Wakefield's Hybrid Account of Disorder and Gender Dysphoria

 This week on Imperfect Cognitions, we showcase a couple of posts by authors with papers published in a special issue from the European Journal of Analytic Philosophy (EuJAP). The special issue is on the Philosophy of Medicine with guest editors Saana Jukola and Anke Bueter. 

Today's post is the second post of the series. Kathleen Murphy-Hollies discusses her paper in the special issue, which you can read here. Kathleen is a philosophy PhD student and teaching fellow at the University of Birmingham, working primarily on confabulation and its effects for embodying virtuous traits. 

Kathleen Murphy-Hollies

In my paper, I discuss whether Wakefield’s hybrid account of disorder helps clarify the thorny issue of whether Gender Dysphoria (GD) should be included in the DSM as a disordered state or left out as merely a socially disvalued state. In the DSM-5, GD is described in individuals as “a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender”, which is accompanied with distress (APA 2013, 453). Symptoms include a desire to be the other gender, a preference for the typical roles, toys and clothes of the other gender, and a strong dislike of one’s physical sex characteristics.

Applying Wakefield’s hybrid account of disorder (1992), it appears that in cases of GD we have both a naturalist component of dysfunction and a normative component of harm (Wakefield and First, 2003). However, I argue it is hard to see the link between a dysfunction and all the symptoms we see in the diagnostic criteria for GD. In particular, I propose that we end up with an overlap of two distinct clinical groups: those who suffer dysphoria relating to their gender role and gendered expectations (which I term ‘gender-role dysphoria’) and those who suffer dysphoria relating to their physical sex characteristics (which I term ‘sex dysphoria’).

Whether we can talk of one dysfunction underlying both gender-role dysphoria and sex dysphoria brings us to the question of how to understand the word ‘gender’ in GD. I outline two very broad kinds of approaches we could take to understanding ‘gender’ here. The first, I call the ‘traditional account’ of gender. This approach understands gender to be an external, inherently harmful set of cultural roles, traits and expectations which are imposed onto people through socialisation, with an individual’s sex determining which roles and expectations are imposed. A second, I call the ‘identity-based account’ of gender. This account understands someone’s gender to be an internally generated part of their identity which in turn tells them which gender roles are appropriate for them.

Now, the DSM-5 appears to employ the latter identity-based account of gender, as this is the only account with which criteria such as “an insistence that one is the other gender” (my emphasis) can make sense. But it is not clear how one would go about justifying that the DSM should indeed be using this account of gender in forming its diagnostic criteria for GD. Without taking a stance on which account of gender we should adopt, I point out that this sociological issue of how we understand gender here has knock-on effects for whether or not cases of GD are indeed cases of pathologising a healthy state. For example, a traditional understanding of gender already understands them as inherently harmful, and so pathologising the rejection of gender roles appears to be appropriate. Whereas, an identity-based understanding of gender might focus on a harmful dysfunction in the formation of gender identity (accounts may vary). These two accounts of gender may also differ in how they approach understanding gender-role dysphoria and sex dysphoria.

In essence, the complex case of GD demonstrates the extent to which a successful account of what constitutes a mental disorder will have to engage with sociological discourses, such as those regarding the stratification of groups in society and how systematic oppression occurs, in order to end psychiatry’s troubled history of pathologising normal and healthy states. Wakefield’s hybrid account does not do this, and it leaves the specific connection between the dysfunction and harm components undertheorized. So, despite tying a normative harm to a naturalistic dysfunction in order to avoid pathologising socially disvalued states, the theory is still not comprehensive enough to do so successfully.