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.

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: [email protected]

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?

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.

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.

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.

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?

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.

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.

Clin Soc Work J (2013) 41:288–296 291

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On December 1, 2012, the Board of Trustees for the

APA approved the final draft of the DSM-5, published in

May of 2013. The term Gender Dysphoria has replaced the

Gender Identity Disorder diagnosis, and it has also been

placed in a distinct chapter in the DSM-5. Numerous

changes in DSM-5 diagnostic criteria have toned-down

sexist language, shifted the focus away from binary gender

categories, and placed the onus of diagnosis on distress and

dysphoria rather than gender nonconformity. The diagnosis

is intended to be used when there is a marked incongruence

between the individual’s expressed or experienced gender

and that which was assigned to the person at birth. This

condition, consistent with other diagnoses, must causes

clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

Gender dysphoria is characterized by a strong desire to be

treated as the ‘‘other’’ gender or to want to change one’s

sex characteristics, and a strong conviction that one has

feelings that are typical of the ‘‘other’’ gender. These

changes represent significant strides forward, both in the

form of the changes, as well as the public discourse the

process has fueled (discussed below). However, the

inclusion of Gender Dysphoria in the DSM-5—i.e., the

inclusion in a diagnostic manual of psychopathology,

ensures that transgender people will continue to be labeled

with a mental illness for decades to come. Like Ego-dys-

tonic Homosexuality, Gender Dysphoria represents a battle

only half won.

In addition to Gender Dysphoria, there is another diag-

nosis that addresses issues of gender diversity, which has

been the focus of far less attention among professionals and

in public forums, but is no less controversial. Transvestic

Fetishism was listed as a paraphila in the DSM-IV, and the

nomenclature has changed in the DSM-5 to Transvestic

Disorder, with the goal of distinguishing between non-

pathological cross-dressing behavior and that which causes

distress to the person or harm to others (Blanchard 2010).

Historically, the diagnosis only included heterosexual men,

surely an arbitrary and judgmental perspective, though it is

unclear how expanding this to include other groups is a

step forward. It is frankly questionable how crossdressing

behavior can ever be ‘‘harmful,’’ and surely it cannot be

harmful to others! The diagnosis is primarily reflective of

the work of Ray Blanchard, who was chair of the sub-

committee on Paraphilias, and since his research has been

viewed negatively by trans-activists for decades, the

inclusion of this diagnosis is quite controversial (Winters

2008b).

We cannot minimize the power of diagnoses in the civil

rights struggles of sexual and gender minorities. Richard

Green (2004) has jested that, ‘‘On that fateful day in 1973

[when homosexuality was removed from the DSM], in

America alone, several million mentally ill persons were

cured.’’ (p. 327). The conceptual trajectory from mental

illness to human diversity is not a simple straight line (no

pun intended); however, it is undeniable that diagnostic

categories impact the social opinions of people with little

knowledge or investment of the inner workings of psy-

chological institutions that determine and define patholo-

gies. As each of the changes have unfolded through various

editions of the DSM (inclusion, revision, removal) for

sexual and gender identity ‘‘disorders,’’ these changes were

incorporated in the years that followed by the World Health

Organization and the International Classification of Dis-

eases. Laura Brown (1994) has said, ‘‘The decision to call a

cluster of behaviors a mental illness is responsive to many

factors that have nothing to do with science but a great deal

to do with the feelings, experiences, and epistemologies of

those in power and dominance in mental health disci-

plines’’ (p. 135). I would add that the consequences of

those acts impact the feelings, experiences, and episte-

mologies of average people, many of whom do not know

the meaning of the word epistemologies.

The DSM-5 has been under serious scrutiny on numer-

ous issues from many sources, receiving much professional

and public criticism. Allen Frances, who was chair of the

DSM-IV Task Force, has been outspoken about many

potential problems with the DSM-5, including criticism of

the field trials, and objection to many new controversial

diagnoses (see Francis 2013). Additionally, the Society for

Humanistic Psychology (Division 32 of the American

Psychological Association) disseminated an Open Letter to

the DSM-5 Task Force stating criticisms about the lack of

involvement of psychologists in the development of the

DSM, a lowering of the threshold of many disorders, and

the de-emphasis of sociocultural phenomena while high-

lighting theories of biological etiology, among other issues

(Society for Humanistic Psychology 2011). This petition

was signed by over 15,000 people including many other

Divisions of the American Psychological Association,

numerous international professional organizations and

academic institutions. Notably NASW posted the petition

on their website, but did not sign it, despite the fact that the

petition speaks to many concerns familiar to social workers

(i.e., the lack of involvement of social workers in the DSM

development process, and the downplaying of the impact of

the social environment on diagnostic processes, and the

close relationship between the pharmaceutical industry and

the APA) (Littrell and Lacasse 2012).

The workgroups for Sexual and Gender Identity Disor-

ders have been under fire since they were first convened in

2008. The appointments of Drs. Kenneth Zucker and

Raymond Blanchard of the Toronto Centre for Addiction

and Mental Illness (CAMH) became the focus of a public

outcry, and a petition requesting their removal from the

DSM committees (see: http://www.thepetitionsite.com/2/

292 Clin Soc Work J (2013) 41:288–296

123

objection-to-dsm-v-committee-members-on-gender-identity-

disorders). Zucker was chair of the Sexual and Gender

Identity Disorders Work Group, and Blanchard was chair of

the sub-committee on Paraphilias; both were also key

authors in the DSM-IV. They are also both productive

researchers and prolific writers whose ideas about trans-

gender identity have been viewed with disdain for nearly

two decades by those advocating de-pathologization of

transgender people (see Lev 2004). These controversies are

complex and nuanced, and can only be briefly stated here.

Zucker has spent much of his career crafting clinical treat-

ments that encourage gender-nonconforming young children

to acclimate to their birth gender, which has been referred to

by transgender community activists as ‘‘gender-reparative

therapies,’’ an accusation that Zucker denies with the

backing of the American Psychiatric Association (APA

2008; Lostracco 2008; National Gay and Lesbian Task Force

2012). Blanchard has developed a construct mentioned

earlier, called autogynephilia, which defines male-to-female

transsexuals who are not exclusively attracted toward men as

having a paraphilia defined by their sexual desire to be a

woman (Blanchard 2010). Many transwomen find Blan-

chard’s theories insulting, and his insistence that these are

evidence-based scientific truths, has only further enraged

both the professional and activist communities (Moser 2010;

Wyndzen 2003). Zucker’s treatments have been blamed for

promoting ‘‘child abuse’’ (Burke 1996), and Blanchard has

been scorned for ‘‘sexualizing’’ transwomen’s desire for

actualization (Winters 2008b). Sorting through the com-

plexities of the social meaning and use of research, the

power of data in the definition of identity development, and

the political position of academics to develop nosologies that

reflect the work of their own careers are larger topics than

can be addressed in this essay.

However, what must be noted here is that numerous lay

and professional groups spoke out publicly about these

issues. For example, more than 7,000 people have signed an

online petition, sponsored by the International Foundation

for Gender Education (IFGE), calling for the removal of

transvestic fetishism (see petition here: http://dsm.ifge.org/

petition/). Additionally, Professionals Concerned about

Gender Diagnoses in the DSM, an ad-hoc group of inter-

national professionals, expressed concern about the lack of

diversity in clinical perspectives represented within the

membership of these workgroups, especially gender spe-

cialists who are affirming of gender diversity and trans-

gender people (Disclosure Statement #1: I am a founding

member of this group). We made recommendations of

potential additions to the workgroups and also made

extensive feedback regarding the proposed diagnoses.

While these battles have raged there have been numerous

other professional changes in regarding the clinical treat-

ment of transgender people. In 2008, the American Medical

Association passed a resolution for removing barriers to care

for transgender people and stated support for public and

private health insurance coverage for treatment of gender

related concerns. The American Psychological Association

released a transgender, gender identity, and gender expres-

sion non-discrimination statement in 2009, and in the same

year NASW affirmed their transgender and gender identity

issues statement. In 2012 the APA itself released a public

policy statement affirming the medical necessity of hor-

monal and/or surgical transition care for transgender people

as well as calling for civil rights protections and an end to

gender-specific discrimination.

The World Professional Association for Transgender

Health (WPATH), which is the leading international mul-

tidisciplinary organization promoting evidence-based

clinical treatment, education, research, and advocacy for

transgender people, released a statement in 2008 asserting

that sex reassignment treatment is a medical necessity for

treating people gender identity issues. In 2010, they issued

a statement urging the de-psychopathologisation of gender

variance worldwide. These public policy statements from

the leading professional organizations are important to set

policy and direction for clinical care, but it is the guidance

set up by WPATH’s Standards of Care (SOC) that is most

essential for determining best practices (Disclosure State-

ment #2: I am a member of the Standards of Care Com-

mittee). The SOC state:

Thus, transsexual, transgender, and gender-noncon-

forming individuals are not inherently disordered.

Rather, the distress of gender dysphoria, when pres-

ent, is the concern that might be diagnosable and for

which various treatment options are available. The

existence of a diagnosis for such dysphoria often

facilitates access to health care and can guide further

research into effective treatments (Coleman et al.

2011, p. 169).

The above statement, judiciously written, expresses the

complexity and diversity of viewpoints, and the struggles

with consensus regarding diagnosis and access to treatment

within WPATH and among professional experts committed

to transgender care. As Ehrbar (2010) said, ‘‘Addressing

this lack of consensus was the first issue the WPATH

Consensus Statement work groups faced’’ (p. 60). There

are areas of agreement among professionals as well as

areas of divergence regarding maintaining gender diagno-

ses in the DSM, and concerns about access to care if it were

removed (DeCuypere et al. 2010; Ehrbar et al. 2009).

Numerous papers were written by workgroups within

WPATH responding to specific issues for children, ado-

lescents, and adults examining potential problems with the

gender identity disorders and the proposals for revision in

the DSM-5. (Although space does not allow for a thorough

Clin Soc Work J (2013) 41:288–296 293

123

extrapolation of these issues, the papers are published in

the International Journal of Transgenderism—see www.

wpath.org).

Because trans people suffer bias, prejudice, and are

denied basic civil justice because of stereotypes that are

reinforced by labels of mental illness (Winter 2008a), most

professionals support actions that depathologize and limit

stigma associated with being gender nonconforming or

transgender (DeCuypere et al. 2010). Additionally, most

professionals agree that trans people should have access to

medical and therapeutic care, which should be reimbursed

by insurance companies, and that all discrimination against

trans people in employment, housing, civil law, and in

access to health care should end (Ehrbar et al. 2009; Lev

et al. 2010). The writers of the DSM-5 are themselves

aware of this dilemma and state that they aim ‘‘to avoid

stigma and ensure clinical care for individuals who see and

feel themselves to be a different gender than their assigned

gender’’ and that ‘‘gender nonconformity is not in itself a

mental disorder’’ (APA 2013).

The question that everyone grapples with is whether one

can best achieve these aims by maintaining a DSM diag-

nosis, or conversely whether one can best achieve these

same aims by removing the diagnosis, that is, does the

diagnosis cause and/or increase stigma, or does it facilitate

access to health care? Perhaps what is most interesting in

reviewing all the ideas published by gender specialists is

that people came to completely different conclusions for

the same reasons. More specifically, some people thought

retaining the diagnosis would facilitate better medical care,

and others thought it would weaken access to care; some

thought it would decrease stigma to remove the diagnosis

and others thought it would increase stigma (Ehrbar et al.

2009; Ehrbar 2010). In the end, the decision by the DSM

Committee was to retain the diagnosis.

I have always taken a definitive position that removal of

the diagnosis would be the best way to depathologize

transgender people. Trans people deserve access to medical

care, not because they are mentally ill and fit the criteria

within a diagnostic manual, but rather precisely because

they are sane and actualizing their authentic gender is their

civil right. Having said that, I think that the change in

nomenclature from the DSM-IV to the DSM-5 is a step

forward, that is, removing the concept of gender as the site

of the disorder and placing the focus on issues of distress

and dysphoria. The placement of the gender dysphoria

diagnosis within its own section in the DSM-5 helps to

separate it from sexual dysfunctions and paraphilias. The

new nomenclature is significantly less sexist, somewhat

less cisgenderist, and helps to distinguish between gender

nonconformity and gender dysphoria. Lastly, the new cri-

terion assists in recognizing the existence of a broad array

of gender identities and expressions, and attempts to step

out of the linguistic limitations of binary gender categories.

It will assist in providing medically necessary services for

transgender people in the decades to come.

Conceptually I understand the fear that if gender diag-

noses are removed from the DSM in future editions that

insurance might not pay for treatment. However, increasing

numbers of insurance companies have begun to cover

transgender care for a number of clients in my practice. I

am relatively sure that insurance companies do not cover

hormones and surgery because I, a mental health profes-

sional, gave the client a mental health diagnosis; they cover

the services because a physician to whom I referred the

client gave the client a medical (ICD) diagnosis. All

medications are prescribed because medical doctors and

surgeons utilize medical diagnosis, not mental health

diagnoses, for medical and surgical procedures. There is,

however, a precedent for the provision of reimbursing

medical care without any pathology, specifically, preg-

nancy; again an appropriate metaphor for the transition

rebirthing process (Lev 2005).

Surely the DSM-5 Sex and Gender Workgroup can be

criticized about their politics, professional biases, and the lack

of professional diversity of the committee itself, but given the

task before them, the climate of hostility in which they

worked, in the end I think they did a good job creating a

diagnosis, though I will continue to affirm that none was

necessary. In defense of the APA, the field trials3 attempted to

gather detailed demographic information to inform their

research on transgender participants asking: ‘‘Sex/Gender

(check all that apply)’’ with the options being, ‘‘Male/Female/

Intersex/Transgender (Male to Female)/Transgender (Female

to Male)/’’ (Disclosure Statement #3: I was part of the field

trials for the DSM-5.) It is unfortunate that, after months of

preparation, the APA halted their field studies barely a few

weeks into the process. Although 5,000 clinicians signed up to

participate and 195 completed the extensive training, only 70

enrolled any patients in trials (Greenberg 2013). My personal

experience was feeling barely prepared, with an unrealistic

time frame to complete an extensive field process. The APA

had a goal of 10,000 participants in the field study; in the end,

they only had 150, 2 of whom were mine.

The APA offered two periods of public feedback,

inviting opinion and criticism, and although gender issues

were only one area under review, they served as a light-

ening-rod for comment. Ken Zucker jokingly referred to

this as the ‘‘DSM-5 Olympics,’’ and noted that the Sex and

Gender Disorders Work group received a ‘‘bronze medal’’

for being the third largest category to receive input

3 The DSM-5 Field Trials were designed to assess the feasibility,

clinical utility, and reliability of the diagnostic criteria by testing it in

clinical populations, including mental health clinics, general psychi-

atry clinics, general medical clinics and solo and small group

practices.

294 Clin Soc Work J (2013) 41:288–296

123

(personal communication, February 27, 2010). I think, all

things considered, the Sexual and Gender Identity Disor-

ders Work Group and sub-committees listened to the

massive influx of opinion from trans people who live with

the consequences of this diagnosis, and the professionals in

WPATH who worked so hard at coming to consensus on

such challenging issues. I think they developed a diagnosis

that identifies what should be the crux of all useful mental

health diagnoses—human distress—and managed to dis-

cuss the issue of gender dysphoria in a relatively non-pa-

thologizing, broadly inclusive manner. Although I still

wish for ultimate removal—and remain convinced if live

long enough I will see that come to be—the gender dys-

phoria diagnosis in the DSM-5 is an improvement over the

DSM-IV diagnostic category of Gender Identity Disorder,

and the extensive public discourse has moved the agenda

forward.

It will be a while before the T catches up with the LGB

communities, but increasing numbers of people think that

transgender people should have access to civil liberties and

the medical services they require to live authentic lives. The

simple binaries we have all been born to believe in based in

male/female dichotomies, a world where opposites naturally

attract, is slowly transforming into a complex world of

multiple and queer ways of expressing gender and sexuality.

How will this impact our clinical work? I encourage every-

one to practice your therapy as if there was no DSM-5

diagnosis for Gender Dysphoria, and at the same time I

caution you to be very conscious of the reality of gender

dysphoria. Krystal the Duchess and Sam had to forge a way

into a new life that had no name 20 years ago. I did the best I

could to help them. Clients in your office tomorrow will need

to do the same. No diagnoses will ever capture the great

diversity of gender expressions and identities available to

humanity, and the distress some will experience transition-

ing will always require the midwife’s loving hands.

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Author Biography

Arlene Istar Lev LCSW-R, CASAC is a part-time lecturer at the State University New York at Albany, School of Social Welfare and is the

Project Director of the Sexual Orientation and Gender Identity Project

(SOGI). She is also an adjunct professor at Smith School of Social

Work, Empire College, and the Rockway Institute, California School of

Professional Psychology at Alliant International University. Arlene is

the Founder and Clinical Director of Choices Counseling and Consult-

ing and The Training Institute for Gender, Relationships, Identity, and

Sexuality (TIGRIS), in Albany, New York (www.choicesconsultint.

com). Arlene has authored numerous journal articles and essays

including authoring two books: The Complete Lesbian and Gay Par-

enting Guide and Transgender Emergence: Therapeutic Guidelines for

Working with Gender-Variant People and their Families winner of the

American Psychological Association (Division 44) Distinguished Book

Award, 2006. She can be reached at [email protected].

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