While the Diagnostic and Statistical Manual of Mental Disorders Catches Up, Our Clients Are Dying

How Lessons From History Can Inform Social Work Practice With Trans and Queer Communities

Photo credit: https://www.washingtonpost.com/news/morning-mix/wp/2016/04/05/the-darker-link-between-ancient-human-sacrifice-and-our-modern-world/?utm_term=.11504cdabf11#comments

I am a social work graduate student. In addition to having had access to education in my lifetime, I also have had the privilege of navigating this world as a white, cisgender, heterosexual American citizen — living on land that was seized by European Americans hundreds of years ago. I am also female, Jewish, disabled and young. It is from these social locations that I reflect on here my recent clinical engagement with a mother of a Trans child and how the Diagnostic and Statistical Manual of Mental Disorders (DSM) quietly and destructively moralizes.

Recall that homosexuality was considered a mental illness — an abnormal behavior, cataloged in the sexual deviance section of the first two publications of the DSM (Perone, 2014). It wasn’t until the early 1970’s, when criticism mounted against the DSM’s exclusionary and stigmatizing portrayal of homosexuality as a mental disorder (Pomeroy & Parrish, 2012), that the idea we were moralizing same sex behavior entered into mainstream clinical consciousness.

While the mental disorder label for homosexuality was finally eliminated from the DSM in 1987, newly recognized “disorders” around gender identity, expression and gender non-conforming individuals were phased-in (Kawa & Giordano, 2012). Okay, so the DSM caught up after a long fought battle was won for gays and lesbians, but where has that left other members of the LGBTQ+ community?

Like the above illustration from SLC Feminist alludes to — misunderstood, misrepresented and tokenized is one answer. Further marginalized and vulnerable is another. In fact, transgender and gender non-conforming people are disproportionately at risk for suicide, substance abuse, socioeconomic oppression, violence and other life-threatening circumstances (Grant et al., 2011). As a social worker, I have a responsibility to advocate for vulnerable populations. I also know that the DSM as is written today will inevitably place me in a position that could harm Trans and queer clients I work with. My recent experience at work is evident of this.

Photo credit: https://www.cchrint.org/psychiatric-disorders/psychiatristsphysicians-on-lack-of-any-medicalscientific-tests/

Ginny came to my office for a routine intake appointment to enroll in a parent education class. She was visibly exhausted, frustrated and petrified. Ginny told me that her nine year old child was transgender and had been recently diagnosed with gender dysphoria by a psychiatrist. Desperately wanting to support her child, Ginny had reached out to our agency hoping to find answers—

My son wants to wear dresses, but what am I supposed to do when our family goes to church…I’m scared he won’t be accepted by our congregation? My son has been bullied at school and the school counselor told me his behavior was “seeking attention” and then nothing was done…how can he be protected at school? My son has been withdrawn more and more; he does not want to play with his best friend anymore. The psychiatrist my son is seeing recommends that we try an anti-depressant for him. What should I do??

In listening to Ginny’s very sincere call out for help, I noticed that she believed the psychiatrist and the accompanying DSM diagnosis. Ginny believed that her son, based on his transgender identity, was intrinsically abnormal. Furthermore, I saw that Ginny had internalized the oppression her gender non-conforming son had and would face moving through the world. And I thought about my responsibility to challenge Ginny’s belief system even though it is in line with the DSM’s current framing of transgender and queer identity.

During our first meeting, part of my case management work with Ginny consisted of me simply bearing witness to her pain. As a social worker, validating the lived experiences of others is a micro-level step within the larger issue of structural oppression. Then, when space opened up in our conversation and I sensed that Ginny could hear me, I assumed an advocacy role on her son’s behalf. Very kindly, I asked Ginny — who decided that being Trans was not normal?

I understand how historically the gender binary, transphobia, cissexism and heteronormativity have all informed the DSM, but what if Ginny knew this?…and what if all mental health professionals knew this?

In addition to the references listed below, I also encourage any of you looking for gender affirming resources to check out this awesome video from one of my favorite gender queer activists.

Video credit: https://www.youtube.com/watch?v=faQuXaGrdAE


Grant, J., Mottet, L., Tanis, J., Harrison, J., Herman, J. & Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force.

Kawa, S., & Giordano, J. (2012). A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice. Philosophy, Ethics, and Humanities in Medicine: PEHM, 7, 2.

Nadal, K., Skolnik, A., & Wong, Y. (2012). Interpersonal and Systemic Microaggressions Toward Transgender People: Implications for Counseling. Journal of LGBT Issues in Counseling, 6(1), 55–82.

Perone, A. (2014). The social construction of mental illness for lesbian, gay, bisexual, and transgender persons in the United States. Qualitative Social Work, 13(6), 766–771.

Pomeroy, E. C., & Parrish, D. E. (2012). The New DSM-5: Where Have We Been and Where Are We Going? Social Work, 57(3), 195–200 6p. doi:sw/sws027