Short Paper: Gender Dysphoria

CLINICAL SOCIAL WORK FORUM

Gender Dysphoria: Two Steps Forward, One Step Back

Arlene Istar Lev

Published online: 18 July 2013

� Springer Science+Business Media New York 2013

Abstract The long-awaited DSM-5 has finally been

published, generating controversy in many areas, including

the revised diagnostic category of Gender Dysphoria. This

commentary contextualizes the history and reform of the

pathologization of diverse gender identities and expres-

sions, within a larger perspective of examining psycho-

logical viewpoints on sexual minority persons, and the

problems with continuing to label gender identities and

expressions as pathological or disordered.

Keywords Transgender � Gender � Diagnosis � GID � Gender dysphoria � Gender identity � LGBT � Trans � LGBTQ

Sexualities keep marching out of the Diagnostic and

Statistical Manual and on to the pages of social

history. Short Paper: Gender Dysphoria

Gayle Rubin 1984, p. 287.

Clinical Social Work has just celebrated its 40th anni-

versary, and this volume marks the first special issue devoted

to lesbian, gay, bisexual, and transgender (LGBT) mental

health and psychotherapy. The lives of LGBT people, people

who are now reclaiming the word queer as a proud self-

descriptor to encompass the term LGBTQ (Tilsen 2013),

have changed dramatically in this same period of time.

LGBTQ people were leading clandestine, marginalized

lives, ostracized by family and friends, unable to have chil-

dren (or retain custody of them), living with a constant threat

of unemployment, creating false narratives about their social

lives to appease others and protect their private lives. Now

LGBTQ people have the potentiality of full lives—out,

proud, married, with families, serving in the military,

working for the government—with strong communities and

federal laws that protect us against bias-related violence.

Forty years ago, I was a 15-year-old Jewish working-class

adolescent, growing up in the tail end of 1960s counter-cul-

ture, and deeply in love with my best girlfriend. My journals

were full of endless, painful monologues about her, about

society, and about where I would fit into the grownup world I

would soon be entering. I wasn’t exactly closeted—I called

myself bisexual—but I was filled with angst and confusion

and drowning in myriad social messages of what it meant to be

a lesbian (which in my journals I spelled ‘‘lesibean’’ because

even simple access to seeing words that reflected my experi-

ences in print was non-existent). I did not know how to talk

with my mother, my friends, my boyfriend, my girlfriend

about my emerging queer identity. What could be the future

for a young dyke? Where could I find a home, a job, a lover, a

life? And if I found my way to therapy, what would the psy-

chotherapist say to me that would affirm my identity? What

education did she have, what trainings had he attended, what

journal articles could she/he have read to help her or him help

me to grow to be a healthy secure and very queer adult?

In entering into this discourse with you, the reader, I must

start with a moment of silence, for all that has not been said

within the therapy professions, within social work and family

therapy—the professional communities I call home—these

past 40 years. The LGBTQ communities have been hard at

work informing politics, changing policy, opening minds,

indeed transforming the world in many ways—and our clin-

ical communities have followed along, taking a mostly pro-

gressive, supportive stance on issues as they have arisen,

incorporating a ‘‘gay-affirmative’’ approach into our clinical

A. I. Lev (&) School of Social Welfare, State University New York at Albany,

Albany, NY, USA

e-mail: arlene.lev@gmail.com

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Clin Soc Work J (2013) 41:288–296

DOI 10.1007/s10615-013-0447-0

 

 

practices (Levy and Koff 2001), but as a social work com-

munity, I wonder if we have done enough (Levy and Koff

2001). Have we been at the vanguard of advocacy and pro-

gressive change, or have we merely followed the evolving

trends (Hegarty 2009)? I hope that this inaugural issue heralds

a change not just in direction, but in conceptualization, so that

LGBTQ issues become not a ‘‘special issue,’’ but are incor-

porated into the framework and organization of the journal. I

was taught many years ago to always ask the questions ‘‘Who

is not present at the table? Whose voice is not being heard?’’

The challenge of fully incorporating LGBTQ clinical

knowledge into the mainstream of clinical social work is to

deconstruct heteronormative thinking, to queer the discourse. I

will try in the words that follow to move this discussion past

‘‘gay-affirmative’’ therapy, and to imagine a more queer psy-

chotherapy, one that truly challenges the pathologizing of

LGBTQ lives, and heteronormativity of non-queer ones. I want

to look at the role that diagnoses play in the development of

identity, communities, and the therapeutic gaze. The context of

this discussion is the change from Gender Identity Disorder to

Gender Dysphoria in the fifth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5; American

Psychiatric Association (APA) 2013), but it is by necessity a

wider discourse about both sexual orientation and gender

identity, the social and political context of the holding envi-

ronment we call therapy, as well as an emerging queer sensi-

bility that challenges the hegemony of pathological labeling.

The shift in diagnostic nomenclature initiates a potential shift in

clinical conceptualization from gender nonconformity as

‘‘other,’’ ‘‘mentally ill,’’ or ‘‘disordered’’ to understanding that

gender, as a biological fact and as a social construct, can be

variable, diverse, and changeable, and existing without the

specter of pathology. De-centering the cisgender assumption

that normal people remain in the natal sex (cis) and that dis-

ordered people change (trans) is at the root of debate regarding

gender diagnoses in the DSM and the battle for their reform.

I became a social worker 25 years ago to work with what

we then called the gay community. I fought and lost the battle

as the Chair of the ‘‘Gay Issues Committee’’ of the New York

State Chapter of the National Association of Social Workers

(NASW) to change the name to the ‘‘Lesbian and Gay Issues

Committee’’; the word lesbian was still foreboden. Although

this was over a decade after homosexuality had been removed

from the DSM, ‘‘gay’’ issues were poorly integrated in my

social work education. The only time I heard the word trans-

sexual as a student (the word transgender had not yet been

coined) was when a teacher said, ‘‘You know that some people

want to change sex?! Really!’’ She leaned into the class and

repeated in a loud incredulous whisper for emphasis,

‘‘Really!’’ When I became an adjunct professor (in the same

Social Work program in the late 1980s) and I asked my col-

leagues how they addressed issues of sexual orientation in the

curricula, I was met with blank stares. Was there really

nothing to say about homosexuality now that it was no longer a

diagnosis in the DSM? Really?! Short Paper: Gender Dysphoria

However, despite the silence within training institutions,

there have been many positive changes for LGB people

socially and politically. In the past few decades lesbian and

gay people have secured many civil rights. It is worth

pondering whether these social changes would have hap-

pened if homosexuality had remained in the DSM. Do you

think we would be seeing these massive social changes,

like marriage equality? Throwing off the yoke and stigma

of ‘‘pathology’’ allowed not only for the coming out of gay,

lesbian, and bisexual people, but also allowed for legal,

political, and clinical transformations that could never have

been granted a ‘‘mentally ill’’ population. How would your

psychotherapy practice look different than it currently

does, if homosexuality was still a mental disorder? These

questions are an important prelude to the discussion of

Gender Dysphoria in the DSM. Short Paper: Gender Dysphoria

The acronym LGBT has become a moniker, a catch-all

expression meant to include a group of people who may not

have all that much in common. It has become a practice of

mine, whenever I receive new classroom textbooks, to look

in the index for the phrase LGBT, and then see what the

content reveals. Most of the time what is revealed is gen-

eral information on lesbian and gay people. The B and T

are too often silent. Although I mentioned above that I feel

relatively secure that lesbians and gay men are receiving

competent care when seeking therapy, I do not pretend to

feel that trusting about the clinical treatment received when

we toss in the unique issues bisexual people face in either

heterosexual or same-sex partnerships (see Scherrer, this

issue for an in-depth discussion regarding bisexual indi-

viduals). And what about the complex issues transgender,

transsexual, and gender non-conforming people experience

within the confines of the consulting room?

I began to work with transgender clients and their

families in the mid-1980s. I had no training in under-

standing gender identity, gender expression, gender dys-

phoria, or the process of transitioning one’s sex medically,

legally, or psychologically. In my first sessions with a

transwoman I will refer to as Krystal the Duchess, I was

initially baffled, bringing to the sessions not much more

than a compassionate heart, an open-mind, and deeply

challenged feminist politic. Krystal arrived in therapy,

presenting as a mild-mannered, disheveled and middle

aged depressed man named Norman who lived at home

with his mother. Norman could have easily been diagnosed

with various personality disturbances, severe anxiety, and

perhaps a mild psychotic disorder, and indeed would have

been if diagnostics were the primary clinical lens I used.

Krystal then revealed herself to me, bigger than life, a drag

artist who traveled to New York City on the weekends to

perform in Greenwich Village; a double-life she had lived

Clin Soc Work J (2013) 41:288–296 289

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for decades. Krystal disclosed that this was no longer

performance, she wanted to fully live as Krystal, but felt

stuck, caught between two genders, two different worlds,

and saw no way to actualize herself, to become Krystal.

Frankly, neither did I. Short Paper: Gender Dysphoria

At the same time, another client was referred to me, a

young masculine female named Sam, who had come out as

a lesbian when she was still a teenager, and received

support from her parents, as well as a gay-affirmative social

worker. She confided to me: ‘‘I’m not really a lesbian; I’m

really a man.’’ I asked her girlfriend what she thought of

this statement, and she conferred, ‘‘Of course, she’s a man.

If she’s not a man, then I would be a lesbian, and I am

definitely not a lesbian!’’ I thought this was the worst case

of internalized homophobia I had ever seen (and I’d seen

plenty by then), if not a mutual delusion system. I was

clearly in over my gay-affirmative head!

Both Krystal and Mel arrived in my office because they

were told I was an ‘‘expert,’’ but perhaps the only real

expertise I had was realizing how little I really knew about

sexuality, sexual orientation, and gender. Being a biblio-

phile, I spent the next 5 years reading everything there was

to read on gender identity, transsexualism, Gender Identity

Disorder, and the political analyses emerging from the

burgeoning transgender liberation movement. Mix thor-

oughly, cook on a low heat, and my book Transgender

Emergence: Therapeutic Guidelines for Working with

Gender-Variant People and Their Families was born.

In the years that have followed, I have worked with

hundreds of trans people, their partners, their children,

and their extended families. I have worked with hetero-

sexual, married men well into mid-life who had been

secretly cross-dressing since they were small boys, and

had never revealed this to anyone, until they told me,

indeed until they showed me; I’ve heard this story more

times than I can count. I worked with butch-identified

lesbians who wanted to live as men, but their lesbian

lovers didn’t want to be with men—they wanted the

particular masculinity that butch women exude. I have

worked with 5-year-old children who were absolutely sure

that they were girls, and having a penis did not in any

way deter them from their convictions; as they matured,

they are still 100 % sure of this. I have worked with

many heterosexual couples trying to come to grips with

whether to allow their teenagers to start hormone-block-

ers, giving them time to decide whether to begin puberty

as a boy or as a girl. I have worked with young adults

who eschew all pronouns, all genders, and call themselves

queer with a fierce pride. I worked with a Roman Cath-

olic priest, who lives full-time as a woman now. Trans-

gender people represent an enormous diversity of

humanity, crossing all racial, ethnic, class, and cultural

populations, all ages, dis/abilities, and religions.

The word transition is used to describe the process of

changing gender that Krystal and Sam and so many others

since were describing; it is also a word used during the

birth of a baby, when the head begins to crown. I have

spent the last few decades witnessing this transition, the

crowning, the birth, their re-birth, if I dare to use such a

term. There is much that I have learned in this process, but

one thing is perfectly clear, transgender people are more

like the rest of us—cisgender people, those who do not

challenge the sex binary—than they are like one another.

For the most part they are mentally stable—no small task

given what they face—and when they are not so stable,

they are unstable in the ways the rest of us are: anxious,

depressed, and sometimes struggling with deeper mental

health issues. But their gender is not disordered (Lev

2005); indeed their gender is quite ordered, just not in

conventional ways. Short Paper: Gender Dysphoria

I live in awe of these transformations and the emotional

cost of these journeys, but in the mid-1980s I was mostly

just infuriated because one thing was blatantly clear read-

ing clinical treatises on trans/gender—the entire field

(small enough at the time that I likely read every tome ever

written) was built on the exact same pathologizing narra-

tive that had made homosexuality a viable diagnosis for

nearly 100 years (Oosterhuis 1997). The story of Gender

Identity Disorder, and the new diagnosis of Gender Dys-

phoria, is a narrative of an oppressed people and their

liberation struggle, amid the psychobabble of gender con-

formity, mental illness, and medicalization of human

diversity. Plummer (1981) has said that the ‘‘…realization that one was collectively oppressed rather than individually

disturbed…’’ (p. 25) was the realization of gay and lesbian people in the 1960s, a realization that began to dawn on transgender people in the 1990s. Short Paper: Gender Dysphoria

The diagnosis of homosexuality rested on simple het-

eronormative assumptions about what was ‘‘natural,’’

‘‘healthy,’’ ‘‘functional,’’ ‘‘common’’ (it is, after all the

Diagnostic and Statistical Manual). Within the confines of

western culture, same-sex love was obviously pathological,

outside the expected boundaries of human behavior and

experience. Based on those assumptions, psychological

theories developed etiologies of ‘‘why’’ someone could be

like ‘‘that.’’ The answers, based initially in psychoanalytic

ideology as well as the behavioral and cognitive theories of

gender acquisition that developed later, led to theories of

faulty child-rearing and mother-blame: homosexuality in

men was caused by over-involved mothers and distant

fathers, causing a disturbance in proper gender socialization

(see Stoller 1966); (in classic pre-feminist psychoanalytic

theory, there was a mostly silence about what caused les-

bianism (Kitzinger 1993). Decades later these ideas seem

anachronistic, as thousands of lesbian, gay, and bisexual

people attest to coming from very different family

290 Clin Soc Work J (2013) 41:288–296

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structures, most whose configuration does not resemble the

suffocating mother/distant father dynamic (see LaSala, this

issue for a detailed discussion of this topic). However, my

review of the literature revealed that these same etiological

theories were resurrected in the late twentieth century to

explain transsexualism.

Few therapists today would treat a lesbian or gay client

using a lens of causality, nor would they try to assist them

in living a heterosexual life (and indeed, if they did so, they

would be going against the ethical and moral standards of

nearly every professional mental health organization, see

Anastas, this issue). However, the field of transgendersim

is only recently coming out (literally) from the shroud of

etiology. What if gender transitions are a normative part of

the diversity of human identity? Research from history,

anthropology, and the biological sciences seem to show

that non-binary gender identities, gender transformations

and transpositions, are ubiquitous across human and non-

human communities, throughout history and cross-cultur-

ally (see Lev 2004). What if there is nothing disordered,

dysfunctional, odd, or unnatural about transgendering? If

transgender is not pathological, then what is it that needs to

be diagnosed? Short Paper: Gender Dysphoria

Although Homosexuality was officially removed from

the DSM in 1973, it was replaced in the DSM-III with an

only somewhat less noxious diagnosis—Ego-Dystonic

Homosexuality, which was not removed until 1980. Dys-

tonic refers to the subjective experience of unhappiness and

is contrasted with syntonic behavior, or one’s comfort with

their same-sex desires. The DSM-III stated that this diag-

nosis should only be used when the client had unwanted

homosexual feelings and it also stated that ‘‘…distress resulting from a conflict between a homosexual and society

should not be classified’’ (APA 1980, p. 282). It soon

became clear that living in a homophobic and heterosexist

culture left few ‘‘happy well-adjusted homosexuals,’’ and

given the complexities of internalizing a stigmatized

minority status, the diagnosis was determined to be biased,

and was removed.1

At about the same time that homosexuality was removed

from the DSM, gender identity diagnoses were included.

From a contemporary perspective, this appears confusing,

especially when you realize it was the same men who

developed the DSM diagnosis for gender identity who were

the strongest advocates for both the removal of

homosexuality from the DSM and also the early pioneers

working with, and supportive of, transsexuals and their

need for medical assistance in transition (see Drescher

2010; Zucker and Spitzer 2005). Why would they want to

pathologize gender identity diversity while we were finally

liberating homosexuality as a diagnosis? It was thought at

the time that the inclusion of a diagnostic category would

legitimize transgender identity and would assist in the

development of treatment and professional attention for

this invisible and vilified population. History has indeed

shown some wisdom in this perspective. However, it has

also left us 30 years later with a diagnostic category that

pathologizes a minority community, and potentially inter-

feres with their pleas for civil rights and acceptance within

the human family. Short Paper: Gender Dysphoria

A brief review of this process follows: In the DSM-III

(APA 1980), two diagnoses were included for the first time,

one called Transsexualism, to be used for adults and ado-

lescents, and the second Gender Identity Disorder of

Childhood. In DSM-III-R (APA 1987), a third diagnosis

was added: Gender Identity Disorder of Adolescence and

Adulthood, non-transsexual type, which was removed

when the DSM-IV (APA 1994) was published.2 Also in the

DSM-IV the two previous diagnoses were conflated into

one, Gender Identity Disorder (GID), with different criteria

sets, one for adolescents and adults, and another for chil-

dren (see pages 537–538). Additionally, the diagnosis of

Transvestic Fetishism, a paraphilia, has undergone

numerous changes in nomenclature and criteria during the

revisions; all were included in the section on Sexual and

Gender Identity Disorders.

For the past few years, there has been a fervent move-

ment among both trans-activists and professionals to

remove the gender diagnoses from the DSM, and in lieu of

that, to at least reform them (see Lev et al. 2010; Winters

2008a). However, depathologizing gender identity in the

DSM mirrors the slow process of change in removing

homosexuality, incrementally through many versions of the

DSM. As Winters (under pseudonym Wilson) noted back in

1997, ‘‘American psychiatric perceptions of transgender

people are remarkably parallel to those for gay and lesbian

people before the declassification of homosexuality as a

mental disorder in 1973’’ (p. 15). Similar to the history of

the removal of homosexuality from the DSM, some head-

way has been made in the construction of the DSM-5, and

improvements are slowly evolving, in gradual stages, of

what appears to be a positive direction.1 Many are not aware that a residual category for homosexuality remained in the DSM-IV under the category of Sexual Disorders Not

Otherwise Specified [NOS]. This category includes three items, the

last one was, ‘‘Persistent and marked distress about sexual orienta-

tion’’ (DSM-IV-TR. 2000, p. 582); ostensibly this could be used for

anyone struggling with sexual orientation, though I suspect it was not

often used for heterosexuals struggling with their straightness. This

has been removed in the DSM-5.

2 The phrase ‘‘non-transsexual type’’ referred primarily to male

cross-dressers, but in some ways was a foreshadowing of the

emergence of diverse gender expressions that might not involve a

complete gender transition. Short Paper: Gender Dysphoria

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