Psy-Disciplines as Gatekeeper: A History of Gender-Affirming Care

A new article critically examines the institutionalization of the psy disciplines as the authority to construct normative, and often pathologizing, accounts of trans life.


A new article published in The American Psychologist critically examines the historical and contemporary practices of the psy-disciplines and their power to create and reinforce normative and pathologizing accounts of trans life.

By evaluating the complex historical interactions between trans individuals and clinicians, the authors situate contemporary problems with trans care in its historical roots. They demonstrate how trans life and the development of transnormativity were structured by dominant discourses shaped by the psy-disciplines and how trans life shaped how these disciplines came to understand them.

The authors, Damien W. Riggs, Ruth Pearce, Carla A. Pfeffer, Sally Hines, Francis Ray White, and Elisabetta Ruspini, investigate the developments and evolution of the Diagnostic Statistical Manual (DSM) and Standards of Care (SOC) to show the consequences of how the psy-disciplines have engaged with gender and sexual diversity throughout history.

They highlight how this has resulted in the creation of the socially constructed categories of binary gender and heterosexuality and the reinforcement of these normative and often pathologizing accounts that persist today. 

The authors define transnormative as “the ways in which dominant narratives about what it means to be trans emphasize a particular and narrow set of tropes to which all trans people are expected to adhere.”

For example, normative accounts of trans life typically require that all trans people conform to the “wrong body narrative,” require medical intervention, and the desire to be perceived as cisgender.

This article highlights the authoritative role the psy-disciplines have in contributing to these normative and often pathologizing accounts. However, the authors take care not to simply state that these power structures control trans life. Instead, they offer a history that shows the mutual development of clinical guidelines for how some trans narratives have been adopted in clinical care and how trans people have also resisted these normative accounts.

They do so to demonstrate both the lasting negative impacts of the psy-disciplines and the dominance of transnormative accounts, as well as highlight and celebrate the critical contributions and resistance from queer and trans people in healthcare.

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  1. Gatekeeping gender affirming care behind psych evaluation risks iatrogenic harm. In the queer spaces I am in online, people seeking medical transition services who are also of minority sexual orientation have reported being subject to conversion therapy type dynamics. I see at least 3-4 accounts a year, for many years now.

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