Les thérapies d’affirmation de genre : activité médicale et normativation du sujet

Abstract

Goals

The objective of this article is to question gender-affirming therapies at the theoretical and clinical levels. They are, in fact, presented in the DSM-5-TR as the only possible therapies for gender dysphoria; we demonstrate that this is questionable from the point of view of the interaction between medical activity and clinical practice with the subject, as well as from the point of view of the evolution of psychopathological models of treatment of gender-related issues, particularly with regard to psychoanalytic data (diagnoses, associated processes and therapies).

Method

Our method combines an analysis of the literature and two clinical cases. First, we study diagnostic developments from transsexualism to gender dysphoria in the field of psychopathology and psychoanalysis. Next, we present two clinical cases of patients who have considered or initiated a transition. Then, we study the medical activity involved in gender-affirming care, based on Canguilhem's theses.

Results

The DSM-5-TR has a reductive and contradictory conception of dysphoria: it implicitly locates the cause and the solution in the social environment, without taking into account the interaction with the patient. Psychoanalytic theories have, on the contrary, maximized the potential of this interaction, thus making it possible to argue the psychotherapeutic interest of gender reassignment (or affirmation), but also to demonstrate its limits, in particular by taking into account the subjective position of the subject in its psychic structure.

Discussion

Reassignment presents itself as a normativation of dysphoria by medical treatments. However, normativation must rather be understood as the process by which subjects establish gender norms that are specific to them and which allow them to treat their dysphoria, by making specific use of medical reassignment protocols. Due to the interaction between subject and environment, normativation is not an adaptation to external or social reality, but implies that the latter is also modified by the former.

Conclusion

We cannot therefore subscribe to the thesis of the DSM-5-TR according to which dysphoria has only one possible predefined, systematic, and general treatment. The internal clinical dimension of medical activity assumes that the suffering of patients precedes the formalization that can be made of it, and that medical tools are designed and applied secondarily to a diversity of psychopathological configurations. This is also what the cases and the history of the ideas and practices presented demonstrate. The standardization of patients applies to their environment including therapies, which therefore should be modified and diversified.