Gender - What Use is Psychiatry?
M. T. Haslam. MD., FRCP(g)., FRC.Psych
Psychiatrist/ Medical Director
The inclusion of sex and gender issues in the curriculum of the medical student is a relatively new phenomenon and, when I qualified, was relegated to two or three lectures which would be described as deviancy, and one on impotence.
Hugo Milne from Bradford can perhaps be credited with the first attempt at a National Conference on the theme in this country (at least in his view) though sexual issues have of course been aired since the Kinsey Report in America and Masters and Johnson's book on Human Sexual Inadequacy published a few years before. Hugo Milne's conference in Bradford in 1974 was noteworthy for being raided and taken over by Bradford students Gay Lib group and led a couple of years later to our conference in York devoting a whole day to sex and gender issues including, for the first time, representatives from the various groups which supported sex and gender minorities (if they can so be described.)
Returning therefore to the theme of the talk one must analyze what the function of the psychiatrist should be in looking at gender issues.
A psychiatrist is a qualified doctor who is specialising in a particular aspect of medical practice. Thus he has learned over a five or six year course to understand and treat illness or disease. Having done a year after qualification and probably taken a higher degree in general medicine or general surgery he or she will decide to specialise or go into general practice. If the former then a further two or three year's study and experience will lead to a qualification in that specialty, be it skin diseases, surgery, or indeed psychiatry.
I would define psychiatry as that branch of medicine which specialises in conditions which affect mood, thinking, memory and behaviour. It is thus a wide ranging speciality but is looking at those conditions which cause disturbances in such areas of functioning. Is straddling the gender divide anything in fact to do with medicine? Is not gender perhaps a continuum with a polarity of ultra feminine at one end and ultra masculine at the other, but with a large number of individuals at some level in between forming a normal curve of distribution, rather than one which is bimodal. The problem is that apart from a very small minority of individuals with abnormal genital development the sexes do divide into those with penises and those with vaginas. The fact that gender does not always seem to match these physical norms is where the difficulty occurs.
I would also take issue with the splitting of transvestism and transsexualism into two discrete (never the twain shall meet) entities following the bimodal model. This division derives largely from early writing by Professor Sir Martin Roth in his days at Newcastle and is to my way of thinking an artificial division created by the type of questions which the researchers or clinician chooses to ask. Such individuals have become more sophisticated and learned now to give the right answers to such professionals in order to develop a particular line which they wish to take. I would suggest that in gender there is a continuum with, at one end of the scale, an individual who has a conviction of an innate brain difference from their genital sex and at the other end of the continuum an individual who is aware of needs which fall more naturally into the other gender than that which matches the physical sex but in which the expression is relatively small and the awareness is not of belonging to the other gender from the sexual match.
We get into all sorts of issues here and overlaps with fetishistic behaviour and homosexual orientation. It is necessary to define norms and to see in what way such differences overlap.
At any event the individual whose gender does not entirely match their physical make up may develop problems as any other minority group, and the common example that I give in such cases is an individual with ginger hair. Ginger hair may be associated (in folk lore), with certain personality difficulties and is certainly deviant in statistical terms but it is very unlikely that such an individual would see a doctor because of that particular facet of their body. The same might be said for green eyes or other variants. The reason that the transvestite end of the continuum seeks out medical help would be no different from that which any other minority group might do so, namely they may, because of their minority situation, become the butt of prejudice by society in general. This is society's problem rather than that of the individual, but the individual may suffer anxiety and insecurity as a consequence.
The reason the transsexual end of the spectrum may seek our psychiatric help however is more to do with the relatively modern possibility of operative intervention to change the external appearance of the body to match the gender which that individual wishes to identify. Gender confusion however can hardly be called a disease; though if there is a genuine mismatch between brain sex and genital sex then this I suppose could be called a disorder and as such might merit treatment. The fact is however there is no treatment that will rematch gender to the body and at best rematching the body to the gender is an imperfect science which does not create a true change.
Psychiatrists therefore are required to prescribe hormones because it is perceived as their role to treat such an individual, and are required to ensure that such individuals do not have a serious mental illness, which might affect their thinking in such a way as to make their concerns about gender unreliable. Thirdly they are needed to satisfy surgeons who do not wish to operate on individuals who are unstable to the extent that they may regret the operation afterwards which of course is irreversible and the surgeon might then get sued! A fourth important role for the psychiatrist is in the psychotherapy and counselling which is necessary for people with major problems. We can say that straddling the gender divide is often a major problem even if it is society who has caused it. The same might apply to somebody who was a black in a white society, or vice versa, a homosexual, or somebody who has had a mutilating operation or a serious disease. Individuals may benefit from a psychotherapeutic approach to their needs.
Over the last twenty to thirty years there have been increasing hints, now turning into increasing evidence, that there is indeed brain difference between male and female, masculine and feminine, and that some individuals do seem to have a mismatch between the brain and the body. This has serious implications for genetic counselling, for legal abortion and for potential opportunity to remove such abnormal genetic developments, in the not all that distant future and is a debate which is already occurring among the homosexual community. If a parent knew that the fetus they were carrying was going to be homosexual would they choose to abort? Should they be allowed to abort? should they be allowed to interfere with nature in this way? What if it were the other way round and a homosexual couple wanted to have a child who was homosexual? Should this be allowed? There are many serious issues which will need to be sorted out in the next fifty years.
Who are these strange people who cross the gender divide and why is it so difficult for society as a whole to deal with such an issue? Gender differences are perhaps still one of the big taboos. As one individual has put it, however: "If you don't want sex with me, why do you want to know my gender or the shape of my genitalia? Who cares anyway?" Perhaps what should be put over to society is that the individual with a gender straddling situation is no threat to anybody and indeed may have better insights than the individual who is at either end of the gender spectrum. Such individuals should be interesting rather than a cause for prejudice. Unfortunately the media, whose object is to entertain, inevitably exploit the prejudices of the masses in developing humour out of such individuals as a cross dresser, the mentally handicapped or the infirm. Such groups are the butt of any poor comedian. Perhaps the psychiatrist should have a role also in trying to educate, as a public health measure, the general population; if nothing else at least in manners.
How far therefore does psychiatry need to go and indeed how far should it go in satisfying the requests of individuals who are not suffering from a mental illness and who want anything beyond counselling or psychotherapy? The issues of hormones has recently been given an airing by Dr Sheila Kirk, GEMS News 32, in her article "a defence for contrahormonal treatment in non transsexuals". This takes things beyond Harry Benjamin's ideas in his standards and scales; which are primarily for the transsexual who is looking for gender operative surgery. We must remember that Harry Benjamin is a man "He is just a man." There are a number of individuals who I would suggest are at the right hand end of my continuum that, while not wishing gender surgery, wish to live a female lifestyle - and to develop female attributes in order to feel more at ease with themselves, to develop breast enlargements and to allow their figure to become more appropriate to their inner needs. Should such people be denied hormones on the whim of a doctor, or should everyone be given whatever they want, in effect removing the necessity of prescription for hormones and allowing free sale. These are moral and ethical issues and many doctors might argue that, since there are risks in giving medications, and since the individual is not suffering from an illness, they themselves should not be involved in such decisions at all.
I have tried in this paper to develop the theme of the purpose of psychiatry within gender problems and to look at some of the issues which are often raised. There are not straightforward solutions and it is perhaps for society to make the decisions or for the sub group in society with differing gender needs from the norm, as to how far and where we should next go.
Haslam, M., (1998), What Use Psychiatry? GENDYS '98, The Fifth International Gender Dysphoria Conference, Manchester England. London: Gendys Conferences.
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