Psychology & Sexuality




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This electronic version on http://ansaraonline.com is an article published in:

Ansara, Y. G., & Hegarty, P. (2011). Cisgenderism in Psychology: Pathologizing and misgendering children from 1999 to 2008. Psychology & Sexuality, iFirst, 1-24.doi: 10.1080/19419899.2011.576696.



Psychology & Sexuality is available online at:

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This article is available online at:

http://www.tandfonline.com/doi/abs/10.1080/19419899.2011.576696
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Cisgenderism in psychology: pathologising and misgendering children from 1999 to 2008
Y. Gavriel Ansara and Peter Hegarty
Department of Psychology, Faculty of Arts and Human Sciences, University of Surrey, Guildford, UK
Author correspondence email: gavriel.ansara@gmail.com

Abstract:
We assessed whether recent psychological literature on children reflects or contrasts
with the zeitgeist of American Psychological Association’s recent non-discrimination
statement on ‘transgender’ and ‘gender variant’ individuals. Article records (N = 94)
on childhood ‘gender identity’ and ‘expression’ published between 1999 and 2008
inclusive were evaluated for two kinds of cisgenderism, the ideology that invali-
dates or pathologises self-designated genders that contrast with external designations.
Misgendering language contradicts children’s own gender assignations and was less
frequent than pathologising language which constructs children’s own gender assigna-
tions and expression as disordered. Articles on children’s gender identity/expression

are increasingly impactful within psychology. Cisgenderism is neither increasing


nor decreasing overall. Mental health professionals are more cisgenderist than other
authors. Articles by members of an ‘invisible college’ structured around the most pro-
lific author in this area are more cisgenderist and impactful than other articles. We
suggest how authors and editors can implement American Psychological Association
policy and change scientific discourse about children’s genders.
Keywords: cisgenderism; content analysis; ‘gender identity disorder’; misgendering;

pathologising; transgender; transsexual




1. Introduction

In August 2008, the American Psychological Association (APA) Council of


Representatives adopted the Resolution on Transgender, Gender Identity and Gender
Expression Non-Discrimination, acknowledging that ‘transgender and gender variant peo-
ple frequently experience prejudice and discrimination and psychologists can, through
their professional actions, address these problems at both an individual and a societal
level’ (American Psychological Association [APA], 2008, para 1). In this document,
APA’s Council of Representatives recognised that ‘psychological research has the poten-
tial to inform treatment, service provision, civil rights and approaches to promoting the
well-being of transgender and gender variant people’ (APA, 2008, para 12) and that
‘psychologists are in a position to influence policies and practices in institutional settings’
(APA, 2008, para 11). The APA defined the ‘professional role’ of psychologists as one
that requires ‘the provision of appropriate, nondiscriminatory treatment to transgender and

Ansara & Hegarty 2011 2
gender variant individuals’ (APA, 2008, para 17), urging psychologists ‘to take a leadership
role in working against discrimination towards transgender and gender variant individuals’
(APA, 2008, para 17).

Among ‘transgender and gender variant individuals’, children are uniquely at risk for


severe consequences of discrimination. As acknowledged in the APA resolution, many of
these children face multiple risks to their well-being, including ‘harassment and violence
in school environments, foster care, residential treatment centers, homeless centers and
juvenile justice programs’ (APA, 2008, para 10). Unlike adults, children in most coun-
tries do not have the legal right to make autonomous decisions about their educational
or living environments. The lack of these legal rights means that children who experi-
ence discrimination may benefit even more than adults from advocacy on their behalf by
psychologists.

The APA resolution demonstrates how some psychologists have begun to respond to


the disparity between mainstream psychological theories and ‘transgender and gender vari-
ant’ individuals’ accounts of their own genders. Some time ago, Parlee (1996) identified
misrepresentation of such individuals by psychologists, and asserted that psychological
approaches to gender research were overwhelmingly pathologising. Parlee found that psy-
chologists failed to identify participants’ genders on participants’ own terms, remaining
limited to theories and terms that view external classifications as more authoritative than
self-designations. More recently, other authors have addressed erasure (Namaste, 2000),
maligning language (Winters, 2008) and pathologising (Namaste, 2000; Serano, 2007;
Winters, 2008) of participants’ genders. Namaste’s (2000) social critique was informed
by qualitative interviews she conducted for community outreach projects; her text provides
detailed narratives that were absent from official agency reports. Serano (2007) also cri-
tiqued cissexism, traditional sexism, oppositional sexism, effemimania and ungendering in
psychomedical literature on ‘trans and gender variant’ individuals. Both authors echoed
Parlee’s (1996) view that psychological literature omits people’s experiences ‘as they are
lived and socially organised’ (Namaste, 2000, p. 65).

Some authors have critiqued psychological research for similar problems, including the


failure to respect children’s own gender designations (e.g., Winters, 2008). The recognition
of children’s own genders is essential both to APA’s desired leadership role in ending dis-
crimination (APA, 2008) and to APA’s stated goal of ‘objectivity in scientific reporting’1
through ‘reducing bias in language’ (APA, n.d.). Accordingly, the present content analy-
sis examined recent psychological research on children to evaluate whether the sentiments
expressed in the 2008 APA policy reflect or contrast with the zeitgeist of the journal article
literature.

1.2. Psychological approaches to children with self-designated gender and expression

In this article, we use the term self-designated gender to refer to a child’s self-identified


gender. We also use the term majority world to refer to the approximately 83% of the world
that is not typically included in the minority of the world that is called ‘western‘ or ‘devel-
oped’ (Majority World, n.d.; see also Alam, n.d.). This majority world includes a number of
indigenous societies that are situated within geopolitical borders claimed by minority world
states. While most children worldwide learn to identify themselves with gender categories,
many majority world societies offer traditional pathways for children to self-designate or
change their recognised gender category (e.g., Bartlett, Vasey, & Bukowski, 2000; Davies,
2007; Graham, 2004; Honingmann, 1964; Vasey & Bartlett, 2007). However, minority
world mental health professions have historically viewed children whose self-designated

Ansara & Hegarty 2011 3
gender differs from the gender category to which they were assigned as having a mental
disorder (Bryant, 2008; Hill, Rozanski, Carfagnini, & Willoughby, 2005; Vasey & Bartlett,
2007).

Psychologist John Money and his colleagues initiated this field of research during the

1950s when they began studying the concept of ‘gender’ in children whose biology did
not conform to social norms of ‘male’ or ‘female’ (e.g., Hampson, Hampson, & Money,
1955; Money, Hampson, & Hampson, 1955a, 1955b). During the 1960s, Richard Green co-
authored several studies with John Money on ‘effeminate’ behaviour in boys (e.g., Green &
Money, 1960, 1961, 1962); Richard Stoller was also a leading researcher during that decade
(Bryant, 2008). Psychological literature documents the use of behavioural modification to
‘fix’ children’s gender identities and expression throughout the 1970s. Spearheaded by
George Rekers, this research addressed topics that included ‘deviant sex-role behaviors’
(Rekers & Lovaas, 1974), ‘feminoid boys’ (Rekers & Yates, 1976) ‘a pre-transsexual boy’
(Rekers & Varni, 1977) and ‘childhood gender disturbance’ (Rekers, Rosen, Lovaas, &
Bentler, 1978).

In 1980, ‘gender identity disorders’ first entered the American Psychiatric Association’s


Diagnostic and Statistical Manual (American Psychiatric Association, 1980). However, as
documented by Bryant (2008), the ‘Gender Identity Disorder of Childhood’ (GIDC) model
dates back to the 1960s. Indeed, related concerns can be seen in Terman and Miles’s writ-
ings from the 1930s (Hegarty, 2007). Between 1980 and the present, various psychological
approaches have been proposed to ‘treat’ children classified as having a ‘GIDC’ (Bryant,
2006). Currently, Zucker and Bradley’s (1995) version of this model is the most widely
used approach to these children in psychology. This approach involves behavioural modifi-
cation techniques and aversive conditioning to ‘fix’ genders that do not match children and adolescents’ external gender assignments (Spiegel, 2008; Zucker & Bradley, 1995). While
this model emerged decades after Rekers and Varni’s (1977) article on the ‘pre-transsexual’
child and some of their original terminology has been replaced by newer terminology, both
approaches share a focus on preventing transsexual adulthoods.

One example of Zucker and Bradley’s (1995) method involved restricting the gender


expression of a five-year-old self-designated girl:
Bradley would no longer be allowed to spend time with girls. She would no longer be allowed
to play with girlish toys or pretend that she was a female character [. . .] As her pile of toys
dwindled, [Bradley’s mother] realized Bradley was hoarding. She would find female action
figures stashed between couch pillows. Rainbow unicorns were hidden in the back of Bradley’s
closet. Bradley seemed at a loss, she said. They gave her male toys, but she chose not to play
at all [. . .] Bradley would populate her pictures with the toys and interests she no longer had
access to — princesses with long flowing hair, fairies in elaborate dresses, rainbows of pink
and purple and pale yellow. So, under Zucker’s direction, [Bradley’s mother] and her husband
sought to change this as well. (Spiegel, 2008; misgendering pronouns corrected)
Bradley’s mother described the negative impact of this aversive conditioning:
‘She was much more emotional . . . [. . .] She didn’t want to go to school anymore,’ she says.
‘Just the smallest thing could, you know, send her into a major crying fit. And . . . she seemed
to feel really heavy and really emotional.’ (Spiegel, 2008; misgendering pronouns corrected)
Some psychological publications have critiqued Zucker and Bradley’s (1995) approach
as problematic or archaic (e.g., Burke, 1996; Hegarty, 2009; Hill et al., 2005; Langer
& Martin, 2004; Lev et al., 2010; Wilson, Griffin, & Wren, 2002). Some psychological
models have also discarded direct behavioural modification for therapeutic interventions
described in psychological literature as ‘supportive’ and ‘affirmative’ towards children’s
self-designated genders (e.g., Hill, Menvielle, Sica, & Johnson, 2010; Klein, 2009; Raj,
2008; Vanderburgh, 2009).

Ansara & Hegarty 2011 4
Indeed, some recent psychological approaches suggest an ideological shift in minority
world psychomedical discourse from depicting ‘gender variance’ as pathology to viewing
self-designated gender as a natural phenomenon. For example, Herbert Schreier, a child
psychologist based at Oakland Children’s Hospital and Research Center, has described
‘gender variance’ not as ‘GIDC’ but instead as children ‘becoming more aware of how it
is to be themselves’ (Brown, 2006, p. 2, para 1). Therapist Diane Ehrensaft has assisted
some children in achieving social recognition for their self-designated genders. Ehrensaft
‘does not think parents should try to modify their child’s behavior’ and ‘does not see
transgenderism itself as a dysfunction’ (Spiegel, 2008, Section ‘Another Family, Another
Approach’, para 16). Adolescent psychiatrist Edgardo Menvielle, founder of a US-based
outreach group for parents of ‘gender variant’ children that now has over 200 members,
asserts that ‘the goal is for the child to be well adjusted, healthy and have good self-esteem’
(Brown, 2006, p. 2, para 3).

While some of these newer models appeal directly to children’s well-being and


autonomy, many also support the eradication of children’s self-designated genders for
paternalistic reasons. For example, one recent psychological approach describes the era-
sure of children’s self-designated gender and expression as a positive therapeutic outcome
because the intervention aims to reduce ‘comorbid’ behaviour associated with ‘extreme
cross-gender’ behaviour (Rosenberg, 2002). Thus, even some ‘supportive’ approaches use
pathologising terms like ‘severe’, ‘conditions’, ‘extreme’ and ‘comorbidity’, similar to ear-
lier clinical models designed to reduce ‘atypical’ gender behaviour (see also Roen, 2011).

Some authors contend that mental health professionals and psychology at large are


lagging behind other arenas in their lack of recognition and support for children’s own
self-designated genders (e.g., Kennedy, 2008; Lelchuk, 2006; Winters, 2008). Others sug-
gest that psychologists are adopting more positive attitudes over time. Brown (2006, p. 1)
argued that ‘until recently, many children who did not conform to gender norms in their
clothing or behaviour and identified intensely with the opposite sex [sic] were steered to
psychoanalysis or behaviour modification’, but that nowadays ‘children as young as 5. . .
are being supported by a growing number of young parents, educators and mental health
professionals’. Similarly, Hill and Willoughby (2005, p. 532) argue that while ‘early studies
of attitudes toward transsexuals among medical and psychiatric professionals documented
fairly negative views. . . attitudes among mental health professionals seem to be fairly posi-
tive 20 years later’. However, questions about the nature and stability of approaches towards
children among mental health professionals and psychologists more generally remain open.
We addressed them here through a content analysis of the psychological literature.

1.3. Cisgenderism

This research focused on children with self-designated genders that differed from those


assigned by the psychological researchers who studied them. We are not the first to theorise
the ideologies that might lead such children to be misunderstood. Prejudice and dis-
crimination researchers have discussed ‘transphobia’ (Hill & Willoughby, 2005; Nagoshi
et al., 2008; Sugano, Nemoto, & Operario, 2006; Winter, Webster, & Cheung, 2008),
‘genderism’ (Browne, 2004; Hill & Willoughby, 2005) and ‘anti-trans prejudice’ (Tee &
Hegarty, 2006). Transphobia has been described as ‘an emotional disgust toward individu-
als who do not conform to society’s gender expectations’ (Hill & Willoughby, 2005), akin
to ‘homophobia’ (Weinberg, 1973). Hill and Willoughby (2005) developed a transphobia
scale that predicted parents’ reactions to gender non-conforming children (see also Martin,
1990). Measures of transphobia and homophobia are correlated (Nagoshi et al., 2008), and

Ansara & Hegarty 2011 5
exposure to transphobia can impact safer sex practices (Sugano et al., 2006) and can trau-
matise (Mizock & Lewis, 2008). In ‘transphobia’ research, violence and discrimination
against people with self-designated genders are typically attributed to negative attitudes
towards people with ‘transgender identity’, and this literature relies heavily on categorical
notions like ‘the transgender community’, ‘transgender people’, ‘transgenders’, ‘transgen-
derists’, ‘transsexuals’ or ‘transpeople’ (e.g., Hill & Willoughby, 2005; Mizock & Lewis,
2008; Tee & Hegarty, 2006; Winters, 2008).

However, the ‘transphobia’ concept fails to challenge two assumptions. The first is


the notion that is implicit in the terms ‘trans’ and ‘gender variant’, that people with
self-designated gender lie ‘across from’ or ‘vary from’ normative human development.
Second, the transphobia framework fails to challenge the assumption that ‘trans people’
and ‘cisgender or cissexual people’ constitute distinct classes of individuals. We think
that these shortcomings exemplify the ways that ‘prejudice’ and related constructs often
emphasise individual attitudes and divert attention away from systemic problems (Billig,
1991; Fernando, 2009; Kitzinger, 1987). For these reasons, many lesbian, bisexual and gay
researchers have abandoned the term ‘homophobia’ in favour of such terms as ‘heteronor-
mativity’ (Warner, 1993), ‘heterosexism’ (Herek, 1990) and ‘sexual prejudice’ (Herek,
2000). We argue that a similar shift is needed to properly engage with the social systems
that children with self-designated genders must navigate. Accordingly, we use the term
cisgenderism2 to name this ideology.

We use the term cisgenderism for three reasons. First, unlike ‘transphobia’, cisgen-


derism describes a prejudicial ideology, rather than an individual attitude, that is systemic,
multi-level and reflected in authoritative cultural discourses. Second, while ‘transphobia’
and ‘genderism’ purport to contrast treatment of different types of people, cisgenderism
problematises the categorical distinction itself between classes of people as either ‘trans-
gender’ or ‘cisgender’ (or as ‘gender variant’ or unmarked) (see also Miller, Taylor, &
Buck, 1991). Our thinking is informed by research that shows that such categorical dis-
tinctions can themselves be components of prejudicial ideologies in areas such ‘race’,
gender and sexual orientation (Haslam & Levy, 2006; Keller, 2005; Martin & Parker, 1995;
Prentice & Miller, 2007; Williams & Eberhardt, 2008). We consider cisgenderism to be
a form of ‘othering’ that takes people categorised as ‘transgender’ as ‘the effect to be
explained’ (Ansara, 2010), consistent with theorising about ‘race’ and ethnicity (DuBois,
1903/2005), ‘sex’ (de Beauvoir, 1949/1974), ‘gender’ (Roughgarden, 2004), ‘disability’
and ‘special needs’ (Allen, 1999), ‘humanity’ (Bradshaw, 2009; Marcu & Chryssochoou,
2005), sexuality (Warner, 1993) and their intersections (Burman, Gowrisunkur, & Sangha,
1998; Purdie-Vaughns & Eibach, 2008). Thus, cisgenderism may be reflected in psycho-
logical research that assumes cisgenderism to be healthy or ideal, just as heterosexist
ideology is evident when researchers ‘conceptualiz[e] human experience in strictly hetero-
sexual terms. . . consequently ignoring, invalidating, or derogating homosexual behaviors
and sexual orientation’ (Herek, Kimmel, Amaro, & Melton, 1991, p. 958) or sexist ideol-
ogy is evident when researchers consider boys only as their model for human development
(e.g., Freud, 1923/1960). Third, cisgenderism provides a clearer frame than ‘transphobia’
or ‘genderism’ for evaluating the role of language in science in the dissemination of prej-
udicial ideology, following similar work in the field of sexist language (e.g., Eichler, 1991;
Hyde, 1984; Martyna, 1980).

1.4. The present study

In the present study, we examined whether cisgenderism has characterised the language of


scientific communication about children in psychology in the period since Parlee’s (1996)

Ansara & Hegarty 2011 6
critical article. The study drew conceptually on feminist research (e.g., Diekman, Eagly,
& Johnson, 2010; Gannon, Luchetta, Rhodes, Pardie, & Segrist, 1992; Sherif, 1998; Voss
& Gannon, 1978) and content analyses of psychological literature (e.g., Ader & Johnson,
1994; Edwards & Pedrotti, 2008; Morin, 1977), in its assumption that scientific language
about participant groups both represents and perpetuates ideology. We evaluated article
records (i.e., abstracts, keywords, subjects, titles, etc.) archived on PsycINFO for two kinds
of cisgenderism. Pathologising is the construction of people’s behaviour or characteristics

as pathological or disordered (Newcomb, 1996; Winters, 2008). The diagnostic classifica-

tion of self-designated gender as a ‘disorder’ led us to predict that pathologising language would be common. Pathologising items that addressed a focus on assessment and eval-

uation were based on Herek et al.’s (1991) guidelines for avoiding ‘heterosexist bias’ in psychological research. Misgendering3 occurred where psychologists categorised a child

into a gender category or gendered behavioural description with which the child themselves

did not identify.

To assess claims that accounts of ‘transgender people’ in psychology are becom-
ing more positive, we examined whether cisgenderism was increasing or decreasing
in the literature over time. We also assessed whether cisgenderism was unevenly dis-
tributed across psychology’s sub-disciplines, testing the specific prediction that authors
from mental health professions would be more likely to pathologise children with self-
designated genders. Finally, we examined one problem that might sustain cisgenderism,
despite increasing recognition regarding this mechanism. Quiñones-Vidal, Lopéz-García,
Peñaranda-Ortega and Tortosa-Gil’s (2004) content analysis of the Journal of Personality
and
Social Psychology (JPSP) showed that citations in that area of psychology were most
common among networks of collaborating authors. Quiñones-Vidal et al. classified these
networks as ‘invisible colleges’ (see also de Solla Price & Beaver, 1966). We tested whether
there were similar networks or ‘invisible colleges’ among authors actively writing about
children with self-designated genders and whether the impact of such networks could help
us to explain the persistence of cisgenderist theories in psychology. To test this hypoth-
esis, we examined the citation count, or impact, of the articles sampled. Authors in this
area sometimes describe citation count as a measure of merit or influence (e.g., Zucker &
Cantor, 2005), but some researchers debate actively the reasons why scientists cite each
other and the extent to which high citation counts can be used as a measure of scientific
merit (e.g., Bornmann & Daniel, 2008).

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