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Journal of LGBT Issues in Counseling

ISSN: 1553-8605 (Print) 1553-8338 (Online) Journal homepage: https://www.tandfonline.com/loi/wlco20

Understanding the Link: “Homosexuality,” Gender Identity, and the DSM

Marion E. Toscano & Elizabeth Maynard

To cite this article: Marion E. Toscano & Elizabeth Maynard (2014) Understanding the Link: “Homosexuality,” Gender Identity, and the DSM, Journal of LGBT Issues in Counseling, 8:3, 248-263, DOI: 10.1080/15538605.2014.897296

To link to this article: https://doi.org/10.1080/15538605.2014.897296

Accepted author version posted online: 07 May 2014. Published online: 30 Aug 2014.

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Journal of LGBT Issues in Counseling, 8:248–263, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1553-8605 print / 1553-8338 online DOI: 10.1080/15538605.2014.897296

Understanding the Link: “Homosexuality,” Gender Identity, and the DSM

MARION E. TOSCANO Department of Pastoral Counseling and Spiritual Care, Loyola University Maryland,

Columbia, Maryland, USA

ELIZABETH MAYNARD Clinical Mental Health Counseling Programs, The University of St. Thomas, Houston,

Texas, USA

This article reviews the historical and present notions of identity, in relation to sexual orientation and gender identity within counsel- ing. It also discusses the link between the historical pathologizing of homosexuality and gender identity, as well as summarizes the implications of the diagnosis of gender dysphoria (GD) as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (5th ed.; DSM-5). The ethics of maintaining GD in the DSM-5 and future diagnostic manuals is discussed. Finally, a brief explanation of the role of the counselor in working with transgender individuals is given.

KEYWORDS DSM, gender identity disorder (GID), gender dyspho- ria, homosexuality, LGBQT issues, sexual identity

INTRODUCTION

Traditionally, any behavior that was considered different from what was so- cially accepted was seen as problematic and/or necessitating treatment. This belief has led many people from differing cultures and eras to isolate, ridicule, discriminate, institutionalize, and pathologize individuals who display ten- dencies outside the norm. No clearer has this practice been demonstrated than with the issues of sexual orientation and gender identity, especially as they are viewed in connection with the Diagnostic and Statistical Manual of

Address correspondence to Marion E. Toscano, Department of Pastoral Counseling and Spiritual Care, Loyola University Maryland, 8890 McGaw Road, Columbia, MD 21045, USA. E-mail: [email protected]

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Mental Disorders (DSM; American Psychiatric Association [APA], 1952, 1968, 1980, 1987, 1994, 2000, 2013). Gender identity can be defined as “a complex system of beliefs about the subjective self in relation to masculinity and fem- ininity, maleness and femaleness, and culturally prescribed roles assigned to those categories” (Ault & Brzuzy, 2009, p. 187).

Today, it is increasingly common for counselors to work with members of the lesbian, gay, bisexual, and transgender (LGBT) community.

The term transgender is often used as an inclusive category for a wide range of identities, including transsexuals, transvestites, male and female impersonators, drag kings and queens, male-to-female (MTF) persons, female-to-male (FTM) persons, cross-dressers, gender benders, gender variant, gender nonconforming, and ambiguously gendered persons. (Wilchins, 1997, 2002, as cited in Bilodeau & Renn, 2005, p. 29, paren- theses included)

It is important for counselors to better comprehend the historical and current connection that the LGBT community has with the DSM and the practices of the larger mental health profession. This article attempts to offer the reader a concise history and understanding of the pathologizing of sexual orientation and gender variation by mental health professionals.

HISTORY

The term homosexuality is utilized to reflect the way in which sexual ori- entation was referenced within previous editions of the DSM. Within the mental health community, homosexuality was and in some respects still is a very controversial topic. The removal of homosexuality as a mental disorder from the DSM in 1973 by no means ended the debate about whether pri- mary attraction to those of the same sex represented a psychiatric disorder. Davison’s (1976) review of the literature of the time concluded that “ther- apists by and large regard homosexual behavior and attitudes to be unde- sirable, sometimes pathological, and at any rate in need of change toward a heterosexual orientation” (p. 158). Removing homosexuality as a disorder from the DSM by the APA divided the organization and was further remark- able because “this may have been the first time in the history of modern medicine that a disease was eliminated by the simple proclamation that it no longer existed” (Greenberg, 1997, p. 256).

To some, the removal of homosexuality from the DSM was seen as a clear assertion that a behavior should not be pathologized simply because it is not congruent with societal norms or preferences. Marmor (1972) posited that “there is nothing ‘sick’ or ‘unnatural’ about homosexual object choice,

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except insofar as this preference represents a socially condemned form of behavior in our culture” (p. 116). However, this assertion seemed to be quickly contradicted by the inclusion of gender identity disorder of childhood (GIDC) in the third edition of the DSM (DSM-III ) in 1980.

At the time of its publication, many mental health professionals and activist groups questioned if the new diagnosis of GIDC was included in the DSM-III as a way to continue pathologizing adult homosexual behav- ior (Ault & Brzuzy, 2009; Kamens, 2011; Langer & Martin, 2004; Zucker & Spitzer, 2005). This was primarily due to the continued belief that “deviations from conventional gender role expectations are symptoms of the homosex- ual disease” (Drescher, 2002, pp. 59–60). In fact, at the time of GIDC’s inclusion in the DSM-III “some clinicians (definitely not all) who treated cross-gender-identified children cited prevention of later homosexuality as one of their explicit goals (e.g. Reckers, 1977)” (Zucker & Spitzer, 2005, p. 33).

Zucker and Spitzer (2005) questioned whether GIDC was introduced into the DSM-III as a “backdoor maneuver,” or an indirect way for the APA and mental health professionals to continue pathologizing homosex- uality. They cited several authors who argued that continued pathologiz- ing of homosexuality was indeed the reason for the addition of GIDC in the DSM-III . One of the strongest of these arguments was made by Bem (1993):

Ironically, this first official pathologizing of gender identity disorders ap- peared in the same DSM in which, for the first time in psychiatric history, there was no official pathologizing of homosexuality. Perhaps this was no coincidence. Perhaps the psychiatric establishment still believed so completely in the pathology of gender nonconformity that if the poli- tics of the times would not allow it to express that belief through ho- mosexuality, then it would instead express it where and how it could. (pp. 106–107)

Even after the official name change in 1994 from GIDC to gender identity disorder (GID) (Langer & Martin, 2004, p. 7), some clinicians continued to agree with Bem’s position that “the GID diagnosis . . . is an attempt to prevent adult homosexuality via psychiatric intervention with children” (Moore, 2002, p. 1). These authors were responding to the assertion of Minter (1999) who stated that “the great majority of children treated for GID grow up to be lesbian, gay, or bisexual” (p. 11), and Coates (1992) who reported that “about two thirds of boys with childhood GID grow up to be homosexual” (p. 246). Although these studies imply that many individuals diagnosed with GID as children grow up to be lesbian, gay, or bisexual, not every child that has an issue with gender later identifies as LGB.

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PRESENT SITUATION

GID is a complex topic; diagnostic arguments are overlapping and intricate. For the purposes of this article, the authors attempt to offer an overview of this area by separating the arguments into four subcategories: The DSM, societal influence, ethics, and medical issues. This categorical approach is offered in the service of brevity and clarity. The first section, “The DSM”, will view the diagnosis based on the criteria in the DSM-IV-TR (4th ed., text rev.; APA, 2000). Although the diagnosis of gender dysphoria (GD) in the DSM-5 (5th ed.; APA, 2013) superficially appears to represent a replacement diagnosis for GID, the GID criteria have been substantively retained with minor revisions in language and structure. Thus, discussion of the DSM- IV-TR serves a historical base as well as a foundation for understanding a number of the concerns related to the new GD diagnosis. The second sec- tion, Societal Influence, focuses on the variances in diagnosis requirements and treatments as well as social understanding. The third section, Ethics, deals with the dilemmas surrounding the maintenance of GID/GD in the DSM, while the fourth section, Medical Issues, briefly discusses the treatment of GID/GD.

The DSM

Critics maintain that “a major problem with pathologizing gender-atypicality is that there is a lack of consensus on gender-appropriateness” (Langer & Martin, 2004, p. 12). According to the DSM-IV-TR, “Gender Identity Disorder can be distinguished from simple nonconformity to stereotypical sex-role behavior by the extent and pervasiveness of the cross-gender wishes, inter- ests, and activities” (APA, 2000, p. 580). Although the DSM-IV-TR goes on to state that “this disorder is not meant to describe a child’s nonconformity to stereotypical sex-role behavior as, for example, in ‘tomboyishness’ in girls or ‘sissyish’ behavior in boys” (p. 580), the subjectivity of the criteria could lead to a diagnosis when a child displays gender-atypical behavior without the child displaying marked distress or impairment. Thus, many LGB adults run the possibility of being misdiagnosed with GID as children because of their outward display of their sexual orientation, rather than their gender identity.

An example of this can be seen in the case of Sam, a young girl who presents with the following symptoms: Sam insists on wearing only shorts or pants with boys’ t-shirts, because girls’ shirts are “ugly” and she will not wear a dress under any circumstance. She only wants to play baseball and football with the boys in the neighborhood and says that she does not like playing with the girls because their games are “stupid;” when her mother makes Sam play with her girl cousin, she will only play as Ken and never as Barbie. Finally, Sam reports that she and her mother tend not to get along because she does not want to go shopping but would rather spend time with

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her father and watch television. This makes Sam feel “really bad” because she loves her mother and wants to spend time with her but does not want to do that “girlie stuff.” This fictional client meets the four required elements of DSM-IV-TR criterion A as well as criterion B and criterion D:

Insistence on wearing only stereotypical masculine clothing . . . prefer- ence for cross-sex roles in make-believe play . . . intense desire to partic- ipate in the stereotypical games and pastimes of the other sex . . . strong preference for playmates of the other sex . . . marked aversion toward normative feminine clothing . . . [and] the disturbance causes clinically significant distress or impairment in social, occupational, or other impor- tant areas of functioning. (APA, 2000, p. 581)

In a real situation, clinical judgment and discretion would be the deciding factor in whether or not Sam would have been diagnosed with GIDC, another disorder such as parent–child relational problems, a V-code, or not diagnosed at all. However, the argument could still be made that if a client displays symptoms of a disorder and no other disorder or general medical condition could better explain those symptoms, clinicians should make a diagnosis. Yet, in the instance of GID that is not always beneficial, because the stigma linked with GID can cause significant distress in an individual and family. Transgender individuals may fear being shunned by family and friends. The diagnosed individual may be forced from his or her support network and can increase the individual’s experience of “depression, anxiety, or adjustment reactions due to the stress of rejection” (Allison, 2010, p. 143). Thus, many clinicians choose not to employ the diagnosis out of concern for the client’s well-being.

Ehrbar, Witty, Ehrbar, and Bockting (2008) randomly sent out one of six vignettes (two cases depicted a child with gender conforming behavior, two with moderately nonconforming behavior, and two with clearly non- conforming behavior) to 73 licensed psychologists and asked the recipients to respond to the case study and offer a diagnosis. The psychologists were not given any specific instructions in regard to diagnosis; that decision was left to the individual professional. Only seven of the 26 professionals who received the nonconforming case studies gave a diagnosis of GID. Although they were not instructed to, most of the professionals gave feedback on whether they diagnosed the client and what the diagnosis was. Several psy- chologists responded to the study stating that “they perceived GID to be a problematic diagnostic category . . . [and] they preferred to use the least stigmatizing diagnosis possible” (pp. 396–397).

This data, albeit from a single convenience sample, shows that even licensed mental health professionals often find it difficult to accept GID as a viable or preferred diagnosis in children. Furthermore, mental health professionals “must weigh the cost of diagnosing a child with GD against

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the clinical benefit of this labeling. When considered, the cost far outweighs any benefits” (Hein & Berger, 2012, p. 238). Accordingly, this may support the position of those who argue that GID may be understood as “sexist, homophobic, and stigmatizing, and of unnecessarily pathologizing gender nonconforming children” (Ehrbar et al., 2008, p. 386).

Societal Influence

Wakefield (1992) argued that disorders in general lie “on the boundary be- tween the given natural world and the constructed social world” (p. 373). In this view, mental disorders as they are known are as much based on societal views as they are on medical evidence of dysfunction and distress. Moreover, if distress is sufficient to warrant a diagnosis of a mental disorder, one must take into consideration that “the stress associated with gender- variant living in an often hostile social environment” (Cole, Denny, Dyler, & Samons, 2000, p. 170) is sufficient enough that “many otherwise healthy transgendered people are likely to meet the criteria for recognized DSM-IV disorders” (p. 170).

Additionally, studies have shown that not all communities view gen- der nonconforming behavior as necessitating treatment, “for example, at the Frankfurt clinic, it is not unusual to see parents who do not consider their child’s obvious GID symptoms to be a problem and who refuse any therapy” (Meyenburg, 1999, p. 306). Furthermore, in those less tolerant communities such as areas of North America, the hostility may not be equally dispersed; “‘tomboys’ are usually tolerated or even admired by their peers” (Bower, 2001, p. 4), whereas in parts of American society men displaying gender nonconforming behavior are treated and perceived less tolerantly. Perhaps “psychotherapy as an essentially conservative social institution, may be as unprepared to deal effectively with such men [gender role non-conforming] as it was with nontraditional women a generation ago” (Robertson & Fitzgerald, 1990, p. 7).

The fact that the DSM-IV-TR had different standards and criteria for diagnosing GID in boys and girls underscores this societal variance. Among the most obvious differences was that listed in Criterion A.2, in which boys must simply act as if “simulating female attire” whereas girls must display an “insistence on wearing only stereotypical masculine clothing” (APA, 2000, p. 581). By DSM-IV-TR criteria, even the simulation of wearing feminine clothing by a boy is enough to meet a criterion for mental illness, whereas girls must show exclusivity in the choice of male clothing to be diagnosed. This disparity suggests maleness or masculine behavior is to be prized but femaleness or feminine behavior is acceptable for girls but not allowed for boys.

Other societal influences can be seen in the difference between the treatment modalities originally utilized for individuals diagnosed with GID and the current clinical consensus. Traditionally, a girl with a GID diagnosis

254 M. E. Toscano and E. Maynard

would be prescribed behavior modification and/or psychotherapy and en- couraged to act in more feminine ways (Meyenburg, 1999, p. 306). Adults were given more intensive treatment, as seen in a case study in which an adult client was reported to have received forty-five 45-minute sessions of behavior modification, followed by twenty-five 45-minute sessions of psy- chotherapy, and twenty-five 30-minute sessions of electrical aversion ther- apy within a 6-month period (Khanna, Desai, & Channabasavanna, 1987, pp. 196–197). Currently, however, there is no recommended or empirically supported treatment modality for GID. However, there is an interdisciplinary consensus that psychotherapy is “not undertaken to cure the gender identity disorder” (Fraser, 2009, p. 111). Furthermore, “surgical sex reassignment has been accepted as the only effective treatment of gender identity disorder” (Bower, 2001, p. 1) in adults. The shift in psychotherapeutic treatment seems to echo the shift in the societal acceptance of such modalities, underscor- ing the influence that society holds on the understanding, treatment, and possible criteria of a mental disorder.

A final societal influence on GID can be seen in the understanding of gender itself; “gender identity often is conceptualized in a bipolar, dichoto- mous manner with a male gender identity at one pole and a female gender identity at the other pole” (Deogracias et al., 2007, p. 370). The problem with the notion of the dichotomy of gender is that it implies clear delin- eation between what is understood to be male and what is understood to be female. However, with the passing of time the lines between the two, at least in terms of “culturally prescribed roles” (Ault & Brzuzy, 2009, p. 187) have been all but eradicated. In today’s society it is no longer noteworthy to see a female construction worker or a male nurse. Nor do the individ- uals who hold those positions claim to be any less female or male than if they pursued other employment. If society has blurred the lines between the two “poles,” and gender identity is partially based on societal conception (Ault & Brzuzy, 2009), are the two truly dichotomous or are they merely parts of a continuum?

Ethics

Understanding the controversies and perceived lack of consistency in the diagnosis of this disorder, the question then must be asked: what could be the purpose of maintaining GID as a mental disorder in the DSM? Ross (2009) questions the ethicality of GID by stating that:

Gender identity disorder is unique among all DSM-IV-TR diagnoses. It is the only disorder in which treatment is designed to confirm, rein- force, and validate the belief that is the basis of the mental disorder. In all other diagnoses, the symptoms in the diagnostic criteria are viewed as pathological and the goal of treatment is to remove the symptom. (p. 165)

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If a man were to enter into therapy claiming to be the Pope, the clinician would not attempt to assist that client in gaining access to the Vatican. In- stead, the clinician would work with the client to assist him in understanding that his belief in this alternate identity is not based on reality and attempt to change the distorted thinking. However, in the case of GID if a man enters into therapy claiming that he is truly a woman, after ruling out other possi- bilities, the clinician would assist the client in understanding and obtaining medical treatment to change his physical appearance to match his thinking. Ross (2009) continues by making the assumption that one of the reasons that GID is maintained as a disorder is so that psychiatrists can be involved in the medical decision process of Sex-Reassignment Surgery (SRS) (p. 165).

Medical

GID is considered by the medical profession to be a medical condition (Harry Benjamin International Gender Dysphoria Association, 1998; Ross, 2009; Sohn & Bosiniski, 2007), because of this:

In order for it [SRS] to be considered medical it must be a treatment for a medical disorder. When there is no identifiable biological abnormality, the backup position is to define the condition as a mental disorder, and place it in the DSM system. (Ross, 2009, p. 166)

Kamens (2011) asserts that “the GID diagnosis is, to date, required for in- surance coverage of hormonal therapy and sex reassignment procedures” (p. 40). Ross’s sentiment is echoed by the fact that the Harry Benjamin In- ternational Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, 5th ed. (SOC) (1998) states “the use of a formal diagno- sis is an important step in . . . providing health insurance coverage” (p. 14). The necessity of a diagnosis of GID may or may not be for the sole benefit of obtaining third-party payment but also, “in view of the irreversible and wide-ranging consequences of SRS . . . [it is] . . . an obvious prerequisite for both the patient and the clinician” (Sohn & Bosinski, 2007, p. 1193).

SRS is a complex, multistaged process that begins with psychological and physical assessments and often ends with the full transformation usually requiring multiple surgeries in which the genitals and gender characteris- tics of the patient are removed and replaced with the genitals and gender characteristics of the other sex. Some patients choose not to have the full set of procedures. For example, some female-to-male transsexuals (FM-TS) may choose to undergo hormonal treatment to lower their voices and grow facial and body hair, mastectomy to remove their breasts, hysterectomy to remove their uterus, and salpingo-oophorectomy to remove their fallopian tubes and ovaries but decide not to have a penile prosthesis implantation

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(Harry Benjamin International Gender Dysphoria Association, 1998; Sohn & Bosiniski, 2007).

EVOLVING SITUATION

It is hard to say what the future will hold for individuals who display tenden- cies that do not conform to gender norms, but with the release of the DSM-5 in May 2013 we now know that GID is a term of the past. Changing GID to gender dysphoria (GD) can be seen as the APA’s first step in responding to its critics. By removing the word disorder from the title the APA can argue that the move represents an attempt to reduce the stigma associated with the diagnosis. The APA also removed GD from the section that included sex- ual dysfunctions and paraphilias and designated a category solely for GD. Furthermore, the APA has divided the criteria requirements, identifying and listing those indicated for children separately from those for adolescents and adults and added the specifiers of with a “disorder of sex development” and “posttransition” (APA, 2013, pp. 452–453).

With the release of the DSM-5, the medical community can continue to perform SRS utilizing a psychological diagnosis as justification and support of their decision to proceed with an extensive and medically invasive proce- dure. However, for many in the LGBT community, the retention of GD in the DSM-5 is nothing less than the continued pathologizing of nonconforming individuals; especially because the APA opted to retain criteria laden with social biases in the DSM-5, such as that of criterion A.2 “in boys . . . simu- lating female attire; or in girls . . . only wearing typical masculine clothing” (APA, 2013, p. 452).

Mental health professionals who argued for GID’s removal are left ques- tioning the continued inclusion of GD within the DSM, whereas those who sought revision of GID must determine if GD is truly a diagnosis based more on distress and less on social norms and pressure in regards to gen- der roles (Ehrbar et al., 2008). The determination must be made if the new language given to the diagnosis in the DSM-5 accurately accounts for the differentiation of the loci of distress. That is, “the anxiety may not be related to an internal discongruence with his/her biology and gender, but rather a discongruence between his/her biology and proscribed social roles” (Hein & Berger, 2012, p. 238).

DISCUSSION

Regardless of the APA’s adjustments, GD can arguably be considered as con- troversial a topic in medicine, mental health, and society as homosexuality was 40 years ago. This assertion can be seen by the continued pleas from

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clinicians, such as Wilson’s (2003) suggestion that “replacing GID with a di- agnosis unambiguously defined by distress rather than social nonconformity would help reduce the harm of stigma and to establish at the same time the medical necessity of sex reassignment procedures for those who require them” (para. 2).

Wilson’s idea seems like a logical compromise between opponents and proponents of this disorder. However, if GID/GD is truly a disorder then not only should it be maintained as it is written, but also psychiatrists should try to stop SRS because of the fact that it would be feeding into the delusion of the client. Yet if the client is not delusional and the mind is correct and the individual is truly a man in a woman’s body, then GID/GD is not a mental disorder and should not be included in the DSM-5 in any form (Ross, 2009).

Ross (2009) explains the dilemma surrounding GID/GD in a very suc- cinct and pragmatic way:

This is fundamentally an ethical problem. Either the diagnosis of gender identity disorder should be removed from the DSM-5, or gender reas- signment should be stopped. Having it both ways protects the financial interests of specialists in GID, but not society or the individual who re- quests gender reassignment. This violates the fundamental principle of “first do no harm.”. . . If gender reassignment is a reasonable and ethi- cal procedure, then believing you are of the opposite gender from your biological gender cannot be a mental disorder. (p. 169)

RECOMMENDATIONS

With the link between homosexuality and gender identity indicated via nu- merous resources and the ethics of GID and SRS questioned, what remains is to discuss possible solutions to the circularity of the situation. Ross (2009) asserted that “gender reassignment should be stopped” (p. 169). Although this notion on the surface may seem to be a pragmatic way of reconciling the maintenance of GD in the DSM, it is not a realistic or viable solution for the medical community or the individuals seeking the reduction of distress. Furthermore, proclaiming an end to SRS would do little more than dam- age the ability of mental health professionals to assist individuals struggling with issues of identity because it will cast a shadow of perceived intoler- ance of individual gender differences upon the profession. Especially since the APA Task Force on the treatment of GID reports that, “overall, the evi- dence suggests that sex reassignment is associated with an improved sense of well-being in the majority of cases” (Byne et al., 2012, p. 766).

Thus, it is the recommendation of the authors to place the responsibility for diagnosing individuals necessitating SRS where it naturally belongs: with the SRS medical teams. The removal of GD in any form from the DSM may allow the medical community to determine a set of criteria that has less to

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do with gender nonconformity and more to do with distress. Removing the diagnosis of GD from the DSM does not eradicate the need for mental health professionals to counsel individuals going through partial or complete sexual transformations.

ROLE OF THE COUNSELOR

For counselors the primary objective is to assist the client in the reduction of distress and relief of symptoms. However, psychotherapy is “not undertaken to cure the gender identity disorder” (Fraser, 2009, p. 111). Therefore, the task of the mental health professional is first and foremost that of providing accurate diagnosis. The counselor must determine if the client fits criteria for a GD diagnosis and is not suffering from an intersex condition, fetishism, somatoform disorder, or other disorder that may better explain the symptoms that the client is reporting (Byne et al., 2012; Cohen-Kettenis & Van Goozen, 1997; Fraser, 2009; Manieri et al., 2008). This rule-out process should not be confused with the diagnosing and treating of comorbid disorders such as depression and anxiety which may be of valid psychological concern and reasons for treatment, but not preclude a diagnosis of GD. Consequently, an individual can be diagnosed with depression, anxiety, or an array of other mental disorders as well as possibly meeting and maintaining criteria for GD.

If a diagnosis of GD is given, the second function of the counselor is to educate the client to the options available to him/her. This includes dis- cussing medically supported treatments such as hormonal therapy and SRS. The counselor must take due care not to present these treatments as cure-alls for the client’s distress (Byne et al., 2012; Cohen-Kettenis & Gooren, 1999; Harry Benjamin International Gender Dysphoria Association, 1998; Manieri et al., 2008; Sohn & Bosinski, 2007). Comorbid disorders and other difficul- ties such as family relational problems may have origins outside the realm of what can be rectified by medical treatments, and need to be discussed with the client as possibly necessitating further psychological interventions. Thus, the next and arguably most important facet of the counselor’s role is pro- viding the client with support for and through whatever process that he/she may choose, be it partial medical treatment, total SRS, or no body modifi- cation at all. Also, to help the client cope and function within his/her new or existing identity, including but not limited to, navigating familial relation- ships, employment, social stigma, and prejudice. “Mental health clinicians can have a significant positive influence in helping transgender people and loved ones build resilience to heal from and cope with societal stigma, pro- moting healthy psychological development, and facilitating timely treatment of mental health concerns” (Bockting, Knudson, & Goldberg, 2006, p. 40).

In the absence of a standardized treatment modality, it is the recom- mendation of the authors to utilize a metatheoretical approach, specifically

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ecological counseling. Ecological counseling is not a treatment modality per se, but more a way of understanding the complexity of the client’s existence. With a greater understanding of the events and forces that impress upon the client, a clinician can begin to introduce more personalized interventions.

According to Bronfenbrenner (1979), “the ecological environment is conceived as a set of nested structures, each inside the next” (p. 3): the microsystem, mesosystem, exosystem, and macrosystem (pp. 22–26). Within this theory the client is located at the center of the nested levels. The mi- crosystem comprises people and places in which the client has the most direct contact, that is, home, immediate family, roommates, and spouses. The next level, the mesosystem, can be understood as the people and places that the client has contact with regularly but are not as intimate as those of the microsystem, such as school, work, extended family, friends, and coworkers (Bronfenbrenner, 1979; Gutkin, 2012; Sheridan & Gutkin, 2000). Bronfenbrenner (1979) describes the exosystem as “one or more settings that do not involve the developing person [client] as an active participant, but in which events occur that affect, or are affected by, what happens in the setting containing the developing person” (p. 25). In the case of clients diagnosed with GD, this level would comprise local, state, and federal laws; school boards; health insurance companies and their guidelines/benefits; so- cietal stigma and prejudice, just to name a few. Finally, the macrosystem can be understood as all the levels and how their interplay may affect the client (Bronfenbrenner, 1979; Gutkin, 2012; Sheridan & Gutkin, 2000).

In agreement with Gutkin (2012), the argument for utilization of the ecological model can be made by stating that “by moving away from an exclusive focus on individuals and toward a meaningful consideration of environmental systems, service providers can develop interventions that ad- dress universal . . . , selective . . . , and indicated populations” (p. 11). Such a shift in paradigm is in line with the American Counseling Association’s (2005) Code of Ethics, in which “counselors advocate to promote change at the individual, group, institutional, and societal levels that improve the quality of life for individuals and groups and remove potential barriers to the provision or access of appropriate services being offered” (p. 9). Fur- thermore, “if human behavior is strongly influenced by micro-, meso-, exo-, and macroenvironments, then changing the characteristics of one or more of these environments should lead to meaningful psychological and psychoed- ucational change in those who populate these environments” (Gutkin, 2012, p. 11). For example, a change in the exosystem such as the extension of benefits to patients seeking hormone therapy, can reduce stress levels in an individual diagnosed with GD because he or she may no longer have to choose between paying uncovered medical bills or other monthly expenses.

As with any client, no behavior exists in a vacuum but rather is am- plified or diminished by his/her environment, “human behavior as a func- tion of ongoing interactions between the characteristics of individuals and

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the multiple environments within which they function” (Sheridan & Gutkin, 2000, p. 489). The effect that external forces have on an individual must be weighed in context with any intervention technique. A counselor would be less likely to recommend to a client suffering from anxiety to take a walk in the local park to reduce stress levels if the counselor knew that the park was a source of stress and anxiety due to unfavorable activity that takes place there.

When counseling a client diagnosed with GD, a therapist must take into consideration the home environment by inquiring about the types and health of relationships with immediate family members (microsystem) and the client’s work/school environment, focusing on the way in which the client relates to peers and authority figures (mesosystem). The therapist should also review the broader environment, such as policies, procedures, and laws that are either in place to help prevent harassment and discrimi- nation, or whether the client constantly worries about losing employment, housing, and/or custody of children due to the societal, religious, or legal determination of dysfunction (exosystem). Once all of this information is gained, the therapist can attempt to comprehend how the client is affected by the interplay of the levels. For example, although the client may have a supportive relationship among immediate family and classmates, a lack of protective policies at work may leave the client open to termination without cause, which can be complicated by navigating the sometimes confusing and contradictory local, state, and national laws (macrosystem).

Thus, “the very nature of the ecological paradigm demands that clin- icians pay significant attention to relevant environments” (Gutkin, 2012, p. 13), not solely the client. The benefit from using this approach is that it allows the mental health professional to try to assist the client and, if applicable, his or her family members to prepare, understand, cope, and ultimately find solace in his/her own identity and world, not the counselor’s impression of that world.

CONCLUSION

As seen by the recent release of the DSM-5, the DSM can be considered a living document, changing with the research and clinical work done by mental health professionals. However, GD reminds us that the DSM is also a document that can be influenced by societal biases. GD is much more than a diagnosis within the DSM; it is a complex and pervasive issue that often reaches into every aspect of the individual’s life. He or she faces the same life stressors as anyone else with the addition of formulating a new identity, trying to sustain and create familial and social bonds, all while navigating stigmatization and prejudice. Counselors are called “to respect the dignity and to promote the welfare of clients” (American Counseling Association, 2005, p. 4). It is with that commitment in mind that this article is offered as

Understanding the Link 261

a resource for understanding the link among homosexuality, gender identity and the DSM.

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