The gender dysphoria disappears
Constructions and cultures of illness from a gender perspective
In the area of norms, disease and gender are closely linked. "Masculinity" and "femininity" are staged in clinical pictures, their interpretation and treatment. Gender-specific forms of illness therefore also contain critical potential in that they demonstrate suffering from gender norms. Certain psychosomatic disorders occur with different frequency in men and women and are socially “legitimate” differently: Eating disorders, anxiety disorders and depression are more “acceptable” for women than for men - women, the psychosomatic gender? Using various disorders, it is shown how adaptation to overwhelming circumstances and contradicting gender norms can make you sick and, conversely, how illness as a refusal to adapt can be a sign of mental health. Finally, approaches for an emancipatory effective attitude in psychotherapy are discussed.
Gender and disease are tightly connected in their normative dimension. Diseases manifest themselves as sociocultural constructions and interpretations of psychic and somatic conditions. The process of forming norms of health and disease produces gendered bodies. Some psychosomatic phenomena like eating disorders, anxiety disorders and depression are socially accepted in women than in men. In the exaggerated incorporation of stereotypes of femininity in these so-called “female diseases” the continuum between “normal” woman and “pathological” femininity becomes obvious. In the ambiguity of adaptation and resistance norms of femininity are hereby confirmed as well as subverted. A feminist understanding of health and disease with its perspective of a normative constitution of masculinity and femininity provides a new approach to the interrelations of psyche and body, gender and society. My work as a psychosocial counselor provides an example for the conflicting mediation of feminist theory and practice. In this way feminist philosophy can function as an emancipating practice in psychosocial counseling.
The phenomena body, gender and illness do not exist outside of culture and society. Body and gender are always venues for social power relations, which is reflected in disease concepts and theories on the origins and healing possibilities of diseases. This perspective is relevant for counseling, psychotherapy and medicine. It requires a transformation of the conventional medical model, namely the inclusion of social and cultural conditions in which diseases arise. Concepts of illness always have to do with discourse power: Who in a society has the power to define certain behaviors as healthy or sick, normal or pathological - or alternatively as criminal or possessed by evil spirits? Psychosomatic symptoms are particularly suitable for choosing from the “symptom pool” of the respective culture and epoch and, in cooperation with doctors, sometimes creating very dramatic and expressive disease formations. Gender difference is also established in the design of disease. Like health, illness turns out to be a socio-culturally produced and gender-politically effective construction and interpretation of physical and psychological states. Sexually marked bodies are staged in the formation of clinical pictures as well as their interpretation and treatment. Gender-specific forms of illness contain socially critical potential in that they make the suffering from hegemonic gender norms visible. In the exaggerated embodiment of femininity stereotypes in so-called “women's diseases”, the continuum between “normal” women and “pathological” femininity becomes clear. In the ambiguity of submission and idiosyncratic appropriation, norms of femininity are both confirmed and subverted here. States of suffering, symptoms and diagnoses are a mirror of social conditions. The problems of our clients are never just individual problems, but always part of social conditions. In this article, I deliberately focus on this social component of the bio-psycho-social disease model, because it is precisely this that seems to me to be severely underexposed in scientific discourse. My perspective is primarily a historical one in order to clarify the theses from a time lag. The clinical pictures were selected because their genesis and use are of particular relevance and effectiveness in terms of gender policy. It is not about individual symptoms, but about the development of these clinical pictures against a patriarchal background.
“Illness” as a representation of social order
Illness can be examined as a socio-culturally produced and gender-politically effective construction and interpretation of physical and psychological states. Sexually marked bodies are staged in the formation of clinical pictures as well as their interpretation and treatment. The societal normativity of “masculinity” and “femininity” - like men and women at a certain time at a time - can be seen in the different types and frequencies of diagnoses at different times, the different explanatory models and the gender-specific differences in the attribution of the disease value of symptoms have to be certain culture - show. Gender-specific forms of illness contain socially critical potential in that they make the suffering from hegemonic gender norms visible. In the exaggerated embodiment of femininity stereotypes in so-called “women's diseases”, the continuum between “normal” women and “pathological” femininity becomes clear. In the ambiguity of submission and idiosyncratic appropriation, norms of femininity are both confirmed and subverted here. The hysteric embodies both the theory of the woman's complete mastery of sexuality and that of the asexual female being. Hysteria undermines these discourses about femininity by demonstrating their production process. It undermines the medically formulated logos by following it, but not adhering to its anatomical and physiological laws with the production of physical symptoms.
Christina von Braun sees the multiple personality disorder, together with the eating disorders anorexia and bulimia, as the contemporary successors of the hysteria of the turn of the century as described by Charcot, Breuer and Freud. Characteristic of all three clinical pictures is the simultaneous affirmation and refusal of the socially intended gender role for women. This is both confirmed in the exaggerated - seemingly parodic - embodiment of femininity clichés and also called into question in terms of their construction (von Braun & Dietze 1999, von Braun 1995).
The emergence of disease diagnoses and the associated etiological theories and paradigms (“Truth Regimes”, Foucault 1977) is inextricably linked with the social meanings implied with them, with power constellations and order discourses of the respective epoch, prominent in the discourse of the sexes. A concept like that of the unconscious is politically explosive. For example, the diagnosis of post-traumatic stress disorder, which is based on dissociated affects and repressed memories, is linked to the guilt and truth discourse on sexual abuse. The educational effect of such a concept can be used to uncover previously hidden violent relationships in the private sphere of the family and to develop legal means of control or sanctions to counteract attacks. The rejection of the concept of repressed memories and the denial of the relationships that become visible as a result (“We do not have abuse / violence in the family”) serve to stabilize existing power and domination relationships.
A new disease designation, a newly described symptomatology or symptom group, offers new, within the medical system, legitimate opportunities to experience, shape and name existing ailments. The epidemic of new diseases is accelerated by their aggressive presence in the mass media (such as the "chronic fatigue syndrome"): severe fatigue lasting for months, usually in combination with muscle pain, without a physiologically clearly demonstrable cause, also discussed as Systemic Exertion Intolerance Disease , so systemic exercise intolerance disease (SEID). The way we experience our bodies is also shaped by medical concepts. The perception and interpretation of a physical or psychological state as healthy or sick, acceptable or in need of treatment is not a matter of biology, but rather depends on the applicable culture-specific body knowledge. This body knowledge is differentiated according to gender, epoch, region, age group and social structure. Subjective and collective interpretations of health and illness can be deciphered as metaphors; they say something about the relationship between the individual and the social order (cf. Sontag 1980; Brähler et al. 2018).
On the history of psychosomatic diseases and their "iatrogenic" production in doctor-patient interaction
From the Greek iatros = doctor: “iatrogenic” is a disease caused by the medical system, medical treatment or the relationship between doctor and patient.
In the area of norms, disease and gender are closely linked. "Masculinity" and "femininity" are staged in clinical pictures, their interpretation and treatment. Gender-specific forms of illness therefore also contain critical potential in that they demonstrate suffering from gender norms. Certain psychosomatic illnesses occur in men and women with very different frequencies and are socially “legitimate” to a different extent: Eating disorders, anxiety disorders and depression are more “acceptable” for women than for men (for more details, see Zehetner 2012). Prescribing practice is also gender-specific: around 2/3 of all sedatives are prescribed to women (cf. Schmid-Siegel and Gutierrez-Lobos 1996).
The plasticity of psychosomatic illnesses - the epidemic emergence of a clinical picture over a certain period of time and its re-disappearance - shows their cultural ties. The unconscious contributes to the formation of psychosomatic illnesses, which in turn is influenced by the collective imaginary of the respective culture. The medical historian Edward Shorter describes in his work "Modern Sufferings" the story of the change in diseases, diagnosis and the experience of disease as a culture-specific symptom production. The interaction between culture and individual problems as well as between doctor and patientFootnote 1 lets a so-called "Symptom pool"(Shorter 1994), a collection of symptoms recognized as signs of illness at a certain time, emerge from which the patient unconsciously" selects ". While the symptoms of organic diseases can be fixed - such as yellowing of the skin in hepatitis - the changes in the symptoms of psychosomatic diseases, according to Shorter, reflect both subjective suffering and the "fashionable" theories of medicine as well as the zeitgeist, such as the hegemonic order of the sexes .
The cultural environment provides staging templates and models of being ill, the "symptom pool" is formed by the collective memory of the culture on questions of correct behavior in the event of illness (e.g. what to do when you feel pain? Grit your teeth, swallow pills , see the doctor or the shaman, rest in bed, pray, etc.). Cultural memory not only defines what to do in the event of illness, but also under which conditions a sensation is considered to be a symptom worthy of illness and worthy of treatment, and how this can be articulated.
Historically, medical professionals produced disease theories and women responded by producing "suitable" symptoms or found a recognized means of expression for unspecific ailments. For the doctors, a wide variety of female complaints were called “nervous disorders” or “neuroses” (Cullen Synopsis Nosologicae Medicae 1785) somehow explainable - however, they were not explained by psychological suffering or suffering from the social situation of women.
The 19th century was the "Golden Age of Motor Hysteria"(Shorter 1994). The most dramatic symptom productions consisted of convulsions ("attaques"), convulsive, excessively long-lasting fainting spells (catalepsy), paralysis of limbs, eyelids or vocal cords or uncontrolled motor activity (thrashing, trembling, twitching). The reflex arc concept promoted the development of motor symptoms (sensory stimuli can cause unwanted motor reactions). Shorter sees such symptom production as the reaction of bourgeois women to the restriction of freedom of movement imposed on them in hermetically sealed privacy. Escape into fainting and paralysis could also mean breaking out of the family psychodrama. With the support of the doctors, which was in most cases unintentional, some women succeeded in instrumentalizing the fashionable medical theories for their own purposes, often at the cost of renewed suffering through the prescribed therapy.
The spectacular convulsions were more and more replaced by the less spectacular paralyzes, which were characterized by mostly temporary loss of the ability to feel and move (paraplegia, hemiplegia). A traumatic experience was assumed to be the triggering phenomenon (similar to the later "railway spine" or the male war neuroses), which, however, was hardly followed up until Freud. The motor ultimately changes to sensory hysteria: Charcot-style hysteria can be seen as the ultimate paradigm for iatrogenic diseases. Charcot transformed the Salpétrière - hospital, nursing home for the poor and insane asylum - into a theater of his hysteria. He developed the concept of the four phases of the classic hysterical attack with clownism (large movements), pathetic postures, délir and the arc-de-cercle (the hysterical arch in which the convulsively bent body only touches the bed with head and feet) . The more sophisticated and bold the master developed his theory, the more imaginatively the patients designed their presentations in the public lectures. The patients played their roles, which were partly inspired by the epileptics interned with them and partly from the pictures of religious rapture and photographs of the best performances in their living rooms, under a hypnosis that amounted to dressage suggestion.
The history of somatization knows of no clearer evidence of the close connection between iatrogenia (production or design impulse emanating from the doctor's side) and actual symptom production or design than the disappearance of hysteria à la Charcot within a single decade after the master's death. (Shorter 1994, p. 334)
At the end of the 20th century, the change from iatrogenic symptom design to media-controlled wave of somatization. Our culture experiences a collective process of vigilance towards the body. When the media launches the “disease of the month” (e.g. mycoses, various allergies), every body sensation can mutate into a sign of illness. Simply being exhausted or ready for a vacation is no longer legitimate, it has to be "Chronic Fatigue Syndrome" (CFS) or "Seasonal Depression" (SAD). Behind all these epidemically spreading and differentiating “fashion diseases” there seems to be a phantasm of perfect health, a kind of fetish to which everyone claims and which everyone has to develop through their own performance. “Health” represents the ultimate ideal after “the good”. In this feasibility ideology, the intensity and duration of feelings are also standardized. What is pathological is what takes too long, for example a feeling of sadness:
According to the criteria of the Diagnostic-Statistical Manual IV, sadness, agitation, feelings of guilt, concentration and sleep difficulties as well as thoughts about the death of a grieving person can be diagnosed as a pronounced depressive phase if they last longer than two months.The idea behind it is: suffering and grief cannot and should not be endured, these feelings should come to an end as quickly as possible (cf. Kleinman 1995, p. 180). Confirmation of this attitude was provided by the youth welfare office in our counseling center, which a woman sent to us with the comment “You have been mourning your husband for too long”. According to the diagnosis manual DSM V, which has been in effect since May 2013, grief lasting more than two months can be diagnosed as a severe depressive disorder (the "Bereavement Reaction", however, has been omitted from this issue). Where does grief still have a place in our society?
On the change of clinical pictures and diagnoses using the example of "Gender Dysphoria"
The pathologization of bodies, identities and forms of life that do not conform to the norms through medicine manifests itself in diagnostics. Homosexuality is no longer a disease-related diagnosis, but the "Gender Identity Disorder" has partly succeeded it: The diagnosis "Gender Identity Disorder" was introduced in the course of the discussions on the Diagnostic Statistical Manual DSM IV in 1980 (after the removal of the diagnosis "Homosexuality “1973). The DSM V (American Psychiatric Association 2013), in which the term “Gender Dysphoria” appears as a superordinate category, has been in effect since May 2013. "Gender dysphoria" is characterized by the incongruence between the experienced or expressed and the attributed gender (for at least six months) plus at least two of the following criteria:
Incongruence of experienced / expressed gender and physical gender characteristics
strong desire to get rid of one's own sexual characteristics (in adolescents: desire to prevent the development of secondary sexual characteristics)
strong desire for the physical gender characteristics of the opposite sex
Strong desire to be / belong to the opposite sex ("or some alternative gender different from one’s assigned")
strong desire to be treated as the opposite sex
strong belief in having the typical feelings and reactions of the opposite sex
plus clinically significant stress or impairment in social, professional or other important areas of functioning or with a significantly increased risk of suffering such as stress or disability / inadequacy.
Polemically asked: Which woman would not rather be treated as a man when it comes to her salary and her career? Instead of questioning embarrassment, discrimination and prohibitions that cause suffering, it is pathologized. On the other hand, people who do not experience themselves as "always-only-male" or "always-only-female" demand recognition of their transgression of the binary polarization towards diverse life and design possibilities of gender, diverse possible combinations and variations of sex, gender identity and desire.
The function of normalization is even more evident in the criteria for “gender dysphoria” in children. For girls, for example, the “strong preference to only wear typically masculine clothing and strong resistance to typically female clothing” and “strong reluctance to typically female toys, games and activities”, for boys “strong reluctance to typically masculine toys, games and activities” Activities and strong avoidance of rough games ('rough-and-tumble play') ”as well as the“ strong preference for cross-gender roles in (fantasy) games (make-believe or fantasy play) ”for both sexes. What the sense of fantasy games should be, if not imagining new creative roles, is not addressed in the diagnostic manual.
The psychodramatist Ernst Silbermayr pointedly asks why, based on the DSM V - diagnostic category “gender dysphoria”, the diagnoses “migration dysphoria”, “poverty dysphoria” or “obesity dysphoria” could not be used here as well the symptoms of discomfort, sadness, anxious depression and irritability occur (Silbermayr 2016). Here the problematic individualization of social problem situations becomes clear: Why don't we rather question a disease-causing social and gender order instead of pathologizing individual people who suffer from it?
Disturbance images as a rebellion against gender norms
The body is a tool and product of power processes, it is the place of never-ending work on the self. The doctrine of neoliberal ideology is: "Everything is possible". To beautify and improve one's own body, to keep it productive and healthy is the individual responsibility of everyone, self-optimization becomes a duty - from the diet that is propagated through youthfulness and fitness to the surgically manufactured, standardized "designer vagina" ( see Borkenhagen 2008; Maasen 2008; Zehetner 2010a).
The ambivalence of the bulimic strategy manifests itself in the fluctuation between the poles of adapting to the required norms of femininity and the secret rebellion against them. “Unfeminine” greed and aggression are lived out only in private spaces when there is a binge of eating - (“I am a greedy monster”) - the facade of controlled, successful femininity is presented to the outside (attractive, ambitious, successful, model “power woman”). In contrast, the anorectic questions the female ideal of slimness by exaggerating it. This to illustrate how women use their body as an object and embody norms of femininity - between adaptation and self-will. The core theme is the struggle for autonomy: the anorexic starves her body as a projection surface for images of femininity determined by others; the bulimic shows outwardly rather standardized femininity and secretly chokes out the unreasonable demands. Today women’s demand for self-control is so internalized that “normal” female eating behavior can be described as collective dieting, for example the widespread division into “permitted” versus “forbidden” foods, the so-called “orthorexia” as a self-imposed compulsion, to eat “properly” or “healthy”.
Bringing up these conflicts (e.g. between autonomy and adaptation / external determination), and thus bringing them into the relationship, can make the symptoms superfluous because the aggression no longer has to be directed against oneself, but rather finds another expression than the self-injurious expression. This re-symbolization is potentially socially critical because it reveals the societal conflicts that cause suffering. In restoring the ability to interact and communicate, alternatives become conceivable.
Psychotherapy must be aware of the current socio-political backlash, the risk of being taken over as a repair workshop, an instrument for defusing a crisis and a machine for permanent self-optimization in order to better meet the demands of the market. - All in the sense of a strategy of isolation as depoliticization, the appropriation of a more flexible gender for an even better utilization of the “human capital” of both genders (cf. McRobbie 2010; Klinger 2014).
From Foucault's theoretical perspective, psychotherapy can be described as a “technology of the self” (cf. Foucault 1993, 2000). Similar to confession, psychotherapy can represent an arena for the production of subjectivity and governmentality as flexible self-control. Self-efficacy expectation (self-efficacy), Belief in control and resilience (hardiness, resilience) should be strengthened. Emancipatory psychotherapy must therefore preserve its socially critical potential and its political stance under all circumstances. The therapeutic attitude must remain critical of the current demands on flexibility, self-marketing, speed and efficiency - also and especially when many clients come with the claim to "function again" as quickly as possible. Emancipatory psychotherapy wants to offer space for reflection. It wants to question norms as a matter of course and make them negotiable - opening up a space for idiosyncratic possibilities of appropriation. “Norms not as instruments of normalization, but as common places of continuous political work” (Butler 2009, p. 366).
Gender-critical competence must also be integrated into psychotherapeutic and medical training. This knowledge enables the perception of patients beyond dichotomous gender stereotypes and the encouragement of behavior that does not conform to gender roles, which has a positive effect on health: less restriction through the either / or, more freedom of action through the both / and. Because the goal of emancipatory counseling and psychotherapy is to expand the possibilities of life and action (for details on the performativity of illness and gender as well as their connection with psychosocial counseling, see Zehetner 2012).
Psychotherapy has also become a marketplace: the care system needs diagnoses, training institutions need paying candidates. At the same time, there is a lack of resources for psychosocial care, support and accompaniment for people who are not fit for the hamster wheel again with a little "empowerment training" (e.g. long-term support through social work instead of quick case management). The term "self-care" (as a fitness program for continued functioning), which is used completely abbreviated today, is based on a reduced concept of freedom as a mere individual freedom of choice between given possibilities, from which, in the event of a lack of motivation and performance, personal responsibility for one's own failure is assigned.
Angelika Grubner sums up the necessary shift in focus from the individual to the social in her pamphlet "The Power of Psychotherapy in Neoliberalism": "It is the responsibility of psychotherapy to refuse this individualization disposition to some extent and to point out the socio-political causes and connections underlying the currently identified increase in mental 'disorders'. So it is about the professional political activity to bring the disease-causing conditions of capitalism in connection with the states of suffering as well as with the self-optimization efforts of the subjects. It seems expedient to position and disseminate knowledge that focuses attention on social conditions as disease-causing conditions and not on the supposed individual failure of often disadvantaged groups of people ”(Grubner 2017, p. 340). Angelika Grubner's argument becomes clear in the current legal obligation to psychotherapy for people receiving rehabilitation allowance in Austria, where a socio-political problem - the devastating labor market situation - is individualized as a therapeutic coercive measure. This shows the constitutive ambivalence of psychotherapy as an emancipatory and disciplining-optimizing practice, as leadership of the tours, as instructions for constant self-investigation, self-examination and self-processing. Psychotherapy is not an “innocent”, power-free space, but acts in the field of tension between the contradicting simultaneity of flexibility and standardization (cf. Zehetner and Russo 2017). As counselors and psychotherapists, we have to ask ourselves the question: Do we want to contribute to the imperative to optimize ourselves with our daily work or do we want to be critical of behavioral expectations, question the norms of the omnipresent economization, encourage small and large transgressions of boundaries and focus on the Focus on ways of a good life? Psychotherapy not as training for better adaptation to disease-causing conditions, but as a practice of freedom - that is the concern of emancipatory psychotherapy and counseling (detailed on the attitude and principles of feminist counseling and psychotherapy Zehetner 2015 and 2018). This can also mean reformulating a so-called individual “disorder” in terms of cultural criticism and the need for social change. From the abandonment of the tyrannical image of individual failure and failure and the learning of the chimerical ideal of complete autonomy, from the awareness of shared vulnerability and fundamental human dependency on one another, new solidarity can arise (detailed on Zehetner 2017). “Psychological sensitivities, read as a mirror of historical power relations, can be transformed into a political mobilization in the psychotherapeutic context. Because the very immediate affects of grief, pain, fear and inadequacy can serve as starting points for political action ”(Grubner 2017, p. 335). - Counseling and psychotherapy as a citizen emancipation movement?
Regarding the gender-specific spelling: Since historically particularly impressive iatrogenic diseases have emerged from the relationship between male doctor and female patient, I mainly write about this combination.
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“Women * advise women *. Institute for Women-Specific Social Research ”, Vienna, Austria
Correspondence to Bettina Zehetner.
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Zehetner, B. Constructions and Cultures of Disease from a Gender Perspective. Psychotherapy Forum23, 11-17 (2019). https://doi.org/10.1007/s00729-019-0110-5
- Disease concepts
- Psychosomatic and gender-specific diagnostics
- Feminist Philosophy
- Feminist theory of the body and disease
- Critical and emancipatory psychotherapy
- Concepts of disease
- Psychosomatic and gender specific diagnostics
- Feminist theory of body and disease
- Critical and emancipatory psychotherapy
- Feminist philosophy
- Philosophy of the body
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