Gender and Diagnosis: Struggles and Suggestions for Counselors.

The field of abnormal psychology has had a troubled relationship with women. Feminists have asserted that "diagnoses such as nymphomania, hysteria, neurasthenia, erotomania, kleptomania, and masochism have served to enforce conformity to norms of female domesticity, subordination, and subservience to men's sexual needs" (Marecek, 1993, p. 115). Feminist theorists have stated that women's anger, depression, and discontent have been refrained as medical or psychiatric symptoms and that, as a result, the often difficult and distressing life circumstances of women have been disregarded. They have stated that it is often forgotten that the roots of women's so-called psychological problems have frequently been social and political rather than individual and intrapsychic in origin (Caplan, McCurdy-Myers, & Gans, 1992; Cook, 1992a, 1992b; Koss, 1990; Ussher, 2000; Wakefield, 1992). Although feminists initially reacted militantly against the male hegemony they believed to be inherent in diagnostic (and many other) systems, further analysis indicated their recognition that both men and women have been hurt by previously unquestioned diagnostic systems. In fact, many authors have pointed out the stigmatizing effects of diagnostic labels; the classist, sexist, racist, and homophobic assumptions embedded in both the International Classification of Diseases (ICD; World Health Organization, 1992-1994) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text. rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000); the resulting pathologizing of behaviors that may be normative within particular gender contexts; and the underdiagnosing of problematic behaviors (Brown, 1990a, 1990b; Eriksen & Kress, 2005). In this article, we report gender-related concerns about diagnosis, including those related to the prevalence of diagnoses by gender, sex bias in diagnosis, the problematic impact of particular diagnoses on women, and the impact of socialization and social conditions on diagnosis. We conclude by proposing alternative diagnoses, diagnostic procedures, and diagnostic loci designed to address some of these concerns. It should be noted that, in general, the disciplines of psychology and psychiatry have "owned" the area of diagnosis because of their greater focus on psychopathology. Therefore, little has been published in counseling-related journals on struggles with diagnosis. However, the nearly universal licensure and increasingly reimbursable status of counselors now makes it a market necessity for counselors of certain specialties to provide diagnoses. Thus, counselors need to increase their knowledge of both diagnosis and its challengers, and they need ideas on how to proceed in ascribing diagnoses in the most sensitive fashion possible. * Prevalence Data of Diagnoses by Gender From the perspective of popular culture, women have historically been considered to be "crazier" than men. As late as 1993, the first author heard a female expert on women and psychology report that more women than men had a mental illness. However, current research on the prevalence of mental illness by gender has yielded contradictory results. Some authors cited evidence that more women than men had a mental illness and that women's prevalence rates were higher than those for men on far more disorders (Cook, Warnke, & Dupuy, 1993; Gove, 1980; Hartung & Widiger, 1998). Other researchers indicated that men and women experienced mental illness at comparable rates (Bijl, deGraaf, Ravelli, Smit, & Vollebergh, 2002; Horsfall, 2001; see Kass, Spitzer, & Williams, 1983, for personality disorders). However, research on specific diagnoses rather than overall rates of mental illness clearly indicates that men predominate in some disorders, and women predominate in others. For instance, men's prevalence rates were higher for substance abuse and sexually related disorders, whereas women's prevalence rates were higher for all forms of mood and anxiety disorders (Bijl et al. …