Gender identity is only one such concept. I am diagnosed with gender identity disorder syndrome, and I am being treated.”
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When anxious parents demanded that he be dismissed, the driver was perplexed: “I don’ t understand what all the fuss is about. On September 5, 1997, the Philadelphia Daily News reported that a school bus driver in rural Selinsgrove, Pennsylvania, felt, as he put it, like a woman trapped in a man's body and expressed himself by wearing women's clothing, a wig, and eyeliner while driving his bus to and from school. What was particularly striking at the end of the 20th century was the variety of contexts in which we have become accustomed to seeing disease concepts being negotiated in public. Was this a disease or a choice? How could a legitimate disease-in most physician's minds, a biopathological phenomenon with a characteristic mechanism and a predictable course-be decided by a vote, especially one influenced by feverish lobbying and public demonstrations (see Bayer 1981 Grob 1991 Kirk and Kutchins 1992 Kutchins and Kirk 1997)? Most conspicuously, psychiatrists voted, argued, then voted again as they reconsidered the problematic category of homosexuality. At about the same time (in the early 1970s) as this coding dilemma, the American Psychiatric Association was undergoing an embarrassingly public struggle over the revision of its Diagnostic and Statistical Manual. The principal investigator faced a methodological dilemma in her critical reading of manuscript death certificates: how were they to code diagnoses like “old age,” “senile,” or “marasmus” still common in 1880 but banished by 1930? In previous archival research, I had been struck by early 19th-century hospital case records in which either no diagnosis was recorded or general descriptive terms ( fever, fits, dropsy) served as diagnosis.
One was my serving as a consultant to a large demographic project studying the causes of death in Philadelphia between 18. My interest in the history-and historicity-of disease categories began more than a quarter century ago with two incidents fortuitously linked in time.
And I have not even mentioned the countless instances in which clinical interventions and expectations have altered the trajectory of individual lives. Everywhere we see specific disease concepts being used to manage deviance, rationalize health policies, plan health care, and structure specialty relationships within the medical profession. Certainly this cultural impact is comparable to those conceptual shifts in terms of the ways in which ordinary men and women think about themselves and others. It would not be inappropriate, however, to compare the cultural impact of modern assumptions about the specific nature of disease with the effects of the Newtonian, Darwinian, or Freudian revolutions, “events” that have been long assimilated into the accepted canon of cultural visibility and the subject matter of history textbooks. This title also would have the virtue of emphasizing both the importance and comparative novelty of 19th- and 20th-century conceptions of disease, ideas we have come to take so much for granted that they have become invisible. In fact, this essay might have been entitled “Diagnosis Mediates an Invisible Revolution: The Social and Intellectual Significance of Specific Disease Concepts.” It would have been even more precise, if rather less arresting. During the past century especially, diagnosis, prognosis, and treatment have been linked ever more tightly to specific, agreed-upon disease categories, in both concept and everyday practice. This modern history of diagnosis is inextricably related to disease specificity, to the notion that diseases can and should be thought of as entities existing outside the unique manifestations of illness in particular men and women. Disease explanations and clinical practices have incorporated, paralleled, and, in some measure, constituted these larger structural changes. Diagnosis has always played a pivotal role in medical practice, but in the past two centuries, that role has been reconfigured and has become more central as medicine-like Western society in general-has become increasingly technical, specialized, and bureaucratized.
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