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When WHO Assigns Our Genders, Who Assigns Our Genders?

flickr/Medical Archive collections at University of Liverpool

The International Classification of Diseases doesn’t list being transgender as a disorder anymore. But gender non-conformity is still pathologized.

The World Health Organization released the International Classification of Diseases, ICD-11, on June 18th of this year, to the excitement of some transgender activists. In past years, the ICD defined being transgender as a disorder; a form of deviance in need of treatment. But this year was different. The latest update forgoes diagnoses such as “transvestic fetishism” in favor of the far friendlier “gender incongruity.” Having someone’s lived gender experience changed from a deviant “fetish” to a simple contradiction felt like a step forward.

Despite much celebratory discussion of this as a progressive step, there are numerous troubling factors in this re/de-classification that are being ignored. This friendly term is still a sexual health condition listed in a classification of diseases. Gender non-conformity is still pathologized, just differently costumed.

The ICD does nothing to “destigmatize” gender incongruence by renaming it, because it still rests on the presupposition of disorderly bodyminds. In defining “disorder,” it must draw arbitrary dividing lines between the real trans experience and the things outside it. They suggest that there is a concrete and diagnosable difference between gender non-conforming (GNC) cis people, and people who are legitimately transgender. And that the only person who could tell that difference is a doctor.

In defining 'disorder,' it must draw arbitrary dividing lines between the real trans experience and the things outside it. Click To Tweet

This notion of gender incongruence reifies the concept of biological sex as the only “real” bodily experience, which is used to further power structures and gender norms under the guise of what is “natural.” For example, cultural norms of male aggression are biologically validated when erroneously connected to testosterone. Cisgender women are pushed toward motherhood because of an imagined “maternal instinct.” But the maternal drive—often arising from pregnancy itself and certainly not from the mere fact of being assigned female—is cultivated, not inherent. Sometimes, this cultivation begins in childhood, but it is still not inborn. The idea that men are born to fight and women are born to birth, instead of being culturally expected to adhere to these norms, is a damaging consequence of the social construction of sex and gender.

Some activists, educators, and others argue that sex is not gender and gender is not sex, in an attempt to to distinguish the “fact” of biological sex from the ‘feeling” of gender. But this distinction will not save us, either. This is especially true when doctors are in the business of diagnosing what is understood as deviant behavior. Contrary to what the ICD—and well-meaning allies—might say, it isn’t that gender is mutable and only sex is concrete. There is no such thing as “incongruent” sex and gender because, as Judith Butler illustrates in Undoing Gender, there is no sex without gender; no gender without sex. The two produce and naturalize each other, just as testosterone and aggression do.

The ICD’s new rules for real-transness were not meant merely to de-pathologize some experiences in favor of others. Instead, they are part of an ongoing process to assign more specific diagnoses to certain experiences; to widen the pathological catalogue. In doing this, it draws arbitrary dividing lines between the real trans experience and the things outside it, suggesting that there is a concrete and diagnosable difference between GNC cis people, and people who are legitimately transgender.

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This is a common practice that Michael Foucault discussed in Madness and Civilization. The trend of meticulously diagnosing difference is a relatively recent phenomenon, Foucault argues. Though we presume these diagnoses to be natural and timeless because a medical authority declared them so, this paradigm is only about two centuries old. It was invented as a means to mark some people as deviant and others as sane—not as a way to realize an essential “truth.” Diagnoses shift not due to a gradual march toward accuracy, but instead as a means of accommodating shifting social (and thus, psychological) conditions.

By these rules, one is only really transgender when one is interpellated that way by some authority figure, like a doctor. I only become “really me” when some authority recognizes me. Introduced by Louis Authusser, “interpellation” happens when a subject is recognized as such within a certain ideological framework: in this case, gender and disease. The classic example of interpellation is a police officer shouting, “hey you!” at a subject. The “hey you!” is the moment of interpellation. Similarly, according to ICD logic, a subject “becomes” trans not when they determine they are, but when a doctor names them gender-incongruous by the WHO’s guidelines. The idea of gender-as-interpellation contradicts the prevailing assumption that transness is intrinsic, and reveals this as a major flaw in the ICD’s thinking.

If we are only trans when some authority hails us that way, I was not trans until age 18. At 18, I began seeing a therapist and had my gender dysphoria “diagnosed,” all with the express intention of getting a bilateral mastectomy covered by my insurance. Although many trans people are “undiagnosed” until adulthood, we are also expected to produce lengthy historical testimony proving our lifetime of transness, divulging the intricacies of dysphoria that supposedly should have afflicted us since childhood.

If we are only trans when some authority hails us that way, I was not trans until age 18. Click To Tweet

If one isn’t trans until marked that way, but must also have been “born that way,” transness-as-diagnosis is revealed as a paradox; it simply doesn’t make sense. And what do we make of trans men and women who choose not to receive sex-reassignment surgery; who are comfortable with and even enjoy the genitalia they were born with? What do we make of the “Borderlands” (a borrowed term from Gloria Anzaldúa’s work) between butchness and transmasculinity, as Jack Halberstam discusses in Female Masculinity? How do we come to basic conclusions about what “normal gender” is so as to define incongruity in the first place?

If we look to Judith Butler, who notes the ways in which gender is an ideal to be imitated and not a fundamental truth, it would appear that efforts to nail down a true trans diagnosis are grounded in efforts to further clarify (primarily Western) gender roles in general, by defining those who violate them. Pathological incongruity helps to mark normative gender’s outer limits.

In attempting to find an ontological difference between true trans people and mere “cisgender GNC people,” the ICD cordons off trans identity that needs to be validated by medical authorities. The layperson is presumed to be unqualified to determine who is diagnosably trans and who isn’t. It also seals up gender norms for all people; in the shadow of the clearly-set rules for gender incongruity are the un/spoken expectations around correct gender congruity.

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Furthermore, in reserving transness for only those who qualify under its medical definition, others in our community are denied the solidarity they need. Medical notions of true transness appear in trans communities themselves, leading to the harassment and vilification of those deemed “not trans enough.” To qualify as real in the first place, one must submit to the scrutinizing eyes of the medical establishment (and be able to afford being seen by a doctor in the first place), and beg to be seen.

In order to qualify for medical transition, I had to strategically choose not only the medical and psychological professionals I sought diagnosis and permission from, but also which aspects of my health history to disclose. In doing transness with a bilateral mastectomy as my goal, I monitored my behavior, clothing choices, vocal pitch, placement of my feet and hips, and disclosure not only of diagnoses but also of aspects of my personality. I wore an oversized men’s shirt and jeans from the boy’s section, hoping that their bagginess would convincingly hide the shape of my body. I spoke with my chest-voice while hiding the fact that my chest was unbound beneath my shirt. An apparent lack of chest binder or improper attire, I feared, could arouse suspicion of my realness. In order to track down the essence of physical dysphoria, guidelines such as the ICD’s push me toward sheer performance of proper gender incongruity. This is not performance in the Butlerian sense, even, but in the literal sense: I was putting on a show.

The ICD’s classificatory shift of transness is by no means worth celebrating, as that “shift” only works to conceal the workings of the medical system; to make onlookers more amenable to its decisions. A long history and present of pathology leaves all people unable to imagine gender (non-)conformity without medicine and psychiatry. This ICD update only draws slightly different distinctions between the “real” (dysphoric) and “fake” (insufficiently dysphoric) trans people. Its depathologization of the latter group will, paradoxically, do more harm to some than good: it forecloses the possibility of getting surgery and hormones for those not trans enough to diagnose.

Those who are diagnosed receive gender-affirmative care, but only at the cost of being marked as a psychological deviant. All of these situations naturalize sex even as they claim to transcend assigned gender. Compared with the real ramifications of the ICD-11, the romanticized notion of a trans-inclusive medical establishment is dangerous at worst, and incongruous at best.