Reducing incongruence or eliminating diversity?

After decades of ruthless stigmatisation and pathologisation, the psychiatric profession has recently converged on a new way of characterising transgender people and the purpose of medical interventions such as cross-sex hormone treatment and gender confirmation surgery — one that deliberately aims to be progressive. According to the DSM-5 and the soon-to-be-released ICD-11, transgender people’s experienced gender is incongruent with their natal sex or their natal gender, and the stated purpose of such medical interventions is to reduce that incongruence. However, I will argue that, firstly, not only is this “incongruence thesis” and its framing of the purpose of such medical interventions conceptually incoherent but, secondly, that this way of characterising transgender people and the purpose of such medical interventions is not progressive but deeply though insiduously regressive, and that it threatens to marginalise sex, gender, and sexuality minorities, and to eliminate diversity.

In regards to my first point, my case will be that if sex, gender, and sexuality are indeed different things, then transgender people’s experienced gender and natal sex cannot possibly be incongruent, simply because no combination of sex, gender, and sexuality can be either congruent or incongruent. And although it is not incoherent to claim that transgender people’s experienced gender might be incongruent with their natal gender, what is incoherent is the suggestion that medical interventions that alter the body’s sexual characteristics can reduce an incongruence between experienced and natal gender. The reason why this matters is because despite the psychiatric profession’s intention to be progressive – to characterise transgender people and these medical interventions in a de-stigmatised and de-pathologised way, and to remove hurdles to accessing transgender health services – on closer inspection this approach appears to be thoroughly though insidiously regressive. My second point will therefore be that psychiatry’s new approach to transgender people in fact rests on an outdated, conservative, and ultimately oppressive view about sex, gender, and sexuality — one which marginalises sex, gender, and sexuality minorities, and which is hostile to rather than truly supportive of diversity.

Admittedly, proponents of the incongruence thesis employ progressive rhetoric, they espouse enlightened attitudes towards sex, gender, and sexuality, and they describe these medical interventions in the euphemistic language of affirmation and confirmation. However, when the only medical interventions available are ones that promote conformity with dominant social norms about what counts as “alignment” between sex and gender – and when transgender people’s pre-medical-intervention alignments of sex and gender are described as incongruent – I cannot help but worry that this new approach is not progressive but deeply regressive, and that it does not affirm diversity but only promotes conformity.

This is an abstract for a talk scheduled for presentation on Aug 10, 2018, at the Plunkett Centre for Ethics, St Vincent’s Hospital & Australian Catholic University, NSW, Australia.