Mental Health Monitor: Counteracting Stigmatizing Diagnoses in the DSM-5
One of the major priorities of the social work field is supporting marginalized people, a task that requires providers to understand patterns of current and historic oppression.1 Sexually and gender-diverse (SGD) people experience structural and interpersonal stigma, which negatively impacts physical health, mental wellness, and suicidality, as well as limits access to economic resources and affirming health care.2-6
Although the human service field, including mental health care and social work clinical case management, strives for culturally competent and client-centered approaches, it is necessary to acknowledge that the field has been shaped by and built upon our collective social context, which includes colonization, racism, and oppressive practices. While this context has seen massive shifts in awareness, advocacy, and advances in protective legislation, it also includes oppressive systemic practices that create a climate of distrust in accessing help and health care services.
A key tool in the provision of mental health services is the DSM, a document created by the American Psychiatric Association. While we are active proponents and advocates of the strength-based framework rather than the medical model, we recognize that our clients’ access to services is still based on a pathology model (eg, through eligibility for insurance reimbursement) rather than building on strengths.
The current version of the DSM, the DSM-5-TR, was built on an evolving document that reflects Western medical premises, cultural beliefs, and—inadvertently—personal and collective biases. For example, within the DSM-1, the stigmatization of attraction and consensual sexual activities between people of the same gender led to the inclusion of homosexuality as a “sociopathic personality disturbance.”7,8
Specific diagnoses that can be considered to be problematic in the DSM-5 include fetishistic disorder, transvestic disorder, and gender dysphoria. Diagnoses such as fetishistic and transvestic disorders can label consensual and affirming practices along the diverse spectrum of sexual and gender expression as problematic. Specifically, fetishistic disorder’s criteria identify intense sexual arousal outside of heteronormative behavior as disordered, while transvestic disorder stigmatizes consensual sexual practices as abnormal based on outdated gender norms. Additionally, these diagnoses are grouped together with pedophilic disorder, thus increasing the pathologizing of diverse sexual and gender identity practices by including them adjacent to sexually violent crimes against minors. The gender dysphoria diagnosis pathologizes gender diversity,9 in contrast to the fact that gender variance “is a common and culturally diverse human phenomenon” worldwide.10
Diagnostic criteria for these disorders rest upon a requirement that the individual experiences distress related to one’s fantasies, urges, or behaviors. There is, however, a failure to acknowledge the role that societal stigma has in the creation of an individual’s distress.9 For example, the gender dysphoria diagnosis depends upon the logical outcome of cisnormativity, namely experiencing distress and struggles with navigating social and/or occupational spheres.
Unfortunately, in the current US health care paradigm, insurance and/or health care providers often regulate the access and financial coverage for life-saving gender-affirming care based on the presence or absence of a gender dysphoria diagnosis.11 In other words, social workers and other health service providers may facilitate access to gender-affirming care for transgender and/or gender-diverse clients with the assignment of a gender dysphoria diagnosis.
Cultural humility. When working with clients who are socioculturally different from themselves, providers must adopt cultural humility, a lifelong practice of openness involving self-reflection and self-critique. Additional components of cultural humility include attention to power imbalances between provider and client, as well as developing mutualistic, nonpaternalistic partnerships with communities to foster community-informed practices.13
Importantly, cultural humility asks providers to resist stereotyping and instead to stay open to differences and be client centered when approaching aspects of cultural background and identity that are salient to the client. Research shows that clients who perceive their therapist as demonstrating cultural humility report a stronger working alliance with their therapist, as well as higher levels of perceived improvement through therapy.14
Employing a stance of cultural humility will aid providers in working alongside SGD clients to provide services—including diagnoses—that are empowering rather than marginalizing.
Mindfulness and metacognition. Since all humans are subject to internal biases, it’s vital to exercise mindfulness and/or metacognition as a means of identifying these biases.15 Mindfulness—the ability to stay focused in a nonjudgmental way—has been shown to reduce correspondence bias and implicit bias and its activation, and modulate neural structures underlying the activation of prejudice.16-18 Metacognition—thinking about thinking and the practice of detaching oneself from the immediate context to reflect on the thinking process used—also shows a reduction in bias, including in situations under various sources of pressure.19
For providers who believe a bias is interfering with an ability to offer affirming care, consider the scope of practice and referring out.
Organizational changes. Research indicates that exposure to negative stereotypes and discriminatory remarks harms SGD people.5 Even with organizational antibias training and practice, such exposure for cisgender/straight people may reinforce structural and interpersonal discrimination against already marginalized groups.
The following organizational practices can help reduce the stigmatization of SGD communities:
• Use the American Psychological Association’s recommended person-first language such as “a person who identifies as queer” or “people with gender-diverse experiences.”20
• Consider linguistic styles and sentence structures that communicate respect, emphasize inherent equality, and acknowledge the wishes of the communities in question.
• Incorporate gender-diverse pronouns (they/them/theirs, xe/xem/xyrs, ze/hir/hirs, ze/zim/zirs, e/em/eirs) in all agency documents, including intake forms.
• Include “write-in response” instead of “other” in race, ethnicity, gender, sexuality, and other demographic queries in all agency documents.
• Don’t assume people’s pronouns. Instead, introduce yourself with your pronouns and invite others to do the same if they wish. Use personal pronouns instead of a blanket “they” when pronouns are known.
• Use terminology that accurately reflects the source of distress (eg, discriminatory views of and/or actions against SGD people).
• Provide staff training on sexual and gender diversity, as well as bias reduction, from reputable sources that involve diverse SGD creators and facilitators.
• Prioritize hiring diverse SGD employees.
• Ensure the availability of literature representing diverse SGD clients and salient topics (eg, a pamphlet on couples therapy should not include references and visual depictions of only heterosexual, cisgender couples).
• Organizationally commit to ongoing self-education to deepen inclusive practices and follow the ever-evolving needs of diverse communities.
Advocacy. The importance of advocating for the removal and alteration of problematic diagnoses built on pathologizing of diversity cannot be overemphasized. While steps have been taken in the DSM-5-TR to reduce stigmatizing language from the diagnosis of gender dysphoria, more work is needed to acknowledge the impact of societal stigma on individual level distress.
It is also imperative to advocate for more affirming pathways to access gender-affirming care for transgender and/or gender-diverse people. To support these efforts, social workers can advocate not only with their clients’ psychiatrists but also with the American Psychiatric Association. Including gender diverse practitioners in the task force for the DSM-6 and hearing the voices of SGD community advocates are important steps toward these goals.
It is also recommended that community members, advocates, and trained gender care mental health providers be consulted to inform social work practices.
Mindfulness, metacognition, cultural humility, advocacy, and careful, purposeful, and collaborative diagnosing that supports wider inclusion of sexual and gender diversity on personal, organizational, and macro levels are keys to reducing stigma.
— Eliot M. Lev (he/him/his) is a San Francisco Bay Area–based, equity-focused advocate, researcher, and counselor who is currently pursuing his MSW with a focus on mental health and International Social Work at Columbia University. As a multiethnic, transgender immigrant with (dis)abilities, Lev is invested in using his lived and professional experiences to advocate with minoritized communities and drive social change.
— O. Winslow Edwards, MPH, (they/them/theirs) is a multiracial, queer, and nonbinary researcher at Emory University. They completed their Master of Public Health in the Social Inequities and Health at Simon Fraser University and currently work as a public health program associate in the epidemiology department at Rollins School of Public Health.
— Jessie Rose Cohen, LCSW, (they/them/theirs) is a transnonbinary identified clinician who has worked with children, youth, families, and adults for over two decades. Trained at the University of Chicago School of Social Service Administration, Cohen serves as director of community-based clinical services and training for the University of California, San Francisco Child and Adolescent Gender Center; a group consultant/guest lecturer for the Palo Alto University LGBTQI+ Academy; and a psychotherapist and gender consultant in private practice in the San Francisco Bay Area.
— Annesa Flentje, PhD, (she/her/hers) is an associate professor at the University of California, San Francisco, focusing on research and advocacy that improves LGBTQ+ health. Flentje is a clinical psychologist who works to reduce health disparities among LGBTQ+ people through prevention, increasing visibility in research, understanding the biological mechanisms of minority stress, and developing interventions to reduce minority stress.
2. Brooks VR. Minority Stress and Lesbian Women. Lexington, MA: Lexington Books; 1981.
3. National Center for Transgender Equality. The report of the 2015 U.S. transgender survey. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Published 2016. Accessed August 1, 2018.
4. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-231.
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10. The World Professional Association for Transgender Health, Inc. https://amo_hub_content.s3.amazonaws.com/Association140/files/de-psychopathologisation%205-26-10%20on%20letterhead.pdf. Published May 26, 2010.
11. dickey lm, Karasic DH, Sharan NG. Mental health considerations with transgender and gender nonconforming clients. UCSF Transgender Care website. https://transcare.ucsf.edu/guidelines/mental-health. Published May 28, 2016. Accessed August 1, 2021.
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20. Disability. American Psychological Association website. https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/disability