So now we've talked about how it's not psychiatrist and psychiatry who determine what's going to get diagnosed and who's going to get diagnosed. We all play a role in that as a social environment and as a society. And what we're going to do next in this segment is look at a diagnosis that really demonstrates how the social context has an impact on. Who gets diagnosed what gets diagnosed and whether treatments are available for it. so this is a topic that I think is really interesting because there are several, there are several diagnoses that we have in psychiatry and in mental health that are contraversial. And they're controversial, partly because they diagnose things that many people think are not a type of pathology. They are not representing an illness, they are just representing differences in human experience. So, for example, something like Social Anxiety Disorder. This is something that gets treated with, usually anti-depression medications, anti-anxiety medications. But there are a lot people who would say, this is not a diagnosis. some people are shy, some people are more extraverted. And it doesn't make sense to decide that shy people acfually have some kind of mental disorder that requires treatment. They're just shy, and we can just let them be shy. So it, it could have gone a different way, and it does go a different way for some people. Not everybody whose shy presents for for treatment for social anxiety disorder. But I'm sure you can imagine there are people who can find You know, have, have issues in that area that can be quite crippling and these are people who will, present for treatment. And it takes us back to that whole issue of you know. how people Functioning is affected right? We don't make diagnosis, you don't meet criteria for a diagnosis usually unless it's actually having an affect on the way that you're functioning. So if you're a shy person and you're functioning okay, you probably won't come to psychiatric attention, but, if you have, severe social anxiety and it's really interfering with you're ability to have quality of life. Order to engage with life. And you may. So, we have many diagnosis like this, where it feels like it could have gone either way. And one that we're going to be focusing on today is gender identity disorder. So, I picked gender identity disorder, partly because of a conversation I had with one of you. One of the people that was registered in this course contacted me. to me and was asking me about some of the research that I'm involved in. I'm on a few teams that are looking at healthcare access issues and, another one that's looking at human rights issues for people across the LGBTQ spectrum. So, in our context that stands for lesbian, bi-sexual, transgendered, and queer. I know in different parts of the world they use different, different letters and in different order. So I'm in a couple of research teams that are doing that kind of work and they wondered if I was going to be talking about it in the course. And, at the time I, that wasn't part of the plan. But then I thought It's actually a great idea to bring these things together because you know one of the reasons I'm doing a project on mental health care access is because people who are sexual engender sexualed engender, sexual engender minority identities, they have healthcare problems like everybody else and as a marginalized group in our. Right here in our society. they have problems with health care access and we'll talk more about that in a later segment but they have issues with health care access and don't have, what I would call, equitable access to health care and mental health care. So that's why that team is working on issues of health care access. But at the same time there's no question that people across that spectrum have had a very tricky history with psych, psychiatry and psychiatric diagnosis. And it's not that long ago that the diagnostic and statistical manual actually pathologize even being lesbian, bi-sexual lesbian bi-sexual, gay and what we would call queer. I'm skipping over transgender because gender identity disorder remains in the diagnostic and statistical manual as a way of attaching a label, a diagnostic label to transgendered experience, and it seems. That that could have gone a different way. And I think it's interesting to talk about and think about, why is this particular identity something that appears in a diagnostic and statistical manual of mental disorders? And that has a lot to do with the social context, so that's why we're going to be talking about that next. The definition of transgender here is from a paper that's in your cited resources list, but it's not available through a link. So you, if you're interested in finding it, you may have to go to a library. it uses a very inclusive definition of transgender, and we will similarly be trying to use the term inclusively in this lecture. The term transgender refers to gender identification that is not matched to the sex at birth. So, we need to make a distinction here between sex and gender. Gender refers to the social and cultural definitions of being male or female. It is how we are all taught to understand what constitutes masculinity and what constitutes femininity. Sex refers to the biological definition of being male or female. It is what is indicated by our physical states, things like hormone levels and reproductive organs. Putting it into social context, we have to consider that part of what makes a trangendered existence remarkable is that it is a socially transgressive identity. People who do not fit neatly or do not attempt to fit themselves neatly into the two rigid categories that society has decided exist for sex and gender expression are violating widely accepted boundaries, not universally accepted, but widely accepted. Gender boundaries are imposed of course in the growing viability of social space of a social space for living at a life that includes transgender experience demonstrates they are not fixed. But the degree to which transgender experience is acceptable, viable or even safe varies depending on the social environment in the given place. Gender identity disorder is a medical label that has been applied to trangendered experience. It's interesting to me that the use of the terms gender and identity clearly signals that this refers to something that is socially constituted, but once we attach the word disorder It becomes something that is pathological. And in our current understanding of psychopathology, this seems to imply something biologically disordered. As you see here, the idea of gender identity disorder has been around for a long time. I was surprised to see that gender reassignment surgeries have been happening since the 1920's. Yet the term,gender identity disorder, was not included in the diagnostic and statistical manual until the third edition in 1980. So why was gender identity disorder introduced at that point? First There have been enough descriptive study of transgendered experience for people to feel they could propose some generalizable idea about what it involved. There was some idea of the potential life course of someone who lived a transgendered experience. But this, but this brought it into the arena of medicine and psychiatry and what started as descriptions of peoples lives then gets turned into descriptions of symptoms. Diagnostic criteria and prognosis. Bringing it into this medical world, and use of this language, was what was necessary at the time for transgendered experience to be recognized. And through recognition, to be elligible for support and treatment. With this recognition, and without this medicalization, there were few ways at the time to garner support, or services for people who wanted to seek out interventions, like sexual reassignment suergeries. So you see, bringing transgender experience into the Diagnostic and Statistical Manual was actually part of a campaign of advocacy for transgendered people. But, I'm sure you can imagine it was a campaign with ambivalent outcomes. On the 1 hand, as with the advocacy that introduced post-traumatic stress disorder to the Diagnostic and Statistical Manual, the introduction of a diagnosis called gender identity disorder increased education and awareness about. About transgendered experience and legitimized attempts by people with that life experience seeking treatment and support from the medical establishment. On the other hand, the introduction of a diagnosis called gender identity disorder also made the life experiences of a group of people inherently pathological. They were essentially seen as ill in the same way that up until that same edition of the DSM. People who are homosexual have been seen as ill. Here is how gender-identity disorder is described in the fourth edition of the DSM. Its wording betrays much about the culture of the DSM and the culture in which it is created. The notion of crossing genders and the idea of desiring to be the other sex speaks volumes about the rigidity with which gender and sex is defined and boundaried in this cultural context. It's important to note that this not a diagnosis that can be made without an indication that there are problems for the individual, problems like distress or problems functioning socially in their job or school or in other important areas. For the most part, people who are presenting for some kind of treatment for gender identity disorder are people who have self-identified as feeling disordered in some way, and wanting some kind of intervention for that disorder. Although, since this is the course, since this a course on the social context of mental health and illness, I hope you're asking yourselves if it's accurate to locate this disorder as something attached to the individual? Or should it be labeled as something that is created by a social context but does not accept or support the individual. Having decided that this was a disorder and that this disorder required treatments, the treatment for gender identity disorder were both biological and psychological. Biological treatment was or is initiated after childhood. Because there is an assumption that gender identification is fixed beyond childhood, therefore surgery and hormones are used to align the biological experience with the gender identification that the individual claim. Psychological treatments were once directed at correcting what was then seen as a delusion of gender misalignment, or a gender disorder resulting from some kind of problem during development. I don't know if psychotherapies like this still exist. It's entirely possible, since the removal of homosexuality from the DSM has not eliminated the practice of psychotherapies and other treatments directed at attempting to change or cure it. However, it is more likely that psychotherapy in the context of gender identity disorder is to deal with the potential distress or functioning problems that are described as being criteria for the disorder. The concerns that I've mentioned about how this daignosis reflects what's wrong with individuals versus what's wrong with our society come to the foreground when we talk about the diagnosis of gender identity disorder in children. Using the criteria listed here, psychiatrists similarly make assessments of whether a child is fitting into an appropriate gender role or presenting in ways that suggest non-normative gender expression. It's certainly possible that children can express distress about gender I, identity, but as I'm sure you may have guessed it is often parents or other adults in the child's life that will sound alarm bells about a child's gender. Their identification. Here it seems less clear whose needs are being met when an individual is presented for a potential diagnosis. In addition, I'm sure that many of you look at this criteria and wonder, how can we make such judgements about children? How can we think about applying a diagnosis like gender identity disorder to a person who is still developing into a full sense of their identity as a whole. If we were to reflect on what we discussed in the previous section about the kind of social agreements that allow diagnosis to happen. The introduction or some would say the invention of this particular diagnosis would have agreed on certain types of social agreements. There was a social agreement that psychiatrist had a role to play in how people lived there gender. There was a social agreement that transgender people could be put under psychiatric scrutiny. There was a social agreement that psychiatry was responsible for dealing with the destructive potential of people who did not fit neatly into what society asserted were two distinct and very different genders. And finally, there was a social agreement that there was no other place, no other institution, where this was to be dealt with, except for medecine. Because, remember, psychiatrists and psychiatry doesn't even get the change to diagnose anything, that we, as a society, don't give it permission to diagnose. Diagnose. I want to make sure you understand, there are people that want this diagnosis. And they want treatments. And without the existence of a diagnosis called gender identity disorder. They would not be able to get them or they would only be able to get them under conditions that could be quite unsafe. At the same time, there is a degree of discomfort that many people feel about the medicalizing of a trans-gendered identity. And the treatment of individuals for distress and problems with functioning, that are not inherent in the individual. But more the result of being in social environments where they are not accepted. There are many places in the world where gender identity is not as fixed and rigid and those are the places where transgendered existence is completely viable and does not have to be treated. It might not even have to be named. So the social agreements that I just mentioned are not in place everywhere. There are other possibilities. So is this diagnosis progressive or oppressive. Is it something that the state uses to contain and control people who may disruptive because of their gender expression, or is it a validation for people who are seeking help. Does it create a space where we can recognize non normative identity? Or, is it an attempt to extinguish that identity? Especially if we think, as some have suggested, the psychotherapy of a child diagnosed with gender identity is an attempt to prevent their development into a transgendered adult. And finally, does gender identity disorder have a place in the manual of mental disorders? Is it a disorder, and will it appear in the fifth edition? I don't know if gender identity disorder is going to appear in the fifth edition of the DSM. But part of what I hope you understand from what we've just covered, is that it definitely could go another way. There are already a lot of places where such a diagnosis does not seem to be necessary at all. But if we're in an environment, for example, I'll speak for North America. In this environment it seems like you do still need something because people are going to. Experience distress. Or they're going to want to transition, or they're going to want to somehow be supported in their transgender experience. And, without a diagnostic label, they're not able to get that. It's hard to know, how we can then move this diagnosis out of the DSM. And, I guess and, if we think about these so, kind of social agreements that I've discussed, it's also hard to know who else would pick this up then. I mean if it's not a psychiatric problem, what kind of problem is it? Honestly I think it's a social problem. And I wonder what a diagnostic and statistical manual of social disorders would look like. Because, this certainly strikes me as 1 of those things that's created by social attitudes and stigma, and discrimination, more than it's actually. Created by anything that's within individuals. But that's part of a larger discussion, and maybe that's part of the discussion you're going to have on your forums. We're going to move on now, and in our next segment we're going to be talking about treatments.
