Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 6, by Sam Winter

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post from
Sam Winter, Ph.D.
Associate Professor
Faculty of Education, University of Hong Kong

Generation G Paranoia.

Coy Mathis clearly identifies as a girl. It was a matter of continuing pain to her that she was not fully recognized and respected as one. The decision of the Colorado civil rights division that she be allowed to use the girls’ bathroom at school went a long way to providing that recognition and respect.

The child’s perspective is entirely missing in Dr. Drescher’s commentary. What, one may ask, would Coy have preferred her parents and school to do about her female identity? Would she have preferred them to allow her to express her femaleness and to be the person she so deeply felt herself to be? Or would she have preferred them to discourage, even prevent, her from expressing her femaleness and add to her pain.

The Times piece reflects an anxiety that the world is full of trans affirmative parents who, seeing the slightest sign of gender-nonconformity in their children, overzealously egg them on into a full transition. This line of reasoning promotes a fear that we may lose a whole generation of youngsters who, if only they had not been so enthusiastically pressed into transitioning, would have turned out to be happily adjusted ‘cisgender’ (that is to say, NOT transgender) gays and lesbians.

What we have here is the fear of a lost gay generation… Generation ‘G’.

When I see them on television, I wonder what will happen when the little boy who is socially transitioned with the mother’s encouragement at the age of 9 decides that he wants to be a boy after all but that he still likes other little boys.
–E mail from Senior WHO HQ Staff, 5th Jan 12013

As this quote illustrates, fear about a lost Generation ‘G’ influences international medical policymakers, who continue to argue that kids like Coy have a disorder that requires medical intervention to put a brake on “overzealous” parents and ensure that more of these kids will grow up to be cisgender gays or lesbians.

Generation ‘G’ fear has little basis in reality. It is more like a paranoia. First, one wonders where these overzealously trans affirmative parents are. Parents like Coy’s agonise long and hard over what they should do to help their transgender children. They don’t make these decisions lightly. Second, kids like Coy spend years pressing for their identities to be respected. There is no reason to think they would hesitate, if ever there was a need, to express a desire to ‘go back’ to their birth-assigned roles. To prevent Coy from  enjoying, right now, the fullest possible recognition of who she is would have been cruel, inhuman and degrading. To do so, just because of some hypothetical fear that she may later want to live as a boy and mysteriously lose her ability to tell anyone, would have been irresponsible. The Colorado civil rights division made the right decision.

Dr Sam Winter is an Associate Professor at the University of Hong Kong and a member of the board of directors of the World Professional Association for Transgender Health (WPATH) and the World Health Organization (WHO) Working Group on Sexual Disorders and Sexual Health. He has been working in rights and health for transgender people for more than 13 years.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 5, by Mary van Balen

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post from
Mary van Balen
Mother, Author, Columnist, Speaker

The New York Times publication of Dr. Jack Drescher’s letter in its July 30 print edition under the headline: Sunday Dialogue: Our Notions of Gender, has generated much response in the paper, on websites, and on blogs, including this one. I have followed the conversation, appreciated the clinical expertise, and would like to add my perspective. I am the mother of a transsexual daughter, now an adult, who lived for twenty-five years with her “secret” telling me only when she had to choose between suicide or finally accepting herself as she was. We spent hours in the family room as she summoned the courage to speak the truth she had known for so long but had kept hidden: “I hate my body. I always have. Do you know what gender dysphoria is? Well, that’s what I have.”

The words stunned. I had imagined other possibilities, but not that. My knowledge of GID was rudimentary. Images that came to mind were of make-up slathered characters in movies or television shows, generally sleazy types. And there was a person I had seen singing in Provincetown whose male face and female attire who made me uncomfortable. “Not my quiet son, the bright physicist,” I thought. This didn’t happen to people like “us.” I had a steep learning curve ahead.

That process included long talks with my daughter, who once out to me, was willing to share stories of her growing up years. Many of them broke my heart. I thought of them as I read Dr. Drescher’s letter and the responses.

“If only I had known,” I thought when my now twenty-something daughter told me that she knew she was a girl since she was three and in first grade at a Catholic school dreamed of a “magic uniform” that would change her into one. As she talked I remembered her playing dress-up with her younger sisters and loving to clomp around the house in glittering silver high heels. I didn’t know that she had also been making up ballets wearing a pink tutu. I didn’t know she was suicidal in sixth grade.

But what if I had known? In the early 80’s what kind of advice would have been given to me? What would I have done? I like to think I would have been accepting, encouraging even. At home, we gave dolls and trucks to all the kids. We encouraged our daughters and son to explore the creek, climb the trees and experiment with chemistry sets as well as cookie recipes. But having a child tell you “he” is a girl stretches a parent well beyond those attempts at gender-neutral play. Would I have stood up against the social norms of the day?

As my daughter and I continued sharing, she lamented not having had the chance to grow up as a girl. She missed all that socializing. “It would’ve helped a lot,” she said as she struggled to move into the world of women with a history of trying to fit into the world of men.

Dr. Drescher’s statement that “Currently experts can’t tell apart kids who outgrow gender dysphoria (desisters) from those who don’t (persisters)…” seems strange to me. My transsexual daughter’s feelings and her positive sense of gender identity by the age of three, are not the same as the desires and feelings of a boy who likes to play with girls toys or dress up.

I read the story of Coy Mathis and applaud the Colorado Civil Rights Division for ruling that she be allowed to use the girl’s restroom. California’s move to allow children K-12 to use the bathroom that matches their gender identity is a step in the right direction. We should listen to the children and follow their lead. Perhaps then there will be fewer who will lament not having had the opportunity to grow up as the person they know themselves to be and fewer adult transsexuals who look at life and consider opting out of it a good choice.

Mary van Balen is an author, columnist, and speaker with a B.S.S.W. and M.A. in Theology. She has worked with abused, single mothers in a family literacy program and served as a curriculum director for an afterschool program for at risk students. She speaks on issues of transsexuality from a parent’s perspective and will be presenting on issues of transgender youth at the national convention of the Catholic Association for Lesbian and Gay Ministries in New Orleans. She was a resident scholar the Collegeville Institute for Ecumenical & and Cultural Research where she worked on her current writing project: “Julia All Along: A Mother’s Journey with her Transsexual Daughter.”

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 4, from the Child and Adolescent Gender Center Clinic

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post from the
Child and Adolescent Gender Center
San Francisco, CA

To the NYT Editors:
June 26, 2013
Dear Editors:

We celebrate the landmark decision by the Colorado Civil Rights Division which allows children to use school facilities in accordance with the gender they know themselves to be. Their decision is consistent with the goals of the affirmative model of gender health–to facilitate a child’s opportunity to live in the gender that feels most real or comfortable to that child and to express that gender with freedom from restriction, aspersion, or rejection. So many of us confuse gender identity–who we are on the spectrum of male to female or another gender entirely–with gender expressions–how we show our gender to the world. There are a small number of children, like Coy Mathis, who let us know at a very early age that they are not the sex that was assigned to them on their birth certificate; that their gender identity is different. Like Coy, these children are persistent, consistent, and insistent about who they are. They are to be distinguished from the children who accept their gender label assigned to them but don’t accept our social rules about boys and girls and how they should act, dress, and play—their gender expressions are unique. Can we tell those two groups of children apart? Not perfectly, but with pretty good accuracy if we spend the time to listen to them and translate what they are saying to us. The Colorado Civil Rights Division did just that in listening to at least one of those children, and in its ruling blazing the trail for children to live authentically in the gender they know themselves to be. When we consider the alternative, that a child sits home because school won’t let them be themselves, how could we do otherwise?

Joel Baum, M.S., Director of Education
Diane Ehrensaft, Ph.D., Director of Mental Health
Stephen Rosenthal, M.D., Medical Director
Ilana Sherer, M.D., Assistant Medical Director
Child and Adolescent Gender Center
San Francisco, CA

The Child and Adolescent Gender Center (CAGC), a collaboration between UCSF and community organizations, offers comprehensive medical and psychological care, as well as advocacy and legal support, to gender non-conforming/transgender youth and adolescents.

400 Parnassus Ave., Second Floor
San Francisco, CA 94143
Appointments: (415) 353-7337
Fax: (415) 476-8214 (Attention: Dr. Stephen Rosenthal)

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 3, by Jenn Burleton

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post by Jenn Burleton
Founder and Executive Director of
TransActive Education & Advocacy
Portland, Oregon

To the Editor:

The letter you recently published from Dr. Jack Drescher regarding the case of the Colorado transgender child contained several misleading and outdated statements regarding the future transgender identity of the young girl in question. Most specifically, his categorical statement that “most [transgender/gender dysphoric] children grow up to be gay, not transgender.”

This statement vastly over-generalizes the complexity and diversity of gender nonconforming self-expression and identity in children and youth. As a result, Dr. Drescher helps perpetuate the harmful notion that children who are gender nonconforming or transgender are simply “going through a phase”. His comments not only lend fuel to those who practice gender-reparative therapy (proven to do great psychological harm to these children) but they encourage those who wish to deny the very existence of transgender identity.

At TransActive, we have provided clinical counseling and medical referral to more than 100 of these children and youth over the past 6 years. At present, we currently have a Portland, Oregon-area client base of approximately 150 family units and we work in various ways with many more families nationwide.

In our experience we find no evidence that those who socially transition gender early desist in their self-identity when that identity represents something other than their assigned sex at birth. Additionally,  while our experience tells us that Dr. Drescher and others are in error when they suggest that an over-generalized majority of all gender dysphoric children will grow up to be gay and not transgender, it is safe to assume that some of these kids will grow up to identify as gay, lesbian, bisexual, queer or pansexual. Their eventual sexual orientation will, however, be most likely based on their experienced gender identity and NOT on their assigned birth sex. In other words, a transgender girl attracted to males will most likely identify as heterosexual and a transgender boy attracted to males would most likely identify as gay.

At one point Dr. Drescher states that, “experts can’t tell apart kids who outgrow gender dysphoria (desisters) from those who don’t (persisters)”. This statement is, to be blunt, not at all reflective of our clinical experience here at TransActive. One can tell these kids apart, not by simply evaluating data acquired with questionable sampling protocols, but by observing the daily lived experiences of these kids and their families. It is vitally important to differentiate children who are gender nonconforming, with no interest in gender transition, from those who are what we call transitional transgender. Simply put, there is a significant difference between kids who say “I like boy/girl things” and those who say “I AM a boy” or “I AM a girl”.

Dr. Drescher has stated that he believes that the treatment (we prefer to approach it from an ‘affirmation’ model rather than a ‘treatment’ model) of gender dysphoric children is “controversial”, and he cites his own article “Controversies in Gender Diagnoses” in support of this opinion.

While controversy exists in some circles around transgender identity and gender nonconformity in general (unavoidable in a misogynistic and patriarchal culture), this controversy is based primarily on socio-political ideology and theology. This controversy is only exacerbated by those who wish to elevate flawed research above the lived reality of transitional children, youth and their families.

For those of us actively working with this population of kids, there is, I believe, considerable consensus as to the most effective care models. At TransActive, we follow a ‘Best Practice’ framework called RACE; Recognition, Affirmation, Congruence and Empowerment. Key aspects of this framework include:

  1. Affirm the child’s gender identity/expression without pushing them in one direction or another. Encourage the family to do so as well.
  2. Support and, if necessary, help facilitate social gender congruence to whatever degree the child expresses a need for.
  3. Diagnose Gender Dysphoria when it exists based upon clinical guidelines and when necessary to access additional services
  4. Remain open to evolving childhood gender identity and expression
  5. Facilitate access to pubertal suppression treatment if desired by the adolescent
  6. Facilitate access to surgical procedures (if desired) when appropriate and in consultation with therapists and medical personnel.
  7. Do not attempt to use gender expression as an indicator of future sexual orientation and, in particular, do not make clinical judgments about ‘desirable’ outcomes with regard to either gender identity or sexual orientation.

“My continued concern is that, in the absence of consensus, the literature still seems to lean toward A) overgeneralizing persistance/desistance in GNC children and, B) suggesting that taking a “do nothing/wait and see” approach will, in the majority of cases, result in desistance. The reality out here, Dr. Drescher, is that far too many parents (and providers/advisors) will interpret “do nothing” as ‘reinforce gender norms’ and/or ‘ignore the repeated and desperate self-expression of the child’.

I realize that neither you, nor the American Psychiatric Association (APA) or World Professional Association for Transgender Health (WPATH) are responsible for the ways in which individuals might implement or use this information. It is, however, vitally important that you understand that the ‘data’ you endorse and promote is clearly incomplete and not sufficiently differentiated. This ‘data’ is, in many cases, contributing to negative outcomes for transitional transgender children and youth. Service providers working in clinical situations (like TransActive and others) are left to either pick up the pieces or go to enormous lengths to explain complex variations in gender expression to parents, social services agencies, etc. simply to overcome the simplified, primary take-away that, “Most gender nonconforming kids desist or turn out to be gay”

I encourage parents of transgender and gender nonconforming children and youth to not be dissuaded from seeking assistance from organizations and individuals that specialize in working with (not researching) this population of children by those who believe that any data, no matter how flawed, is superior to the real world, boots on the ground, daily interactions that care providers are having with these kids and their families.

Jenn Burleton

Jenn Burleton is a leading expert in advocating for the rights and gender affirming care of transgender children and youth, is the Founder and Executive Director of TransActive Education & Advocacy and a co-founder of Trans Youth Family Allies. She has served on the Board of the Oregon Safe Schools and Communities Coalition and currently serves on the Advisory Board of the Trans Youth Equality Foundation, the Multnomah County DHS LGBTQ Youth Workgroup and the Development Committee for the Oregon Health & Science University Transgender Program. She was also named to the inaugural “Trans 100” list of individuals working towards positive change for transgender people and recognized by the National Gay and Lesbian Task Force as one of “90 Women Leading the Way To Equality”.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 2, by Arlene Istar Lev

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post by Arlene Istar Lev LCSW-R, CASAC
Albany New York
Social Worker, Family Therapist, Gender Specialist, Activist
Choices Counseling and Consulting

To the Editor:

Thank you for opening this dialogue and recognizing the importance of public discourse on the issue of transgender children and their civil rights.

My colleague, Dr. Drescher, is correct that “no one knows” whether Coy will identify as a girl or boy when she matures; however, the same can be said for Coy’s classmates. He is also correct that theories abound in this newly emerging field and that experts are engaged in heated discussions about how to best support gender dysphoric children and their families. The concept of children transitioning gender in elementary is clearly a recent, and controversial, phenomenon, one which is increasingly being supported by mental health specialists, school policies, and legal decisions.

Dr. Drescher states that most “children like [Coy] grow up to be gay, not transgender.” This is a misleading statement for a number of reasons. First of all, the research he is referring to is a few decades old; gender atypical children who are now gay adults matured into their identities before transgender expression was a viable social option (especially for children!), and in the early days of the gay liberation movement. More options exist in the modern world for exploration of gender identity and expression, as well as the freedom to live an out gay life. This research also examined gender non-conforming children, not necessarily those who were gender dysphoric, a distinction that may appear academic, but is crucial to understanding the experiences and potential trajectories of children’s emerging gender identities.

Gender non-conforming behavior can exist in a wide-range of children, and can cause distress since our culture can (still!) be extremely rigid about gender roles and rules, especially for boys. One can imagine a gender atypical boy, particularly one who might be aware of attractions to other boys, might be struggling psychologically. Gender dysphoria is, however, markedly different from the social and identity challenges of a gender non-conforming child who will grow up to be gay. Transgender children are suffering in an intensely personal way, with a body and a social world that is at odds with their deepest sense of self.

I am not saying it is always easy to determine what is happening within a young child’s psyche, not as a therapist, and not as a parent. I agree with Dr. Drescher that parents must educate themselves on all the treatment approaches, and recognize the current limitations of science. I also believe that parents can see the difference between a profoundly suffering little boy and a happy contented little girl. A child who is not transgender would simply not adjust to a gender transition with a lessening of mental health symptoms, and an increasing satisfying social life. A boy, no matter how atypical his gender might be, has no interest in using the girls’ bathroom. For a child who is a girl, it is an essential part of her identity.

Thank you Colorado for recognizing this obvious truth. Thank you to Dr. Drescher for initiating respectful public and professional dialogue on this controversial subject. Thank you to Coy and her parents, for allowing their personal family struggles to be a guiding light to others.

Arlene Istar Lev

Arlene Istar Lev, LCSW, CASAC

Arlene Lev is a social worker, family therapist, educator, and writer whose work addresses the unique therapeutic needs of lesbian, gay, bisexual, and transgender people. She is the Founder and Clinical Director of Choices Counseling and Consulting in Albany, New York, providing family therapy for LGBTQ people and is on a Lecturer at the University at Albany, School of Social Welfare, and an adjunct at Empire College. She is also the Founder and Clinical Director of TIGRIS, The Institute for Gender, Relationships, Identity, and Sexuality, a post-graduate training program serving people seeking greater relational and sexual intimacy, people who identify as sexual minorities, and those interested in exploring sexuality, gender, and identity issues. Arlene is the author of The Complete Lesbian and Gay Parenting Guide andTransgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families, winner of the American Psychological Association Distinguished Book Award, 2006. She serves on the editorial Boards of theJournal of GLBT Family StudiesThe Journal of Lesbian Studies, and the Journal of Transgenderism. Arlene is the organizer of Professionals Concerned with Gender Diagnoses in the DSM.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 1, by Kelley Winters

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

Kelley Winters, Ph.D.
GID Reform Advocates

The Sunday Dialogue feature of the June 30 edition of the New York Times responded to the recent Colorado Human Rights Division ruling in favor of Coy Mathis, a six year old transgender girl who sought the same equal treatment and facilities access as other girls at her public school. The Times editors turned to Dr. Jack Drescher, a New York psychiatrist who served on the Work Group on Sexual and Gender Identity Disorders for the DSM-5, the diagnostic manual of mental disorders published by the American Psychiatric Association. Dr. Drescher  could have taken this opportunity to acknowledge young Ms. Mathis’ remarkable courage and tenacity. He could have taken this teachable moment to note the barriers of intolerance and injustice that transgender people face as children, both in and out of the closet. But, instead, Dr. Drescher said this:

Actually, no one knows whether Coy will continue to feel that she is a girl when her body develops further, since most children like her grow up to be gay, not transgender.

Although Coy has identified as a girl, lived happily as a girl and attended school as a girl since kindergarten, Drescher’s statement impugns her legitimacy as a girl and suggests that her strong sense of gender identity is a likely just a passing phase. The statement not so subtly passes judgement on the Mathis family for allowing Coy to be herself as she sees herself. Although the “passing phase” mantra is heard frequently among psychiatric policy makers and institutional researchers in recent years, serious questions remain. Is this prediction based on scientific evidence? And, what exactly is meant by, “children like her”?

Conflating Gender Expression with Gender Identity

Young children, like Coy, who strongly, consistently and persistently identify as other than their birth-assigned sex, and who have fully lived in their affirmed gender roles, have been criticized while left unstudied by researcher/policymakers who publish literature on gender variant youth. Since the early 90s, most study populations have instead been selected by much broader diagnostic criteria for Gender Identity Disorder in Children (GIDC) from the DSM-IV and IV-TR, published in 1994 and 2000. Under these controversial criteria, children could be diagnosed with GIDC strictly on the basis of gender nonconforming behavior, with no evidence that they identified as other than their birth-assigned gender. Therefore, children who were intensely distressed by their birth-sex or assigned gender roles (gender dysphoria) were not distinguished from larger numbers of effeminate male-identified boys or masculine female-identified girls. Under these criteria, gender expression that differed from birth-assigned roles was deemed psychopathological, no matter how happy, functional and well adjusted the child. Moreover, children who conformed to birth-assigned stereotypes were exempt from GIDC diagnosis, no matter how gravely distressed with those roles and even if conformity was compelled under duress or physical punishment.

In 2000, Bartlett, et al., noted shortcomings in the GIDC criteria:

…it appears that a minority of children diagnosed with GID have a sense of discomfort with their biological sex.

Concerns about broad false-positive diagnosis of children who were never actually transgender and potential therapeutic abuse of youth suspected of being “pre-gay” led to revision of the Gender Dysphoria in Children category in the DSM-5 in 2013. Its criteria were tightened to resemble the prior DSM-III and DSM-III-R GIDC categories, requiring evidence of desire or insistence of other than the birth-assigned gender. In other words, the childhood diagnosis was restricted in the DSM-5 to gender dysphoric children in conflict with their birth-sex or assigned role, not merely gender nonconforming. However, sample bias resulting from old diagnostic flaws in the DSM-IV and IV-TR was not subsequently acknowledged by researchers who based their studies on GIDC diagnosis. Dr. Drescher’s remark about Coy Mathis was informed by dated research and old attitudes that conflated gender nonconformity with gender dysphoria, not controlled studies of children who actually resembled Coy.

The Doctrine of Desistence

Medical and public policy have long been influenced by research, suggesting that gender variance from birth-assigned roles in young children will most likely “desist” by adolescence and adulthood, when they will identify with their birth-assigned sex. Dr. Kenneth Zucker, of the Toronto Centre for Addiction and Mental Health (CAMH) and chairman of the DSM-5 Work Group on Sexual and Gender Identity Disorders, is the most prolific proponent of the 80%-desistence assumption. In 2006, he remarked to the New York Times:

80 percent [of preadolescent gender variant children] grow out of the behavior, but 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex.

This “it’s just a phase” stereotype, has been repeated for many years and has underpinned policies that keep gender dysphoric children in the closets of their birth-assigned gender.  It is based primarily on studies at Dr. Zucker’s own practice at CAMH and at VU University Medical Center in Amsterdam. Since 1994, sample selection for these studies has relied on diagnostic criteria for Gender Identity Disorder in Children (GIDC) in the DSM-IV and IV-TR. In fact, Zucker and his colleagues at CAMH were instrumental in defining these criteria. As discussed earlier, these criteria required only gender nonconforming behavior for diagnosis, and not necessarily evidence of gender dysphoria  (persistent distress or incongruence with birth-sex or birth-assigned gender role). Gender dysphoric subjects in the resulting study samples were diluted by gender nonconforming children who were not gender dysphoric.

Therefore, much of this research actually suggests that the majority of children who are merely gender nonconforming, and meet the overinclusive GIDC criteria in the DSM-IV and IV-TR, will not be gender dysphoric later in life and will identify with their birth-assigned gender. However, some researcher/policymakers have inexplicably interpolated the 80%-desistance assumption to a smaller subset of children who are gender dysphoric. They have arbitrarily substituted “gender dysphoria” for “gender identity disorder” or “gender variance” in their literature, even though these terms have widely disparate definitions. As a consequence, there are concerns that these studies have scooped up large proportions of gender nonconconforming kids who were never actually gender dysphoric, found them still not gender dysphoric at puberty, and then declared them “desistent” in the literature.

In his NY Times commentary, Dr. Drescher went further still, applying the desistence doctrine to an even smaller subset of extremely gender dysphoric children like Coy Mathis, who have surmounted formidable barriers to live a real life experience in their affirmed gender roles at school. However, the Toronto and Amsterdam studies  discouraged  real life experience social transition before puberty and therefore lacked validity for “children like her.”

While mental health researchers and policymakers may not know Coy’s inner gender identity, there is a real chance that she does. Unlike those of past generations, Coy has been given a chance at a childhood, a life, without closets, without shame and without punishment for behaviors and expression that would be ordinary or even exemplary for other children. The real questions are, whether this chance should be taken away from her, and on what scientific basis?

In his response comment in the Times, Dr. Drescher called for “less polemics and fewer opinions presented as hard facts.” We might start with closer scrutiny of the 80%-desistence doctrine. In the meantime, Coy Mathis is busy defying false stereotypes, political attacks and media sensationalism by being herself in her Colorado first grade classroom. American psychiatry could learn a lot from this brave little girl.

© 2013 Kelley Winters, GID Reform Advocates

GID Reform in the DSM-5 and ICD-11: a Status Update

I prepared this presentation for the 2013 Philadelphia Transgender Health Conference but did not have the opportunity to attend. It is a summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.  It is based on proposed revisions to the ICD-11 presented by Drs. Geoffrey Reed, Peggy Cohen-Kettenis and Richard Krueger at the National Transgender Health Summit in Oakland last month and on discussions at the Global Action for Trans* Equality (GATE) Civil Society Expert Working Group in Buenos Aires last April.

In my view, there are two primary issues in medical diagnostic policy for trans people. The first is harmful stigma and false stereotyping of mental defectiveness and sexual deviance, that was perpetuated by the former categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the DSM-IV-TR. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. The latter requires some kind of diagnostic coding, but coding that is congruent with medical transition care, not contradictory to it. I have long felt that these two issues must be addressed together –not one at the expense of the other, or to benefit part of the trans community at the expense of harming another.

The DSM-5 Falls Short, Despite Some Significant Improvements

The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from  gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated. This message is reinforced by the August 2012 Public Policy Statement from the American Psychiatric Association, affirming the medical necessity of hormonal and/or surgical transition care. In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria, and the APA Working Group has rejected pressure to add an “autogynephilia” specifier to falsely stereotype and sexualize trans women. Children can no longer be falsely diagnosed with this mental disorder label, strictly on the basis of nonconformity to birth assignment.

However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.

More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments.  This contradiction may be used to support gender conversion/reparative psychotherapies– practices described as no longer ethical in the current WPATH Standards of Care.

Finally, the Transvestic Disorder category in the DSM-5 is even more harmful than its predecessor, Transvestic Fetishism. Punitive and scientifically capricious, it only serves to punish nonconformity to assigned birth roles and has no relevance to established definition of mental disorder. The Transvestic Disorder category has been expanded in the DSM-5 to implicate trans men as well as trans women, with a new specifier of “autoandrophilia,” apparently pulled from thin air without supporting research or clinical evidence.

The ICD-11, a Historic New Approach

The 11th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization (WHO). It is a global diagnostic manual that contains chapters for both physical medical conditions and mental conditions. In contrast to the DSM-5, the ICD-11 holds promise for unprecedented forward progress on both issues of social stigma and barriers to medical transition care.  At the National Transgender Health Summit in Oakland last month, members of the ICD-11 Working Group for Sexual Disorders and Sexual Health confirmed proposals for  substantive changes in gender and transition related codings.

The Working Group has proposed a historic shift of transition related categories, now labeled “Gender Incongruence,”  out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely. It is to be placed in a new, non-psychiatric chapter, called “Certain conditions related to sexual health.” The Incongruence title is distinct from DSM-5 dysphoria title, to clarify that this is no longer a mental disorder coding.  They have also proposed to eliminate victimless sexual paraphilia categories from the manual, including: F65.1: Transvestic fetishism. A similar category describing dual gender individuals, F64.1: Dual-role Transvestism, would be deleted as well. These changes have the potential for enormous progress in reducing both stigma and barriers to medical transition care, for those who need it. When implemented, they would effectively obsolete the new psychopathology categories of Gender Dysphoria and Transvestic Disorder in the DSM-5.

There are also questions and shortcomings in the current  ICD-11 proposals.  While the proposed children’s coding of  Gender Incongruence of Childhood is no longer a mental disorder label,  any pathologizing coding of happy gender nonconforming or socially transitioned children, who are too young to need any medical transition or puberty-blocking treatment, is highly controversial among clinicians, families and community members.  The diagnostic criteria for children, like those in the DSM-5, still emphasize nonconformity to anachronistic gender stereotypes as symptomatic of sickness. The adult and adolescent criteria have copied ambiguous language from the DSM-5 that cast desire for transition, in itself, as pathological. Worse yet, false-positive diagnosis of happy post-transition subjects inadvertently contradicts rather than supports medical transition care.

The ICD-11 Working Group for Sexual Disorders and Sexual Health should be commended for advancing these historic reforms. However, it is important that Group members listen to the remaining concerns of community members and supportive care providers.  Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clearer description of the problem to be treated. Young children, who may only need information, monitoring and support, have very different diagnostic needs and diagnostic risks than adults and adolescents.


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