Discourse & Society

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Gatekeeping gender: some features of the use of hypothetical questions in the psychiatric assessment of transsexual patients Susan A. Speer and Ceri Parsons Discourse Society 2006; 17; 785 DOI: 10.1177/0957926506068433 The online version of this article can be found at: http://das.sagepub.com/cgi/content/abstract/17/6/785

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Gatekeeping gender: some features of the use of hypothetical questions in the psychiatric assessment of transsexual patients SUSAN A. SPEER MANCHESTER UNIVERSITY

C E R I PA R S O N S S TA F F O R D S H I R E U N I V E R S I T Y

Discourse & Society Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) http://das.sagepub.com Vol 17(6): 785–812 10.1177/ 0957926506068433

ABSTRACT.

Psychiatrists, like other medical professionals with a diagnosing or prescribing role, control access to a range of forms of treatment, medication and service that their patient, or their patient’s carer, may want access to. In this article, we explore psychiatrist–patient interactions in the distinctive institutional site of a UK NHS Gender Identity Clinic, where the psychiatrist’s gatekeeping role is renowned. We focus on some interactional features of the psychiatrist’s gatekeeping role as it gets played out and oriented to in a specific class of question that they ask their patients. This class of questions involves the psychiatrist putting to the patient a possible future hypothetical scenario where the patient’s treatment is withdrawn. We show how these hypothetical questions function in the psychiatric assessment of transsexuals, and how the psychiatrist’s institutional, gatekeeping role is made manifest both in the design of the hypothetical question and in the response that is elicited from the patient. We end by considering the extent to which hypothetical questions may be deemed a ‘useful’ or a ‘successful’ strategy in the psychiatric assessment of transsexual patients.

KEY WORDS:

gender identity, hypothetical questions, medical interaction, psychiatry, transsexualism

Introduction Psychiatrists, like other medical professionals with a diagnosing or prescribing role, control access to a range of forms of treatment, medication and service that their patient, or their patient’s carer, may want access to. This ‘gatekeeping’ role is particularly acute in settings where a patient’s desire for a certain medicine or treatment (e.g. for the drug methadone, or for ‘cross-sex’ hormones and sex reassignment surgery) may also be interpreted as a symptom of their ‘condition’ (e.g. heroin addiction, or transsexualism).1 The UK National Health Service (NHS) Gender Identity Clinic (GIC) is one setting where the psychiatrist’s gatekeeping role is renowned.


786 Discourse & Society 17(6)

Practitioners in a GIC deal primarily with patients who self-identify as ‘transsexual’.2 Transsexualism is formally designated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) as a ‘Gender Identity Disorder’ (GID). Persons diagnosed with GID are said to exhibit ‘a strong and persistent cross-gender identification and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex’ (Harry Benjamin Standards of Care [HBIGDA], 2001: 4). Statistically, transsexualism is thought to affect 1 in 11,900 males and 1 in 30,400 females (HBIGDA, 2001: 2). The treatment for the majority of transsexuals consists of taking high doses of crosssex hormones (hormone replacement therapy) and undergoing gender/sex reassignment surgery (GRS/SRS; Green, 2000). Male-to-female transsexuals may also elect to undergo facial and body hair removal, voice training, and facial feminization surgery (FFS). In order to obtain hormones and be referred for surgery, pre-operative transsexuals must be assessed by two psychiatrists at a GIC. Psychiatrists meet with patients attending the clinic once every three to six months prior to surgery. Follow-up consultations are also held in the months after surgery. One of the psychiatrist’s principal concerns during the assessment sessions is to decide whether the patient is an appropriate candidate for treatment. They assess the patient according to a pre-defined set of medical criteria, and aim to produce a ‘differential diagnosis’ (that is, to accurately diagnose the type of gender identity disorder and to determine that the patient is not suffering from some other related or unrelated mental health problem). As Louise Newman (2000: 400) puts it, ‘for the mental health clinician . . . the task is to distinguish the “true transsexual” (or primary transsexual) from others with lesser degrees of gender dysphoria or other gender issues for which surgery is not considered appropriate treatment’. Although the psychiatrists at the clinic we are studying do not work with a standardized patient interview protocol, they share some common goals: to document the history of the patient’s gender identity struggles from their ‘first awareness’, to examine their motivations for hormones and sex change, and to explore whether they have realistic expectations for the future. Psychiatrists also counsel patients about the range of treatment options available, their likely risks and benefits (in particular, what surgery and hormones can and cannot achieve), and the social, psychological and legal consequences of transitioning.3 The Harry Benjamin International Gender Dysphoria Association’s ‘Standards of Care for Gender Identity Disorders’ (HBIGDA, 2001) specifies that, before they can be referred for surgery, psychiatrists must establish that patients meet both ‘eligibility’ and ‘readiness’ requirements. As part of the eligibility requirement, patients must participate in the ‘Real Life Test’ (also known as the ‘Real Life Experience’), in which they must demonstrate that they have been living full-time within their aspired-for gender role for a period of at least a year. This will include at least one year on high doses of cross-sex hormones. To meet


Speer and Parsons: Gatekeeping gender 787

the ‘readiness’ requirement, patients must demonstrate ‘further consolidation of the evolving gender identity or improving mental health in the new or confirmed gender role’ (HBIGDA, 2001: 7). Transsexual patients undergoing psychiatric assessment at the GIC are driven by a different and typically contrasting set of concerns. For example, one of their principal concerns is to persuade the psychiatrist that they are an appropriate candidate for treatment. Research suggests that some will be resentful at having to see a psychiatrist at all (Green, 2000: 914); they regard the psychiatrist as an ‘unwelcome intruder’ (Brown and Rounsley, 2003) and find the ritual process associated with the Real Life Test unnecessarily strict, lengthy and humiliating (Reid, 1998). Many view the assessment process as an inconvenient hoop they must ‘jump through’ in order to get what they need (Newman, 2000: 399). Indeed, the NHS assessment process has been widely criticized by patients who have completed their treatment and who report ‘aggressive and rude handling, punitive rules’ and ‘threats to withdraw treatment’ (Burns, 2004a; see also West, 2004). The contrasting concerns of psychiatrists and patients generate a number of tensions within the treatment context. Commentators have noted that patients, concerned not to delay or risk being refused surgery, are unlikely to report any ambivalence about their chosen gender identity, believing (often correctly) that it will be a ‘contra-indication’ for surgery. Similarly, they actively resist suggestions that they have a ‘gender problem’, and simply repeat a stereotyped gender narrative found commonly in ‘the published developmental histories of transsexuals who preceded them’ (Green, 1987: 7–8, 1974; Stone, 1993), claiming, for example, that they have ‘always felt’ this way – that they are a ‘woman/man trapped in a male/female body’ (Raymond, 1994: xvi). Thus, the practitioner-patient consultation has been described as an ‘adversarial encounter’ (Newman, 2000: 399), which results in a ‘cat-andmouse’ game that mitigates against the goals of both psychiatrists and patients. For the psychiatrist, the issue is, ‘how can I be sure that this person is a ‘true transsexual’ and not just telling me what they think I want to hear in order to obtain treatment?’ For the patients it is, ‘how can I convince this skeptical psychiatrist that I am a true transsexual, and tell him what I think he wants to hear in order to get my treatment?’ There now exist a number of commentaries and ethnographies reporting on some of the tensions in the assessment and treatment of transsexual patients. One particular account which stands out is Sandy Stone’s (1993) compelling response to Janice Raymond’s (1979) radical feminist book The Transsexual Empire. Stone (1993: 13) argues: in pursuit of differential diagnosis a question sometimes asked of a prospective transsexual is ‘suppose that you could be a man [or woman] in every way except for your genitals; would you be content?’ There are several possible answers, but only one is clinically correct.



Here Stone alludes to some of the tensions generated by the gatekeeping role of the psychiatrist and the institutional demands of the clinic. The idea that patients must provide a ‘clinically correct’ answer to this hypothetical question in order to be recommended for surgery (i.e. to state that they would not be content if they could not change their genitals) captures something of the way these tensions, and the game of ‘cat-and-mouse’ referred to above, get played out interactionally. Indeed, to the extent that the patient’s response to this question is diagnostic implicative, then this class of question would appear to hold a great deal of institutional weight. However, there are a number of problems with existing accounts of treatment like Stone’s. As is characteristic in this literature, Stone’s observations are based on second-hand, retrospective reports on treatment rather than first-hand examples of real-life, real-time consultations between psychiatrists and transsexual patients. Consequently, we have no way of knowing whether this kind of diagnostic, hypothetical question – and the associated interactional tensions it is supposed to illustrate – actually exist anywhere in empirical reality. Moreover, if such questions do exist, then we have no way of knowing how such questions get played out interactionally. Our aim in this article is to use spontaneous, naturally occurring materials from actual treatment contexts in order to gain some analytic purchase on precisely these issues. Can we find examples of this class of question in our data? If we can, then how does the psychiatrist use this kind of question to establish the correctness of his diagnosis and the proposed treatment (i.e. that the patient is indeed a ‘true’ transsexual). How do patients respond to these kinds of questions and work to persuade the psychiatrist that they are an appropriate candidate for surgery? And do psychiatrists and patients treat only one possible response as ‘clinically correct’, as Stone (1993) suggests?4

Materials and procedures The data we use in this article derive from a corpus of materials collected by the second author, which consist of audio-recordings of 95 one-to-one, psychiatristpatient consultations in a UK NHS GIC.5 This is the largest GIC in the world: 95 percent of all NHS referrals are dealt with here, and psychiatrists at the clinic see 600 new patients each year. There are four consultant psychiatrists at the clinic, and of these, two were involved in recording their sessions with patients for this study. Each session lasts between 15–60 minutes.6 We found six examples of our target hypothetical question in our data. Like the question Stone refers to above, they involve the psychiatrist putting to the patient a hypothetical scenario where sex reassignment surgery is not granted, or where the patient’s cross-sex hormone treatment is withdrawn. The psychiatrist proceeds to ask the patient what they would do in that situation. These sequences typically consist of the two-part structure – ‘suppose that you could not do/have X treatment. . . .What would you do?’7 Each example was delivered by the same



psychiatrist, usually in the context of a first or second meeting with a patient.8 The extracts were transcribed by the first author using transcription symbols developed by Gail Jefferson (2004).9 We have included four representative examples of these questions for analysis below, and one example that gives the reader a flavour for how patient responses to these questions run off.10 In each case, we have included a few lines prior to the hypothetical question in order to give the reader a sense of the sequential environment in which the question is asked. We will show how this class of question is built, and how it functions in the psychiatric assessment of transsexual patients. We explore how these hypothetical question–answer sequences are bound up with the (institutionally sanctioned) gatekeeping of gender, and the interactional tensions and troubles that have been widely reported in this institutional setting but whose existence and function have hitherto been asserted rather than demonstrated. Finally, we consider the extent to which this kind of hypothetical question may be deemed a useful, or ‘successful’ strategy in the psychiatric assessment and treatment of transsexual patients.

The interactional organization of hypothetical questions The hypothetical questions in our data follow a strikingly similar pattern, each being composed of three identifiable parts: (1) an invitation to the patient to imagine something; (2) a description of the hypothetical scenario that the patient is being asked to imagine; (3) a question component which asks the patient what they would do if that scenario were to occur. Consider our first excerpt below. The question (whose parts are marked with → in the left-hand margin) comes at a point where the psychiatrist has spent some time exploring with the patient how well she passes as female, and whether she has a realistic view of herself in her new role. The patient is in the process of defending herself against the psychiatrist’s suggestion just prior to the start of this excerpt that she may still look more like a man than a woman – and thus not pass very well at all: (1) [T11 Session 2 17.38–19.30] 1 2 3 4 5 6 7 8 9 10

Patient: Patient:

Patient: Psy:

I think I’m feminine enough (I know) .hhh (.) I mean without ma:jor surgery and (talt)alterin’ my fac:e (1.2) I’ve- this is the face I’m ↑stuck with basica(h)lly(h) [(hh) .hhh [Oh ↑yes, yes, right, oka:y. .hh uh::m (0.6)


790 Discourse & Society 17(6) 11 Psy: (1)→ .Pt .hh suppo:se, (.) just suppose it- (.) for 12 (2)→ some reason it wudn’t be- it wasn’t possible for 13 you to go any fu:rther with trea:tment 14 (3)→ what would you do:.

The psychiatrist begins, in the first part of the sequence, by inviting the patient to imagine something: ‘suppo:se, (.) just suppose’ (line 11). As Peräkylä (1993, 1995) shows in his work on the use of hypothetical questions in AIDS counselling, a speaker may begin their turn in this way in order to manage the ‘conditionality’ and ‘epistemological status’ of the hypothetical scenario that is about to be described (1993: 301ff). In this excerpt, by elongating the second syllable on ‘suppo:se’, and then issuing a repair in which he adds the word ‘just’ (line 11), the psychiatrist draws attention to or ‘marks’ the special nature of what he is inviting the patient to do (i.e. it is marked as ‘purely suppositional’ or hypothetical). In this sense, he is guiding, or instructing the patient how they should interpret, or read what comes next, at the same time as ‘upgrading’ the conditionality of the description (Peräkylä, 1995: 292). The psychiatrist proceeds in the second part of the sequence to describe the future hypothetical scenario that he is inviting the patient to imagine: ‘it- (.) for some reason it wudn’t be- it wasn’t possible for you to go any fu:rther with trea:tment’ (lines 11–13). The self-repairs and perturbations in this excerpt are very revealing. Note the way in which the psychiatrist begins as though to launch immediately into the description of the hypothetical scenario – ‘suppose it wasn’t possible for you to go any further with treatment’. Instead, however, the cut-off on ‘it-’ (line 11) initiates a repair in which the additional turn component – ‘for some reason’ (lines 11–12) is added. This repair does further work to manage the epistemological status of the forthcoming description and its ‘purely suppositional’ nature. In particular, the psychiatrist presents the possible reason or cause for the hypothetical scenario he is about to put to the patient as a generalized one that is not pre-established or decided (by him or by anyone else) in advance. By constructing his turn in this way, he works to remove the imputation that is potentially available to the patient at this time that the hypothetical scenario he is about to describe may become a reality. The additional repair in which ‘wudn’t be-’ is replaced by ‘wasn’t’: ‘it wudn’t be- it wasn’t possible for you to go any fu:rther with trea:tment’ (lines 12–13) does additional work to maintain the hypothetical nature of the scenario that is being described. In this case, ‘wasn’t possible for you’ is more distant and conditional sounding than ‘wudn’t be possible for you’. The latter construction brings the hypothetical scenario further into the realms of possibility, making it appear more immediate and hence more threatening for the patient. In the third and final part of the sequence the psychiatrist puts a question to the patient – ‘what would you do:.’ (line 14). This furnishes the patient with the information they need in order to determine how they should respond in relation to the hypothetical situation that they have just been asked to imagine. Specifically, by asking what the patient ‘would’ do, the question is inviting the



patient to describe something dispositional – to formulate their own likely behaviour pattern in the hypothetical scenario given what they know about themselves (for more on the function of ‘would’ see Edwards, 2002, 2006). Note that a question has already been projected by virtue of the first and second parts of the sequence: With ‘suppose scenario X’ the psychiatrist projects ‘then question Y’ (see Lerner, 1991: 442ff). It is worth noting that the question could equally run off in the opposite direction as in ‘question Y’ if ‘scenario X’ (e.g. ‘what would you do if you couldn’t proceed to surgery?’). However, the virtue of the former turn design is that it allows the psychiatrist to mark and manage the hypothetical, conditional character of the scenario ‘up front’, and thus deflect the patient’s potential worries that the scenario that he is about to describe may come about. In addition, he marks this as a special class of question in a series of questions, thereby ensuring that he will get a particular kind of hearing for the talk with which he is about to be engaged, and that he is talking to a correctly prepared and aligned recipient. It may also, as we shall see below, be one of a number of ways in which the psychiatrist secures the patient’s cooperation in advance of raising an issue that he deems will be of a delicate or sensitive nature for the patient. Our second excerpt follows a very similar pattern. Here, the hypothetical question comes toward the very end of the session, after the psychiatrist has asked the patient whether she has ‘anything else’ that she wishes to bring up ‘at this time’ (lines 1–2). (2) [T 11 Session 1 7.25–8.24] 1 2 3 4 5 6 7 8 9 10 11 12 13

So that’s that sorted, .hh anything else that you want to bring up at this time. Patient: .hhh no as I said I feel quite (0.4) happy (.) that I- ˚I feel much more comfortable˚ (with my) ((VAR activates)) Psy: You fit in better no:w. Patient: Yes. Psy: R[ight. Patient: [˚Much [more comfortable˚ Psy: (1)→ [.h h h Suppo:se, and this is just a sojust a (.) supposition it’s >nothing (2)→ more than that< suppose you couldn‘t go any (3)→ further with treatment what would you do:: Psy:

As in Excerpt 1, the hypothetical question consists of three recognizable parts: an invitation to the patient to imagine something: ‘Suppo:se, and this is just a sojust a (.) supposition it’s >nothing more than thatnothing more than thatit’s ↑only a supposition.
I’m sompthin’ I’m no:w< I’m now a woman now: >I- this is it I couldn’t go back.< (0.2) Patient: >Oh no there’s no going ba:ck.< (.) Patient: °No° (0.2) Psy: .Pt °interesting° ri:ght. Psy:


804 Discourse & Society 17(6) 41 42 43 44 45 46 47 48

Patient: Patient: Patient:

Psy:

No going back (°no:°). (.) >I w’dn’t wanna go back no::w< (would there). (1.0) This is- this is me: I love it I:, this is me: I’ve never been so happy in my li:fe. (.) .Hh (.) Ri:ght? hh.

The patient’s response is noticeably delayed (line 2) – a classic sign of dispreference (Pomerantz, 1984). Moreover, it does not – initially at least – deal with the psychiatrist’s question on its own terms (i.e. in terms of what the patient would do). Instead, the patient provides a reflexive comment on their not having considered or even ‘thought about’ the very hypothetical situation they’re being asked about: ‘(I ha’n’t cum)- I ha’n’t thought about that really’ (lines 3–4). Of course, it is perfectly reasonable to argue that this patient really ‘has not thought’ about how she would respond if the hypothetical scenario that is being put to her were to actually occur. However, this kind of response – that is, one which indexes a cognitive inability or lack of knowledge of some sort – turns out to be a very common patient response to this question. And perhaps it is rather more common than one would expect if one were to attempt to explain patient responses exclusively in terms of cognitive processes. As discursive psychologists and conversation analysts have shown, the detail of what members say in such ‘state formulations’ cannot be reduced (that is, they cannot be explained exclusively or primarily in terms of) cognitive processes, or members’ desire to describe some internal ‘reality’. Instead, members consistently describe cognitive processes as part of doing things (Edwards, 1997). Utterances which index cognitive difficulties, lack of knowledge, thought processes and the like, operate at an action level, to do interactional, identityimplicative work (Hutchby, 2002; Jefferson, 1984a; Potter, 2004; Speer, 2005). Thus, although statements such as ‘I haven’t thought about it’ or ‘ I don’t know’ may appear to be a straightforward cognitive ‘dump’ (Potter, 1996: 142) or factual reporting by the patients of the contents of their minds, as Jefferson (1984a: 7) notes, ‘reported first thoughts’ are ‘not necessarily giving access to – what people are actually thinking’ (1984a: 13). Rather, they are ‘subject to social organization . . . appropriate to some situation’ (1984a: 7), and are typically managed in ways that show a concern for the identity of the speaker. What identity implicative work might this kind of response achieve for this patient in this case? First, it works as an account for not answering the question with the kind of answer made relevant by it, and which may thereby be expectable in this position – namely a description of the patient’s hypothetical actions. Second, it allows the patient to defer answering the question on its own terms – and at least until they have gleaned more information from the psychiatrist regarding what the implications of their response might be. Finally – and crucially – the patient’s initial response may inoculate her from precisely



the imputation that may be made available at this time, that she is not an authentic candidate for surgery, that she has entertained the possibility of not wanting or having surgery, or that she is a strategist who has rehearsed her response in accordance with some kind of script that is designed to manage just such a question. Indeed, even while this patient may not have read the Stone quote cited earlier, the trans community is such that patients usually enter treatment with an armoury of research and knowledge about the kinds of questions they may be asked, and are alert to the kinds of issues for which they may be held accountable. So in this context we can tentatively assume that although it comes ‘out of the blue’, this kind of question may not come as such a surprise to the patient. By treating the hypothetical scenario as one that they had not previously thought about, or entertained, and by indicating that they are unable to grasp what the question is (apparently) getting at (i.e. that if they couldn’t have surgery, would they revert to the male sex), their response seems designed precisely so as to display that the possibilities contained within the hypothetical (withdrawal of treatment and/or reverting to the male sex) have not even crossed their minds, and that only one outcome (surgery in order to ‘become a woman’) preoccupies them. To a certain extent, then, by putting the patient ‘on the spot’, the psychiatrist may inadvertently assist the patient in providing just this kind of ‘spontaneous’ and ‘authentic’ answer.14 So how does the psychiatrist respond to the patient’s apparent difficulties? One common way in which parties to an interaction deal with evident signs of trouble in a co-interactant’s talk is to treat it as caused in some way by something in their just prior turn. One possibility open to the psychiatrist in this case is to work to identify and remedy that trouble-source – say by re-working his question so that it is easier for the patient to respond, or else by providing some form of clarification in his next turn (Davidson, 1984). Interestingly, however, the psychiatrist does not (initially) treat the patient’s response as an indication that his question was problematic, or that it might need re-working or reformulating in some way. Thus, he does not come in with a revised, subsequent version of the question, or a clarification (something which he could very appropriately do at such a juncture if he wishes to appear tentative and helpful). Instead, he treats the patient’s response in a literal fashion (as evidence for her not having thought about it) and proceeds to invite her to think about it now (at the same time as reflexively commenting on the nature of the action with which he is currently engaged): ‘I’d like to invite you to: to give it some thought no:w.’ (lines 8–9). Later, he simply repeats the original question without repairing it: ‘so what would you do:. (line 22), thus implying that it is the patient’s response that is inadequate, and not his question. As we have seen, the question component ‘what would you do?’ projects as a relevant next action that the patient responds in terms of her actions and not her feelings. However, initially, the patient responds in terms of her hypothetical feelings and not her actions: ‘I’d be upse:t, ye:ah very’ (line 13) . In each case, the



psychiatrist rejects the validity of ‘feelings talk’ by treating such talk as self evident and as patently not news. So he says: ‘Yes I’m sure you w’d °yes.°’ (line 15), and when the patient elaborates with the account ‘C’z this is sompthing I really want’ (lines 16–17), he simply says ‘Ye:s’ (line 19) before reiterating the almost identical version of his original question, as noted above. It is only after some lengthy delays, and the patient’s two ‘don’t know’ responses (lines 23–9), that the psychiatrist clarifies what his question was apparently getting at: ‘w’d you continue to li- live as a woman or’ (line 31).

Discussion In this article, we have explored what light an analysis of the design, delivery and interactional management of a specific class of hypothetical question might shed on the institutional and gatekeeping role of the gender clinic psychiatrist, and on the tensions and troubles widely reported as characteristic of this setting. On the basis of an analysis of four of the six examples we found in our corpus, we noted that the hypothetical question consists of three identifiable parts: an invitation to the patient to imagine something; a description of the hypothetical scenario that the patient has been invited to imagine; and a question component that asks the patient what they would do if that hypothetical scenario were to become a reality. We also noted that in some instances this three part sequence is preceded by an additional preliminary (‘prepre’) component, in which the psychiatrist announces the kind of action with which he is about to be engaged. We suggested that the overall sequential organization and internal constitution of the hypothetical question appears to be attentive to positioning the hypothetical status of the forthcoming description ‘up front’, thereby ensuring an appropriately aligned recipient (in particular, orienting the recipient toward the potentially special or delicate status of the issues to be raised by the hypothetical); and finally, to deflect the potential imputation available to the patient at this time that the hypothetical scenario may be imminently possible or likely. Our comparison of the function of hypothetical questions in psychiatric versus therapeutic settings has shown that the precise function of hypothetical questions is highly dependent on the interactional environment in which they occur. Moreover, psychiatrists’ and patients’ views about what psychiatry is in this context get played out interactionally and oriented to by both parties to the interaction. In other words, the interaction reflects, constitutes and reconstitutes this (and the respective parties’ roles as part of) a certain kind of institution or social structure. Peräkylä (1993, 1995) argues that counsellors use hypothetical questions because they help them to deal with the distinctive challenges that their work entails. For example, they facilitate the preparation of clients who may currently have no symptoms, for a possible future in which they become ill and may die.



There are few alternatives open to them. However, we have argued that in contexts where the doctor is a gatekeeper, hypothetical questions work rather differently than they have been shown to do in the more therapeutic environments discussed by Peräkylä. In particular, where in AIDS counselling the counsellor has no control over whether the proposed hypothetical scenario may come about (for example, the counsellors in Peräkylä’s data cannot influence whether the client will die of an AIDS-related illness), in our data, by contrast, the psychiatrist does have the institutional authority to influence whether the proposed hypothetical scenario may come about. Since patients are attuned to this, it follows that they must continuously monitor themselves for displays of authenticity and for their genuine commitment to their aspired-for gender role. It is this, in part, which accounts for the interactionally ‘troubled’ nature of their responses. Part of this trouble can be traced to the diagnostic (as opposed to the therapeutic) function of the hypothetical question in this setting. Indeed, unlike counselling or psychotherapy, where the questioner treats as valid and actively encourages the patients’ feelings talk, we have shown that the psychiatrist uses the question to ask about, and prioritize as relevant the patient’s talk about their hypothetical actions (‘what would you do?’), rather than their feelings. By contrast, the patient responds initially with a description of her feelings. At each stage the psychiatrist treats this feelings talk as inadequate in some way – and as patently not news. We have only begun to touch on some of the things that are going on in these data. However, what we do hope to have done is to give the reader a feel for the kinds of work that is done with hypothetical questions in this distinctive institutional context. Our analyses have not been unmotivated. As we have noted, psychiatrists, patients and trans theorists often write about the problems and tensions within the NHS assessment and treatment process (see, for example, Burns 2004a, 2004b, 2005,; Reid, 1998; Stone, 1993; West, 2004), and we have made use of such members’ accounts to direct us to a particular interactional phenomenon. This brings its own risks as well as advantages. For example, there are some within the CA community who are sceptical about the application of CA insights to applied settings (i.e. institutional talk where there are differential rights of turn-allocation and turn-type, as there are here). For them the concern is over whether, in adopting a pre-existing question or frame of reference that motivates the analysis, the researcher consciously or inadvertently ‘goes native’, by seeing things from the participants’ point of view and so clouding the analysis.15 However, for us, so long as these potential risks are recognized, they are worth it. Indeed, by using members’ accounts of the troubles they face in certain settings to direct us to a particular class of hypothetical question, we have been able to bring the tools of CA to bear on illuminating the interactional manifestation of delicate matters which are a problem in members’ own terms. By holding up just one – albeit extended – hypothetical question and answer sequence to scrutiny, we have been able to



shed light on what is at stake for both parties in this setting, and to offer a window on the kinds of larger scale issues, agendas and tensions that are associated with the GIC environment. Indeed, the hypothetical question and patients’ responses to it displays something of these tensions in microcosm. It is up to the reader to subject out data to their own independent analysis and to decide whether we have managed to avoid ‘going native’. We want to end by considering the extent to which the psychiatrist’s interactional strategies can be considered successful. And what are the implications of this analysis for the psychiatric assessment and treatment of transsexual patients, and for ‘gatekeeping’ within psychiatry more broadly? On the one hand, we could argue that transsexual patients are already very skilled at managing a difficult situation. They respond actively and creatively to the demands of the encounter and are managing well within a problematic set of constraints. In particular, the patients show that they know that what they say in response to such innocuously presented questions may have a direct bearing on the course of their treatment, and they tailor their responses and their life narratives accordingly. In this sense, psychiatrists may be losing the ‘cat and mouse’ game identified earlier, and may need to ‘up their game’ so that patients are not continuously second guessing them. On the other hand, although the patients’ responses to the hypothetical questions may be interactionally marked as dispreferred, this does not necessarily mean that the psychiatrist’s questioning strategy is unsuccessful, or that they are bad, hostile, insensitive gatekeepers. Indeed, as we have shown, the psychiatrist may intend to make things difficult for the patient, put them ‘on the spot’, or make them think that their answers will be inconsequential, in order to avoid precisely the kinds of second guessing and stereotyped narrative script alluded to in the literature, and make an accurate differential diagnosis. Psychiatrists are in a difficult situation here, and it is hard to imagine an alternative means by which they may produce a reliable diagnosis, and without somehow troubling the patient. Even though the psychiatrist’s questioning seems hostile, then, we must ask, given the current socio-legal and medical context within which they must work, could the psychiatrist proceed in any other way? If so, how? AC K N OW L E D G E M E N T S

Susan Speer would like to acknowledge the support of the ESRC (award number RES 148–0029) and The British Academy (Overseas Conference Grant OCG 38081). The latter financed dissemination of some of our findings at the International Gender and Language Association Conference, Cornell University, 5–7 June 2004. Both authors would like to thank Victoria Clarke, Elizabeth Stokoe, two anonymous reviewers, and colleagues who attended the CA and Psychotherapy Conference at Manchester University, 11–12 June 2004, for their useful comments on an earlier draft.


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5.

6. 7.

It is important to note that we are not wishing to imply a particular connection between transsexualism and drug addiction here. We use the medical term ‘transsexual’ as opposed to the more political term ‘transgender’ to describe our research participants, because this research deals specifically with individuals who seek medical treatment to change their sex. The notion of transgender is often used in a political context by transgender activists, specifically in order to avoid medical categorization. Although practices may vary cross-culturally (and between NHS and private treatment within the UK), these observations are based on prescriptions for practice as set out in the internationally recognized Harry Benjamin International Gender Dysphoria Association’s ‘Standards of Care for Gender Identity Disorders’ (HBIGDA, 2001). We recognize that making use of members’ accounts to direct us to a particular interactional phenomenon brings its own risks as well as advantages. We will return to this issue in the discussion. Although it is preferable to make video-recordings when dealing with co-present interactions (to access the interlacing of talk and gesture, for example), in this case ethical constraints restricted us to the use of audio only. For us, and as Sacks (1984: 26) observed, ‘the taperecorded materials constituted a “good enough” record of what had happened. Other things, to be sure, happened, but at least what was on the tape had happened’. The first author is currently collecting video-recordings as part of a large scale ESRC funded project at this clinic (Speer and Green, forthcoming). Since patients meet with psychiatrists relatively infrequently (every 3–6 months); none of the patients appear in this corpus more than once. This is just one of a number of different kinds of hypothetical question that we identified across our corpus. These other questions also involve the psychiatrist asking their patients how they would respond to a possible hypothetical future scenario. For example, in the context of the patient’s family not knowing that their son has begun living full-time in the female role, the psychiatrist asks ‘what are you going to do if you see them [your family] next Christmas?; in the context of a discussion about the patient’s future employment – ‘what would you like to do if you retrained?’; in the context of investigating the patient’s reactions to the possible effects of treatment, ‘how would you feel if it [your sex drive] disappeared again?’. We also found one particularly emotive example where the patient puts a hypothetical scenario to the psychiatrist – in the context of not getting what they want: ‘If I was to go out this door and throw myself off a bridge wouldn’t that be your responsibility for not giving me what I wanted, causing me to go out and throw myself off that bridge?’ Although these other hypothetical questions are interesting for all sorts of reasons, they occur in the course of discussing a different set of issues, and, as such, they will not concern us here. In this article we restrict our analyses to hypothetical questions where possible withdrawal of treatment is topicalized by the psychiatrist. Indeed, our interest in these questions stems less from a desire to produce a generalizable sequential rule for the operation of hypothetical questions across contexts than it does from a concern to unpack what interactional business this distinctive interactional object does for this psychiatrist in this institutional setting. Future analyses may be usefully directed toward exploring the extent to which hypothetical questions share generic or ‘context free’ features across institutional and mundane settings.


810 Discourse & Society 17(6) 8. Although both psychiatrists were oriented to the same medical and assessment goals and to similar interactional business, since they did not use a standardized protocol when assessing patients it is perhaps unsurprising that just one of them put this particular hypothetical question to his patients. 9. The notation ‘VAR activates’ refers to those moments where the ‘Voice Activated Recording’ starts, after several seconds silence. Although not ideal for analytic purposes, in that it is impossible to know how long these longer length silences last, the vast majority of the pauses and gaps we transcribed were relatively brief, and thus unaffected by the VAR function. 10. All of the patients in the extracts included here are ‘male-to-female’ pre-operative transsexuals, which reflects the much higher proportion of these patients in the trans community more broadly. 11. Note that here again the hypothetical scenario is ‘agentless’ in that the reason for the withdrawal of treatment is presented as something organic (it will ‘emerge’). 12. We recognize that there are problems in making claims about what speakers must already ‘know’. However, part of what we are aiming to do here is to demonstrate that the delicate and detailed way in which the respective parties to the interaction manage their questions and responses provides an exemplification of, and an orientation toward, these ‘prior knowledges’. 13. We use ‘topic’ here in the vernacular sense of the term, as in ‘what is talked about’ (Schegloff, 1979: 270 n.13). 14. Indeed, as soon as it becomes evident precisely what the psychiatrist is getting at (would they give up living as a woman and revert to the male role?), the patient moves to an immediate and emphatic ‘yes’ response (lines 32–3). The ‘oh yes’ marks a change of state (Heritage, 1998) and orients toward the problematic nature of the question in that it presumes that such a possibility might even have been considered. The patient also thereby casts her initial difficulties in answering the psychiatrist, as having been caused by some ambiguity in the question, and not by some (cognitive, accountable) failure within herself. 15. I am grateful to an anonymous reviewer for framing the problem in this way.

REFERENCES

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is a Senior Lecturer in Psychology at the University of Manchester, UK. Her research focuses on topics and debates at the intersection of feminism and conversation analysis. She is currently Principal Investigator (with Prof. Richard Green, Imperial College School of Medicine, and Charing Cross Hospital Gender Identity Clinic) on an ESRC-funded project, ‘Transsexual Identities: Constructions of Gender in an NHS Gender Identity Clinic’, which is part of the Identities and Social Action Research Programme. Her book, Gender Talk: Feminism, Discourse and Conversation Analysis, was published by Routledge in 2005. A D D R E S S : School of Psychological Sciences, Coupland 1, University of Manchester, Oxford Road, Manchester M13 9PL, UK. [email: [email protected]]

SUSAN A. SPEER

is a Senior Lecturer in Psychology at Staffordshire University. Her research interests are in the area of the social construction of gender and sexuality and she has investigated people’s experiences of ‘changing sex’ from a critical psychological perspective. Her PhD research, which was awarded in 2002, examined the interactions that take place between psychiatrists and transsexuals at a UK gender identity clinic using conversation and discourse analytic methods. [email: [email protected]]

C E R I PA R S O N S


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