what was tragically the first of two World Wars, and it was in the United States where they spent their professional life, with a private practice in New York, on the prodigious Park Avenue.

However during the 20’s and early 30’s, they were a frequent visitor to the Berlin based “Institute for Sexual Science”, and had a lasting friendship with its founder Dr Magnus Hirschfeld, who we met in the episode, “What Are Words Worth”.

It was in 1910 that Dr Hirschfeld, coined the term transvestite”, for people who dressed in clothes generally associated with the opposite gender, as before this term was created, they would have been categorized as lesbian or gay, now we would use the term transgender.

Although Dr Benjamin had a very successful private practice, he did not find it that challenging, and began research into the therapeutic possibilities of hormones, and when commercial hormone products became available, he began to offer them to his aging patients.

It was through his association with Dr Hirschfeld, and his research into hormone therapy that in 1949, the sexologist Professor Alfred Kinsey referred a patient to him, who although assigned male at birth, was raised as a girl, and Dr Benjamin was able to help her align her body to her gender.

It was as result of Dr Benjamin’s experience with this patient, that he decided to devote himself to what we would now call transgender health care.

You may have come across Professor Kinsey through the 2004 biographical film, “Kinsey”, which was about this renowned pioneering sex researcher, portrayed by Liam Neeson.

Kinsey founded the “Institute for Sex Research”, and it was researchers from this institute who in the 1940’s conducted thousands of interviews with people about their sexual histories, and as a result of this research two books were published, the first in 1948, “Sexual Behavior in the Human Male” .

It was in the Sexual Behavior in the Human Male, that the “Heterosexual-Homosexual Rating Scale” first appeared, this is also known as the “Kinsey Scale”, which rates sexual orientation from zero, “exclusively heterosexual”, to six, “exclusively homosexual”, and also includes X for “no socio-sexual contacts or reactions”.

Following on from the book on the Human Male, was published five years later, the “Sexual Behavior of the Human Female” in 1953.

Some, however felt that the two dimensional aspect of the Kinsey Scale, did not fully encompass sexual orientation, and in 1978, Fritz Klein published, “The Bisexual Option”, where they expanded the Kinsey Scale into a three-dimensional grid, called “The Klein Sexual Orientation Grid”.

This now viewed sexual orientation in the past, the present and in the idealized future, and used different values, 1 to 7, and viewed sexuality as not being fixed, but could vary across an individual’s lifetime, and these variables were; sexual attraction, sexual behaviour, sexual fantasies, emotional preference, social preference, your lifestyle and self-identification.

Each variable was referenced in respect of female and male, from zero percent to one hundred percent, so taking the first variable, sexual orientation as an example, the matrix would show the percentage of attraction an individual would have towards someone who is male and also to someone who was female.

Then in 2009, my psychotherapist, Dr Kenneth Demsky built upon, “The Klein Sexual Orientation Grid”, proposing, “The Klein-Demsky Matrix of Sex and Gender”, that included an additional two variables, a psychological one, gender identity, and a physiological, anatomy, so as to encompass transgender and intersex individuals.

The gender identity variable, recorded how female and how male an individual felt, again on a scale from zero percent to 100 percent, and for the anatomy variable how female and how male an individual’s body, and if you would like to read the presentation of The Klein-Demsky Matrix of Sex and Gender, it can be found on “The Beaumont Trust” website.

So using myself as an example for these two variables, for gender identity I consider myself pretty much 100% female, as for anatomy, post my gender affirming surgery, and that I transitioned late in life, I would say I am high eighty percent female, and speaking of gender identity and anatomy, it brings us nicely back to Dr Benjamin.

The care that Dr Benjamin afforded was the exact opposite of the majority of physicians, who would have instead tried to aligned the mind to the body, which is exactly the aim of that hateful practice of, “conversion therapy”, which some lesbian and gay people may also have encountered.

Currently it is not illegal in the United Kingdom, although since 2018, successive UK governments have described these practices as abhorrent, and committed to introducing legislation to ban them, however as of yet this has not occurred.

Professional organizations such as NHS England and the British Psychological Society consider all forms of conversion therapy, unethical and potentially harmful.

The care Dr Benjamin offered to transgender people soon spread, although perhaps by todays standards, he set a high bar for who should be considered for surgical transition, seeing surgery as a last resort, and urging his patients to progress slowly.

Dr Benjamin also found following up his patients difficult, as many once they had transitioned, just wanted to get on with their life, however over time he was able to amass documented evidence of his medical transitions, and in 1966, aged 81, he published his ground breaking book, “The Transsexual Phenomenon”.

Dr Benjamin’s cautious, and one might even suggest paternalistic approach, would unfortunately influence the early standards of transgender care, that said, his patients held him in high esteem, and given his perseverance in the face of hostility from his medical peers, I feel he still deserves a place with the pantheon of transgender supporting heroes.

In 1979, “The Harry Benjamin International Gender Dysphoria Association” (HBIGDA) was founded, and drew on the work of Dr Benjamin, to provide clinical guidelines for gender-affirming medical interventions, devising a standard known as the Harry Benjamin Rules.

The Harry Benjamin Rules, where a six-tier scale, which one might think of as a degree of gender dysphoria, they also placed an emphasis on a straight sexual orientation, like there are no lesbian trans women, err like myself.

The first four versions, published in 1979, 1980, 1981 and 1990, were all titled “Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons”, and followed as mentioned the limiting and restrictive criteria of Dr Benjamin, and required a mental health assessment and psychotherapy.

I think at this point it would be worth considering other professional organisations, and their understanding of gender identity, in the United States there is the “American Psychiatric Association”, and their, “Diagnostic and Statistical Manual of Mental Disorders”, (DSM).

The first two editions of DSM didn’t address gender identity, however although this is an explanation of transgender health care, I think it would be instructive to examine how DSM, viewed same gender relationships.

In DSM-I published in 1952, homosexuality was classed as, “Sexual Deviation“, under the heading of, “Sociopathic personality disturbance”, or to put it crudely, gay people were thought to be nuts.

Did things improve with DSM-II published in 1968, well no, initially being gay was still classed as a mental disorder, however with the 1973 edition of DSM-II, homosexuality was no longer categorised as a mental disorder, but detailed under “Sexual Orientation Disturbance”, OK not great, but an improvement over being considered mentally ill.

Which brings us to DSM-III in 1980, and the first mention of gender identity, any guesses how it was described?

It was detailed under the heading, “Psychosexual Disorders” and for adolescents and adults it was categorised as “Transsexualism” and for children, “Gender Identity Disorder of Childhood”, which I think illustrates how the understanding of gender identity, lagged behind “sexual orientation”.

That said, DSM-III did introduce the term, ”Ego-Dystonic Homosexuality”, which it stated was a conflict between how sexual orientation felt and how it was wished to be, and that sexual orientation was not innate, whereas now it is generally accepted that sexual orientation is innate, it is how we are born, and some are born lesbian or gay.

I doubt advocates of conversion therapy would have seized upon ”Ego-Dystonic Homosexuality”, as the ignorant rarely feel they need of a justification for their prejudice.

However with the release in 1987 of DSM-III-R, Revision, this term was removed, yet three years later the “World Health Organisation”, the W.H.O., thought it would be a good idea to include in the tenth edition of the, “International Classification of Diseases”, ICD-10.

And was there any improvement in respect of gender identity, well slightly, it was now categorised under the heading, “Disorders Usually First Evident in Infancy, Childhood, or Adolescent”, but gender identity was still pathologized as a mental disorder.

And having mentioned the W.H.O. how did they fare in respect of gender identity?

The first mention of a gender identity was in 1965 with ICD-8, with the introduction of the term “Transvestism”, which was classed as a sexual deviation under the chapter of “Mental Disorders”, do you see a pattern here?

In 1975 with ICD-9, different classifications of gender identities were detailed under the heading of “Sexual Disorders and Deviation”, still in the chapter Mental Disorders, I mean seriously.

But with the already mentioned 1990 ICD-10, gender identities were detailed under, “Gender Identity Disorder”, in the chapter, “Mental and Behavioural Disorders”, the ICD’s focus being specific conditions rather than a single encompassing disorder as in DSM.

In 1994 DSM-IV was published, with gender identity categorized under the single heading of “Gender Identity Disorder”, and yes it was still pathologized as a mental disorder.

But back to HBIGDA, which faced criticism from within the trans community regarding its strict criteria for treatment, and they where consulted prior to the publication of the fifth version in 1998.

The publication was now titled “Standards of Care for Gender Identity Disorders”, I think that term must be infectious, and no longer required psychotherapy, instead merely recommending it.

Then in 2001 the 6th version of HBIGDA was published, and advocated a more individual and flexible approach to gender care, and had a better representation of the trans masculine experience.

Then in 2007, HBIGDA officially changed its name to the World Professional Association for Transgender Health (WPATH), and shifted from pathologizing gender identity to the health and well being of transgender people.

The 2012 seventh version of the WPATH’s Standards of Care, changed its title to, “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People".

It replaced gender identity disorder with “Gender Dysphoria”, which acknowledges the distress experienced by some transgender people stemming from the incongruence between their gender identity and the sex assigned at birth.

Finally, I was no longer a disorder, and although as mentioned in the previous episode, I was diagnosed with gender dysphoria, I wasn’t in a state of severe distress or unhappiness at the start of my transition journey, it was just that my physiology didn’t match my gender identity and I wanted it changed.

The 7th version also abandoned the “Sex Orientation Scale”, the official name of the “Benjamin Scale” and shifted the focus onto individual symptoms and addressed gender identity and sexual orientation as separate aspects of a person.

In 2013 DSM-V Was published and now also used the term “gender dysphoria”, and finally changed the emphasis away from pathologizing the person.

Then in 2019 ICD-11, which officially came into effect on the 1st of January 2022, trumped DSM-V, by replacing gender identity disorder, not by gender dysphoria but by “Gender Incongruence” and moved it to "Conditions Related to Sexual Health".

I feel that gender incongruence, that is the feeling of a mismatch between an individual's gender identity and the sex they were assigned at birth, is a more accurate description of how I felt prior to finally having my gender affirming surgery.

2022 also saw the release DSM-V-TR Text Revision, that made further changes to terminology so as to be more inclusive, such as, "expressed gender" was changed to "experienced gender" and "cross-sex gender-affirming surgery" was now "gender affirming surgery", which is how I would describe my surgery.

And lastly in 2022, saw the publication, and with a slight title change, Standards of Care for the Health of Transgender and Gender Diverse People version 8, which also like ICD-11, used the term “Gender Incongruence”.

I called this episode, “I Am Not A Disorder”, and as you have heard it took three internationally recognised bodies, quite some time to finally recognise that trans and non-binary people are just part of the wonderful diversity of humanity.

This episode was written and presented by me, Carolyne O’Reilly, thank you for listening.

And as the next episode should be published five days before Christmas, what should it be about I wonder, any ideas dear listeners?

You can, anonymously if you wish, leave any suggestions on the Have Your Say page of this pod’s website at www.twts.co.uk.