Gender Policing in the Clinical Setting: Discussion of Sandra Silverman’s “The Colonized Mind: Gender, Trauma, and Mentalization”

Abstract

This is a discussion of Sandra Silverman’s clinical paper “The Colonized Mind: Gender, Trauma, and Mentalization.” Her patient, David née Ava, started early in life as a gender variant child. In adolescence, she became more stereotypically gender conforming. She entered treatment with Silverman as a young adult who was feeling great shame about both her past and present gender dysphoria. This discussion focuses on the clinical problem of gender policing, its external and internal manifestations as well as its appearance in the countertransference.

Notes

¹ Members of the transgender community have coined the term “cisgender” to describe those whose psychological gender is concordant with their anatomical sex and who usually think of their gender identity as just “normal.” Similarly, the term “homosexual” preceded and necessitated the creation of the term “heterosexual”; the latter term emerged as a more specific signifier of what people used to think of as “normal.” “Cisgender has its origin in the Latin-derived prefix cis, meaning ‘on the same side’ as in the cis-trans distinction in chemistry. In this case, ‘cis’ refers to the unity of a gender identity with a gender role” (“Cisgender,” n.d.). Some trans writers (Serano, 2007) prefer cissexual rather than cisgender.

² The language used to describe gender-nonconforming children (and adults) is a subject of controversy. Gender variance is a nonpathologizing and normalizing term in contrast to gender identity disorder (GID), a diagnostic category of the DSM and ICD. Gender dysphoria as used here is not as the new DSM-5 diagnosis that replaced GID (Zucker et al., 2013), but in a historic, descriptive sense to describe the internal distress felt by individuals when they do not feel their anatomy aligns with their experienced gender.

³ The transgender community has coined the term, transphobia, akin to homophobia, to describe both the prejudice they experience from others and the self-loathing they may feel themselves.

⁴ For theories of how gender identity develops, see Coates, Friedman, and Wolfe (1991); Fausto-Sterling (2012); Green (1987); Money (1994); Stoller (1964); and Zucker (2008).

⁵ Money (1986) theorized, “Identifications and complementation each have their representation or schema implanted in the brain. One is the schema of one’s own gender status. The other is the schema of the other gender status to which one must complement one’s own” (pp. 118–119).

⁶ Queer theory challenges implicit assumptions that underlie conventional, binary categories like “masculinity–femininity,” “homosexuality—heterosexuality,” and more recently “transgenderism—cisgenderism.” It challenges cultural norms, seen as oppressive, by “deconstructing” the implicit assumptions on which such norms are based. It argues that identities (including but not limited to sexual identities) do not arise from biological (essentialist) factors, queer theory draws attention to the ways in which identities are socially constructed through history, language, and custom.

⁷ While Butler’s use of the term “gender policing” does not appear in the original edition of her seminal 1990 work—it appears in a 1999 preface to a revised edition of Gender Trouble—the concept is well articulated in her work before then.

⁸ Beatie transitioned to a man as an adult and married a woman in a legal heterosexual marriage. Although he had taken masculinizing hormones and undergone a double mastectomy (“top surgery”) as part of his transition, like many transmen he had not had genital (“bottom”) surgery. While still in possession of his ovaries and uterus he and his wife decided he would bear a child. After bearing three children, Beatie eventually had bottom surgery in 2012. Wikipedia’s entry (http://en.wikipedia.org/wiki/Thomas_Beatie) provides a riveting account of the many ways in which Beatie’s pregnancies and subsequent divorce raised many gender policing issues too numerous to recount in this discussion.

⁹ For example, boys with micropenises were castrated and raised as girl, while girls with congenital adrenal hyperplasia had their larger than average clitorises surgically reduced to “look normal.”

¹⁰ For controversies regarding the treatment of prepubescent gender variant children, see Drescher (2014) and Drescher and Byne (2013).

¹¹ Her survival strategy also brings to mind Riviere’s (1929) observation that “womanliness therefore could be assumed and worn as a mask, both to hide the possession of masculinity and to avert the reprisals expected if she was found to possess it” (p. 306).

¹² The terms homosexuality and heterosexuality have limited heuristic value when discussing individuals who transition from one gender to another. The terms androphilic (attracted to men) and gynephilic (attracted to women) are descriptive and deem unnecessary any reference to the sex/gender of the person feeling the attraction.

¹³ The World Professional Association for Transgender Health (2011) categorizes stages of transition as “reversible” and “irreversible.”

¹⁴ Many countries require mental health professionals to act as gatekeepers to transition services for transgender people. This gatekeeping function is ostensibly to reduce the incidence of postsurgical regrets. Yet there is a somewhat irrational, gender policing quality to this requirement since few other major surgical procedures with a high risk rate require psychiatric evaluation and approval. In some countries, transgender people wishing to transition must prove to psychiatrists that they are the “right” kind of transgender and that they have been so for a sufficiently long period of time in order to qualify for services. This has created some controversy, as many individuals seeking transition do not otherwise have a mental disorder or desire mental health treatment, and the gatekeeping function may be seen as an unnecessarily burdensome requirement. How the gatekeeping role is performed has contributed to considerable tension between mental health professionals and transgender advocacy groups (Drescher, Cohen-Kettenis, & Winter, 2012).

¹⁵ This brought to mind a not uncommon occurrence with closeted gay patients who come out to themselves privately months before they admitted they have come out to the therapist (Drescher, 1998, 2002).

Additional information

Notes on contributors

Jack Drescher

Jack Drescher, M.D., is Training and Supervising Analyst at William Alanson White Institute, Adjunct Professor in the New York University Posdoctoral Program in Psychotherapy and Psychoanalysis, and a member of the World Health Organization’s ICD-11 Working Group on Sexual Disorders and Sexual Health.