Disallowed Identities, Disaffirmed Childhood

 

Kelley Winters, Ph.D.

GID Reform Advocates

http://www.gidreform.org

 

 

Jazz, a beautiful seven year old girl with long brown hair and poise beyond her years, explained gender diversity from her porch swing in a YouTube video this summer:

 

“If someone asks me why I used to be a boy and now I’m a girl, I would say that I have a girl brain and a boy body.  I think like a girl, but I just have a boy body and it’s different than you.” [1]

 

The American Psychiatric Association might learn a lot from this young girl. Last year, Jazz and her family appeared with Barbara Walters in the television news magazine 20/20. They shared how painful her assigned birth-role had been for her until her family acknowledged her feminine identity at age five and created safe space for Jazz to be herself. They shared how her distress was relieved with transition to a female social role and how she has thrived since.[2]

 

It is important to note that for preadolescent children, transition refers to a change in social gender role and not medical or surgical intervention. The earliest medical treatments, if needed, would come later at initial stages of puberty. According to endocrinologist Norman Spack, hormone blockers called GnRH analogues may be prescribed to delay onset of unwanted puberty and avoid resulting emotional trauma as well as “the physically and psychologically painful procedures required to reverse puberty’s physical manifestations.” [3]

 

In the context of children, transition is not an assignment by parents or clinicians. Transition means simply creating an environment where gender variant or transcendent [4] children may safely define their own roles that are congruent with their inner sense of gender identity. These roles may be stereotypically masculine, feminine or uniquely in between and may include self-expression in clothing and mannerisms and identification in name and pronouns. However, the APA  labels all youth who transition their social gender roles as mentally disordered in the Diagnostic and Statistical Manual of Mental Disorders, ed. IV-TR (DSM), [5]  regardless of how happy and well they are in their new roles. Many of the barriers these youth face in school and society are exacerbated by these psychiatric labels.  In the Byzantine nomenclature of the current Gender Identity Disorder in Children (GIDC) diagnosis, gender transcendent children should be closeted and not seen nor heard.

 

In fact, gender role transition itself is misconstrued as symptomatic of psychosexual illness in the diagnostic criteria for GIDC. Of the four criteria for diagnosis, [6] the first is intended to address gender identity and is the most confusing and controversial:

 

Criterion A for Gender Identity Disorder in Children:

 

A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:

 

1.      repeatedly stated desire to be, or insistence that he or she is, the other sex

2.      in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

3.      strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

4.      intense desire to participate in the stereotypical games and pastimes of the other sex

5.      strong preferences for playmates of the other sex

 

Of the five characteristics of criterion A, only the first has anything to do with gender identity and it is not required for diagnosis.  The remaining four are based strictly on nonconformity to social birth-sex stereotypes, and only four of the five characteristics are required. Thus, a child may be diagnosed with Gender Identity Disorder without evidence of gender identity that is incongruent with natal sex — without ever stating any desire to be the “other sex.”

 

The last four characteristics pathologize as mental illness and sexual disorder behaviors and self-expression that would be considered ordinary for other children. In the supporting text of the GIDC diagnosis, these are described to include playing with Barbie dolls, homemaking and nurturing role play for birth-assigned males and aversion to cars, trucks, competitive sports and so-called “rough and tumble” play. For birth-assigned females, pathology is implied by playing Batman or Superman, competitive contact sports, and aversion to dolls or wearing dresses. Criterion A serves a punitive role in enforcing these dated, narrow and sexist gender stereotypes for children, upon penalty of diagnosis of mental disorder.  The fifth characteristic, a “strong preference for playmates of the other sex” seems to equate mental health with sexual discrimination. [7]

 

In criterion A, birth-assigned males are inexplicably held to a much stricter standard of conformity than birth-assigned females in their choice of clothing and activities. A simple preference for cross-dressing or “simulating” female attire meets the diagnostic criterion for the former but not for the latter, who must insist on wearing only male clothing to merit diagnosis. In modern Western culture where children’s clothing is often unisex and gender  roles are as political as social, terms like “stereotypical” or “normative” clothing seem archaic. [8]

 

In criterion A, “other sex,” “cross-sex,” and “cross-dressing,” are defined with respect to assigned birth sex with no clarification regarding current affirmed gender role. This is evidenced in the criterion and supporting text, where children are always termed by birth-sex pronouns, regardless of transition status.  For example, an affirmed transitioned girl, such as Jazz, is maligned as a “boy” and “he” in the DSM.  There is no exit from diagnosis for her or other transitioned youth who are happy and well adjusted in their affirmed gender roles; they will permanently meet criterion A as it is currently written.

 

Criterion B for Gender Identity Disorder in Children:

 

Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following:

 

·         in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games and activities;

·         in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

 

The second diagnostic criterion is intended to embody gender dysphoria, coined by Dr. Norman Fisk in 1973, [9]  but profoundly misses its mark.  From a Greek root for distress, gender dysphoria is defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role. [10]  While a dated definition of gender dysphoria remains in the DSM-IV-TR glossary, [11] its meaning in the current criterion B is far less clear than in previous editions.

 

“Discomfort” and “inappropriateness” seem euphemistic in describing the intense and often debilitating distress that many children experience with their anatomy or assigned birth-sex role. While the criterion describes elements of anatomic dysphoria, [12]  it lacks clarity for distress with anticipated physical sex characteristics for preadolescent birth-assigned males, such as facial hair, voice change and upper body musculature. Most troubling, criterion B substitutes nonconformity to gender stereotypes for clear distress with assigned birth-sex role. The phrases following the “or” in the sentences for “boys” and “girls,” which include “rough-and-tumble play” and “normative feminine clothing,” make criterion B redundant to criterion A.  For example, children who are profoundly distressed by their birth-sex assignment and corresponding names and pronouns are not clearly described in criterion B, while gender nonconforming youth with no clear evidence of anatomic dysphoria or distress with their birth-sex may be falsely implicated. Like the first criterion, there is no exit for children whose gender dysphoria has been relieved by social role transition. Transitioned youth would permanently meet criterion B as it is currently written, even more so than before transition.

 

Criterion C for Gender Identity Disorder in Children:

 

The disturbance is not concurrent with a physical intersex condition.

 

The DSM-IV Subcommittee on Gender Identity Disorders recommended at one point that individuals born with anatomical or chromosomal intersex conditions be included in the GID diagnoses for adults, adolescents and children, [13] as did previous editions of the DSM.  However, the final decision was to exclude them from GID diagnosis and recommend diagnosis of Gender Identity Disorder Not Otherwise Specified. [14]

 

Criterion D for Gender Identity Disorder in Children:

 

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

 

A significant change in the 1994 DSM-IV from prior editions was the addition of a clinical significance criterion to most diagnostic categories. Its purpose was to establish a definition of mental disorder and limit false positive diagnosis of those who do not meet that definition. [15]  This policy change was controversial within mental health professions [16]  and was particularly opposed by some members of the DSM-IV Subcommittee on Gender Identity Disorders. In an article on the Transvestic Fetishism diagnosis, Dr. Kenneth Zucker, chair of the present DSM-V Sexual and Gender Identity Disorders work group and Dr. Raymond Blanchard, chair of the DSM-V paraphilias subcommittee, dismissed the clinical significance criterion as “muddled” and having “little import.” [17]  This view seems to conflict with that of Dr. Darrel Regier, Vice Chair of the DSM-V Task Force:

 

“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” [18]

 

The central flaw in criterion D for the GID in Children category is that it fails to distinguish distress and impairment caused by gender dysphoria from those  resulting from societal prejudice or intolerance. Dr.  Zucker notes, “the standard of impairment in children with GID has been their poor same-sex peer relations, with attendant social ostracism.” [19]  Thus, ego-syntonic or self-accepting gender variant children who are victimized by prejudice at school meet criterion D only because of hate from others.  Gender variant children with healthy peer relations with children of the same gender identity also meet criterion D, because their friends are not of the same birth-assigned sex.  This lack of clarity serves to promote gender-reparative psychotherapies that attempt to change gender identity and repress all gender expression not conforming to birth sex. Zucker continues,

 

“I hope that the vagaries of the distress/impairment criterion do not dissuade clinicians from providing early therapeutic intervention”

 

Moreover, Drs. Zucker and Susan Bradley, who chaired the DSM-IV GID Subcommittee, invoked circular logic to cast all children diagnosed with GID as cognitively impaired. They claimed that diagnosed children were more likely to “misclassify their own gender, which … surely must lead to confusion in their social interactions.” [20]  In other words, children who disagree with their birth-assigned roles were presumed impaired by fiat. But are these children actually misclassifying their gender or are they certain of it? Is it more likely that their psychiatric examiners are confused about the true gender of these children?

 

The current diagnostic criteria for Gender Identity Disorder of Childhood are broadly over-inclusive. They encourage false-positive diagnosis of gender nonconforming children having no significant distress of gender dysphoria, and they encourage diagnosis of mental illness on the basis of victimization from prejudice and intolerance. Authors of the GIDC diagnosis in the DSM-IV acknowledged that nearly 30% of children who did not meet the DSM-III criteria would meet the current criteria in the DSM-IV, based on changes to criterion A alone, using data from the Toronto Centre for Addiction and Mental Health (CAMH), formerly the Clarke Institute of Psychiatry. [21]

 

While the American Psychiatric Association has emphasized that the DSM “does not provide treatment recommendations or guidelines,” [22]  the GIDC diagnostic criteria are heavily biased in favor of gender-reparative therapies that attempt to change gender identity and expression differing from birth-sex assignment.  Children whose gender variant expression is shamed into the closet by these treatments no longer meet criteria A,B or D, even if they continue to verbalize unhappiness and rejection of their birth-sex assignment. (Criterion C, regarding concurrent intersex conditions, would not be relevant to gender expression or transition status in this example) 

 

Emerging alternatives to gender-reparative interventions have very recently been termed “Gender Identity Actualization” by therapist Reid Vanderburgh. [23] Sadly, the diagnostic criteria for Gender Identity Disorder in Children contradict these affirming treatment approaches, including social role transition to relieve distress of gender dysphoria. Youth who are happy and well adjusted after transition to affirmed gender roles and who may experience intolerance at school continue to meet criteria A, B and D, even if they are not distressed by their anatomy. In fact they are stereotyped as even more symptomatic of mental disorder, according to these criteria, than before transition.

 

According to the American Psychiatric Association, the purpose of the DSM includes facilitation of research and communication among clinicians and researchers. [24] However, the diagnostic criteria for Gender Identity Disorder in Children arguably bias research on the persistence of gender identity in youth.  Follow-up studies of gender variant children commonly use GIDC diagnosis to select the study sample and evaluate gender dysphoria or transsexualism later in adolescence or adulthood. [25,26] Since children can meet the DSM-IV criteria for GIDC on the basis of gender role nonconformity with no stated anatomic dysphoria, it follows that rates of persistent dysphoria at follow-up could be under-reported. The actual impact of this error on current published literature is unclear, as follow-up studies still partially rely on data from subjects selected under the DSM-III and III-R.  Drs. Zucker, Bradley and others have acknowledged concerns that the DSM-IV criteria for GID of Childhood may “’scoop in’ youngsters who show extreme cross-gender behavior but are not necessarily gender-dysphoric.” For example, Zucker has suggested that,

 

“Because of the putative conflation of gender identity dysphoria and gender role

behavior, particularly in the Point A criterion, one could argue that reform of the

criteria is called for.”  [27]

 

With the publication of the DSM-V, there is opportunity to address very serious shortcomings in the diagnosis of Gender Identity Disorder in Children. I hope that the Sexual and Gender Identity Disorders Work Group will clarify distress with physical sex characteristics (including those anticipated at puberty) and distress with birth-sex assignment as the focus of diagnostic nomenclature.  I urge the Work Group to remove all references to gender expressions that differ from birth-sex roles from the diagnostic criteria. Expressions that would be ordinary or even exemplary for all other youth do not constitute mental illness in gender variant youth.

 

Back on Jazz’s porch swing, the seven year old concluded,

 

“It’s ok to be different because it just matters who you are. It doesn’t matter if you’re different than anybody else. It just matters that you’re having a good time and you like who you are.”

 

We all might learn a lot from this young girl.

 

 

 

[1] Jazz, “7yr. old Jazz’s thoughts on being a Transgender Child,” http://www.youtube.com/watch?v=7S5usRgY720

 

[2] A. Goldberg and J. Adriano, “’I’m a Girl’ — Understanding Transgender Children,” ABC News 20/20, April 27, 2007, http://abcnews.go.com/2020/story?id=3088298&page=1

 

[3] N. Spack, “Transgenderism,” Lahey Clinic Medical Ethics Journal, Fall 2005,  http://www.lahey.org/newspubs/publications/ethics/journalfall2005/journal_fall2005_feature.asp

 

[4] I define transgender, gender variant and gender transcendent in a broadly inclusive community sense: describing those whose inner sense of gender identity or outer gender expression transcend social gender stereotypes or differ from those associated with assigned birth sex.  I use the terms roughly synonymously, although I am coming to prefer gender transcendence for its affirming shade of meaning.

 

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

 

[6] DSM-IV-TR, 2000, p. 581.

 

[7] K. Winters (under pen-name K. Wilson), “The Disparate Classification of Gender and Sexual Orientation in American Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association,  Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997,  www.priory.com/psych/disparat.htm.

 

[8] Winters, 1998.

 

[9] Fisk, N. (1973). Gender dysphoria syndrome. (The how, what, and why of a disease). In D. Laub & P. Gandy (Eds.), Proceedings of the second interdisciplinary symposium on gender dysphoria syndrome (pp. 7–14). Palo Alto, CA: Stanford University Press.

 

[10] Working definition of Gender dysphoria by Dr. Randall Ehrbar and I following our panel presentations at the 2007 convention of the American Psychological Association.

 

[11] DSM-IV-TR, 2000, App. C, p. 823.  “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.”

 

[12] K. Zucker and S. Bradley, Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, Guilford Press, 1995, pp. 21-22.

 

[13] S. Bradley, Ray Blanchard, et al., “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorder,” Archives of Sexual Behavior, Vol. 20, 4, p. 339.

 

[14] DSM-IV-TR, 2000, p. 582.

 

[15] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., 1994, pp.xxi, 7.

 

[16] Spitzer R.L., Wakefield J.C. (1999). “DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem?”  Am. J. Psychiatry 156:1856-64   http://ajp.psychiatryonline.org/cgi/content/abstract/156/12/1856.

 

[17] K. Zucker and R. Blanchard, “Transvestic Fetishism Psychopathology and Theory,” in D. Lays and W. O’Donohue, eds., Sexual Deviance: Theory, Assessment, and Treatment, Guilford, 1997, p. 258.

 

[18] B. Alexander, “What’s ‘normal’ sex? Shrinks seek definition,” MSNBC , May 22, 2008, http://www.msnbc.msn.com/id/24664654/.

 

[19] K. Zucker, “Commentary on Richardson’s (1996) ‘Setting Limits on Gender Health,’” Harvard Rev Psychiatry, vol 7, 1999, p. 41.

 

[20] Zucker & Bradley, 1995, p. 58.

 

[21] K. Zucker, R. Green, et al., “Gender Identity Disorder of Childhood: Diagnostic Issues,” in T. Widiger, A. Frances, et al., DSM-IV Sourcebook, Am. Psychiatric Assoc., 1998, p. 511.

 

[22] American Psychiatric Association, “APA STATEMENT ON GID AND THE DSM-V, “

http://www.psych.org/MainMenu/Research/DSMIV/DSMV/APAStatements/APAStatementonGIDandTheDSMV.aspx  , May 23, 2008.

 

[23] R. Vanderburgh, “Appropriate Therapeutic Care for Families with Pre-Pubescent Transgender/Gender-Dissonant  Children,” to be published in Child Adolesc Soc Work J, 2008.

 

[24] DSM-IV, 1994, p. xxiii.

 

[25] K. Drummond, S. Bradley, M. Peterson-Badali, K. Zucker, “A follow-up study of girls with gender identity disorder,” Developmental Psychology, vol. 44, 1, Jan 2008, p. 34-45.

 

[26] Zucker & Bradley, 1995, p. 290-301.

 

[27] K. Zucker, “Gender Identity Disorder in Children and Adolescents,” Annu. Rev. Clin. Psychol., vol. 1, 2005. p. 17.9.

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates 

Blinded Me With Science: The Burden of Proof

Blinded Me With Science: The Burden of Proof

 

Kelley Winters, Ph.D.

GID Reform Advocates

www.gidreform.org

 

 

In the movie, Ghostbusters, professor Peter Venkman, played by Bill Murray, deflected  questions with a quip,

 

“Back off, man. I’m a scientist.“[1]

 

In the reality of human gender diversity, the current diagnostic categories of Gender Identity Disorder  (GID) and Transvestic Fetishism in the Diagnostic and Statistical Manual of Mental Disorders (DSM) convey a presumption that internal gender identity or social gender expression that vary from assigned birth sex roles are intrinsically pathological and sexually deviant. Their authors and supporters have defended this axiom by disparaging skeptical criticism and indignation as “attack” on science and academic expression.  Thus, the premise of ‘disordered’ gender identity has ascended to the level of dogma in American psychiatry and psychology, imposing a near-impossible burden of proof upon contrary evidence, dissenting opinion and especially upon transitioned individuals to demonstrate our legitimacy in our affirmed roles.

 

In an interview with MSNBC this year, Dr. Kenneth Zucker, chairman of the current DSM-V Sexual and Gender Identity Disorders work group and a chief author of the current GID diagnosis, stated that there “has to be an empirical basis to modify anything” in the DSM.” [2]  But has the appropriate burden of proof been  reversed here?  Should his work group be equally committed to review the validity of the current diagnostic categories? What is the basis, where is the science to substantiate the premise of ‘disordered’ gender identity that underlies them? 

 

Lilienfeld, Lynn and Lorh, editors of  Science and Pseudoscience in Clinical Psychology, noted that

 

“the burden of proof in science rests invariably on the individuals making a claim, not on the critic.” [3] 

 

At the core of the GID diagnosis is the presumption that social or medical transition contrary to birth sex is always a negative outcome and acquiescence to birth sex role is a  positive one.  This is reflected in the diagnostic criteria, which tar even the happiest, most well adjusted post-operative transsexual men and women as disordered, and absolve closeted or concealed gender dysphoria (distress with current physical sex characteristics or ascribed gender role) from diagnosis of mental illness [4].  This doctrine of ‘disordered’ gender identity is underscored throughout the supporting text, where persistent gender identity differing from birth sex is termed a “chronic course” of disorder and the need for gender congruence is disparaged as “preoccupation” [5].  

 

In the Treatment Companion to the DSM-IV-TR Casebook, also published by the APA, gender-conversion or gender-reparative therapies, which attempt to change gender identity or expression that differ from birth sex, are recommended to clinicians for birth-role nonconforming and gender-dysphoric children to the exclusion of supporting and affirming treatment approaches. In a chapter authored by Dr. Kenneth Zucker, clinicians are advised to suspect parents in the “genesis and/or perpetuation of GID,” and parents are told to “set limits” on gender role expression or even fantasy play nonconforming to birth sex. Successful outcome is only described in terms of “fading of … cross-gender identification” and of being “helped so that the desire to change sex does not persist into adolescence and adulthood.”  Persistent (or un-closeted) gender identity or expression that differs from birth sex is cast as failure, with alarming predictions of social withdrawal and rejection by “both boys and girls.” [6]

 

Zucker repeated these dire warnings to parents of gender variant children in an interview on National Public Radio last May:

 

“He explained that unless Carol and her husband helped the child to change his behavior, as Bradley grew older, he likely would be rejected by both peer groups. Boys would find his feminine interests unappealing. Girls would want more boyish boys. Bradley would be an outcast.”  [7]

 

Was this prediction based on science or just substitution of opinion as fact? In the same National Public Radio interview, Dr. Zucker’s patient, “Bradley,” was contrasted with a young girl, Jona, whose transition from male birth-role to female affirmed-role was supported by her parents and therapist, Dr. Diane Ehrensaft.  Far from outcast or withdrawn, Jona’s father described her as thriving:

 

“She’s so comfortable with her own being when she’s simply left to be who she is without any of these restrictions being put on her. It’s just remarkable to see.”

 

Jona’s case is far from unique. A growing number of parents and their affirming care providers are rejecting derogatory diagnosis and punitive conversion psychotherapies and are working with schools and communities to create safe spaces for their gender variant children and adolescents to simply be themselves. TransYouth Family Allies (TYFA), an education and support organization for gender variant youth and families [8], provided assistance to 15 families nationwide in 2007 and more than double that number early this year [9]. These children offer dramatic counter-examples to the DSM-IV-TR and its Treatment Companion text. For example, Boulder, Colorado pediatrician Dr. Jeff Richker recently described a very positive outcome for an affirmed girl (MTF), who began her social role transition at age eight:

 

“Lucia is 90 percent happier than Luc ever was … I think the transition has gone a long way to alleviating so much of the unhappiness in her life.” [10]

 

Yet, the very existence well adjusted, transitioned children is denied in the DSM-IV-TR Treatment Companion and subsequent literature, which denigrate real-life experience in affirmed gender roles as “fantasy solution”.  In their 1995 book, Drs. Zucker and Susan Bradley, previous Chair of the DSM-IV Subcommittee on Gender Identity Disorders,  condemned affirming support of gender variant children as therapeutic “nihilism,” invoking a double-negative statement to justify gender-reparative psychotherapies: “we have found no compelling reason not to offer treatment to a child with gender identity disorder.”  Moreover, Zucker and Bradley insulted the intelligence of all parents who reject or question gender-reparative therapies for their gender-nonconforming children: “Some parents, especially the well-functioning and intellectually sophisticated ones, are able to carry out these recommendations relatively easily and without ambivalence.” [11]

 

 Although Dr. Zucker concedes “that contrasex hormonal and surgical sex change may well be the best methods of treatment” for gender dysphoric adolescents, he casts this in a negative context of “much poorer” prognosis and failure of gender-conversion in earlier childhood.  A derogatory view of nonconformity to assigned/birth sex roles is repeated in recent literature, coauthored by Zucker and Bradley, where “typical” and “normative” gender behavior are defined as synonymous.  The authors incorrectly term persistence of masculine identity as “persistence of gender dysphoria” [12], obscuring the proven roles of social transition and medical treatment (the latter for adolescents and adults) in relieving distress with ascribed gender role and anatomical sex.

 

For adolescents suffering gender dysphoria, there is growing clinical evidence that social transition and postponement of adverse puberty (development of birth-sex characteristics incongruent with inner identity) enable positive outcomes. In a presentation last year to the Wold Association for Transgender Health (WPATH), Dr. Annelou De Vries reported significant reduction of behavior and socialization problems for transitioned adolescents given puberty-blocking treatment, based on the Child Behavior Checklist (CBCL) and Youth Self-Report (YSL) assessment [13]. He noted “stable, improved psychological functioning” for these youth in contrast to the typecast of “much poorer” prognosis.

 

For adults, the myth of ‘disordered’ gender identity is also contradicted by co-morbidity studies that find a notable absence of psychopathology among transsexual individuals. In a large-scale 1997 study of 435 gender dysphoric subjects (318 MTF women and 117 FTM men), Cole, et al., concluded,

 

“This study should help to clear up certain misperceptions about gender dysphoria per se. Specifically, individuals presenting with gender dysphoria often do not have problems indicative of coexisting psychiatric illness such as schizophrenia or major depression. Instead, these finding suggest that gender dysphoria is usually an isolated diagnosis.”  [14]

 

While analogous findings about the mental health of gay men by Dr. Evelyn Hooker [15] were instrumental to the reform of the homosexuality diagnosis in the DSM-II and III, these analogous studies of gender variant people have been largely disregarded by DSM policy makers.  As noted in an earlier essay, studies of postoperative transsexual individuals from non-clinical populations also suggest positive outcomes for social role transition and corrective medical procedures that relieve distress of gender dysphoria in adults [16,17].  These data are corroborated by numerous positive post-transition narratives in print [18-21] and online [22].  Yet, counter-examples to presumptions of ‘disordered’ gender identity and negative transition outcome have had no impact on DSM policy. 

 

In fact, clinicians and scholars with dissenting opinion and criticism of the GID and TF diagnoses have been met with hostility and personal insult themselves [23]. In her 1996 book Gender Shock: Exploding the Myths of Male and Female author Phyllis Burke described how the GID diagnosis was used to facilitate reparative therapy and hospitalization of gender non-conforming youth suspected of being “prehomosexual.” She quoted Dr. Kenneth Zucker that parents bring children to gender clinics mostly “because they don’t want their kid to be gay” [24]. In an interview for Brain, Child magazine, Zucker responded by attacking Ms. Burke ad hominem:

 

“He dismisses her book as “simplistic” and “not particularly illuminating,” the work of a journalist whose views shouldn’t be put into the same camp as those of scientists like Richard Green or himself. “ [25]

 

Such personal attacks are not limited to journalists. In a 1999 letter to the Journal of Sex and Marital Therapy, Dr. Zucker fired scathing insults at Richard Isay, M.D., who had raised similar concerns about the GID diagnosis for children in Psychiatric News [26]. Zucker stated, “one must raise the thorny and difficult question of Isay’s professional credentials to comment on the validity of the diagnosis of gender identity disorder.” Zucker called Dr. Isay’s opinion “uninformed, both clinically and empirically” and his work “a cheap imitation of his predecessors” [27].

 

Negative stereotypes about transition outcomes are also refuted by the magnitude of post-transition and post-operative populations that have integrated into society so completely that they are undetectable to the psychiatric research establishment. At the 2007 WPATH conference, Professors Femke Olyslager and Lynn Conway [28] presented evidence of mathematical flaws in earlier studies, suggesting that vastly more people have transitioned with corrective surgeries than figures cited in the DSM. Although their conclusions were independently corroborated in a health benefit cost analysis by Dr. Mary Ann Horton [29], mental health policy makers in both APA organizations have ignored these challenges to longstanding belief about the prevalence of transsexualism.  A 2008 report from the American Psychological Association Task Force on Gender Identity and Gender Variance rejected Olyslager and Conway’s work in a footnote, without bothering to examine the math or even list a citation to their paper. Just as disappointing, the APA (psychological) invoked a guilt-by-association tactic to discredit Olyslager and Conway by claiming that their analysis was endorsed by “transgender activists.” [30]

 

Suppressing dissent by labeling critics of derogatory psychiatric policies as transgender or transsexual “activists” is an unfortunate trend in recent literature. For example, Dr. J. Michael Bailey, psychologist and author of, The Man Who Would be Queen: The Science of Gender-Bending and Transsexualism [31], and coauthor Kiira Triea panned critics of his controversial book and its underlying theory of “autogynephilia.” Both the book and the theory, that all male-to-female transition is motivated by either homosexuality or narcissistic sexual paraphilia [32], have evoked outrage among a great number of gender transcendent people [33-34].  In an article entitled, “What Many Transgender Activists Don’t Want You to Know and Why You Should Know It Anyway,” the authors maligned Bailey’s critics ad hominem with labels of  “nonhomosexual MTF transsexuals” and “autogynephiles in denial.” Bailey and Triea exceeded the bounds of professionalism so far as to publicly speculate about the sexual orientations and private medical histories of people they had never met, including Becky Allison, M.D., Christine Burns, M.B.E., Professor Lynn Conway, Andrea James, Deirdre McCloskey, Ph.D., Nancy Nangeroni, and Joan Roughgarden, Ph.D.  Their scorn also extended to clinicians who disagree with these derogatory depictions of transsexual women, describing supportive care providers as “colluding with autogynephiles in denial” [35]. 

 

Dr. Alice Dreger, a colleague of Bailey’s at Northwestern University,  voiced similar derogatory  presumptions about the private sex lives and transitions of dissenting “transgender activists”  in the Archives of Sexual Behavior (ASB): “women such as they might be labeled autogynephilic—individuals with paraphilias whose cross-sex identification was not about gender but eroticism.” Although published as a peer-reviewed work in a scientific journal, Dreger’s paper seemed astonishingly acrimonious, remarking that,

 

“trans activists … have behaved so crazily, the entire population they ‘’represent’’ has been marked by researchers as being too unstable and dangerous to bother with.”  [36]

 

The editor of the Archives of Sexual Behavior is Dr. Kenneth Zucker of the DSM-V Sexual and GID Work Group, and its editorial board includes Dr. Bailey himself, as well as Dr. Ray Blanchard, author of the “autogynephilia” theory and Chair of the DSM-V Paraphilias Subcommittee [37].

 

Perhaps the most frightening abuse of scientific authority against dissenting opinion has come from sexologist Dr. Anne Lawrence, also an editorial board member of the Archives of Sexual Behavior, who has strongly supported Blanchard’s theories of “autogynephilia.”  In a commentary article in ASB, Dr. Lawrence once again repeated personal speculation about sexual orientations of opponents of Bailey’s book.  Moreover, she diagnosed critics with “narcissistic disorders.” Lawrence invoked a label of “narcissistic rage” to disparage, as further mental illness, the indignation expressed by transpeople in response to psychiatric stereotypes of sexual deviance. She stated,

 

“Meanwhile, clinicians and scholars should perhaps be more aware that angry reactions they elicit from nonhomosexual MtF transsexuals might represent narcissistic rage, rather than mature, instrumental anger.” [38]

 

This tactic to discredit dissent has been termed “medicalization of critics” [39] by psychiatrist Dan Karasic, M.D. of U.C. San Francisco, co-editor of Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation [40].

 

In an interview for the New York Times, Dr. Dreger condemned outrage and dissent from the trans-community with alarming hyperbole, as “problems not only for science but free expression itself.” [41]  This begs the question, do oppressed people speaking in protest of their own oppression honestly threaten free expression for policy makers? In the discourse of psychiatric policy, who holds the power to bias either scientific enquiry or its dissemination — the authors of the DSM and its allied literature or the subjects of their classification?

 

At the 1973 annual meeting of the American Psychiatric Association, Dr. Robert Spitzer noted,

 

“In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a “mental illness” the burden of proof is on them to demonstrate their competence, reliability, or mental stability.”[42]

 

Under the current doctrine of ‘disordered’ gender identity in American psychiatry and psychology, this remains as true today for gender transcendent people and their supportive clinicians as it was for gay and lesbian people then. Writer Élise Hendrick explained it this way at the 2008 National Women’s Studies Association conference,

 

“It is not the butterfly’s place to lecture the entomologist; it may feel pain whilst being pinned to a corkboard, but it had best keep that to itself. “ [43]

 

The current diagnostic categories of Gender Identity Disorder and Transvestic Fetishism in the Diagnostical and Statistical Manual of Mental Disorders and their supporting literature perpetuate a doctrine of “disordered” gender identity and expression in American psychiatry and psychology. This axiom imposes an unreasonable burden of proof upon gender variant people who defy this stereotype, upon researchers and scholars who present opposing data, and upon change to the status quo in the DSM.  Given harsh consequences that the current diagnoses of mental illness and sexual deviance inflict on human dignity, civil justice and access to somatic medical treatment, should the burden of proof instead be guided by reduction of harm to people?  In drafting the Fifth Edition of the DSM, members of Sexual and Gender Identity Disorders Work Group have a fresh opportunity to examine all of the evidence and question the premise that gender identities and expression that differ from birth-sex roles are inherently disordered.

 

 

 

[1] I. Reitman and B. Brillstein, directors, Ghostbusters, Columbia Pictures, 1984.

 

[2]  B. Alexander,  “What’s ‘normal’ sex? Shrinks seek definition,” MSNBC, http://www.msnbc.msn.com/id/24664654/ .

 

[3]  Lilienfeld, Lynn and Lorh, eds., Science and Pseudoscience in Clinical Psychology, Guildford Press, 2004, p.7.

 

[4] K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Ed.  Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89, 2005.

 

[5] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, p.577, 580.

 

[6] Spitzer, First, Gibbon, Williams, eds., Treatment Companion to the Dsm-IV-TR Casebook, American Psychiatric Publishing, 2004, pp. 128-134.

 

[7] A. Speigel, “Two Families Grapple with Sons’ Gender Preferences,” National Public Radio, All Things Considered,” http://www.npr.org/templates/story/story.php?storyId=90247842, May 7, 2008.

 

[8] Trans-Youth Family Allies, www.imatyfa.org.

 

[9] J. Kass, “It’s Me in a Different Way,” Rocky Mountain News, March 1, 2008.

 

[10]  M. Potter, “Second Nature,”  5280, March 2008.  http://www.5280.com/issues/story_for_print.php?pageID=1017

 

[11] K. Zucker and S. Bradley, Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, Guilford Press, 1995, pp. 280-282.

 

[12] K. Drummond, S. Bradley, M. Peterson-Badali, and K. Zucker,  “A follow-up study of girls with gender identity disorder,” Developmental Psychology, v. 44,1, Jan 2008, 34-45.

 

[13] A. De Vries, T. Steensma, P. Cohen-Kettenis, “Effects of GNRH Analogue Treatment to Delay Puberty: Effects on Psychological Functioning at

 16 Years,” World Professional Association for Transgender Health, 20^th Biennial Symposium, Chicago, Sep 2007.

 

[14] Cole, C., O’Boyle, M., Emory, L., and Meyer, W (1997), “Comorbidity of Gender Dysphoria and Other Major Psychiatric Diagnoses,” Archives of Sexual Behavior, Vol. 26, No. 1, Feb. 1997, p.25.

 

[15] E. Hooker, “A Preliminary Analysis of Group Behavior of Homosexuals.” Journal of Psychology,  #41, p. 219, 1956

 

[16] 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, v. 157: pp. 261-264, 1990.

 

[17] F. Pfäfflin, A. Junge , Sex Reassignment: Thirty Years of International Follow-Up Studies after SRS — A Comprehensive Review, 1961-1991. 1992, English translation 1998. http://209.143.139.183/ijtbooks/pfaefflin/1000.asp

 

[18] J. Morris, Conundrum: An Extraordinary Narrative of Transsexualism, Holt, 1987.

 

[19] J. Green, Becoming a Visible Man, Vanderbilt University Press, 2004

 

[20] D. McCloskey, Crossing: A Memoir, University of Chicago Press, 1999.

 

[21] Kailey, Just Add Hormones: An Insider’s Guide to the Transsexual Experience, Beacon, 2006.

 

[22] L. Conway, “Transsexual Women’s Successes: Links and Photos,” http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSsuccesses.html ; “Successful TransMen: Links and Photos,”  http://ai.eecs.umich.edu/people/conway/TSsuccesses/TransMen.html.;

Professor Conway’s own extraordinary narrative is available at www.lynnconway.com.

 

[23] K. Winters (under pen-name K. Wilson), “The Disparate Classification of Gender and Sexual Orientation in American Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association,  Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997,  http://www.priory.com/psych/disparat.htm.

 

[24] P. Burke,  Gender Shock, Exploding the Myths of Male and Female,  Anchor Books, 1996, p. 100.

 

[25] S. Wilkinson, “Drop the Barbie! If You Bend Gender Far Enough, Does It Break?” Brain, Child, fall 2001, http://www.brainchildmag.com/essays/fall2001_wilkinson.htm

 

[26]  R. Isay, “Remove Gender Identity Disorder in DSM,” Psychiatric News, v. 32,9, p. 13, November 1997.

 

[27] K. Zucker, “Gender Identity Disorder in the DSM-IV” [Letter to the Editor], J Sex and Marital Therapy, vol 25, 1999, pp. 5-9.

 

[28] F.  Olyslager and L.Conway, “On the Calculation of the Prevalence of Transsexualism,” WPATH 20th International Symposium, Chicago, Illinois, 2007. http://ai.eecs.umich.edu/people/conway/TS/Prevalence/Reports/Prevalence%20of%20Transsexualism.pdf , Submitted for publication, International Journal of Transgenderism (IJT).

 

[29] M. Horton, “The Cost of Transgender Health Benefits,” Out and Equal Convention, Denver CO, 2006,  http://www.tgender.net/taw/thbcost.html

 

[30] American Psychological Association, “Report of the Task Force on Gender Identity and Gender Variance,” p. 37, www.apa.org/pi/lgbc/transgender/2008TaskForceReport.pdf

 

[31] J. Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, Joseph Henry Press, 2003.

 

[32] R. Blanchard, “The Classification and Labeling of Nonhomosexual Gender Dysphorias,” Archives of Sexual Behavior, Vol 18(4),  Aug 1989, pp. 315-334.

 

[33] B. Allison, “Janice Raymond and Autogynephilia,” 2004 http://www.drbecky.com/raymond.html

 

[34] M. Wyndzen, “Autogynephilia and Ray Blanchard’s mis-directed sex-drive model of transsexuality,” 2003,  http://www.genderpsychology.org/autogynephilia/ray_blanchard/

 

[35] J. Bailey, K. Triea, “What Many Transgender Activists Don’t Want You to Know and Why You Should Know It Anyway,” Perspectives in Biology and Medicine, v. 50, 4,  autumn 2007, pp. 527-529, 531.

 

[36] A. Dreger, “The Controversy Surrounding The Man Who Would Be Queen:

A Case History of the Politics of Science, Identity, and Sex in the Internet Age,” Arch Sex Behav, v. 37, 2008, p. 387, 413,     http://bioethics.northwestern.edu/faculty/work/dreger/controversy_tmwwbq.pdf

 

[37] Archives of Sexual Behavior, The Official Publication of the International Academy of Sex Research, Editorial Board,  http://www.springer.com/public+health/journal/10508?detailsPage=editorialBoard

 

[38] A. Lawrence, “Shame and Narcissistic Rage in Autogynephilic Transsexualism,”  Arch Sex Behav , v. 37, p. 457.

 

[39] D. Karasic, “Sexuality and Gender Identity in the DSM V: Current Controversies,” UCSF Grand Rounds in the Dept of Psychiatry, U.C. San Francisco, June 26, 2008. 

 

[40] D. Karasic and J. Drescher, Eds., Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM) a Reevaluation, Haworth Press, 2005

 

[41] B. Carey,   “Criticism of a Gender Theory, and a Scientist Under Siege,” The New York Times, August 21, 2007

 

[42] R. Spitzer, “A Proposal About Homosexuality and the APA Nomenclature: Homosexuality as an Irregular Form of Sexual Behavior and Sexual Orientation Disturbance as a Psychiatric Disorder,” American Journal of Psychiatry, Vol. 130, No. 11, November 1973 p.1216

 

[43] E. Hendrick,  “Quiet Down There! The Discourse of Academic Freedom as Defence of Hierarchy in the Aftermath of J. Michael Bailey’s The Man Who Would Be Queen,” panel presentation, 2008 National Women’s Studies Association conference,  June 21, 2008.  http://ai.eecs.umich.edu/people/conway/TS/News/US/NWSA/Papers/Quiet_Down_There.pdf 

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates