Professional prejudice : Are psychology and psychiatry helping or hindering our understanding of sexualities and gender ?

South Africa is grappling with high levels of gender based violence and rape, some of it extreme in the lengths to which perpetrators go to assert dominance, mostly over women. Who can forget the horrific crime of rape, robbery and murder which took place at Rhodes Park in Johannesburg in October 2015, resulting in the recent sentencing of the perpetrators, all men? Please note this is a trigger warning for the next paragraph.

Not only is gender based violence in South Africa mostly a matter of "heterosexual" acts, but gender is firmly policed too, in itself a way to make heterosexuality "compulsory" (a term popularised by Adrienne Rich).Township-based black lesbian women, trans men 1 and individuals assigned female at birth but who do not "conform" 2 to feminine gender norms, face extraordinary levels of harm and humiliation.These occur at home, in school, in faith spaces, in the streets and at work.In some cases the abuse is sexual and may result in murder.A Human Rights Watch Report from 2011, titled "We'll show you you're a woman" argues that the narrow focus on so-called "corrective rape" deflects from the larger question of how we have become such a violent society which polices gender and sexuality so harshly.Echoing the sentiments from Tosh's book, the report suggests that delineating "extreme" forms of sexual violence from "ordinary" sexual violence normalises sexual violence and dislocates it from its social, economic and political contexts.
It can be argued that sexualised violence towards women in general and non-conforming women in particular, finds its origins in a broader climate of intolerance towards "difference" in South Africa, firmly located in (sometimes violent) heteropatriarchal forces which police gender and sexuality.
In June 2016 the Gauteng City-Region Observatory Quality of Life survey (of 30 000 residents) was released3 , indicating that 14% of the province's citizens say it is acceptable to be violent to gay and lesbian people.In the same year the Other Foundation released its Progressive Prudes report, based on interviews with 3000 people, offering a slightly more nuanced view of homophobia and transphobia in South Africa more broadly.It found that while one in four people across all groups and contexts reported having a friend or family member who was gay or lesbian, three quarters felt that same-sex sexual activity was morally wrong, despite just over half indicating that gay and lesbian people should have the same human rights as all.On gender non-conformity, around eight in ten people had not harmed or would not consider harming a gender non-conforming person, but, by extrapolation, nearly half a million had physically harmed a gender nonconforming woman and nearly a quarter of a million had physically assaulted gender non-conforming men.
Against this backdrop, it is useful to ask not only how society and the academy view people who are sexually violent, and what motivates them, but also how we come to think about gender non-conformity and how that gender non-conformity provokes social anxiety.Given that the position of sexually and gender diverse persons in 1 I use the term trans here as shorthand for transgender, noting that there are contestations in terminology.

2
The term gender non-conformity is used throughout Tosh's book and I acknowledge that the term itself can suggest that the gender binary is unproblematic, though clearly this is not the book's intention.
South Africa is so precarious, and that sexual violence is gendered, this matter has urgency.
Perverse psychology examines the history of psychiatry and how it constructed the idea of the "crazy" stranger rapist archetype and created new notions of pathology and diagnosis; and similarly looks at how psychiatry has constructed and diagnosed gender non-conformity.Jemma Tosh concludes with reflections on "perversion" and how psychology and psychiatry can themselves be considered to be "perverse" in their theories and how they treat sexual violence and gender non-conformity.
On sexual violence, Tosh makes a compelling case for the discipline of psychology taking an interest in the perpetrator rather than the victim while psychiatry has contributed to definitions of rape as a mental illness.In both instances, she argues, there are problems: being perpetrator focused does a disservice to victims of sexual violence; and an obsession with diagnoses moves the conversation away from the realm of patriarchy and societies founded on gender inequality.In sum, the professions should do better.
Tosh argues that the distinction between a pathological minority and the "norm" masks their similarities (for example she describes heterosexuality as having sadistic norms) and fails to question the heteronorm, heterosexuality and masculinity.Perhaps we should rather examine how we understand power and its relationship to violence, and how we all relate to each other, rather than looking at sexual fantasies and uncontrollable urges as exceptional phenomena.She goes on to argue that the medicalisation of rape creates a hierarchy of pathologies, distinguishing perhaps between different forms of violence, coercion and desire, which undermine the project which seeks to see rape and sexual violence as embedded in gender relations.
On what she calls "transgenderism", a term which seems slightly awkward to this reader, Tosh suggests there has been a pathologisation of gender non-conformity, particularly effeminacy, often associating the latter with homosexuality, hence an interest in feminine boys in the last few decades.Treatment options for feminine boys -or prehomosexual children -represented a focus on individual "difference" while ignoring the social context, and endorsed forms of disciplinary power.The fact that pre-homosexual boys, in being feminine, may be hard to distinguish from trans girls means that the boys may get included in prevention interventions around gender "dysphoria".This is problematic, not only because they are wrongly "diagnosed", but because it is a travesty the diagnosis exists at all, says Tosh.She concludes that the "construction of gender 'normality' from within the psychiatric discourse of 'gender dysphoria'" (p 94) promotes hegemonic masculinity and draws on evolutionary and biomedical discourses to naturalise it.We arrive then at the idea of "natural" masculinity which often parallels views of "natural" masculinity in publications like the DSM, and this underpins how we think about certain "disorders" and the "inevitability" of male violence.Ultimately Tosh asks the trenchant question: where does the line between "abnormal" and "normal" lie in psychiatric theorising?She concludes that it is psychiatry and psychology which are perverse because in relation to gender and sexuality they are "directed away from what is right and good" (p 114), and "obstinately persisting in an error or fault" (p 115).
Continuing, she writes: "If psychology considers transgenderism to be 'abnormal' and rape to be 'normal', or argues that transgenderism should be prevented but masculine aggression should be encouraged, then it sounds to me like psychology is the one that is perverse and in need of an intervention (p 116)." These are strong words, and while this book is compellingly argued, is it not an easy read and sometimes sections appear to lack cohesion and flow.Nevertheless one is forced to challenge many assumptions about sexual violence and how it is configured, as well as how society imagines the lives and identities of young people who are gender non-conforming.
As noted earlier, being gender non-conforming not only makes one potentially more vulnerable to rape in South Africa, but forms of rape are often extremely violent.Being gay or lesbian is often implied by gender non-conformity too, making all queer people, even those who do not identify as gay or lesbian, vulnerable.It is pertinent to ask how the psychology profession and other researchers have stepped into this space here.
PsySSA, for example, has in recent years developed guidelines on affirming therapies for sexually and gender diverse clients and has divisions which specifically focus on sexualities and gender, and violence.In the interests of disclosure I must acknowledge I sit on the executive of the Sexuality and Gender Division (SGD) and that the division's work has been to complexify our understanding of sexuality and gender and to bring a "queer" lens to the field.This sits slightly at odds, perhaps, with the Academy of Science in South Africa (ASSAf) report on sexuality which suggested deep biological aspects to sexuality and gender -while this strategic essentialism may meet the needs of some activists who need to organise around clear identity categories, others might argue that notions of fluidity, constructionism and contingency are pushed to the margins.