The pathology paradigm

From ActuallyAutistic Wiki

They're either a benefit or a hazard. If they're a benefit, it's not my problem.

— Rick Deckard, Blade Runner

The pathology paradigm, or medical model, consists of trying to get people's bodies and actions to conform to entitled societal expectations. It's essentially medicalised conformity to the majority. This includes, but is not limited to, conversion "therapy". Contrast with the diversity paradigm, or social model, which allows consent and bodily autonomy, asserting instead that people who belong to minorities are not broken and that a healthy population benefits from diversity.

To a large extent, the twentieth century view of mental health, and even some physical health, was chiefly concerned with making people in minority groups — especially invisible minority groups — conform to the majority. Fundamentally, the goal was to force a diverse range of people to conform to the unrealistic and entitled standards of the majority: to pass for straight, cisgender, endosex, allistic, and so on.

Twentieth century mental health professionals didn't concern themselves with improving minority groups' comfort, such as by reducing causes of minority stress. Instead, they concerned themselves with improving the comfort of the majority groups those people interacted with, actively increasing their minority stress. Those of us who were making other people uncomfortable enough were seen as a problem to fix.

Many doctors still think in terms of the medical model, trying to make people's bodies and minds conform to social norms, regardless of the wants and needs of the people actually in those bodies, who are those minds. Many doctors had, and still have, a paternalistic complete disregard for consent. They ignore people's lived experience in favour of their own beliefs, largely a collection of stereotypes, believing themselves to be objective and unbiased in much the same way a colonialist might believe they're the only person without an accent.

You would see this with John Money, Richard Green, and Ole Ivar Løvaas, all of whom were far too influential.

Note the commonalities in:

These all very negatively affect the patients' mental health, because they're not trying to help people be comfortable. They're trying to force people to conform, for other people's entitled comfort.

As a society, we can be better, and we need to be better.


While the gatekeepers consistently argued that these methods were designed to protect the transsexual, the way they were executed (especially prior to the mid-1990s) reveals an underlying agenda. Whether unconscious or deliberate, the gatekeepers clearly sought to (1) minimize the number of transsexuals who transitioned, (2) ensure that most people who did transition would not be "gender-ambiguous" in any way, and (3) make certain that those transsexuals who fully transitioned would remain silent about their trans status. These goals were clearly disadvantageous to transsexuals, as they limited trans people's ability to obtain relief from gender dissonance and served to isolate trans people from one another, thus rendering them invisible. Rather, these goals were primarily designed to protect the cissexual public from thier own gender anxiety by ensuring that most cissexuals would never come face-to-face with someone they knew to be transsexual.

— Julia Serano, Whipping Girl, 2007[1]

This insensitivity towards trans people's pain indicates that the gatekeepers were far more concerned with protecting the cissexual world from the existence of transsexuality than they were with treating trans people's gender dissonance. Perhaps nothing demonstrates this better than the gatekeepers' willingness to deny trans people treatment (despite knowing how common it was for this group to become depressed and suicidal when unable to transition) solely based on the superficial criteria of trans people's appearances.

— Julia Serano, Whipping Girl, 2007[1]

In what seems to be complete contradiction of the most basic tenets of psychotherapy, trans people were required to invent gender-consistent (i.e., cissexual) histories for themselves, so that if they were ever questioned about their pasts, they would not have to reveal their trans status. While this requirement was purportedly put into place to protect the transsexual from the cissexual public, it is clear that what concerned the gatekeepers the most was protecting the cissexual public from the transsexual... Canonical writings on transsexuality also argued that, for transsexuals embarking on their transitions, "a change in geographic location is almost mandatory," and that "continued association with an employer... should be terminated so as to avoid any embarrassment to the employer."... At every turn, the gatekeepers prioritized their concern for the feelings of cissexuals who were related to, or acquainted with, the transsexual over those of the trans person.

— Julia Serano, Whipping Girl, 2007[1]

In terms of discourse, research, and policy, the pathology paradigm asks, in essence, "What do we do about the problem of these people not being normal," while the neurodiversity paradigm asks, "What do we do about the problem of these people being oppressed, marginalised, and/or poorly served and poorly accommodated by the pervailing culture?"

— Nick Walker, Neuroqueer Heresies, 2013[2]

This is the fundamental problem with the diagnostic criteria, which define autism entirely based on how autistic people inconvenience or bother neurotypicals. That is why the main treatments are focused on modifying our behavior, not on helping us live with the experience of being autistic better.

You cannot learn to not be autistic, but practitioners do indeed un-diagnose people or fail to diagnose people if they have learned to mask or compensate because frankly, they don't give a toss how much that masking costs us.

— fietsvrouw, 2021[3]


  1. 1.0 1.1 1.2 Whipping Girl, Julia Serano, pages 120-125
  2. Neuroqueer Heresies, Nick Walker, page 29
  3. This is the fundamental problem with the diagnostic criteria...