I cannot wait to purchase my copy [of Female-to-Male Transsexualism: Historical, Clinical and Theoretical Issues] and read it cover to cover. Thank you Dr. Lothstein for such a much-needed and long-overdue reference on f-m tsism [female-to-male transsexualism].
Raj’s words emphasize the scarcity of resources for trans people in postwar America and the anticipation with which Dr. Leslie Lothstein’s book was received. However, many were disappointed with the content of the book. Lothstein’s work argued that transsexualism was a mental illness, a concept that gathered momentum during the period between the publication of the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III ) in 1980 and DSM IV in 1994. Transsexualism was added to the American Psychiatric Association’s DSM III in 1980, making gender-variant behavior an officially classified mental disorder and solidifying it as a major concern of the medical and psychological establishments. Publications in the years following the DSM III document the responses to this pathologization from trans people and mental health professionals alike. Lothstein’s work elicited a diverse range of reactions from trans communities, all of which demonstrated intense engagement with the medical and psychological establishments.
The 1980s saw a surge in grassroots trans publications and networks that sought to engage with a medical community that was becoming increasingly interested in transsexualism. One such network was Rupert Raj’s Metamorphosis Medical Research Foundation and his publication, Metamorphosis, which provided a platform for trans people to communicate with each other. Readers of Metamorphosis closely followed professional publications concerning transsexualism, such as Dr. Lothstein’s Female-to-Male Transsexualism, and engaged with the medical community as surgeries became more widely available.
Lothstein’s book outlined a treatment strategy that favored a therapy-only approach. Despite Raj’s hopes for a definitive FtM reference book, Lothstein used the case studies of trans men—whom he referred to as female transsexuals—to assert that (female) transsexualism was “not a normal variant of sexuality or an alternative life style [sic], but a profound psychological disorder.” Lothstein, like many clinical psychologists, argued against gender realignment surgery (except in rare cases) in favor of intensive psychotherapy.
Gender-conforming (cisgender) professionals like Lothstein became more confident and empowered in treating transsexuals after diagnostic guidelines supported their treatment. As Lothstein notes, “prior to DSM III only a few select clinicians had widespread clinical experience with so-called transsexuals.” Once transsexualism could be diagnosed as a psychiatric problem, the medical and psychological establishments felt comfortable treating it as one. The divide between trans individuals and the cis professionals treating them was entrenched by the codification of diagnostic criteria, where one party could judge the other.
In his review of the book, Raj criticized the dissonance between trans experience and professional publications as a problem of “perspective”; in his words, “the professional is on the outside looking in (i.e. an objective clinical observation) and the transsexual is on the inside looking out.” Raj highlighted the divide that existed between the needs of trans communities and what cis professionals offered or limited. The “us vs. them” mentality that Raj alluded to in his discussion of “perspective” is illustrated in one reader’s response, who said, “it doesn’t sound very good if his treatment is psychological rather than surgical. Does he really think he can talk us back into the kitchen?” This reader’s dissatisfaction with the shift towards favoring a psychological approach lay in the recommendation that surgery become even less accessible. The use of “us” divided mental health professionals and trans people into two separate groups with clashing agendas and perspectives, pitting the in-group of those seeking surgery against the professionals who controlled access to diagnoses and treatments.
Many responses to the book emphasized this intense separation. Some responded by calling it “awful,” lamenting the way Lothstein “[approaches] the subject as an illness or pathology.” Responders generally criticized how the psychological establishment is “only interested in manipulating transsexuals into getting tied up for years and years in psychotherapy of dubious benefit so that they can study us like white rats.” Another retort slammed the mental illness model as “dangerous and regressive, reminiscent of the early psychological theories of ‘what makes a boy homosexual.’” Many of Raj’s readers feared the power over trans lives that a psychiatric diagnosis gave to professionals, drawing connections to the earlier diagnosis of homosexuality that led to the establishment of conversion therapy.
Despite this tension, not all responders to the book shared the same dissatisfaction with the provider-patient dynamic and the psychiatric classification of transsexualism. While Raj criticized the book as “largely theoretical, highly speculative, and generally inconclusive,” another reader offered a more generous interpretation of Lothstein’s approach. This reader pointed out that there was no conclusive explanation for trans identity: “You must recognize that your stance (that TSism is non-pathological, that the masculine identity is real/not a false self, etc.) is just as speculative and inconclusive.” This individual attempted to bridge the divide between the separated “us” and “them” by criticizing Raj’s stance in the same way that Raj criticized Lothstein’s. They did not fault mental health professionals for medicalizing transsexualism because Raj and other members of the trans community could not prove that it was not in fact pathological. While others would vehemently disagree, this reader urged for “more and better communication between professionals, researchers, and TSs.”
Trans activists and historians alike have engaged in debate about the role of clinicians in trans people’s lives in the periods before and after the DSM III. For instance, legal activist and theorist Dean Spade criticized the medical community’s overbearing role in trans lives in “Mutilating Gender,” while historian Joanne Meyerowitz describes the tension prior to the DSM III in “A Fierce and Demanding Drive.” The conversation sparked by the DSM III, and illustrated by the debates over Lothstein’s book, soon moved to pragmatic considerations. For example, the medicalization of transsexuality, while harmful to treatment and public perception, proved helpful for legal protection. The 1992 “Minority Report on the Recommendations of Health Law” argued for continued diagnosis to protect against legal discrimination.
The complex relationship between physicians, clinical psychologists, and trans communities is succinctly articulated in one Metamorphosis reader’s response to Lothstein’s publication: “what transsexuals have gained through medicine (hormones and surgery), we’ve paid back dearly as an easy target of those who need to believe THEY are the ‘normal ones’.” This reader drew on the concept of normalcy to criticize the intentions with which trans individuals were treated by the medical and psychological establishments. While trans activists would later debate the legal benefits of pathologization, the potential benefits came at the cost of the divide between the “normalcy” of the professionals and the “deviance” of those they diagnosed as mentally ill.
Galen Comerford is an undergraduate student at the College of the Holy Cross in Worcester, Massachusetts. She works as a research volunteer at the Digital Transgender Archive under the direction of her advisor, Professor K.J. Rawson. Her research this summer with Mithra Salmassi focused on the medicalization of the trans community in the twentieth century.
Editors’ Note: In this third installment of NOTCHES’ four-part series on trans history, Galen Comerford addresses the history of trans pathologization and trans responses to changing medical and psychiatric frameworks for treating trans individuals. While studies of transgender histories often overemphasize medical histories by treating medical transition as the central issue in trans lives, Comerford draws attention to the ways that trans communities sought out and responded to medical studies. We hope that this piece prompts discussion over the historical significance of medical care and pathologization in transgender history. Should historians continue to study the history of medical care, which was and continues to be so important to many trans individuals? Or does this historical focus place too much emphasis on medical histories? And given the imbalance of power in the relationships between providers and patients, how should historians engage archival sources that record these struggles over power and perspective?
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