Based on Module Four’s articles on gender dysphoria, write a short paper about the influence of acceptance, parenting styles, and how these can directly steer a child’s gender identity.Moreover, think about society today and acceptance of varied gender roles compared to the 1950s. What is different today in parenting styles compared to the 1950s? Additionally, think about the criteria and changes made in the DSM in the most recent version (DSM-5) compared to earlier, outdated versions.Also, consider and explore society’s influence on gender dysphoria in your argument. Is there a direct correlation to gender identity and society or not?
The Early Development of Gender Differences
Author(s): Matthew H. McIntyre and Carolyn Pope Edwards
Source: Annual Review of Anthropology , 2009, Vol. 38 (2009), pp. 83-97
Published by: Annual Reviews
Stable URL: https://www.jstor.org/stable/20622642
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The Early Development
of Gender Differences
Matthew H. Mclntyre1 and Carolyn Pope Edwards2
1 Department of Anthropology, University of Central Florida, Orlando, Florida 32816;
email: mmcintyr@mail.ucf.edu
2 Departments of Psychology and Child, Youth, and Family Studies, University of Nebraska,
Lincoln, Nebraska 68588; email: cedwards@unlnotes.unl.edu
Annu. Rev. Anthropol. 2009.38:83-97
Key Words
First published online as a Review in Advance on
June 17,2009
The Annual Review of Anthropology is online at
anthro.annualreviews.org
This article’s doi:
10.11467annurev-anthro-091908-1643 3 8
Copyright ? 2009 by Annual Reviews.
All rights reserved
0084-6570/09/1021-0083$20.00
reproductive ecology, evolutionary psychology, patriarchy,
dominance, temperament
Abstract
This article reviews findings from anthropology, psychology, and other
disciplines about the role of biological factors in the development of
sex differences in human behavior, including biological theories, the
developmental course of sex differences, and the interaction of biologi
cal and cultural gendering processes at different ages. Current evidence
suggests that major biological influences on individual differences in
human gender, to the extent that they exist, operate primarily in early
development, during and especially prior to puberty. Biological effects
are likely to be mediated by relatively simple processes, like temper
ament, which are then elaborated through social interactions (as with
mother and peers) into more complex gendered features of adult person
ality. Biological anthropologists and psychologists interested in gender
should direct more attention to understanding how social processes in
fluence the development and function of the reproductive endocrine
system.
83
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INTRODUCTION
physical conflict with others who are seeking
mates,
or coercion of the potential mates them
The purpose of this review is to summarize the
selves (Bateman 1948, Clutton-Brock & Parker
current evidence about the role of biological
1992, Dewsbury 1982). For reasons that are not
factors in the development of human gender
fully
understood (Kokko et al. 2006, Wade &
over the life course. Rather than accept the
Shuster 2002), parental investment activities of
distinction between biological sex and cultural
many kinds are often, but not always, enacted by
gender, we employ the term gender very
one physical form, which is also often the form
broadly to include both sex differences them
with larger gametes, called female, and mating
selves and the cultural and biological processes
activities by another physical form, often with
that shape them. At the risk of over-reaching,
smaller, more motile gametes, called male.
we address between-sex differences, related
In most mammals, virtually all parental in
within-sex variation, and broader features of
vestment is done by females and all mating ef
human social systems such as patriarchy. Our
fort by males, resulting in more notable sex
review begins with biological theory about
differences than in other taxa (Clutton-Brock
gender and its application to the evolution
1989, Orians 1969). The few exceptions are in
of human sex differentiation, followed by
species in which roles may be partially mixed
a discussion of the developmental course
and the sexes have less notable differences, and
of human sex differences and the various
which more often have mating systems charac
biological and social gendering processes. As
terized as monogamous (Jarman 1983, Plavcan
such, we also consider research from many
2001). The primate order includes a relatively
disciplines, including tentative consideration
large
of sociocultural studies conducted from
a number of monogamous species, often
characterized by some level of male parental
humanistic perspective. One important topic
investment (Fuentes 1998). The characteriza
that we unfortunately leave out is sexuality.
tion of patterns of human parental investment
and mating effort has been the subject of debate
BIOLOGICAL THEORIES ABOUT
among evolutionary anthropologists (Hawkes
HUMAN GENDER
et al. 1991, 2001; Hill & Kaplan 1993; Kaplan
et al. 2000), partly because of the substantial
Biological theory about gender (even if that
among even hunter-gatherer societies
term is not always used) refers to the variation
exis
in foraging and marriage systems (Wobst 1978).
tence, in sexually reproducing species, of two
Geary (2002, 2006) has suggested that
distinct reproductive strategies called parental
evolved human psychological sex differences in
investment and mating effort, which have
been elaborated from Darwin’s descriptionclude
of {a) adaptations for child care in women
sexual selection. Parental investment encom
and interpersonal dominance striving in men,
both of which should be largely primitive
passes activities that are cosdy to parents but
evolutionarily in that similar sex differences
direcdy contribute to the growth or survival
are present even in nonprimate mammals,
of offspring (Trivers 1972). For some species,
(b) adaptations for coalitional aggression in
this investment consists almost entirely of the
men, which might be homologous with chim
initial cytoplasm contained in the gametes, with
(Wrangham 1999), and (c) adaptations
no further support provided by parents, panzees
but
supporting the sexual division of labor, with par
mammals have a number of additional parental
ticular focus on hunting. The latter two do
functions including lactation. Parental invest
mains can be considered relatively more derived
ment is, in principle, common to both sexual
as athey would have evolved later.
and asexual reproduction. However, finding
Feminine psychological adaptations for
mate is only relevant to sexual reproduction. In
parental care have been linked to the psy
some species, finding a mate may involve travel
chometric construct of empathy, and reduced
over long distances, displays of health or beauty,
84 Mclntyre Edwards
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empathy in men has been linked, in turn, to related to hunting ability, the psychological di
lower thresholds for aggression (Baron-Cohen mensions investigators have proposed to sup
2002, Campbell 2006). Although dominance port sex differences in hunting and gathering
striving has been studied using a variety of tech
in the literature are mostly cognitive, e.g., spa
niques, it has not yet been closely linked with,
tial rotation and object memory, rather than re
or developed as, a particular psychometric con
lated to emotions or personality, in keeping with
an emphasis on cognitive changes in human
with narcissism, sensation seeking, instrumen evolution (Kaplan et al. 2000).
struct (Burgoon et al. 1998). Weak associations
tal motivations, and externalizing behavior are
The role of the reproductive endocrine sys
likely, and there may be a developmental link tem in human sex differences has been assessed
between low empathy and dominance striving, using several techniques. For concurrent ef
making femininity-masculinity at least partly fects in children and adults, concentrations of
unidimensional (Campbell 2006, Mclntyre & sex hormones can be measured in the blood
Hooven 2009). Theorists have proposed that or saliva. For prenatal effects, several indirect
the primitive sex differences in parental care
and interpersonal dominance striving should
techniques have been used, including compar
ison of children with congenital adrenal hy
be reduced in humans owing to relatively low perplasia with controls, concentrations of sex
hormones in amniotic fluid, and the relative
levels of polygyny and high levels of male
parental investment (Geary 2002). Despite
lengths of the index and ring fingers, abbre
such a reduction, it would be surprising not viated as 2D:4D (Cohen-Bendahan et al. 2005,
to find associations of basic psychological di Mclntyre 2006).
mensions of parental investment or male-male
competition with biological factors, such as
sex hormones, given the established role of
these factors in nonhuman sex differences.
SOME EVIDENCE FROM ADULT
MEN AND WOMEN
Wliere interesting and surprising results might
Some evidence indicates at least a small role of
be found is in the interaction of these primitive
the reproductive endocrine system (especially
androgens, like testosterone) in the ongoing
the evolved processes related to biological gen maintenance of adult sex differences in em
der operate in different cultural and economic pathy and dominance striving. For example,
conditions?
Deady et al. (2006) found a negative association
Human sex differences in coalitional aggres of basal testosterone concentrations with ma
biological factors with social forces. How do
sion and the division of labor are of particular ternal ambitions in women, and Hermans et al.
interest to anthropologists because of their rel
(2006b) found evidence that an exogenous dose
atively recent evolution and probable role in the of testosterone reduces empathy as assessed by
origins of patriarchy (Smuts 1995). It is difficult unconscious facial mimicry. However, levels of
to predict how such biological systems might testosterone in women vary over the course of
operate given the relative uniqueness, among the menstrual cycle and even over the course
all animals, of coalitional aggression and hunt of several days (Sellers et al. 2007). A number
ing as sex dimorphic features. The psycholog of studies have found associations between
ical construct that has been most commonly basal or exogenous levels of testosterone
and behaviors or attitudes associated with
proposed as reflecting adaptations for coali
tional aggression is called social dominance ori dominance striving in men and women (Dabbs
entation, defined as “the extent to which one 1997, Wirth & Schultheiss 2007) and women
desires that one’s in-group dominate and be
superior to out-groups” (Pratto et al. 1994,
alone (Cashdan 1995, Grant & France 2001,
Hermans et al. 2006a).
p. 742), which shows substantial sex differences.
However, as noted by O’Carroll (O’Carroll
1998), the interpretation of these results is
Although many physical sex differences may be
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complicated by the interesting, and better es relationships through moralistic aggression.
tablished, observation that men’s testosterone However, as we noted, social dominance orien
levels also fall in response to failures in domi
tation is the most established measure of group
nance contests of various kinds (Archer 2006,
level affiliation and a recent study found no
Dabbs & Dabbs 2000, Elias 1981, Mazur & association of social dominance orientation
Booth 1998), especially for men who strive with either testosterone or 2D:4D (Johnson
more for dominance (Schultheiss et al. 2005).
Archer (2006) proposed that this response is
et al. 2006, Mclntyre et al. 2007).
There are a number of established sex dif
part of a primitive, evolved system by which
ferences in the performance of Western adults
men’s willingness to enter dominance contests
on a number of cognitive tests, including men
is informed by their previous record of success.
tal rotation of shapes on which men perform
Recent evidence suggests that willingness to
better and verbal and object memory on which
enter new contests is influenced by basal testos women perform better (Kimura 1999). How
terone level (Mehta et al. 2008) and/or testos ever, Ecuyer-Dab & Robert (2004) have noted
terone response to winning or losing (Carre & that there are two competing evolutionary in
McCormick 2008), and the effect is probably terpretations of these differences. They may be
mediated by subtle physiological, rather than part of the primitive systems supporting sex dif
ferences in ranging and mate seeking (Gaulin
psychological, shifts (van Honk et al. 2004).
Of course, hormones also have many other & FitzGerald 1986, Jones et al. 2003), or they
nonpsychological functions, including the reg may be derived specifically to support hunting
ulation of muscle mass, which could be evolu by men and gathering by women (Silverman
tionarily meaningful (Bribiescas 2001).
& Eals 1992). A sex difference in throwing and
In keeping with the view that male parental
targeting ability might be more recently derived
investment increased during human evolution,
in response to male hunting (Westergaard et al.
a number of studies have identified possible
suppressive effects of romantic relationships,
marriage, or fatherhood on testosterone lev
els in men from several societies and, surpris
2000), but the developmental trajectory of these
abilities is obviously complex and includes fac
tors such as size and strength, which are often
ignored (Jones & Marlowe 2002). Some of the
effects of androgens on mental rotation tasks
ingly, lesbians (Gray 2003; Gray et al. 2002,
2004, 2006, 2007; Mazur & Michalek 1998; may not be related to cognitive ability (Hooven
Mclntyre et al. 2006; van Anders & Watson et al. 2004), and these associations vary across
2006, 2007). Many of these studies have re cultures (Yang et al. 2007).
social and psychological factors might play sub
Given the limitations of evidence coming
from adult sex differences, it is useful to con
tle roles in regulating the suppression of testos
sider the role of biological factors in the ear
vealed interesting interactions suggesting that
lier development of sex differences in infancy
In the case of coalitional aggression, little and childhood. Researchers with both biolog
evidence indicates that hormones play a major ical and sociocultural perspectives have turned
role in sex differences. Burnham (2007) found to studies of children to reduce the complex
terone and mating effort.
that men with higher testosterone reject low of problem of personal life histories, which result
fers in an economic experiment called the ulti from the continuous transaction of physical, fa
matum game. This could be interpreted simply milial, and sociocultural processes with the de
as a reaction to a perceived threat to personal veloping individual. However, we would take
status or dominance. However, he also noted this a step further and argue that a better un
a nonsignificant trend for men with higher
testosterone to make larger offers in the game.
derstanding of biosocial interactions over the
life course also provides valuable insights into
Together these trends might suggest a role for how biological systems affect sex differences, al
testosterone in the establishment of reciprocal lowing for the formulation of hypotheses about
86 Mclntyre Edwards
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how sex differences might develop in a vari
ety of sociocultural systems, including ones that
no longer exist (and ones that might someday
exist).
remain poorly understood because most of
the proposals have found limited support
(Maccoby et al. 1984).
Adults play only a small role in directly en
couraging sex segregation in Western societies
THE DEVELOPMENTAL COURSE
OF GENDER
(Aydt & Corsaro 2003, Maccoby 1998, Thorne
1993), and their role appears to be even more
limited in many other societies in which chil
Edwards (1993) noted several differences be dren are under less supervision (Edwards 1993,
tween the activities of boys and girls observed2000; Whiting & Edwards 1973, 1988). Even
when adults try to encourage cross-sex play
in many human societies:
groups, children resist and quickly return to
1. From age three, girls spend more time
same-sex partners when adult supervision is re
working, whereas boys spend more time
duced (Serbin et al. 1977). These findings are
in play.
generally supported by twin studies of the heri
2. When playing in groups, children self
tability of individual variation in gender-related
segregate by sex, in addition to age.
behaviors. Heritability studies allocate varia
3. Boys begin to spend more time than girls
tion among three categories (genetic, shared
away from home and their mothers.
environmental, and nonshared or other envi
4. Girls engage in more infant contact and
ronmental variation) based on differential sim
care.
ilarities between identical twins, fraternal twins,
5. Boys engage in more rough-and-tumble
and other siblings. The role of socialization by
play than girls do.
parents should mostly appear as shared envi
6. Boys engage in more practice play with
ronmental. Studies of variation in adult and
weapons and vehicles than girls do.
adolescent gender role (as with most other
7. Girls engage in more grooming (real and
personality dimensions) find moderate genetic
play) than boys do.
effects (25%?50%) and large nonshared envi
ronmental effects (30%?75%) with little room
Some cases, such as patterns of rough-and
tumble play in boys, the tendency for play
for substantial effects of family-based social
ization (Cleveland et al. 2001, Loehlin et al.
groups to segregate by sex, and the high fre
quency of infant care by girls, demonstrate 2005).
ap
Although recent studies in young chil
parent similarities to patterns observed in other
dren have found larger shared environmental
primates (Fagan 1993, Fairbanks 1993).
effects, especially in boys (Iervolino et al. 2005,
Sex-different patterns of behavior begin
Knafo et al. 2005), this difference might be ex
to emerge clearly in young children, during
plained by their use of parent reports about
a period when biological sex differentiationtheir
is children’s gendered behavior. Rather than
minimal, long before puberty and the develop
finding variation in gender-related behavior
ment of important secondary sex differences.
attributable to parental influence, they may
Patterns of sex segregation, in which children
have found variation in parental attitudes to
play in same-sex groups, which accompany ward
dif their children’s gender (a type of rater
ferences in the types of games played, emerge
bias). This is especially likely because effects
by five years old and often earlier in many
so stronger in boys, and American parents
were
cieties (Munroe & Romney 2006; Waiting
are&more concerned, and have stronger views,
Edwards 1973, 1988). The psychologist
about their sons’ than their daughters’ gender
Eleanor Maccoby (1998, 2002) has argued
appropriate behavior (Fagot 1977, Langlois &
Downs
1980).
that this pattern of sex segregation plays
a
key role in the development of adult gender.Older children clearly use cognitive ideas
Unfortunately the causes of sex segregation
about gender (some of which may come from
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cultural norms) in their play; much of the cur
limited evidence that exists (all from Western
rent thinking about sex segregation focuses on children) about the relationship between play
the importance of gender-related sociolinguis type preferences and sex-of-partner preferences
tic categories to children (Bandura & Bussey has been mixed (Alexander & Hines 1994,
2004, Kyratzis 2004, Martin & Ruble 2004) Hoffmann & Powlishta 2001, Moller & Serbin
and argues that children choose playmates on
1996).
To the extent that segregation or “border
their own gender and that of other children work,” as described by Barrie Thorne, is ac
(Powlishta et al. 1993, Serbin et al. 2001). These tively undertaken, scholars have debated its im
the basis of their categorical understanding of
arguments follow Kohlberg’s (1966) ideas about portance and source. Thorne has documented
the importance of cognitive knowledge about
the importance of borderwork in American
gender, such as knowledge of its constancy. For
preschools, and girls seem to play a more
example, Martin & Ruble (2004) regard chil
important role than boys do. That is, spaces
dren as young as four years old as “gender de are more likely to be declared off-limits to boys
tectives” who are actively trying to discover ex than off-limits to girls (Aydt & Corsaro 2003,
aggerated stereotypes about men and women Thorne 1993). This observation also makes
by listening to and observing adults and often sense from Munroe & Romney’s aggregation
make amusing errors. Children are motivated perspective if sex segregation is being driven
first by the knowledge that they are boys or girls
partly by refusal on the part of some girls to par
and that this will not change (gender constancy)
ticipate in large-group, rough-and-tumble play
and second by a desire for in-group dominance.
This knowledge would imply a fascinating and
THE ROLE OF BIOLOGICAL
very radical evolutionary change in which sex
SEX DIFFERENCES
differences in adult behaviors, like empathetic
parenting by women and dominance striving by Secondary sex differentiation in mammals,
men, which appear similar to sex differences ob which has usually been conceived as includ
served in many other species, nevertheless de
ing behavior, is guided primarily by sex hor
velop in a completely novel way via cultural and mones produced in the fetal gonads, especially
cognitive processes with limited input from the androgens, and sex differentiation in humans
(Hughes 2001) and other primates (Wallen
However, there has been some disagree 2005) is thought to entail similar processes. As
reproductive endocrine system.
ment about whether cognitive knowledge about such, human researchers employing a biological
gender is necessary, especially in younger chil approach to studying behavioral gender in chil
dren. Differences among children in their cog dren have focused primarily on prenatal andro
gens (Cohen-Bendahan et al. 2005, Mclntyre
to the sex of their play partners (Munroe & & Hooven 2009). The evidence that childhood
nitive understanding of gender are unrelated
Romney 2006, Serbin et al. 1994). Munroe & sex differences are directly shaped by effects of
Romney (2006) further argue that the term sex
sex hormones on the brain remains somewhat
aggregation should be used instead of segre
weak, despite substantial research, but, to be
gation because larger groups of boys, which
fair, also in the face of substantial methodolog
may or may not include a few girls, break out
ical limitations (Mclntyre & Hooven 2009). In
to engage in rough-and-tumble play. Children particular, it is difficult, for technical and eth
ical reasons, to directly measure prenatal hor
who do not join these groups (mostly girls)
tend to play alone, in dyads, or in smaller mones of fetuses in carefully designed studies.
groups. This occurrence implies a primary role However, the possibility that sex segregation is
for differences between boys and girls in the driven partly by sex differences in play prefer
types of games played rather than in the pre ences provides an opportunity for biological sex
ferred sex of the play partners. Nevertheless, the differences to influence gender development in
88 Mclntyre Edwards
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subtler ways. The construct of temperament
(Kagan 2003, Rothbart 1989) might be one av
enue for biological influences.
(Meyer-Bahlburg et al. 2004, Pasterski et al.
2005).
These temperamental differences or
Infant boys and girls show small but consis differences in their effects on later gender
tent differences in dimensions of temperament. development might also result, at least in
In particular, girls show higher fear when part, from differential parental treatment of
infant boys and girls. However, evidence to
date
about differential treatment of infant
as shorter latency to or threshold of crying
(Else-Quest et al. 2006, Martin et al. 1997). boys and girls has come largely from Western
Boys show a higher motor activity level societies and yielded mixed results. The body
(Campbell & Eaton 1999, Else-Quest et al. of findings does not present a strong case for
confronted with a novel stimulus, expressed
2006). Some evidence indicates that individual
the effect of infant sex or gender label per se
(and perhaps sex) differences in reactive fear on parental treatment, particularly in younger
(DiPietro et al. 2008) and especially motor infants (Biringen et al. 1999, Jacklin et al. 1984,
activity (Almli et al. 2001, Eaton & Saudino Lytton & Romney 1991, Robinson et al. 1993,
1992, Groome et al. 1999) begin to develop Stern & Karraker 1989). In American infants,
in utero. Infant boys also show greater at individual variations in infant temperament are
tention to mechanical crib mobiles than girls
also almost entirely explicable by genetic vari
do (Connellan et al. 2000), but girls show ation (Goldsmith et al. 1999), and the presence
greater attention to faces by 12 months old
of analogous sex differences in nonhuman pri
(Lutchmaya & Baron-Cohen 2002). These at mates (Alexander & Hines 2002, Hassett et al.
tentional biases have been linked with toy pref 2008, Herman et al. 2003) probably argues
erences and characterized as a primitive mascu against a major role of socialization. Many
line attentional bias to movement and feminine findings of caregiving variations in treatment
attentional bias to people (Alexander 2003).
of girl and boy infants do not remove variance
Infant temperament has been further linked contributed by what the infants themselves
with measures of personality later in life that are
elicit on the basis of their activity levels, capac
salient to the dominance/empathy paradigm.
ity for mutual gaze, emotional expressiveness,
Infants with greater fear reactivity develop both or other temperamental differences. When
greater empathy and social anxiety as toddlers
child characteristics are included, gender
(Spinrad & Stifter 2006). Although infant tem differences in maternal behavior are reduced.
perament has not been studied in relation to For instance, Moss (1967) found that mothers
later dominance orientation per se in humans, of three-week-old infants were observed to
male rhesus monkey infants with higher activ hold, look at, arouse, and stimulate physically
ity levels rise higher in dominance hierarchies
sons more than daughters; however, sons were
later in life (Weinstein & Capitanio 2008), and more irritable and when infant irritability was
human infants displaying lower fear reactivity covaried in the analyses differences in holding
(Burgess et al. 2003) and physical activity levels and looking dropped out. Some researchers
(Canals et al. 2006) display more externalizing (e.g., Donovan et al. 2007) have attempted to
behavior as children.
remove child-temperament effects by devel
Increasing evidence shows that variation in oping experiments in which adults respond
infant and childhood temperament is influ
to a stranger infant (or photographs), but
enced by genetic and hormonal factors. Greater these studies have the weakness of measuring
attention to faces has been associated with lower parental behavior in a nonnatural situation in
prenatal testosterone concentrations measured which they are struggling to read the (often
in amniotic fluid (Lutchmaya et al. 2002). Girls ambiguous) signals of an unknown child and,
with congenital adrenal hyperplasia show a hence, are in a situation in which they would be
preference for male-typed toys such as trucks expected to be most guided by expectations and
www.annualreviews.org Early Development of Gender Differences 89
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stereotypes rather than by meaningful child
social processes. Ours is certainly not the first
cues. In sum, although it is widely assumed that call for complex descriptions of biocultural in
adult perceptual sets and gender stereotypes
teractions (Edwards 1993; Mclntyre & Hooven
influence caregiver behavior toward male 2009; Worthman 1993, 1995). Biocultural in
versus female infants, independent of the teractions happen repeatedly over the course of
child’s characteristics, such differences have
life to subjects that are themselves the products
not been clearly demonstrated. The issue is of previous interactions. Therefore, we should
complicated even further by the fact that infant
not be tempted to think that even the bod
girls and boys might react differently to the ies of infants are, so to speak, all biology and
same caregiver behaviors in light of their own no culture. Paying attention to broader social
individual differences, such as differences in processes is a more difficult proposition and
temperament. For example, boys tend to react will force evolutionary anthropologists and psy
more strongly than girls do to differential ma
chologists to gently set aside the reconstructed
ternal sensitivity (Biringen et al. 1999, Warren Paleolithic society in favor of the actual soci
& Simmens 2005, Weinberg et al. 2006), eties in which they work.
particularly if the infant is difficult (Warren
For example, some research has shifted
& Simmens 2005) or in challenging social
greater focus to the individual interests and
agency of the child, and adult, actors involved
contexts (Weinberg et al. 2006). This pattern
of transactions between mother and infant
in the day-to-day enactment of gender (Aydt &
could lead to complex amplification of initially Corsaro 2003, Knobloch et al. 2005, Kyratzis
small differences in either infant or caregiver 2004) . Recent analyses particularly from hu
behavioral variation, which might also be manistic (Montgomery 2005), but also from bi
influenced by the social context, for example, ological (Crittenden & Marlowe 2008, Hrdy
by the extent to which fathers and siblings are
involved in care of the child. Bornstein et al.
2005) , frameworks have argued for greater at
tention to the economic value of girls’ labor
(2008) found that mothers from metropolitan and the roles of parental power and coercion
regions were more emotionally available than in the establishment of gendered patterns of
were those from rural regions, and sons, but play and work. This approach might allow us
not daughters, from metropolitan regions to think about the effects of infant tempera
were more responsive than were those from ment in different ways. The temperaments of
rural regions. These findings suggest that key young girls, which are characterized by greater
developmental systems are highly sensitive to empathy, social anxiety, and social attention,
sociocultural and/or economic factors, which might be considered more suitable for doing
as Beatrice Whiting (1976) suggested are work around the house and caring for siblings,
complex “packaged variables” that need to be or they might be more cooperative with moth
broken down and analyzed in terms of compo ers owing to their greater physiological matu
nents that really matter. Developmental studies rity and/or same-sex identification (Whiting &
about how biological sex differences in children Edwards 1988). Boys, however, might gain
operate in varied social contexts will continue agency by virtue of their high levels of physical
to be informative, particularly as societies are
activity and perceived irresponsibility, freeing
radically transformed by globalization.
them from some household responsibilities.
Similarly interesting questions arise with
REFOCUSING BIOLOGICAL
STUDIES OF HUMAN GENDER
regard to social institutions outside of the home.
Whereas evolutionary anthropologists and psy
chologists have been looking for associations
We suggest that biological studies of gender between testosterone and dominance striving,
can be benefited by paying more attention Mclntyre & Hooven (2009) argue that the re
to (a) infancy and childhood and (b) broader ality in Western societies is far more complex
po Mclntyre Edwards
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and fascinating. Boys with high testosterone
are dominant over their peers in adolescence
appearances and the very real effects which have
been produced, in people’s bodies and in their
(Tremblay et al. 1998), but as they leave the brains, by a long collective labor of socializa
world of peers and family and come into con tion of the biological and of biologization of
tact with other social institutions the trajecto the social combine to overturn the relationship
ries of their lives are more often characterized between causes and effects…” (Bourdieu 1990,
by delinquency (Rowe et al. 2004), criminal ac p. 12). We further argue that biological work re
tivities (Archer 2006, Archer et al. 1998), lack of lying on insights from humanistic social science
education (Dabbs & Dabbs 2000), and low so research, far from being an alternative to evo
cial prestige (Dabbs 1992, Johnson et al. 2007).
lutionary explanations (Bribiescas 2001, Ellison
Even if this tendency results from a mismatch 2003), can also make the social sciences more
between ancestral and current conditions, it is useful contributors to biological and evolution
a mismatch worthy of careful study, if for no ary thinking about gender in other species.
other reason than it is likely to affect the re Recent work in a number of species, includ
sults of any research that we conduct. It is not ing those whose biological gender can reverse
possible to escape these questions by studying during life, has highlighted the central roles
of social stratification, power differences, and
simpler societies.
Our suggestions are similar to those of coercive or violent tactics in explaining pat
Goodman & Leatherman’s (1998) Biocultural terns of sex or gender role change (Anthes &
Synthesis, which encourages more study of the Michiels 2007, Black & Grober 2003, Grober
effects of political and economic systems on hu & Rodgers 2008, Rodgers et al. 2007). As these
man biology but applied to reproductive biol processes are particularly elaborated and var
ogy and sex differences, in addition to nutrition ied in humans, the human sciences might offer
and growth. We also echo some of Bourdieu’s
rich and surprising theoretical insights, even for
observations about patriarchy. “The biological
ichthyologists.
SUMMARY POINTS
1. For the most part, biological influences on psychological sex differences probably occur
early in life via simple mechanisms such as temperament.
2. Small sex differences in temperament interact with social factors in complex ways that
might result in further psychological differentiation but not always in ways that are clearly
predicted by existing evolutionary theories.
FUTURE ISSUES
1. How do sex differences in physical maturity and social competence influence how children
interact with one another or are treated by adults, and what are the biological or social
causes of these sex differences?
2. More evidence is needed about the social processes and individual differences that result
in sex segregation in children. In particular, the relative importance of gender cognitions
and activity or play-style preferences remains unclear.
3. Longer-term longitudinal studies would help us to understand the role of early processes
(including sex segregation) on the further consolidation of psychological sex differences
during puberty and adulthood.
www.anntialreviews.org Early Development of Gender Differences p/
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DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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Clin Soc Work J (2013) 41:288–296
DOI 10.1007/s10615-013-0447-0
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 expressions, within a larger perspective of examining psychological 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 anniversary, 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 selfdescriptor 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 children (or retain custody of them), living with a constant threat
A. I. Lev (&)
School of Social Welfare, State University New York at Albany,
Albany, NY, USA
e-mail: arlene.lev@gmail.com
123
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-culture, 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 experiences 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 psychotherapist 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 clinical communities have followed along, taking a mostly progressive, supportive stance on issues as they have arisen,
incorporating a ‘‘gay-affirmative’’ approach into our clinical
Clin Soc Work J (2013) 41:288–296
practices (Levy and Koff 2001), but as a social work community, I wonder if we have done enough (Levy and Koff
2001). Have we been at the vanguard of advocacy and progressive 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 incorporated 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 psychotherapy, 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 environment we call therapy, as well as an emerging queer sensibility 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 disordered 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 transsexual 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 colleagues how they addressed issues of sexual orientation in the
curricula, I was met with blank stares. Was there really
289
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 happened 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 general 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 individuals). 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 understanding gender identity, gender expression, gender dysphoria, 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
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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 bibliophile, 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 thoroughly, 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 heterosexual, 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-blockers, 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 Catholic priest, who lives full-time as a woman now. Transgender people represent an enormous diversity of
humanity, crossing all racial, ethnic, class, and cultural
populations, all ages, dis/abilities, and religions.
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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 reading 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 narrative 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 Dysphoria, is a narrative of an oppressed people and their
liberation struggle, amid the psychobabble of gender conformity, 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 heteronormative 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 lesbianism (Kitzinger 1993). Decades later these ideas seem
anachronistic, as thousands of lesbian, gay, and bisexual
people attest to coming from very different family
Clin Soc Work J (2013) 41:288–296
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 nonhuman communities, throughout history and cross-culturally (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. Dystonic 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 diagnosis 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
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 orientation’’ (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.
291
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 interferes 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 adolescents, 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 children (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 movement 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 headway 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.
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.
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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-dystonic Homosexuality, Gender Dysphoria represents a battle
only half won.
In addition to Gender Dysphoria, there is another diagnosis 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 nonpathological 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 subcommittee 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
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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 psychological institutions that determine and define pathologies. 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 Diseases. 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 disciplines’’ (p. 135). I would add that the consequences of
those acts impact the feelings, experiences, and epistemologies of average people, many of whom do not know
the meaning of the word epistemologies.
The DSM-5 has been under serious scrutiny on numerous 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 highlighting 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 Disorders 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/
Clin Soc Work J (2013) 41:288–296
objection-to-dsm-v-committee-members-on-gender-identitydisorders). 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 transgender 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 treatments 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 Blanchard’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 complexities 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 international professionals, expressed concern about the lack of
diversity in clinical perspectives represented within the
membership of these workgroups, especially gender specialists who are affirming of gender diversity and transgender 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 treatment of transgender people. In 2008, the American Medical
293
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 expression 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 hormonal 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 multidisciplinary 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 Statement #2: I am a member of the Standards of Care Committee). The SOC state:
Thus, transsexual, transgender, and gender-nonconforming individuals are not inherently disordered.
Rather, the distress of gender dysphoria, when present, 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 diagnoses 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, adolescents, 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
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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 diagnosis, 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 criterion assists in recognizing the existence of a broad array
of gender identities and expressions, and attempts to step
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Clin Soc Work J (2013) 41:288–296
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 diagnoses 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 professional, 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, pregnancy; 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,…
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