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.

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

123

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?!

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.

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?