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Peering into Gaps in the Diagnostic and Statistical Manual of Mental

Disorders: Student Perspectives on Gender and Informing Education

Jessica A. Joseph, Dulcinea Pitagora, Adrian Tworecke and Kailey E.

Roberts
Department of Psychology, The New School for Social Research

Abstract

At the intersection of psychology and critical theories, graduate students in

psychology are uniquely situated to analyze the pedagogical assumptions and
practices that shape constructions of gender normativity in the field. Writing
from the perspective of current students, we examine how the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition Text-Revision’s (DSM-IV-
TR) work group members represent gender in their own publications. In line with
previous criticisms, we suggest that many of the work group members uphold
traditional binary systems; perpetuate statistical reinforcement and social loops;
and pathologize (or deem developmentally lagging) gender diverse behavior. We
question whether the DSM-IV-TR has been revised by diverse voices and make
recommendations on how graduate-level curricula might broaden its pedagogy to
include more fluid and inclusive concepts of gender expression.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders-Fourth

Edition-Text Revision [(DSM-IV-TR); American Psychiatric Association (APA),
2000] is the current standard for the diagnosis of mental disorders, and is
frequently utilized by clinicians as such. Because of this, the DSM is often used
in graduate level psychopathology courses to train future clinicians in how to
recognize symptoms, as well as the frequency, duration, and alternate
manifestations of the disorders. The extent to which coursework focuses on the
language and information provided in the DSM vary, with some instructors
emphasizing its authority and others offering critiques of the manual. Students
may be taught that the specific criteria listed under disorders in the manual are
essential factors to diagnosing mental disorders, or they may be taught to rely
more on clinical judgment. Regardless of the level to which the manual’s
authority is emphasized in coursework, many students are taught that the DSM
will be an inevitable factor in their future clinical practice, particularly in
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communicating with insurance companies to ensure reimbursement for services.

Because the DSM continues to be an essential tool in the mental health field, it is
important for students learning from this manual to understand how DSM
contributors conceptualize individual disorders, disorder categories, and broader
themes such as race, ethnicity, sexuality, and gender.

As a reference source and pedagogical tool, the DSM seeks to provide

“guidelines for making diagnoses” using a collection of criteria that “enhances
agreement among clinicians and investigators” (p. xxxvii). The authors of the
manual state an intention to employ “clarity of language” and provide “explicit
statements of the constructs embodied in the diagnostic criteria” (p. xxiii).
Revisions to the DSM are conducted for reasons that include correcting flawed
information, improving its “educational value” (p. xxix), and ensuring that current
and relevant literature is represented. A text revision of the DSM-IV was
published in July 2000, eighteen years after the original DSM-IV was published in
1994. The primary goal of DSM-IV-TR was to sustain the currency of the DSM-
IV; the next major revision of the DSM will not be published until 2013.

The DSM-IV-TR task force was chaired by psychiatrist Allen Frances

with a steering committee of 27 people including four psychologists. From here,
the steering committee created 13 work groups of five to 16 members, each
assigned a primary responsibility for a section of the manual (APA, 2000).
Collectively, the work group members represented research scientists from
psychiatry, psychology, and other disciplines with experience in biology,
statistics, and genetics; others were clinical practitioners. Researchers that
informed the DSM’s revisions were selected to “represent diverse clinical and
research expertise, disciplines, backgrounds, and settings” (p. xxiii).

The work groups for the DSM-IV-TR conducted a three-step process. First,
each group conducted a broad literature review of their diagnoses (i.e., their
assigned sections). Next, they requested data from scholars and scientists,
conducting analyses to decide which criteria necessitated change. Finally, they
undertook multicenter field tests in order to connect diagnoses to clinical practice.
In arriving at the final DSM-IV-TR conclusions, the work groups reviewed
extensive empirical evidence and correspondence (APA, 2000).

Revisions to the DSM-IV began in 1997, and the DSM-IV work groups
were consulted when selecting the DSM-IV-TR work group members. The DSM-
IV-TR work groups reviewed the DSM-IV, located any errors, and conducted a
systematic review of relevant literature since 1992. These work group members
made revision drafts that were reviewed by the DSM-IV work group member
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advisers and, eventually, the American Psychiatric Association’s Committee on

Psychiatric Diagnosis and Assessment (APA, 2000). Most changes occurred in
the following sections: “Associated Features and Disorders . . . ; Specific Culture,
Age, and Gender Features; Prevalence; Course; and Familial Pattern” (p. xxx).
These sections are offered in the DSM to give clinicians a sense of frequency
ratings, patterns, and variations for each diagnosis pertaining to identifications
such as culture, age, gender, family history with the diagnosis, the disorder’s
progression, and chance of diagnosis in various settings.

The persisting tendency to link a binary conceptualization of gender to

psychopathology is an aspect of the DSM that has been frequently criticized,
particularly by feminist researchers (e.g. Marecek, 1993, 2001). It has been
suggested that diagnoses’ fixed understanding of what it means to be “feminine”
ignores personal experience and cultural contexts, propagates traditional gender
conformity, leads to inappropriate diagnoses, and pathologizes femininity.
Likewise, the DSM has been criticized for adhering to gender biased diagnostic
criteria, sampling methodology (Hartung & Widiger, 1998), and assessment
measures (Lindsay, Sankis & Widiger, 2000).

In addition to upholding narrow views of gender expression, the DSM has

also been criticized for adhering to a disease model where psychological problems
are regularly defined “in medicalized terms” (Marecek, 2001, p. 306), with little
emphasis given to socially constructed categories or roles (e.g., gender or
ethnicity). Interestingly, while the DSM (APA, 2000) warns that “a clinician who
is unfamiliar with the nuances of an individual’s cultural frame of reference may
incorrectly judge as psychopathology those normal variations in behavior, belief,
or experience that are particular to the individual’s culture” (p. xxxiv), no such
caveat is made for the construct of gender. As aspiring clinical psychologists
whose training in psychopathology has centered on the DSM, we find this
exclusion of gender especially problematic, given that the DSM often reports
gender differences within diagnostic descriptions; these differences are referred to
as differential prevalences. For example, when discussing gender features
associated with major depressive episodes, the DSM states that “women are at
significantly greater risk than men to develop Major Depressive Episodes at some
point during their lives” (p. 354), but without any critical discussion of why this
might occur. In other words, such an inclusive gender difference statement fails
to acknowledge individual experiences and/or social constructions that might
explain findings of heightened depression among women.

While we acknowledge that the DSM has been well-critiqued for its
portrayal of a restricted, fixed, and essentialist model of gender, we present an
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alternative account from the student perspective. We seek to better understand

how contributors to the DSM have conceptualized and incorporated gender into
their personal research. We question whether the DSM has adequately
represented “diverse . . . research expertise” (italics added for emphasis; APA,
2000, p. xxiii) when selecting work group members for revision. We are also
interested in bringing into question the disconnect between graduate level
psychology pedagogy (which is largely influenced by the DSM) and the
underutilized literature that reflects a more nuanced and fluid concept of gender.
We cannot speak for all graduate programs and can only speak to our personal
experiences as graduate students of psychology. However, diagnostic assessment
and conceptualization of mental disorders is a component of APA accreditation of
graduate programs (APA, 2009); this, coupled with the fact that the DSM is the
current standard for mental disorder diagnosis, it stands to reason that most
graduate psychology programs not only rely but also focus on the DSM.

In the interest of offering clearer definitions of concepts often misused and

misunderstood, we broadly define “sex” as the physical attributes of the body, and
“gender” as the behavior and psychological phenomena that are associated with
one’s self-identified sex. These definitions emphasize the two concepts’
uniqueness from one another and their necessary coexistence. We find Jordan-
Young’s (2010) likening of sex, gender, and sexuality to a three-ply yarn apropos
in that the strands are “simultaneously distinct, interrelated, and somewhat fuzzy
around the boundaries” (p. 16). While the biology of sex and the social aspect of
gender overlap, Jordan-Young asserts that they are still distinctly separate pieces
of the puzzle. The three-ply yarn analogy also suggests the importance of an
individual’s personal interpretations of the three spheres and their interconnection.
In other words, the interactions between one’s physical body, sexual desires, and
the societal norms influencing those interactions are crucial to how one conceives
the meaning of gender.

To be clear, we do not claim that gender is necessarily qualified by sex [as

implicated in Money and Ehrhardt’s (1972) definition of gender roles and gender
identity]. Instead, we consider sex as not immune from gender’s influence (e.g.,
consider the child who is intersex and is raised as a girl or as a boy). Kessler
(1998) highlights the power of gender relative to that of sex: “Everyday world
gender attributions are made without access to genital inspection. . . . There is no
sex, only gender, and what has primacy in everyday life is the gender that is
performed, regardless of the flesh’s configuration” (p. 90). Additionally, we
consider sex and gender to be socially constructed concepts (Kessler, 1998;
Kessler & McKenna, 1985; Lorber, 1994).
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Though we feel a clarified and inclusive definition of gender is paramount,

we do not consider gender categorical or fixed in nature. Gender is neither
necessarily best exemplified by a binary (i.e., either the masculine or the
feminine), nor is one’s gender identification necessarily stable over time (Fausto-
Sterling, 1999; Hare-Mustin & Marecek, 1994). We view gender as a construct
residing in a fluid, multidimensional space in which it influences and reacts to
sex, as opposed to one that can be mapped onto a linear continuum marked by
polarities (Fausto-Sterling, 2000).

In examining our conceptualization of gender and its intersect with the

literature that informs the DSM, we found Drescher’s (2010) association of the
former DSM diagnosis of homosexuality with the current DSM-IV-TR diagnosis
of gender identity disorder (GID) to be particularly relevant. Drescher explains
this association in terms of three etiologies (normal variation, pathology, and
immaturity), which we also find applicable to a broader conceptualization of
gender nonconforming behavior. Theories of normal variation assume that
specific phenomena—such as gender diversity—are natural, similar to the way
that left-handedness is considered natural, albeit less common. Because of this
normalized viewpoint, theories of normal variation would protest such
phenomena’s inclusion “in a psychiatric diagnostic manual” (p. 432). Theories of
pathology conceptualize such phenomena within a disease model framework.
This implies that gender identifications varying from the traditional binary result
from biological defect or environmental maladies. Theories of immaturity
consider such phenomena part of a twofold process. If gender nonconformity is
evident in childhood, it is a result of a “passing phase that one outgrows” (p. 432).
However, if by adulthood one is still behaving in a gender nonconforming
fashion, theories of immaturity assume that the individual is stunted or
developmentally lagging. We find the theories of pathology and immaturity to be
unacceptable, and align ourselves with theories of normal variation.

In light of this conceptualization of gender and understanding of etiologies

of gender diversity, we focus on how the DSM contributors have portrayed gender
within their own publications that are not directly associated with the DSM. We
consider examining their own work suggests the extent to which they actually
“represent diverse . . . research expertise” (APA, 2000, p. xxiii) in relation to
portraying and discussing gender. We then integrate our review of the DSM
contributors’ research with a discussion of graduate level psychology coursework
and literature focusing on more fluid concepts of gender.

Review of DSM Contributors’ Literature

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Discussion of Approach to Literature Review

To investigate those that inform the DSM-IV-TR (APA, 2000), we focused

on literature authored by work group members as listed in the front of the DSM-
IV-TR in the “Work Groups or the DSM-IV Text Revision” subsection. The
literature search was limited to articles published between 1994 and 2000 to
reflect the body of work published between the DSM-IV and DSM-IV-TR.
PsycINFO database was used to conduct the literature review. Work group author
names were searched for, as well as their particular work group “disorder”
category and/or diagnosis, and the keyword gender. Because we were focused on
the work group disorder and gender, our literature review produced approximately
sixty articles. These were spilt between the authors and reviewed for how the
authors portrayed or discussed gender. Articles by the work group authors were
considered applicable to the current review regardless of authorship order. Efforts
were made to ensure that all articles falling under the above criteria were
identified. The purpose of the literature search was not to be exhaustive, but to
gain a general idea of how the DSM-IV-TR work group members write about and
conceptualize gender in their own research. After conducting the literature search
in the manner described above, the authors grouped each article under three
themes: gender binary, locus of distress, and developmental lag. We were
influenced by Drescher’s (2010) theory of immaturity described earlier when we
began organizing the examined articles into the developmental lag theme.
However, this theme, along with the other two, was not predetermined until after
the retrieved literature was examined and discussed among the authors. In the
following sections, all referenced publications are authored by DSM-IV-TR work
group members.

The Gender Binary: An Impediment to Pedagogy

Our research revealed a tendency for the DSM contributors to routinely

confound the constructs of sex and gender by using them in an inconsistent and
incorrect manner. Confusion within and between these constructs propagates the
use of the terms as interchangeable, produces a focus on one pole of the binary or
the other, and reinforces the binary within the literature. In doing so, a vital
acknowledgement of normal variation is denied.

The use of the terms sex and gender in the contributors’ publications are
not clearly defined and are not used in context. There are instances when the
terms are used interchangeably to relate to biological sex characteristics. For
example, in Hollander’s (1995) editorial review of behavioral response to
pharmacological challenges, the term gender is used in place of sex, and “woman”
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and “man” are used instead of “female” and “male.” This transposing of
terminology can also be found in numerous articles dealing with biology and
schizophrenia (e.g. Jeste, Lindamer, Evans, & Lacro, 1996; Zisook et al., 1999;
Lindamer, Lohr, Harris, & Jeste, 1997; Ho, Andreasen, Flaum, Nopoulos, &
Miller, 2000). According to an article by Lindamer et al. (1997), “a literature
review examining gender differences in schizophrenia found that 72 percent of
the studies appearing in four major journals from 1985 to 1989 included more
male than female subjects” (p. 221). The authors use the term gender and the
terms male and female in the same sentence, blurring the distinction between sex
and gender, in effect assigning them the same definition.

Conversely, there are instances when both sex and gender are used to refer
to the psychological expression of gender and associations with gender roles, such
as in studies examining behavioral differences in those diagnosed with mood
disorders or gender identity disorder (e.g., Brooner, King, Kidorf, Schmidt, &
Bigelow, 1997; Zucker et al., 1997). While there has been mention of the
difference between sex and gender within the literature surrounding gender
identity disorder, the potential for progress is eclipsed when the authors stress the
need to “maintain continuity with the extant literature” (Zucker, et al., 1999, p.
476) by using the word gender in cases where sex may be more appropriate. This
choice to maintain continuity instead of elaborating upon differences further
muddles the variables of sex and gender, and denies a crucial opportunity to
adhere to more appropriate usage of the terms and set an example for further
research and graduate-level psychology curricula.

The DSM contributors tended to default to the use of binaries such as

“man/woman” and “girl/boy.” The oversimplification of gender as presented in
this stark, heteronormative manner is widespread, and leads to the deleterious
consequence of leaving the complexities of gender out of the discussion.
Verbiage such as “both sexes” and “cross-gender” indicates and upholds a strict
adherence to the binary (e.g., Wallace & Pfohl, 1995; Kornstein et al., 2000).

A useful discussion of alternative and acceptable gender behavior is often

times missing in articles pathologizing gender identity disorder (e.g., Zucker et
al., 1997). For example, in Zucker’s (2000) “Commentary on Walter and
Whitehead’s 1997 ‘Anorexia Nervosa in a Young Boy with Gender Identity
Disorder of Childhood: A Case Report,’” rigid guidelines are set forth regarding
what constitutes appropriate behavior for a boy and what constitutes appropriate
behavior for a girl. Interest in Barbie dolls, interacting with female peers, having
long hair, and wearing dresses are all considered definitively feminine in nature.
In contrast, the young boy is deemed effectively cured of gender identity disorder
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when he begins to engage in “stereotypically masculine behaviors” (Zucker, 2000,

p. 236), such as having friends that are boys, playing hockey, and emulating
males in fantasy play. This case study suggests that one must adhere to the
societal norms of being a boy or a girl without exception, and illustrates the fixed
nature of gender portrayed by some of the DSM contributors.

The Looping Locus of Distress

In the majority of the publications we reviewed, differential prevalences of

most diagnoses were referenced solely in terms of the gender and/or sex binary.
An additional problem exists in the absence of explanation for these prevalences;
there is rarely any discussion of their origin or significance. This effectively links
certain mental disorders with sex or gender, creating bidirectional, self-fulfilling
prophecies that ensure a pathologizing and obfuscating link will remain intact.
We propose that the self-fulfilling prophecies created by the omission of
important information (such as unique experiences and the intersection of social
constructions with diagnoses) can be described in terms of two reinforcement
loops: a statistical loop (in which statistics are reinforced by diagnoses that are
influenced by statistics), and a social loop (in which societal tendencies to
pathologize gender diversity both reinforce bias and are influenced by bias).

An example of the statistical loop can be found in Jeste et al.’s (1996)

article on the relationship of ethnicity and gender to schizophrenia and
neuroleptics, stating that “in general, women have later onset of schizophrenia,
more positive symptoms, fewer negative symptoms, better therapeutic response to
neuroleptics, and better outcome” (Jeste et al., 1996, p. 246). These sex
differences are mentioned most often without elaboration. While this article
discusses estrogen as a potential mediating factor for schizophrenia, the authors
note that there has not been enough research from which to draw significant
conclusions. In other words, mere exposure to published prevalences likely
propagates a tendency to diagnose patients in accordance with familiar sex or
gender prevalences (or some conflation of the two; e.g., estrogen is associated
with biological sex, not necessarily gender). It follows that sex or gender is
linked directly to psychopathology via statistical prevalence. In order to
understand the significance of differential prevalences, more information is
required to clarify whether they relate to either sex or to gender—or to both or
neither sex and gender—and specifically whether and how they might relate
biologically or behaviorally to a given disorder. Without this information,
published differential prevalences serve to confound rather than inform.
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Among the contributors’ publications, differential prevalence is widely

reported in depressive disorders, in reference to rapid cycling (e.g., Bauer et al.,
1994); dysthymia and chronic depression (e.g., Berndt et al., 2000); and
comorbidity with alcoholism (e.g., Cornelius et al., 1995). Another category with
frequent differential prevalence reports is the schizophrenia spectrum. One study
conflates the terms sex and gender when describing differences in brain structure
and function in individuals with schizophrenia (e.g., Flaum, Andreasen, Swayze,
O’Leary, & Alliger, 1994); another study uses the term gender instead of sex to
report an association with poor outcome in males (e.g., Ho et al., 2000). In the
DSM category of sexual and gender identity disorders, there seems to be a
persistent focus on associating pathology with feminine traits in males, as well as
a tendency to conflate the terms sex and gender when describing differential
prevalences (e.g., Blanchard, Zucker, Bradley, & Hume, 1995; McDermid,
Zucker, Bradley, & Maing, 1998; Zucker et al., 1997). A few cases found in the
literature we reviewed attempted to unpack sex and/or gender differences,
explaining them in terms of individual behavior differences or environmental
influences. In a study comparing gender differences in social phobia, an
exploration of the origin of differential prevalence was touched upon, but in the
end reverted to an assumption of gender role adherence (e.g., Turk & Heimberg,
1998). Similarly, a study investigating gender differences in posttraumatic stress
disorder opened the door to a discussion regarding the type of trauma that might
affect women more so than men, but left it to future research recommendations to
finish the conversation (e.g., Stein, Walker, & Forde, 2000). When differences
are published without adequate clarification, they might be doing more harm than
good by propagating a statistical reinforcement loop.

In addition to a lack of discourse on variations of gender expression,

pathologizing language used to describe nonconforming behavior places the locus
of distress in the individual, instead of on external influences such as societal
pressure to conform. Blaming words infiltrate the reviewed literature in terms
that are laced with connotations of pathology. For example, the term “social
deviance” is equated with “non-normative behavior” (e.g., Brown et al., 1996)
and “gender variant behavior” with “de-identification.” In using the term “gender
dysphorics” to refer to “individuals with gender dysphoria,” individuals are
reduced to an embodiment of their disorder (e.g., Blanchard et al., 1995;
Blanchard et al., 1996).

Another bidirectional loop that occurs when sex and gender differences
are presented without explanation involves the reinforcing of societal tendencies
to pathologize gender nonconformity. This loop of social reinforcement cycles
between mental health professionals and the general public; for example, control
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groups often reflect the heteronormative population, and, by definition,

pathologize gender nonconforming individuals (e.g., Blanchard et al., 1995;
Blanchard, Zucker, Cohen-Kettenis, Gooren, & Bailey, 1996; Brown, Wise,
Costa, Herbst, Fagan, & Schmidt, 1996). The loop continues between individuals
and society, as exemplified in a study analyzing the social undesirability and
maladaptivity of certain personality traits in contrast to preferable “normative”
gender roles (e.g., Sankis, Corbitt, & Widiger, 1999). The loop also connects
society, mental health professionals, and students training to be clinicians; biases
and pathologizing language used in the publications that inform mental health
professionals and clinicians-in-training may not adequately reflect changing
societal attitudes (Hartung & Widiger, 1998). The progression and evolution of
societal attitudes at both training and professional levels could very well be
slowed as a result.

Though sex and gender differences are widely reported among the
reviewed publications, little attention is given to ways in which disorders might
manifest differentially from individual to individual. Specifically in the case of
reported sex differences, most of the DSM contributors’ publications do not
attempt to explain whether these statistics actually refer to gender differences, or
whether they might equate to gender biases in mental health professionals and the
assessment instruments they use. Though few and far between, it is heartening to
find exceptions in the literature that do attempt to address these issues. For
example, Hartung and Widiger (1998) point out that studies highlighting sex
differences do not use adequately representational samples, but instead use
samples that focus on a particular gender that has historically been associated with
a given disorder. Lindsay and Widiger (1995) suggest the criteria derived from
such research may propagate the under- or over-diagnoses of disorders, such as
dependent and borderline personality disorders in females, and antisocial and
paranoid personality disorders in males.

The statistical loop that reinforces inaccuracies in sex and gender

differences cannot be corrected without addressing the existence of gender bias.
In particular, diagnostic criteria have been a controversial, if understudied, target
of scrutiny in terms of such bias (e.g., Hartung & Widiger, 1998). Lindsay and
Widiger (1995) examined the potential for over-diagnosis due to sex and gender
bias based on correlations between sex or gender role and nonpathological items
in commonly used instruments to assess Axis I and Axis II disorders of the DSM
as well as those used to generate personality profiles (such as Millon Clinical
Multiaxial Inventory-II; Minnesota Multiphasic Personality Inventory; and the
Personality Diagnostic Questionnaire-Revised; MCMI-II, MMPI, and PDQ-R; as
cited in Lindsay & Widiger, 1995). They found that many items in these
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instruments more frequently predicted sex or gender roles than personality

dysfunction, rendering them less effective than their intended design.
Unfortunately, despite an effort to use the terms “sex” and “gender” distinctly
(“sex and gender bias” and “sex or gender”are used throughout the paper,
including in the title), Lindsay and Widiger (1995) use the term sex bias to refer
to what appears to be gender bias. In doing so, they somewhat dilute their effort
to exemplify and indicate sex and gender bias by confounding the two.

In a follow up study by Lindsay et al. (2000), a broader range of

personality assessment instruments were analyzed. Their original results were
corroborated—many of the items were potentially gender-biased in that they
related more to the individual’s gender than an expression of dysfunction.
Lindsay et al. also clarified that their criteria pertained specifically to gender (and
not sex) biases by referencing Widiger and Spitzer’s (1991, as cited in Lindsay et
al., 2000) explanation that “the first criterion for gender bias is necessary because
the presence of a differential prevalence rate across the biological sexes does not
itself identify the presence of a gender bias” (p. 219). The overriding theme
seems to be a lack of attention to the fact that individuals of diverse gender
expression can be well adjusted, though they may not express the stereotypically
feminine or masculine traits expected of them by a predominantly
heteronormative society. The tendency to reinforce gender bias and pathologize
gender diversity places the blame on nonconforming individuals, and ignores the
possibility that distress can be caused by societal disapproval of nonconforming
behavior.

There is likely no transparent answer to the question of where distress and

dysphoria originate, within the individual, or from external sources such as
societal disapproval of deviation from the norm. There is dissonance between the
contributors’ works, which alternately suggest that individuals are distressed as a
result of their “problem” (e.g., Bradley & Zucker, 1997), and that there are
individuals who are not distressed by their own behavior or lifestyle, but seek
treatment nonetheless to appease those around them (e.g., Brown et al., 1996). As
students of psychology, we are often taught that there is a bidirectional interaction
between an individual and the environment, which can result in adaptive or non-
adaptive psychological manifestations. It stands to reason that the same literature
that might inform the diagnostic practices outlined in the DSM-IV-TR might also
contribute to a societal viewpoint that could exacerbate the onset of certain
disorders, as well as influence sex or gender differential prevalences, and
contribute to the perpetuation of blaming and pathologizing the nonconforming
individual. In other words, the stress of living in a society that does not
acknowledge—much less make an effort to understand or embrace—diversity in
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sex differences or gender expression may contribute directly to distress, the very
distress that is a required diagnostic criterion. The lack of effort in changing this
trend in the literature reviewed could in effect be seen as causing harm to
individuals.

Developmental Lag

While the DSM contributors’ publications on personality disorders appear

to take a more inclusive and critical stance on gender, there were notable
instances where gender diversity was painted as developmentally lagging—
similar to Drescher’s (2010) theory of immaturity. Overall Widiger (1998) and
Lindsay and Widiger (1995) emphasize that not one gender role is more mature or
less pathological. Instead, they suggest that all symptoms of personality
disorders, including those that are more associated with one gender, are
maladaptive variants of normal traits. Yet, Lindsay and Widiger (1995)
demonstrate that certain diagnostic criteria of personality disorders, such as
borderline and dependent, are more concordant with the feminine gender role and
therefore more likely to be assigned to a woman who identifies with the feminine
gender role. In this mode of thinking, if men and women are assumed to identify
with their stereotypical gender role, and they do not meet what is expected of that
role or they display extreme variants of traits associated with that gender role,
then they may be deemed developmentally lagging or abnormal.

Within the reviewed literature, theories of immaturity are most prominent

in articles investigating gender identity disorder (GID). For example, studies on
the relationship between birth order and homosexual males with GID suggest that
non-normative variation in these males is associated with being the younger son
in a family (e.g., Blanchard et al., 1996; Zucker et al., 1997). In being paired with
birth order, GID and homosexuality are connected to development, and in
emphasizing that the normative gender development literature does not find the
same association between birth order and feminine traits in males, Zucker et al.
(1997) imply that this developmental course is in some way non-normative. It
should be noted that homosexuality, no longer a DSM diagnosis, is used in these
studies as another category of deviation by default when it is paired with GID as a
combined category of disordered gender expression. An expression of sexuality
that is considered healthy and normal should not be used to further differentiate
and problematize development. Furthermore, explanations for the birth order
findings vary and include maternal stress during pregnancy, maternal-paternal
hormone levels, and chromosomal differences (e.g., Blanchard et al., 1995;
Blanchard et al., 1996; Zucker et al., 1997). In connecting the birth order finding
with biological origins, the articles suggest that the relationship between birth
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order and GID may be due to an early developmental and biological abnormality.
However, as Drescher (2010) points out, these types of assertions were once
applied to the prior “disorder” of homosexuality, though it was eventually
acknowledged to be a normative sexual orientation and was ultimately removed
from the DSM. Gender identity disorder, then, seems to have fallen prey to
pathologization in the same way, and seems to be following a similar trajectory
(Drescher, 2010).

Blanchard et al. (1996) propose that the birth order finding can be
explained by the de-identifying theory, which suggests that in a two-brother
sibling pair, the older brother may take on more masculine traits and, in order to
de-identify with the older brother, the younger brother may become more
feminine. While Blanchard et al. (1996) do not present this as developmentally
abnormal behavior, they do suggest this birth order effect can contribute to the
development of GID, which by its very name is associated with “disorder.” Thus,
de-identifying could be seen as a developmentally immature way of coping with
same-sex sibling rivalry. By associating “de-identifying” with “disordered”
gender presentation, these articles suggest that normative development involves
identifying with what is stereotypically expected and supported by society, thus
presenting gender as a rigid binary. While this may be the view of some
researchers, it is essential for the researchers contributing to the DSM to take a
more objective and encompassing stance on socially sensitive and provocative
issues within their own research.

The concept of gender immaturity is also seen in Zucker and colleagues’

(1999) study investigating the hypothesis that a lack of gender constancy (i.e.,
when gender identity is not consistent with assigned sex) in children with GID is
influenced by cognitive immaturity. Zucker et al. (1999) suggest that children
with GID experience a developmental lag in gender constancy, but in rate of
acquisition, not sequence of acquisition (stages including gender discrimination,
identity, stability, and consistency). While this finding may be valid within the
context of the study, it is not clear why a lack of gender constancy would be
equated with a developmental lag. In their study on girls with GID, Fridell,
Zucker, Bradley, and Maing (1996) also present the view that the source of
gender diversity may be identified in physical developmental factors. Fridell et
al. (1996) found that, when blind-rated, females with GID were judged as less
physically attractive. They suggest that gender-appropriate physical
attractiveness influences the gender identity development of children by
contributing to differing social interactions (i.e. masculine-appearing females may
develop more masculine social traits). While it is plausible that others may then
treat a stereotypically masculine-appearing female as if she also has masculine
 117 
 

personality traits and in turn internalize these traits, this relationship between
appearance and personality is not necessarily the case for all individuals. For
example, masculine-appearing females can also develop feminine personality
traits. Thus, the discussion of findings in both of these studies implies a
somewhat rigid, limited, and dated view of gender that does not allow for the
possibility that children (and adults) with GID might simply have more fluid ways
of expressing gender that can not be attributed to physical appearance or
socialization in a straightforward manner.

The purposes and findings of Zucker et al.’s (1999) study seem to imply
that viewing gender as constant is the normal or healthy pattern of gender identity
development. Similarly, the findings of Fridell et al. (1996) suggest that girls
must conform to a stereotypically feminine physical appearance and dress to be
considered on target for gender identity development. The idea that gender
constancy is necessary for normative development is highly problematic,
particularly when an adult who did not develop in this manner is faced with a
potential psychiatric diagnosis. If individuals who identify as a gender other than
what is offered in the binary are seen as deficient in their early childhood
development, it ostensibly follows that they might be diagnosed with a mental
illness, GID. However, it is important to consider whether this view of
development is based on an objective path of development or social biases. While
these studies may not have been conducted with the intention of reinforcing a
rigid view of non-normative gender variation as a product of immature
development, the fact remains that they may perpetuate social biases toward a
strict binary concept of gender.

Conclusions, Consequences, and Suggestions

In examining the aforementioned literature published by some of the

DSM-IV-TR work group members, we came to three broad conclusions regarding
the publications’ representation of gender. First, much of the literature we
encountered failed to differentiate between sex and gender, and reinforced the sex
and gender binaries as “normal” while simultaneously normalizing a specific
pairing of gender and sex (e.g., the feminine gender with the female sex). Such
adherence to traditional binaries and binary pairings stifled discussion of
normalized gender diverse behavior. Second, through statistical reinforcement
and social loops, the locus of distress is placed on those expressing gender
nonconforming behavior, without acknowledging that distress might originate
from societal pressures to conform to the gender binary. While biases within
diagnostic criteria and assessment measures were sometimes noted, they still
failed to clearly differentiate sex from gender, or acknowledge that individuals
 118 
 

expressing gender nonconformity can be well adjusted. Finally, a fixed concept

of gender that can only be achieved through the traditional binary was reinforced;
those expressing gender diverse behavior were assumed to be developmentally
delayed or lagging, having failed to “achieve” a stable gender in accordance with
the binary.

Given these observations, we conclude that the DSM-IV-TR (APA, 2000)

has fallen short of its goal to select work group members that “represent diverse . .
. research expertise” (p. xxiii). While the DSM indicates that a pathological
behavior or pattern must cause dysfunction in the individual and must not be the
result of an incompatibility between the individual and society, we suggest that
many of the reviewed DSM contributors contradict this qualification by
reinforcing a gender binary that excludes and pathologizes gender diverse
behavior that does not conform to societal standards.

The Danger of Gender Biases and Differential Prevalences

Because of the lack of information regarding the differential gender

prevalences noted in the reviewed publications of the DSM contributors, it is
difficult to ascertain whether they provide anything more than a convenient way
to group characteristics based on traditional stereotypes. Indeed, Hare-Mustin and
Marecek (1994) suggest that such gender prevalences only serve a topically
descriptive function that fails to detail “the processes involved in the
psychological phenomena under scrutiny” while giving such prevalences
“prescriptive force” (pp. 533-534). It may be useful to highlight certain
prevalences found in certain disorders, but it seems preferable to specify the
behavior(s) rather than use gender prevalences, which serve to emphasize a
collection of behaviors that cannot possibly apply broadly to the general public
and account for individual differences. Likewise, Chodorow (1996) suggests that
when gender is denied its uniqueness for each individual, gender diversity is
overlooked, and such a disregard for diversity results in overgeneralizing, then
universalizing, and possibly essentializing gender expressions.

The problem of sex and gender bias appears to be so pervasive—within

the publications of the work group members that inform the DSM, the DSM itself,
as well as in academia in general—that the prospect of addressing it is daunting.
As suggested in Lilienfeld, Wood, and Garb’s (2006) paper discussing the
persisting use of questionable instruments, it seems likely that de-biasing is
impeded by clinical tradition and educational inertia, and that researchers,
educators, and students too often succumb to the ad populum fallacy: “the
erroneous belief that a technique that is widely used must be valid or effective”
 119 
 

(p. 11). Perhaps many in the mental health field do not feel that addressing sex
and gender biases is of particular urgency. Alternatively, perhaps they feel that
the prospect of eradicating sex and gender biases from empirical studies and the
DSM would be such an enormous undertaking and create such a dramatic change
in the tone of the DSM and other literature related to psychopathology that it
would simply be too risky.

Having said that, we should as a field, at minimum, engage in discussion

and recognize that there is an issue to be investigated. It would certainly be an
arduous and perhaps impossible process to reanalyze historical data in terms of
specific characteristics or behavioral traits instead of sex or gender prevalence. A
more realistic opportunity might exist in veering away from the automatic
tendency to analyze by sex or gender, and moving forward by incorporating other
sorts of determinants in data collection processes that might better relate to
differential prevalences. At the very least, we believe the field should attend to
Hare-Mustin and Marecek’s (1994) call to move away from categorical
descriptions of gender toward more appropriate means of research that examine
the “ongoing relations of privilege, power, subordination and rebellion among
individuals provisionally demarcated by their gender” (p. 534).

Reclaiming Education

We do not claim that the DSM upholds traditional binary systems;

perpetuates statistical reinforcement and social loops; and pathologizes (or deems
developmentally lagging) gender diverse behavior merely because many of the
studies conducted by the work group members do. However, it is apparent that
the DSM has failed to include diverse work group member voices in relation to
gender and who, instead, pathologize normal variations. Because the DSM is one
of our primary learning tools as graduate students of psychology, we find this
particularly problematic, given that it has failed to maintain a certain level of
diversity and objectivity.

Because of this, we suggest that graduate coursework incorporate

alternative viewpoints encouraging students to critically examine how gender is
portrayed. We wish to see the literature that informed our conceptualization of
gender as presented above offered as a legitimate lens within all of our
psychology courses, not merely in classes that focus on feminist psychology or
gender. Furthermore, we take “legitimate lens” to mean an underlying theme
incorporated into the core of the course, not simply represented by a few
interspersed articles. This is similar to Marecek’s (1993) suggestion that courses
“mirror more closely the multiplicity of approaches and points of view in the field
 120 
 

[of gender], its multifocality and the honest differences among working
psychologists” (p. 121). We believe our programs should mandate courses that
focus on varying theories with regard to gender diversity and gender within
mental health, preferably toward the beginning of curricula to ensure students
have a solid foundation with which to critically approach gender within
psychopathology.

We would also like our clinical training to discuss theories of normal

variation, as critically studying gender means little if not applied in practice. As
clinicians-in-training, we must be taught about abnormal and normal presentation.
There is generally little discussion within coursework regarding how gender
diverse behavior can be presented as normal. Educators are not to blame, per se;
they are held hostage by a system that compels them to rely on a reference
material and learning tool fraught with and informed by individuals that may hold
a constricted, fixed, and binary view of gender. While we support such
modifications to clinical training and coursework, we suggest that further research
be done to understand if educators and fellow students consider such alternative
teaching models to be feasible and desirable.

It stands to reason that unexplained gender prevalences will prevail, at

least in the near future, especially given that the DSM-V work groups include
several of the DSM-IV-TR work group authors referenced here (APA, 2000; APA,
2010). Instead, our objective is to encourage educators and students alike to
question how gender is presented, and demand that a more inclusive,
multidimensional, and fluid concept of gender be discussed and incorporated
within graduate-level psychology pedagogy as well as among those that inform
the DSM.

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Author Biographies:

Jessica A. Joseph is a doctoral student in clinical psychology at The New School

for Social Research. Her research interests include motherhood, the maternal
body and psychological outcomes in relation to social constructions such as
gender, power, culture and oppression; gender diversity in psychology pedagogy
and practice; and fat studies. As the current Statue Foundation Fellow at NSSR,
she assists in promoting diversity awareness and social justice within academic
and clinical settings. She has multiple academic publications and has presented
her research at the Association for Women in Psychology and the National
Transgender Health Summit.
 126 
 

Dulcinea Pitagora holds a Master of Arts in Psychology from the New School
for Social Research, and and is currently pursuing a Master of Social Work from
New York University toward LCSW licensure. Pitagora has published articles in
peer-reviewed journals on the topics of alternative sexuality and gender diversity,
and has presented at the Association for Women in Psychology, National
Transgender Health Summit, Popular Culture Association/American Cultuer
Association, and American Psychosocial Oncology Society conferences on these
topics as well as health psychology. After obtaining an MSW, Pitagora plans to
pursue a research Ph.D. human sexuality from Widener University.

Kailey Roberts is a doctoral student in clinical psychology at The New School

for Social Research. Her research interests include bereavement, psycho-
oncology, sexuality and gender, and existential psychotherapy. Currently, Kailey
is engaged in research on cancer-related bereavement at Memorial Sloan-
Kettering Cancer Center where she is supported by an NIH pre-doctoral training
grant. Kailey intends to pursue a career as a clinician in a medical setting while
continuing to conduct research. To date, she has co-authored a paper and posters
on meaning-making following the loss of a child to cancer, with a particular
emphasis on the role of spirituality and religion.

Adrian Tworecke holds a Master of Arts in Psychology from the New School for
Social Research, and is currently pursuing her doctoral degree in Child Clinical
and School Psychology at Pace University. Her research interests include the
psychological and cultural influences on women’s development and identity; how
social media effects women's self-esteem and body image; and issues concerning
sex, gender, and sexuality. Adrian has presented at the Association for Women in
Psychology and the American Psychosocial Oncology Society conferences on
these topics as well as health psychology. Adrian is currently continuing her work
on women’s issues under the direction of Dr. Florence Denmark.