The pluralisation of transsexual phenomena (or the recognition of the diversity) suggests that the borders of transsexuality had become fuzzy throughout the 1990s and early 2000s. This situation complicated the differential diagnosis on a practical and theoretical level. Several sexologists problematised this issue,
splitting mechanisms and a lack of psychic maturity that is assumed to be a precondition to the genital orgasmic function (Sigusch/Meyenburg/Reiche 1979: 270).
I suggest that it was not that transsexual individuals were necessarily asexual. Rather, it was due to a limited approach that transsexual individuals engaging in sexual activities were rendered unthinkable.
39 | As late as in 1995 Soyka and Nedopil parroted Sigusch, Meyenburg and Reiche’s cardinal symptoms, including the eighth symptom, which describes transsexual individu-als as heterosexual (Soyka/Nedopil 1995: 46), despite the fact that from 1991 onward Sigusch published revisions of the cardinal symptoms in several medical journals.
and they nevertheless developed various systems to distinguish transsexuality from similar, if not partially overlapping, phenomena.
While Clement and Senf addressed the practical side of the problem, Si-gusch pointed out to a theoretical dilemma that arises in the event of having to isolate transsexuality from other phenomena. Clement and Senf suggested that while e. g. fetishist transvestism40 was distinguishable from transsexuality, epi-sodes of transvestism did not necessarily rule out a transsexual development:
The categorically unambiguous distinction cannot […] always be met with in every sin-gle diagnostic case. Transsexuals do not rarely report earlier transvestic phases in the course of their transsexual development. Also, there are occasional reports of transves-tites who picture themselves as women with whom they are having sex in masturbation fantasies. (Clement/Senf 1996: 4)
While Sigusch insisted on a differential diagnosis when establishing a case of transsexuality, he cautioned that such a procedure necessarily ignored combi-nations »which cannot be simply considered transitions from one big and clear form to another« (Sigusch 1991a: 317). According to Sigusch, the infinite multi-plicity of sexual and gender identities is reduced in order to fit into general and clinical understandings (ibid).
Sexologists considered different gender manifestations that could be mis-taken for transsexuality. With the exception of so-called gender identity disor-ders, which arise as an effect of intersex or in the event that an intersex individ-ual feels that s/he has been socially and surgically falsely assigned to another gender at an early age, Clement and Senf’s categories resembled those of the 1970s and 1980s. Clement and Senf distinguished transsexuality from fetishist transvestism, effeminate behaviour in some homosexual men and gender iden-tity disorders in the course of a psychosis. Unlike the differential diagnoses in the earlier period, however, neither transvestism, nor psychotic developments or intersex necessarily excluded a diagnosis of transsexuality (Clement/Senf 1996: 4 f.).
Unlike the APA, the authors of the German Standards did not mention any somatic phenomena, such as intersex as diagnostic categories that needed to be distinguished from transsexuality. The German Standards suggest the follow-ing differential diagnoses:
40 | Clement and Senf defined fetishist transvestism as an inclination to cross-dress for the purpose of sexual arousal. This behaviour is not linked to a consciousness of belonging to, or a desire to belong to the ›other‹ gender. The clothing is not a means to express the individual’s identity, as it would be in the case of transsexuality. Instead, it is a fetishistic object. In other words, clothing is an object to a transvestite, while it is a part of oneself to a transsexual (Clement/Senf 1996: 4).
– discomfort, difficulties or non-conformity with established gender role expectations that do not coincide with a lasting and profound gender identity disorder;
– partial or fleeting gender identity disorders, such as adolescent crises;
– transvestism and fetishist transvestism in the course of which critical constitutions can arise;
– difficulties with the gender identity that result from a rejection of a homosexual orienta-tion;
– a psychotic misjudgement of the gender identity;
– severe personality disorders with an effect on the gender identity (Becker et al. 1997:
149).41
In his critique of the German Standards, Seikowski suggested cisidentity be added to the differential diagnosis. Seikowski defined cisidentified individuals as persons who wish to live as ›both‹ genders and who may want to undergo hormonal treatment but not sex reassignment surgery (Seikowski 1997: 352).
In her response to the critique of the German Standards, Becker rejected Sei-kowski’s suggestion. In her opinion, such a differential diagnosis was clinically not useful (Becker 1998: 159 f.).
Sigusch suggested a set of psychiatric, psychological and somatic condi-tions as differential diagnoses. The former are identical with those listed in the German Standards. However, Sigusch added »psychopathologically rather in-conspicuous ›cultural‹ confusions and transgressions of gender roles, e. g. with a transgender gender dysphoria« (Sigusch 2007: 354) to the developments that needed to be distinguished from transsexuality or that could possibly develop into transsexuality. Sigusch suggested organic ›conditions‹ such as intersex or temporal lobe diseases as somatic differential diagnoses (ibid).
Hence, the blurring of the boundaries of transsexuality revealed in the clin-ical pictures resounded in the differential diagnosis. Not only did differential diagnostic concepts become more diverse. In the period between the 1990s and the end of the first decade of 21st century, the differential diagnosis increasingly allowed phenomena to overlap, such as e. g. transvestism and transsexuality.
41 | Bosinski’s (2003: 716) and Beier, Bosinski and Loewit’s (2005: 381-383) differential diagnoses are identical, except that they pull together psychotic misjudgement of the gender identity and severe personality disorders with an effect on the gender identity.
Unlike the German Standards, which did not elaborate on the treatment of trans adolescents, Beier, Bosinski and Loewit rejected sex reassigning measures in adolescents and suggested using reversible puberty suppressants instead in the event of a severe gender identity disorder that does not cease despite psychiatric-psychopharmaceutic and psychotherapeutic interventions (Beier/Bosinski/Loewit 2005: 382).
3.1.3 Diagnosing transsexuality and assessing transsexual individuals
During the 1990s and the first decade of the 21st century, medical surveillance and (exclusive) medical expertise was not only challenged by trans individu-als and/or social scientists and legal experts42 involved in the sexological de-bate, but by individual sexologists themselves,43 albeit to a significantly lesser degree. Various aspects of the tension between trans self-determination and medical control and contestations over medical and extra-medical expertise in the sexological debate throughout the 1990s and early 2000s are mirrored in the diagnostic parameters patient history, psychopathological and physical ex-amination, psychotherapy and ›real life test‹, which have formally remained unchanged since the introduction of the German Standards in 1997.