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  • Walnut

Queering Diagnosis and Theory

• By Danna Bodenheimer


When the Walnut Psychotherapy Center opened in 2015, we intended to decenter the diagnostic process from our consideration of each individual client’s psychic life. We knew, after years in field, that pathologization of queer minds was a tool of social control largely supported by the DSM, otherwise known as the Diagnostic Statistical Manual.


On the website for the DSM, it states that

“The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research.”

It is true that the book is the product of a series teams of professionals working together to come up with shared ideas of what substantiates mental illness and what symptoms meet the threshold for diagnosis.


It is also true that the book itself costs $160, making it out of reach for many, and intentionally so. Furthermore, there is no real transparency about the identity of the people on the working groups who create the Manual. But suffice it to say, it is largely written by psychiatrists who have had the privilege of attending and affording medical school. It has historically been written by those in power, about those who hold very little power.


The DSM has been used in pointed and dangerous ways against the queer community, specifically. It was not until 1974 that homosexuality was removed from the DSM. Up until that point it accredited the problematic notion that homosexuality was a disease which could be treated and thus erased. This is the exact mechanism that has been the underpinning of conversion therapies that are still actively and abusively practicing today.


And yet, Walnut is not free from the need to diagnose. Simply put, there is a mandate, professionally, to use the book. This is because every session, therefore every client, requires a diagnosis in order for someone’s therapy to be covered by insurance. Without diagnosis, there is no coverage and without coverage there is no payment and without payment there is no therapy. The book, with no obvious or tangible author responsible for it, controls treatment.


As a practice, Walnut must rely on diagnosing Gender Dysphoria. Without the formal presence of that diagnosis, most gender affirming and confirming treatments are out of financial reach of the trans population. This means that even when we are working to de-pathologize trans identities, we are simultaneously engaged in the very system that serves to perpetuate their often-problematic medicalization. (For more on this complex issue, please see this article by the National LGBTQ Task Force)


To participate in the act of diagnosis frequently means that we at Walnut are negating our knowledge of the role that socioeconomic factors play in psychological functionality. Participating in diagnosis also means that the marginalization of a client’s identity is not taken into account when thinking about them diagnostically.


That said, we do not think about diagnosis in a vacuum. We work actively to co-construct theory, alongside our clients, to make sense of psychological functioning with deep contextualization of several sociological realities. We layer our diagnostic thinking with several theories which complicate the assertions of the DSM. These theoretical orientations are queer theory, critical race theory and psychodynamic theory (which holds trauma theory as central to its understanding of the psyche). As this blog unfolds, we are going to make our understanding of these theories readily accessible to our clients, so that our thinking about psychological functioning is as transparent as possible.


Here are some of the ways in which we consider queer theory in our work:

  • Gender and sex are two distinct concepts.

  • Gender and sexuality are two distinct concepts.

  • Sex and sexuality are two distinct concepts.

  • Sometimes sexuality is tied to gender, sometimes it is not.

  • Sometimes sexuality shifts with gender, sometimes it does not.

  • There is a societal compulsion to place people, from birth, into the gender binary.

  • Gender is a social construct.

  • Gender is assigned at birth, based on biological presentation, and the assignment can be faulty.

  • Gender can exist on a spectrum for some and as a binary for others.

  • Biological characteristics are not deterministic of internal experience.

  • One’s internal gender experience and external presentation can be different. This can lead to dysphoria for some, but not all.

  • Gender at its most “healthy” is self-determined.

  • The closet is incompatible with strong mental health but can understood as self-protective. Therefore, pathologies associated with the closet are typically better assigned to societal demands than to psychological dysfunction.

  • Mental health functioning and freedom of gender expression/identity are correlated. We believe that this correlation suggests a causation, whereby suppression of gender expressions can result in mental unwellness.

  • Monogamy is not a sign of better or worse health functioning than any other relationship model.

  • The pathological need for society to maintain a gender binary is in the service protecting a capitalistic, heteronormative form of governing.

  • For some the gender binary can be experienced as a form of psychological imprisonment. For others it can be experienced as a form of liberation.

  • Medical interventions to support the development of one’s gender identity are not a sign of poor mental health.

  • Medical interventions do not need to be performed to place someone inside the gender binary. Oftentimes the interventions are required to remove someone from it.

  • Gender cannot be properly understood without an examination of other intersecting identities.

  • Sexuality cannot be understood without an examination of other intersecting identities

  • Mental health is improved through the provision of mirroring and twin-ship of one’s marginalized sexual or gender identity.

  • The DSM was written by a largely white, heteronormative group of mental health practitioners. Queer theory was produced by, oftentimes, queer writers and thinkers. Because of this positionality we hold queer theory in higher esteem than diagnostic techniques and theory.

  • Positionality and identity in the mental health treatment relationship must be overtly examined and named in order for therapeutic work to occur.

  • Authentic expression of self is a part of mental health but does not represent mental health in its entirety.

  • To be closeted is a form of psychological trauma.

  • The body is a topic that ought to be addressed in psychological treatment.

  • The body is a landscape upon which several economic wars are waged in the service of profit for large corporate and governmental forces.

  • We consider the impact of these wars before we consider how to classify intrapsychic pathology.

  • Pronouns and precise use of language have a direct impact on psychological life.

  • Linguistic precision is a means by which the self is brought into being.


As always, thanks for reading and sharing! We welcome your feedback at info@walnutpsychotherapycenter.com. To support mental health in the LGBTQ community, check out www.walnutwellnessfund.com.