Biological reductionism in psychiatry obscures and trivializes social factors that play a crucial role in the development, expression, treatment, and consequences of the illness.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association is widely used as a psychiatric diagnostic system in many countries.
Sex/Gender bias in classification of mental disorders and problems that arise from it are reflected in both the diagnostic criteria and the epidemiological data. DSM is criticized for over-representation of women in certain diagnostic categories in each edition. Feminist scholars on mental health organized a protest against DSM around mid-1980s and criticized the three new diagnostic categories, namely Masochistic Personality Disorder, Premenstrual Dysphoric Disorder, and Paraphilic Rape (which later was referred to as Paraphilic Compulsive Disorder, Sexual Sadism Disorder) recommended to be included in DSM-III-R. Additionally, despite numerous evidence against them, none of these categories were rejected. Criticisms towards DSM span from sex/gender bias issues due to psychoanalytic approach to labeling illnesses that are traditionally accepted to be feminine as pathological features, for example, specific diagnosis such as Depression, Premenstrual Dysphoric Disorder, and Histrionic, Dependent, and Borderline Personality Disorders.
The fact that diagnostic criteria consist of those that can only be experienced by women is suspected to cause different rates of diagnostics between women and men. As an example, diagnostic of Somatization Disorder that evolved from “hysteria” consists of sex/gender bias in its early foundations. While a criterion specific to men (erection or ejaculation problems) were added to DSM-IV to ensure its independence from sex/gender, some criteria specific to women were removed, as others were retained.
The history of psychiatry bequeathed biological reductionism to understanding the causes of mental disorders by locating them inside the body of an individual rather than adopting a holistic relational and contextual approach. The classical example of such an approach is how “hysteria”, defined as a mental disorder, was linked to uterus and sexual intercourse. This reductionism in psychiatry obscures and trivializes social factors that play a crucial role in the development, expression, treatment, and consequences of the illness. Not taking social factors directly related to certain assigned roles to women into account represents a certain “gender blindness”. This gender blindness and prejudice affects both men and women. In other words, there are certain socially accepted patterns of behavior: What is expected of men is that they refrain from sentimentality, focus on what they are doing, be competitive and independent individuals. On the other hand, women are expected to put others before themselves, their needs and demands, be emotional and relatively more passive individuals. If clinicians cannot match their findings with the person’s sex, they can consider these findings pathological.
For example, Möller-Leimkühler (2005) argues that emotional expressions in a depressive man or aggressive behaviors in a depressive woman do not align with traditional gender characteristics and that the discrepancy could lie in a misdiagnosis of Major Depressive Disorder. A study that looks at effects of sex/Gender-bias in personality disorder diagnoses showed that clinicians were more often inclined to diagnose women to have Histrionic Personality Disorder than Antisocial Personality Disorder despite the fact that women met the diagnostic criteria for the latter.
Five paraphilic disorders in DSM-I are listed under sexual deviation title, and “rape, sexual assault and mutilation” are provided as examples of sexual sadism. While rape was listed as a form of sexual sadism, it was removed from that category in DSM-II.
The early DSMs categorized homosexuality under “sexual deviations”. Homosexuality was removed from the category of paraphilias in DSM-III but continued to be mentioned under “Other Psychosexual Disorders” as “Ego-Dystonic Homosexuality”. It is not until 1987 that it was completely removed DSM with the publication of DSM-III-R. Additionally, prior to 1987, this diagnostic system was criticized for its attitude towards homosexuality, and not differentiating between the concepts of gender and sex for a long time.
It is important to underline once again that the language of DSM is heterosexist and closely linked to concepts of gender, patriarchy, and power. In this context, it would not be wrong to claim that the language of translation manifests that “dominance”. An example of that would be the decision to translate “partner” as “spouse” in the Turkish translation of DSM.
Among other criticisms of DSM is the prioritization of neurobiological framework over sociopolitical context. It is usually highlighted that the effect of how a space becomes hostile or renders someone vulnerable should be included among the diagnostic criteria for women’s fear or anxiety of open spaces, agoraphobia. Feminist writers state that the place of abuse is an important factor of somatization (expressing mental distress as physical symptoms) in women. It is said that most DSM categories have limited international applicability or a genuine multi-cultural perspective. Non-western feminist critique of DSM focus on applicability of specific diagnostic categories such as eating disorders.
Researchers and clinicians claim that this manual is founded on a cultural understanding of mental health and illness of the West, or rather, that of an Anglo-Saxon centric, white, middle class. It is emphasized that DSM ignores experiences of non-white women of diverse ethnicities and lacks sensitivity for cultural and gender experiences in its diagnostics.
It is important to put a couple of DSM diagnostic categories under the microscope. Premenstrual Dysphoria Disorder was listed as an illness called Late Luteal Phase Dysphoric Disorder in DSM-III-R (1987), then as Premenstrual Dysphoric Disorder in DSM-IV (1994) and as Premenstrual Dysphoria Disorder in DSM-5. It is argued that this diagnostic for the mood related distress in women stems from variations in hormones during the menstrual cycle. Researchers point at the lack of evidence for the validity of this diagnostic as a separate “mental disorder” and how women are conceptualized solely within a biological framework. We could label each “out of the ordinary” state by cross-sectionally looking at the context in which it presents as an illness/pathology. And that’s exactly where the “danger/diagnosis” lies.
Until the publication of DSM-5, it was assumed that women and men had similar sexual responses. For both sexes, DSM-IV-TR assumed a cycle where desire, arousal and orgasm stages linearly followed. This categorization was criticized for not considering the complexity of sexual experiences that are different for every individual (for female and male sex within the diagnostic categories system). Lately, it is thought that different sexes experience sexual interest, motivation, arousal, and pleasure differently. According to that, diagnostics carried from the previous versions are being revised in DSM-5. Hypoactive Sexual Desire Disorder and Sexual Arousal Disorder are defined as Female Sexual Interest/Arousal Disorder. The Female Sexual Interest/Arousal Disorder diagnostic in DSM-5 received criticism for evaluating the differences in “desire” within the framework of sex, and not identifying the sociopolitical, relational, and contextual factors that accompany each individual’s illness. When sexual desire and “sex” are narrowly defined and evaluated, the evaluation can be reduced to a context of inadequate capacity to “respond/reciprocate”. It is thought that all types of desire such as never/often, emotional/physical can represent normal sexual variations, sex and desire can have multiple meanings and interpretations.
DSM-5 underlines that 75% of the diagnoses of Borderline Personality Disorder (BPD) is for women. Emotionality, addiction, instability in relationships, which are characteristics for BPD diagnostic criteria, are also historically labelled as “appropriate for feminine tendencies”. Criticisms have shown that research on BPD diagnoses demonstrate a sex/gender bias. DSM defines personality disorder as “an individual’s pattern of internal experience and behavior that deviates from the expectations of the culture and lasts over time”. If our society dictates women to be “kind and agreeable”, women who do not conform to the criteria can easily be labelled as sick or to be suffering from a mental illness. The interpretation of behaviors and emotions is the exact point where the issue of sex/gender enter into evaluation and diagnosis of an individual diagnosed with BPD. An evaluation that is independent from sex/gender bias will reduce the risk of stigmatization due to illness.
In this sense, feminist approach and feminist therapies have made important contributions to transform the perspective on women’s mental health. Feminist or Gender-Sensitive Therapy was developed because traditional psychotherapy was not adequately supportive and most probably harmful towards women. In traditional approaches, social and cultural reasons for mental illness/symptoms were either ignored or did not weigh in a lot. Feminist therapy claims that women hold a disadvantaged position in the world due to gender and biological sex, sexuality, race, ethnicity, religion, age and other categories. Feminist therapists argue that most of the problems that arise in therapy are due to social disempowerment; therefore, the objective of the therapy is to recognize these powers and empower the counselee. It also focuses on the social, cultural, and political causes and solutions of the problems encountered during the counseling process.
Even when you consider that diagnostic systems like DSM are created to build a common language in the literature, you should be careful as to how biased and stigmatizing they can be. What is −consciously or not− considered as “common” has a lot to do with the cultural, sociological, political values of the era. I would like to extend my gratitude to everyone who helped bring this issue to the fore – like all other values we have acquired in the history of women– by “struggling/criticizing/raising awareness”…
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Maj, M. (2014). DSM-5, ICD-11 and ‘pathologization of normal conditions.’ Australian & New Zealand Journal of Psychiatry, 48(2), 193–194. https://doi.org/10.1177/0004867413518825
Marecek, Jeanne, and Nicola Gavey. “DSM-5 and beyond: A critical feminist engagement with psychodiagnosis.” (2013): 3-9.
Thomas, E. J., & Gurevich, M. (2021). Difference or dysfunction?: Deconstructing desire in the DSM-5 diagnosis of Female Sexual Interest/Arousal Disorder. Feminism & Psychology, 31(1), 81-98.
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Yüksel Ş, Gülseren L, Başterzi AD. Kadınların Yaşamı ve Kadın Ruh Sağlığı, Ankara: Türkiye Psikiyatri Derneği Yayınları; 2013.
Translator: Deniz İnal
Proof-reader: Müge Karahan