In her cogent article titled “Transforming Gender Identity (Into A) Disorder,'' published in 2014, academic psychologist Jemma Tosh delves into the extensive history of the problematic pathologization of gender nonconforming people by the psychiatric community. Tosh frequently uses the term “pathologization”, in which a normal characteristic - in this case, a facet of one’s identity - is misunderstood as a sickness or disorder that requires therapeutic treatment. The predominant focus of Tosh’s thesis centers on how contemporary psychiatric practices pathologize nonconforming gender expression into a mental illness, in the form of gender dysphoric disorder (GDD), by centering the criteria for GDD around the societal illusion of the gender binary. Tosh underscores an example of this phenomenon when discussing the social hostility towards the “feminine boy” in 20th century America, in which men who expressed characteristics that deviated from society’s hegemonic perception of masculinity were accused of “lower[ing] their social status to achieve access to women for the purposes of sex” (Tosh, 79). This pools into a secondary point in Tosh’s historical analysis of gender expression: the thresholds society has established for gender roles, specifically for women, are derived from cultural perceptions of women as “fragile” and “subordinate” in comparison to their “strong”, “steadfast” male counterparts (Tosh, 78, 79). This misconception of female inferiority not only serves as the foundation for America’s tacit gender hierarchy, but also reconvenes with Tosh’s central topic of gender expression and its pathologization into GDD. Society has generated cultural norms for an imaginary gender binary to which each of the supposed two genders is expected to adhere, and when either binary deviates from these cultural norms, it is problematically pathologized into a disorder that “justifies psychiatric intervention” (Tosh, 87).
In 1952, this pathologization maniefested in the form of the first Diagnostic Statistics Manual of Mental Disorders (DSM-1), a catalog of “impairments” that created distinct categories of gender that don’t apply to the majority of gender nonconforming people (APA ; Tosh, 90). In narrating the tragic history of medical pathologization of gender nonconforming people to evaluating the source of this discrimination, Tosh calls attention to the societal consequences of pathologization of GDD, and states that psychiatry’s attempts at constructing “gender normality” in their practices only perpetuate violence against gender nonconforming people and uplifts the toxic gender norms currently seen in contemporary America (Tosh, 87).
In her discussion of the causes of GDD pathologization, Tosh constructs a well-supported argument that highlights the role of America’s gender hierarchy in the psychiatric medicalization of gender expression. She posits that “the hostility directed towards those who transgressed gender norms is deeply embedded in societal perceptions of women and femininity,” and that many of the so-called symptoms that the DSM-5 associates with female GDD, such as “a strong rejection of feminine activities,” are based on these societal perceptions of femininity (Tosh, 93). While I agree with her claim, Tosh's analysis may be strengthened by broadening such an evaluation to include other overlooked precursors that play an equally relevant role in the medicalization of GDD. Among these is religion, a factor Tosh quickly dismisses by stating that society’s toxic gender norms are “deeply embedded in societal perceptions of women and femininity rather than religious discourse per se” (Tosh, 79). I would argue that Tosh’s underestimation of religion as a contributor to these gender norms not only narrows the scope of her argument to gender-specific precursors, but contradicts instances within her own analysis that support the significance of religion in this debate.
To offer a broader perspective on the religious causes of GDD medicalization in modern psychiatry, one may consider the work of Linda Woodhead, a religious studies expert who, in her dissertation titled “Gender Differences in Religious Practice and its Significance,” discusses how religion perpetuates the gender roles rampant in American culture. The specifics by which this occurs vary across the religious spectrum since, despite the prevalence of Christianity in the U.S., America is a melting pot of diverse religions that cannot be generalized by using a Protestant standard. That being said, Woodhead posits that the best means of understanding how religion holistically affects gender roles in society “is by viewing religion as a system of power” in which different types of “powers” are disproportionately distributed to different facets of religious communities: in this case, men and women (Woodhead). Such powers include “sacred power,” one’s spiritual knowledge within their religion, and “secular power,” which alludes to one’s position in the social hierarchy (Woodhead). Woodhead argues that the former has the ability to completely shape the latter, stating that a group of individuals who already have a great deal of social power—in this case, men—may use their religious status to “enhance and legitimize their social power,” thus maintaining their dominance in the social hierarchy (Woodhead). This manipulation of faith uplifts male status and oppresses women;consequently, over successive generations of this forced differential status, we achieve the ingrained societal perceptions of “male headship” and “female domesticity” that Tosh blames for the gender roles that psychiatry uses as a reference point for GDD diagnosis (Woodhead).
Moreover, I would argue that one can derive a significant theme present in both Woodhead and Tosh’s pieces: control. In the case of Woodhead, she argues that the most privileged subset of society has the ability to use religion to control social hierarchy and maintain dominant power. For Tosh, there is a tacit theme of control when she claims that “conformity to rigid gender performances is unsurprising within a context where deviations can result in victimization,” which one sees in Tosh’s historical analysis of “the feminine boy” (Tosh 95). Not only do both works highlight a historic restriction of gender expression,but also how various aspects of society’s infrastructure concerning religion and gender stereotypes can powerfully inhibit the advancement of, or can control, marginalized populations, whether women or gender-nonconforming people today.
Granted, psychiatric control and religious control are distinctive in that religious control is often done with the intention of manipulating society’s opaque faith in scripture to repress minorities whose oppression directly benefits the social majority, such as evangelical Americans during the Post-Columbian Slave Era or religious antisemites in Weimar Germany. Conversely, the psychiatric community’s grip on society is simply a structural consequence of psychiatry’s susceptibility to societal stereotypes. However, they are both similar in that, inadvertently or not, they drastically inhibit the development of minorities—minorities that can pose a threat to the majority party by normalizing their existence to the point where there is no longer a “majority” to begin with. More largely, one must not only acknowledge the two specific minority populations discussed by these two authors, but also acknowledge that this can be extended to any group that is not actively elevated by society.
Admittedly, Tosh may never have intended to take her theory outside the scope of gender expression and awareness of injustices committed against gender-nonconforming people. However, I believe her dismissal of religion as a major cause of the propagation of the very gender stereotypes that ruthlessly harm this marginalized community prevents an analysis of the full cultural implications.
Religion is simply one of the numerous aspects of society that have played a role in the creation of gender hierarchies. Even while staying within the somewhat narrow confines of gender hierarchy and its relationship with the DSM-5, Tosh not only manages to posit a compelling case for how society’s gender stereotypes have influenced pathologization in the DSM-5, but also provides an equally sound argument for how the pathologization of gender nonconformity in the DSM-5 has influenced gender stereotypes. In regard to the former, Tosh argues that the creation of gender stereotypes leads to the construction of a gender normality which, for reasons previously established, creates a set of criteria that the binaries are expected to follow. However, in regard to the latter, Tosh also argues that the DSM-5 perpetuates gender stereotypes—using the DSM’s criteria for male GDD as a prime example of this. Tosh astutely claims that by characterizing male GDD as a “strong rejection of typically masculine toys, games, and activities” such as “rough and tumble play,” the DSM-5 plays a problematic role “in the construction of normative and natural masculinity as aggressive” (Tosh, 95). Hidden under all the historical analysis and proofs behind her claims, there is the implication of a positive feedback loop whereby GDD pathologization and the harmful societal perceptions of gender symbiotically contribute to one another. Being an experienced academic, she may have done so intentionally. However, I believe it could only ever benefit us to tease out this implication a bit more and make it explicit how this symbiotic relationship between GDD pathologization and gender hierarchy has been established.
To firmly establish this relationship, one may consider the work of Ian Hacking, a critical philosopher who, in his article titled “Making Up People'' analyzes the ghostly phenomenon of how psychiatric diagnoses and societal subjectivities are constantly shaping each other. Hacking posits that, when people receive a diagnosis on the basis of a particular set of traits, “they interact with these traits, and change themselves” often incorporating these traits to form a different identity from who they were previously (Hacking). Should they return for another visit to the psychiatrist, they will have become completely separate people that have fully embraced the societal stereotypes assigned to them by these psychiatrists. As this occurs amongst many patients, the stereotypes perpetuated by the DSM become even more prominent in society as more people adopt and exhibit them—creating new perceptions of “disorder.” After successive years of such phenomena, the criteria for this mental disorder will evolve based on these new societal perceptions and psychiatrists’ new experiences with treating people exhibiting this “disorder”—though psychiatrists will be ignorant to the fact that the evolution of their patients was their own doing. Hacking refers to this theory of psychiatric diagnoses and societal stereotypes shaping each other as “the looping effect”—a process by which the psychiatric stereotypes that are present in medical diagnoses cause more people to believe such stereotypes to be credible, which, in turn, enhances such stereotypes in future revisions of the criteria for this so-called mental disorder (Hacking).
With this, one could potentially tease out an implication that neither Tosh nor Hacking directly touch upon, but is worth considering: that the issue in contemporary psychiatry, though certainly propagated by the stereotypical criteria of the DSM, stems greatly from how modern psychiatric practices are carried out. Both Tosh and Hackingposit that societal stereotypes contribute to inaccuracies in psychiatric diagnoses through the creation of gender norms that psychiatrists interpret as criteria for how men and women should behave. However, it is necessary to question how these societal stereotypes are able to affect psychiatric practices to begin with ; an answer may be found in Tosh’s analysis of the distress factor of GDD. She claims that gender nonconformists exhibit a “distress from incongruence between physical body and gender identity” and struggle with how to define themselves (Tosh, 87). However, as Tosh also acknowledges, “psychiatry has been less concerned with how individuals define themselves and more interested in creating categories,” despite the fact that the main struggle of gender-nonconforming people pertains to their identity and subsequent ostracism (Tosh, 77). This begs the question: if psychiatry was not so fixated on neat categorization of patients, would psychiatrists so hastily create inaccurate criteria for the “disorders” they wish to identify? It is certainly a significant question, considering that Hacking does not simply apply his concept of the looping effect to gender, but rather he claims that all mental diagnoses are subject to it (Hacking). With much of the human population exhibiting some psychological disorder, it is worth asking how we can improve psychiatry so as to hinder this “looping effect” as much as possible in diagnoses.
Given the implications of these ancillary sources, it is possible that society may face a future issue greater than any of the dilemmas introduced in this discussion. By combining the concept of controlling minority populations through societal stereotypes and Hacking’s implication that these stereotypes will only get worse and worse through the “looping effect” of diagnoses, we can predict thatwithout the necessary interference and protection, we may not see the wide range of gender diversity and acceptance that gender-nonconforming people have fought for centuries to achieve. Though more of a possibility than a certainty, it is evident that—given the nuances to the situation introduced by Woodhead, Hacking, and Tosh—the very next question we should discuss is how to address the dilemma of stereotyping gender traits in psychiatric diagnoses so that we don’t lose generations of blood to ill-informed generalizations in contemporary medicine.
Mohamed Diagne is a 3rd Year student at the University of Virginia.
Woodhead, Linda. “Gender Differences In Religious Practice and Significance.” Cairn,
Hacking, Ian. “Ian Hacking · Making Up People: Clinical Classifications · LRB 17 August 2006.” London Review of Books, London Review of Books, 7 Nov. 2019,
Tosh, Jemma. Perverse Psychology: The Pathologization of Sexual Violence and Transgenderism, Taylor & Francis Group, 2014. ProQuest Ebook Central,
DSM History, APA, www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm
I would like to extend my thanks to the various individuals who have helped me shape this critical analysis of Jemma Tosh’s position on psychiatric pathologization.
I acknowledge Shaur Kumar, whose detailed feedback on the tone and style of the critical analysis in my original essay played a massive role in creating the final outcome. I took great inspiration from his own work, which was not only an intellectual stimulant, but aided me in visualizing how I would approach my own analysis.
Furthermore, I would like to thank Shreya Gundelly, whose critique on the structure of my essay helped immensely in creating a solid workflow that was much easier on both my own eyes and the readers'.
Finally, I would like to thank Professor Liston, who guided me through the process of creating a university-level critical analysis and helped me improve my writing throughout the process.