Blinded Me With Science: Sampling Error


Kelley Winters, Ph.D.

GID Reform Advocates


On May 28th, the American Psychiatric Association issued a “Statement on GID and the DSM-V” that emphasized,


“The APA’s goal is to develop a manual that is based on sound scientific data…”[1]


But has the APA met this standard with the Gender Identity Disorder diagnosis in the current edition IV-TR of the Diagnostic and Statistical Manual of Mental Disorders? [2] Where is the “sound scientific data” to suggest, as do the title, diagnostic criteria and supporting text of the GID category, that gender variant identities and expressions are intrinsically “disordered?”


The eminent physicist Bertrand Russell said of scientific method,


“A habit of basing convictions upon evidence, and of giving to them only that degree of certainty which the evidence warrants, would, if it became general, cure most of the ills from which this world is suffering.” [3]


The cornerstone of empirical science is elimination of bias by sampling data that is representative of the population under study.  Unfortunately, the APA track record for scientific vigor in the DSM is spotty.  For decades, the classification of same-sex orientation as mental disorder was justified by “research” of subjects limited to clinical populations.  Psychologist Evelyn Hooker noted in 1957 and earlier that gay and lesbian people seeking psychiatric help or incarcerated in prisons and hospitals did not constitute representative populations.


“…few clinicians have ever had the opportunity to examine homosexual subjects who neither came for psychological help nor were found in mental hospitals, disciplinary barracks in the Armed Services, or in prison populations. It therefore seemed important, when I set out to investigate the adjustment of the homosexual, to obtain a sample of overt homosexuals who did not come from these sources” [4]


Astonishingly, another 16 years passed before psychiatric policy makers began to take note. Psychiatrist Judd Marmor, urging removal of homosexuality from the DSM in 1973, argued,


“if our judgment about the mental health of heterosexuals were based only on those whom we see in our clinical practices we would have to conclude that all heterosexuals are also mentally ill” [5]


The authors of the GID diagnosis in the DSM-IV and current revision IV-TR employed similarly unrepresentative data to conclude that all gender variant people, whose gender identity or expression vary from their assigned birth sex roles, are mentally ill.  For example, the GID authors relied upon their own clinical populations from the “Sissy Boy” studies at UCLA [6] and the Clarke Institute of Psychiatry (currently the Centre for Addiction and Mental Health, CAMH, in Toronto) in developing the diagnostic criteria for children:


“Currently, the authors are analyzing data sets from Green’s (1987) study and from the database of the Child and Adolescent Gender Identity Clinic at the Clarke Institute of Psychiatry, Toronto, Canada, to examine the similarities and differences between children referred for gender identity concerns who do and do not verbalize the wish to be of the opposite sex.”  [7]


Moreover, clinical populations in mental health care, at least in the case of transvestic fetishism, were pre-judged a priori as impaired by Drs. Kenneth Zucker and Ray Blanchard of CAMH, members of the Sexual and Gender Identity Disorders work groups for the DSM-IV and DSM-V editions.  They stated in 1997 that individuals,  “…who consult mental health professionals are presumably, in some respect, distressed or impaired by their condition.” [8]  Their reasoning seems strangely reminiscent of Alice’s experience in Wonderland:


“Said the Cheshire Cat: ‘We’re all mad here. I’m mad. You’re mad.’
’How do you know I’m mad?’ said Alice.
’You must be,’ said the Cat, ‘or you wouldn’t have come here.”[9]


And what of non-clinical populations of gender variant people? There is little evidence that follow-up studies, suggesting overwhelmingly positive outcomes for transsexual individuals whose gender dysphoria had been relieved by transition and corrective surgeries, were considered by the GID authors in the DSM-IV. [10] A unique controlled 1990 study of the benefit of genital surgery for (MTF) transsexual women by Mate-Kole, et al. [11], and a comprehensive 1992 review of 80 case studies spanning 30 years by Pfäfflin and Junge [12] are absent from the DSM-IV Sourcebook citations.  Pfäfflin and Junge concluded that, “… we found most of the desired changes in the areas of partnership and sexual experience, mental stability and socio-economic functioning level.”   This data would have been helpful in refuting stereotypes of inherent psychological pathology that were embodied in the GID diagnostic criteria and supporting text.


To gain “sound scientific data,” it is necessary to understand the demographics of the population under study in order to access its members.  To this end, the DSM-IV-TR cites the prevalence of GID as, “… roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery” [p. 579]  These estimates are based on studies by Wålinder [13] and Hoenig [14] in the 1960s and 70s of patients who sought help in gender clinics in Sweden and the U.K.  Last year, Professors Femke Olyslager and Lynn Conway presented an analysis to the World Professional Association for Transgender Health (WPATH) that revealed startling flaws in these figures [15].  For example, prevalence in the Hoenig study is understated by more than a factor of six, based on the study’s own data, if the relevant general populations of birth-assigned males and females are corrected for appropriate age.


Aggregating a number of earlier studies, and accounting for general population demographics and conflation of prevalence with incidence in the early years of available surgical treatments, Olyslager and Conway reported that the prevalence of corrective surgical transition procedures was much higher than previously acknowledged in psychiatric literature. Their re-analysis of data from prior studies suggests a lower bound of 1:2900 to 1:5800 of the total population that has had or will have corrective surgery in support of transition, and they reported an even higher rate based on data from surgeons. Dr. Mary Ann Horton independently reported a similar surgical prevalence of 1:3100 per lifetime among US citizens. [16]  As only a subset of transsexual individuals require or obtain surgical treatment, Olyslager and Conway went on to estimate the lower bound on prevalence of transsexualism at 1:500. [15]  Moreover, transsexual individuals represent a subset of those meeting the current diagnosis of Gender Identity Disorder in the DSM-IV-TR, which relies heavily on gender role nonconformity rather than specific distress or incongruence with assigned birth sex.


These recent studies raise a crucial question, how can the American Psychiatric Association claim that the current GID diagnosis is based on “sound scientific data,” representative of the gender variant population, when they are unaware of the existence of as much as 99% of that population?  Conway noted,


“Such a truly egregious error presents a direct challenge to the psychiatric profession’s credibility in the entire area of transsexualism.” [17]


Where is this hidden silent majority of gender variant people who are not to be found in clinical populations?   Conway has compiled a collection of photos and stories for over 200 transitioned transsexual man and women living full lives, ordinary and extraordinary:


“They are successes in living ‘life in the large.’ We see it in the happy faces, and sense it in between the lines of their stories. These are the successes of women who have survived and corrected their earlier transsexualism, and gone on to find joy and comfort and peace in their lives.” [18]


Transsexual people are only the tip of the iceberg of gender variant adults and youth currently implicated as mentally ill. In more than two decades that I have been active in the trans-community, I have been honored to meet hundreds of remarkable individuals who defy anachronistic stereotypes of mental impairment – people who have transitioned into very ordinary conventional male and female roles and into unique roles that defy convention, people who live in “stealth,” quietly assimilated into society, and those who are out and proud as advocates and role models. I have heard their narratives, stories of grace and courage in the face of adversity that would likely overwhelm most other people. These are real people in the real world with little resemblance to the doctrine of “disordered” gender identity perpetuated in the current DSM-IV-TR.


What Dr. Evelyn Hooker noted of gay men a half-century ago is perhaps even more true for gender variant individuals today:


“But what is difficult to accept (for most clinicians) is that some homosexuals may be very ordinary individuals, indistinguishable, except in sexual pattern, from ordinary individuals who are heterosexual. Or – and I do not know whether this would be more or less difficult to accept – that some may be quite superior individuals, not only devoid of pathology (unless one insists that homosexuality itself is a sign of pathology) but also functioning at a superior level.”[4]


The current diagnosis of Gender Identity Disorder in the DSM allows no possibility for the existence of countless well-adjusted transsexual and gender variant people already in society.  The Sexual and Gender Identity Disorders work group has an opportunity to replace stereotype with science in the DSM-V, to base diagnostic nomenclature on sound data that is representative of real gender variant people from non-clinical populations.



[1] American Psychiatric Association, “APA Statement on GID and the DSM-V,” , May 23, 2008.


[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.


[3] Bertrand Russell,


[4] E. Hooker, E., “The Adjustment of the Male Overt Homosexual,” Journal of Projective Techniques, #21, p.18, 1957.


[5] R. Stoller, J. Marmor, I. Beiber, et al.,”A Symposium: Should Homosexuality be in the APA Nomenclature?” American Journal of Psychiatry, vol. 130, pp. 1208-1209, 1973.


[6] R. Green, The “Sissy Boy Syndrome” and the Development of Homosexuality, Yale University Press, New Haven CT, 1987.


[7] T. Widiger, et al., eds., DSM-IV Sourcebook, Vol. 3, American Psychiatric Association, 1997, p. 320.


[8] K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” in D. Laws and W. O’Donohue (Eds.), Sexual Deviance: Theory and Application, Guilford Press, New York, 1997, p. 258.


[9] Charles Dodgson {Lewis Caroll}, Alice’s Adventures in Wonderland, 1865.


[10] Note: One post-operative follow-up study cited in the DSM-IV Sourcebook by Blanchard, et al., was cited to support a remark in the text of the DSM-IV and DSM-IV-TR that transsexual women attracted to other women and transitioning in adulthood are “less likely to be satisfied after sex-reassignment surgery.” [p. 580]  This statement has posed barriers to surgical transition care for transsexual women, maligned as “males” in the supporting text, on the basis of their sexual orientation.  R. Blanchard, B. Steiner, L. Clemmensen, R. Dickey, “Prediction of Regrets in Postoperative Transsexuals,” Can. J. Psychiatry, 34, pp.43-45, 1989.


[11] C. Mate-Kole, M. Freschi , and A. Robin, “A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals.” Brit J Psychiat 157: pp. 261-264, 1990.


[12] F. Pfäfflin, A. Junge , Sex Reassignment: Thirty Years of International Follow-Up Studies after SRS — A Comprehensive Review, 1961-1991. 1992, English translation 1998.  available on the Internet at <;.


[13] J. Wålinder, Incidence and Sex Ratio of Transsexualism in Sweden , British

Journal of Psychiatry, vol. 119, pp. 195-196, 1971.


[14] J. Hoenig and J.C. Kenna, “The prevalence of transsexualism in England and Wales,”

British Journal of Psychiatry, vol. 124, pp. 181-190, 1974.


[15] F.  Olyslager and L.Conway, “On the Calculation of the Prevalence of Transsexualism,” WPATH 20th International Symposium, Chicago, Illinois, 2007. , Submitted for publication in the International Journal of Transgenderism (IJT).


[16] M. Horton, “The Cost of Transgender Health Benefits,” Transgender at Work, .


[17] L. Conway, “The Numbers Don’t Add; Transsexual Prevalence,” .


[18] L. Conway, “Transsexual Women’s Successes: Links and Photos,” ;

“Successful TransMen: Links and Photos,”



Copyright © 2008 Kelley Winters, GID Reform Advocates

About Kelley
Dr. Kelley Winters is a writer and consultant on issues of gender diversity in medical and public policy. She is the author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008) and a past member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care, the Global Action for Trans* Equality (GATE) Expert Working Group, and the Advisory Boards for TransYouth Family Allies (TYFA). She was recognized in the 2013 Trans 100 Inaugural List for work supporting the transgender community in the US. Kelley has presented papers and presentations on gender policy issues at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Kelley wanders the highways of America in an old Mazda, ever in search of comfort food.

3 Responses to Blinded Me With Science: Sampling Error

  1. Michelle says:

    Transsexuals pose a unique problem in the mental health world, and in particular with respect to quantification and description in any statistically meaningful manner.

    Too few of us are willing to participate at all in the very studies that ultimately do factor into the literature that should underly the DSM.

    Worse, post transition, post operatively, even fewer are willing to participate in follow-up studies. (The studies I am familiar with are lucky to get sample sizes as a high as a hundred or so – hardly the kind of “large n” needed to do serious statistical modelling, and condemning researchers to being criticized for utilizing ‘convenience samples’.

    The reasons for this are irrelevant. But if we are going to be critical of the data used, then it becomes in part our responsibility to help provide that data in a meaningful manner.

  2. In the UK study after study is now demonstrating that trans people are willing to contribute towards good quality, respectfully constructed, studies in very significant numbers — so long as researchers are able to demonstrate that they are trustworthy and that the purpose of the research is to benefit the subject rather than the researcher’s career. Official numbers now available also make a mockery of population estimates still cited by the DSM. Having a formal process for legal recognition provides one way of measuring a part of the population. Approaching the small number of gender clinics who meet the vast majority of people seeking help also provides an indication of the scale of numbers coming forward every year — about 1,000pa in a national population of 60 million. Those numbers soon inevitably clock up into a much larger population than anyone previously imagined

  3. Rev Dr Linda Miskimen says:

    The Issue of “Too few of us are willing to participate at all in the very studies that ultimately do factor into the literature that should underly the DSM.” “ In the UK study after study is now demonstrating that trans people are willing to contribute towards good quality, respectfully constructed, studies in very significant numbers.” Which begs the question of how many years of study are needed?
    You see researchers have been studying male to female transsexual for now will over 4,000 and they still cannot explain Transsexualism. At the very beginning of human of civilizations, 2000 B.C.E. in ancient Thebes inscribed on pottery is listing of three genders males, eunuchs, and females. In the Egyptian story of the creation of the archetypal beings (gods), the first being is male and female, and its name is Atum. Through asexual reproduction, Atum divides and creates two other beings, Shu and Tefnut. These two in turn produce another pair, Geb and Nut. Finally, Geb and Nut, the earth and the sky, combine and produce the two pairs of Isis and Osiris, and Seth and Nephthys. Isis exemplifies the reproductive female, Osiris the reproductive male, Seth the nonreproductive eunuch, and Nephthys the unmarried virgin .
    In the very first book of the Bible Genesis is the story Joseph and the Eunuch’s Wife . THE SECOND BOOK OF THE KINGS COMMONLY CALLED THE FOURTH BOOK OF THE KINGS CHAPTER 20: 18 “And of thy asons that shall issue from thee, which thou shalt beget, shall they take away; and they shall be beunuchs in the palace of the king of Babylon.” ISAIAH CHAPTER 39 1-8 “1 At that time aMerodach-baladan, the son of Baladan, king of Babylon, sent letters and a present to Hezekiah: for he had heard that he had been sick, and was recovered. 2 And aHezekiah was glad of them, and shewed them the house of his precious things, the silver, and the gold, and the spices, and the precious ointment, and all the house of his armour, and all that was found in his treasures: there was nothing in his house, nor in all his dominion, that Hezekiah shewed them not. 3 ¶ Then came Isaiah the prophet unto king Hezekiah, and said unto him, What said these men? and from whence came they unto thee? And Hezekiah said, They are come from a far country unto me, even from Babylon. 4 Then said he, What have they seen in thine house? And Hezekiah answered, All that is in mine house have they seen: there is nothing among my treasures that I have not shewed them. 5 Then said Isaiah to Hezekiah, aHear the word of the Lord of hosts: 6 Behold, the days come, that all that is in thine house, and that which thy fathers have laid up in store until this day, shall be carried to Babylon: nothing shall be left, saith the Lord. 7 And of thy asons that shall issue from thee, which thou shalt beget, shall they take away; and they shall be eunuchs in the palace of the king of Babylon. 8 Then said Hezekiah to Isaiah, Good is the word of the Lord which thou hast spoken. He said moreover, For there shall be peace and truth in my days.”
    The Hebrew word for eunuch is saris, a secondary meaning of saris is to castrate. As Christians believe Jesus speaks with divine authority as such when He teaches that not all eunuchs are castrated, Matthew 19:12. According to Jesus, some eunuchs are born that way, in distinction from a man who has been physically castrated. Jewish rabbis in ancient times used the word saris to describe both castrated individuals and uncastrated individuals, men the rabbis referred to as natural eunuchs. The Hebrew word saris-eunuch, is found 45 times in the Old Testament, translated in the King James Bible as eunuch 17 times, chamberlain 13 times, officer 12 times and Rabsaris, 3 times. Eunuchs are mentioned 10 times in six verses in the New Testament.
    When it comes to research may be because after 4,000 of so years of the same bull that TS people see it for what it is junk.

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