APA issues statement regarding GID and the DSM-V

The American Psychiatric Association released a statement on Friday regarding some “inquiries about the DSM-V process.” I suspect many of those inquiries have focused on the disputes over treatment highlighted by the recent NPR broadcast on gender identity, often involving Dr. Ken Zucker. I asked Ken Zucker and Michael Bailey for their reactions to this press release from a transgender advocacy group. Dr. Zucker declined to comment, but sent the following APA statement. Dr. Bailey’s comment follows.

May 9, 2008
The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns raised about the Sexual and Gender Identity Disorders Work Group.
The APA has a long-standing mission to provide guidelines for the diagnosis and treatment of mental disorders, based on the most current clinical and scientific knowledge. Through advocacy and education of the public and policymakers, the APA also affirms it commitment to reducing stigma and discrimination.
The DSM addresses criteria for the diagnosis of mental disorders. The DSM does not provide treatment recommendations or guidelines. The APA is aware of the need for greater scientific and clinical consensus on the best treatments for individuals with Gender Identity Disorder (GID). Toward that end, the APA Board of Trustees voted to create a special APA Task Force to review the scientific and clinical literature on the treatment of GID. It is expected that members of the Task Force will be appointed shortly.
There are 13 DSM-V work groups. Collectively, the work group members will review all existing diagnostic categories in the current DSM. Each work group will be able to make proposals to revise existing diagnostic criteria, to consider new diagnostic categories, and to suggest deleting existing diagnostic categories.
All DSM-V work group proposals will be based on a careful, balanced review and analysis of the best clinical and scientific data. Evidence accumulated from work group members and hundreds of additional advisors to the DSM-V effort will be considered before final recommendations are made.
The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., will have 13 members who will form three subcommittees:
– Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.
– Paraphilias, chaired by Ray Blanchard, Ph.D.
– Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.
Each subcommittee will pursue its own charge, provide ongoing peer review, and consult with outside experts. The DSM-V is expected to be published in 2012.

Regarding the Transactive organization’s statement about the DSM-V, Dr. Bailey took strong exception to this statement:

“Zucker has stated that a secure gender identity possibly prevents the development of later homosexuality. This raised several red flags for those of us who work with gender non-conforming children, youth and their families. TransActive’s position is that “prevention of homosexuality” should not be the concern of childhood gender identity specialists.”

To which, Bailey said:

This is an utterly false characterization of Zucker’s position. He has no desire, stated or otherwise, to prevent homosexuality. Experience and logic suggest that when people have reasonable and sound positions, they do not need to mischaracterize the positions of others they disagree with.

I agree with Bailey, I have seen nothing which would suggest Zucker has a stake in the eventual sexual orientation of children. And I certainly agree with the last sentence which has some special significance to me in light of the cancellation of the APA symposium.
In my opinion, there are some advocates who implore various audiences to trust science but really do not want this unless the outcome suits their advocacy goals.

Ken Zucker compares ethnic identity conflict and gender identity conflict

Ken Zucker, a psychologist featured in the NPR series on gender identity, recently posted the following on the SEXNET listserv. Are ethnic identity conflict and gender identity conflict analogous? In this post, Dr. Zucker addresses the topic and I thank him for giving me permission to re-post it here:

In the interview I had with the NPR journalist, Alix Spiegel, I posed the question: How would a clinician respond to a young child (in this instance a Black youngster) who presented with the wish to be White? I had already sent Ms. Spiegel an essay that I published in 2006 in which I had presented this analogy and she told me that she was intrigued by the argument.
In this post, I list some references that I have accumulated over the years that discusses issues of ethnic identity conflict in children and adults. In the 2006 paper, I was particularly influenced, rightly or wrongly, by an essay Brody (1963) wrote many years ago. I think it is worth reading. Thus, I did not invent the analogy out of thin air. I had been influenced by three things: first, I was aware of this literature on ethnic identity conflict and I thought it had some lessons in it; second, I had observed, over the years, that some kids that I have seen in my clinic who had a biracial ethnic background also sometimes struggled with that (e.g., wanting to be White, like their mother, and not wanting to be Black or non-white Hispanic, like their father) or wanting to be an American (and not a Canadian) or wanting to be a dog (and not a human). I have thought about these desires as, perhaps, an indication of a more general identity confusion. Third, I was influenced by a remark Richard Pleak made in a 1999 essay, in which he wrote that the notion that “attempting to change children’s gender identity for [the purpose of reducing social ostracism] seems as ethically repellant as bleaching black children’s skin in order to improve their social life among white children” (p. 14). I thought about his argument and decided that it could be flipped. Thus, in the 2006 essay, I wrote:
This is an interesting argument, but I believe that there are a number of problems with the analysis. I am not aware of any contemporary clinician who would advocate “bleaching” for a Black child (or adult) who requests it. Indeed, there is a clinical and sociological literature that considers the cultural context of the “bleaching syndrome” vis-a-vis racism and prejudice (see, e.g., Hall, 1992, 1995). Interestingly, there is an older clinical literature on young Black children who want to be White (Brody, 1963)–what might be termed “ethnic identity disorder” and there are, in my view, clear parallels to GID. Brody’s analysis led him to conclude that the proximal etiology was in the mother’s “deliberate but unwitting indoctrination” of racial identity conflict in her son because of her own negative experiences as a Black person. Presumably, the treatment goal would not be to endorse the Black child’s wish to be White, but rather to treat the underlying factors that have led the child to believe that his life would be better as a White person. As an aside, there is also a clinical literature on the relation between distorted ethnic identity (e.g., a Black person’s claim that he was actually born White, but then transformed) and psychosis (see Bhugra, 2001; Levy, Jones, & Olin, 1992). Of course, in this situation, the treatment is aimed at targeting the underlying psychosis and not the symptom.
The ethnic identity literature leads to a fundamental question about the psychosocial causes of GID, which Langer and Martin do not really address. In fact, they appear to endorse implicitly what I would characterize as “liberal essentialism,” i.e., that children with GID are “born that way” and should simply be left alone. Just like Brody was interested in understanding the psychological, social, and cultural factors that led his Black child patients to desire to be White, one can, along the same lines, seek to understand the psychological, social, and cultural factors that lead boys to want to be girls and girls to want to be boys. Many contemporary clinicians have argued that GID in children is the result, at least in part, of psychodynamic and psychosocial mechanisms, which lead to an analogous fantasy solution: that becoming a member of the other sex would somehow resolve internalized distress (e.g., Coates, Friedman, & Wolfe, 1991; Coates & Person, 1985; Coates & Wolfe, 1995). Of course, Langer and Martin may disagree with these formulations, but they should address them, critique them, and explain why they think they are incorrect. I would argue that it is as legitimate to want to make youngsters comfortable with their gender identity (to make it correspond to the physical reality of their biological sex) as it is to make youngsters comfortable with their ethnic identity (to make it correspond to the physical reality of the color of their skin).
On this point, however, I take a decidedly developmental perspective. If the primary goal of treatment is to alleviate the suffering of the individual, there are now a variety of data sets that suggest that persistent gender dysphoria, at least when it continues into adolescence, is unlikely to be alleviated in the majority of cases by psychological means, and thus is likely best treated by hormonal and physical contra-sex interventions, particularly after a period of living in the cross-gender role indicates that this will result in the best adaptation for the adolescent male or female (e.g., Cohen-Kettenis & van Goozen, 1997; Smith, van Goozen, & Cohen-Kettenis, 2001; Zucker, 2006). In childhood, however, the evidence suggests that there is a much greater plasticity in outcome (see Zucker, 2005a). As a result, many clinicians, and I am one of them, take the position that a trial of psychological treatment, including individual therapy and parent counseling, is warranted (for a review of various intervention approaches, see Zucker, 2001). To return briefly to the ethnic identity disorder comparison, I would speculate that one might find similar results, i.e., that it would be relatively easier to resolve ethnic identity dissatisfaction in children than it would be in adolescents (or adults). Although I am not aware of any available data to test this conjecture, I think of Michael Jackson’s progressively “white” appearance as an example of the narrowing of plasticity in adulthood.
Two caveats: first, the literature on psychosis and ethnic identity conflict that is cited in no way was meant to imply that transgendered people are psychotic; the comparison is to a very small number of people who have “delusions” of gender change in which the primary diagnosis is Schizophrenia. This was first noted in the DSM-III and remains in the DSM-IV text description; second, I can criticize my own argument along these lines: “Well, this may all be true, but surely there is no evidence for a biological factor that would cause a Black person to want to be White, but maybe there is a biological factor or set of biological factors that either predispose or cause a person with the phenotype of one sex to feel like they are of the other sex (gender).” And to that I would say fair enough.
Bhugra, D. (2001). Ideas of distorted ethnic identity in 43 cases of psychosis. International Journal of Social Psychiatry, 47, 1-7.
Brody, E. B. (1963). Color and identity conflict in young boys: Observations of Negro mothers and sons in urban Baltimore. Psychiatry, 26, 188-201.
Brunsma, D. L., & Rockquemore, K. A. (2001). The new color complex: Appearances and biracial identity. Identity: An International Journal of Theory and Research, 1, 225-246.
Fuller, T. (2006, May 14). A vision of pale beauty carries risks for Asia’s women. New York Times.
Goodman, M. E. (1952). Race awareness in young children. Cambridge: Addison-Wesley.
Hall, R. (1992). Bias among African-Americans regarding skin color: Implications for social work practice. Research on Social Work Practice, 2, 479-486.
Hall, R. (1995). The bleaching syndrome: African Americans’ response to cultural domination vis-B-vis skin color. Journal of Black Studies, 26, 172-184.
Lauerma, H. (1996). Distortion of racial identity in schizophrenia. Nordic Journal of Psychiatry, 50, 71-72.
Levy, A. S., Jones, R. M., & Olin, C. H. (1992). Distortion of racial identity and psychosis [Letter]. American Journal of Psychiatry, 149, 845.
Mann, M. A. (2006). The formation and development of individual and ethnic identity: Insights from psychiatry and psychoanalytic theory. American Journal of Psychoanalysis, 66, 211-224.
Russell, K., Wilson, M., & Hall, R. (1992). The color complex: The politics of skin color among African Americans. New York: Harcourt Brace Jovanovich.
Sanders Thompson, V. L. (2001). The complexity of African American racial identification. Journal of Black Studies, 32, 155-165.
Schneck, J. M. (1977). Trichotillomania and racial identity [Letter to the Editor]. Diseases of the Nervous System, 38, 219.
Stephan, C. W., & Stephan, W. G. (2000). The measurement of racial and ethnic identity. International Journal of Intercultural Relations, 24, 541-552.
Tate, C., & Audette, D. (2001). Theory and research on ‘race’ as a natural kind variable in psychology. Theory & Psychology, 11, 495-520.
Ken Zucker

Keep talking: Sounds like a good idea to me

John Corvino’s latest post could be read with profit by some leaders in the American Psychiatric Association. We did not even have a debate planned; we had an academic program planned for over 7 months. Then, group four as identified in this essay became vocal and as the APA wrote, “misinformation and rhetoric” became the story.
Here is the punchline, but please read the whole piece.

Then there are those who wonder whether the silence I’m lamenting really is a problem at all. My Aquinas cancellation suggests that it is: intentionally or not, the cancellation sent students the message that this topic is literally unspeakable. But the problem is by no means limited to one side. Last year I did a same-sex marriage debate (with Glenn Stanton of Focus on the Family) at another Catholic college. A week before the event, my host told me that a student was trying to organize a protest. “Because he doesn’t want a gay-rights speaker on a Catholic campus?” I asked.
“No, because he doesn’t want your opponent here,” she answered. The student thought that opposition to same-sex marriage should not be dignified with a hearing. On a Catholic campus!
That student, like the rest of us, would do well to recall the words of John Stuart Mill. In his 1859 classic On Liberty Mill argued that those who silence opinions — even false ones — rob the world of great gifts:
“If the opinion is right, they are deprived of the opportunity of exchanging error for truth; if wrong, they lose, what is almost as great a benefit, the clearer perception and livelier impression of truth, produced by its collision with error.”
The moral of the story? Let’s keep talking.

I just noticed that this may not be John’s latest post as it was first posted on 365Gay on April 28. However, it is timely…

Phelps and WBC a no-show at Eastern Michigan University

In case you heard the rumors…
The Phelps clan had planned to picket at Eastern Michigan University (why there, I don’t know) due to the participation of several Campus Crusade for Christ groups in the Golden Rule Pledge/Day of Silence. I will not link to the Westboro page but this blogger has links enough to keep anyone busy for awhile looking at the whole story.
Now, back to final exams…

Two families, two approaches to gender preferences

This National Public Radio broadcast provides a look at the controversies surrounding how to treat gender identity concerns in childhood. Essentially dividing the field into two camps, the program follows the treatment choices of two families. One approach, represented by Kenneth Zucker, advocates making “the child comfortable with the sex he or she was born with.” The reporter elaborates further:

So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. 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.

Zucker’s approach is contrasted with Oakland, CA therapist, Diane Ehrensaft’s approach. She advocates:

She describes children like Bradley and Jonah as transgender. And, unlike Zucker, she does not think parents should try to modify their child’s behavior. In fact, when Pam and Joel came to see her, she discouraged them from putting Jonah into any kind of therapy at all. Pam says because Ehrensaft does not see transgenderism itself as a dysfunction, the therapist didn’t think Pam and Joel should try to cure Jonah.
Ehrensaft did eventually encourage Joel and Pam to allow Jonah to live as a little girl. By the time he was 5, Jonah had made it very clear to his parents that he wanted to wear girl clothes full time — that he wanted to be known as a girl. He wanted them to call him their daughter. And though Ehrensaft does not always encourage children who express gender flexibility to “transition” to living as a member of the opposite sex, in the case of Jonah, she thought it was appropriate.

The whole program is intriguing, controversial and worth a review.
UPDATE – The second part of this story is out today here and a school district in Southeastern PA is confronting this issue.

Wayne Besen links rape and the ex-gay movement

This is just off the wall.
Wayne Besen has a blog post this morning with this title:

‘Corrective Rape’ of Lesbians In South African Schools Shows Sickness of ‘Ex-Gay’ Movement

In a confusing post, Besen first suggests via his title that the rape of lesbians in South Africa somehow demonstrates something about the ex-gay movement. Then he says, “these extreme cases do not represent the so-called “ex-gay” movement in general.” However, in the last sentence of the post, he hints again at a link with this: “It is time to end the sickening abuse in all of its injurious forms that occur in the name of “corrective” or “ex-gay” therapy.”
This is outrageous. When Paul Cameron links gays and teacher-student sex, he is rightly denounced and dismissed. In my opinion, this post from Besen is the same kind of tactic. What is the point of that post and that headline? How does it further accurate understanding of the story he claims to be telling?
I call on people of good will to challenge this kind of shrill, polarizing rhetoric. I didn’t approve of Sally Kern calling the gay agenda worse than terrorists and I hope people will condemn this linking of sexual violence with people who refrain from homosexual behavior due to conscience of religious belief.

APA travelogue

This will be short. This morning I spoke at the Christian Medical Society breakfast along with Dr. Al Mohler. We presented abbreviated versions of the remarks originally planned for the APA symposium. From there, I had conversations with several psychiatrists who were quite enthusiastic about the Sexual Identity Therapy Framework. Without naming names, I learned that there is a group of gay psychiatrists and observers who were not happy that the symposium did not happen.
Something I want to mention is that I presented a similar program regarding the SIT framwork at the American Psychological Association last August in San Francisco. At that meeting, there were no protests and few distortions of my views and work. Why the difference here? Part of it may have related to Dr. Mohler’s presence but I am struck by the extreme differences at this APA.
I enjoyed meeting the participants of the symposium and reflecting on the turn of events.

More on the APA symposium cancellation

The Washington Times has a lengthy article on the APA cancellation with an interview from David Scasta. For now, I only have time to post it. I hope to have more comment about the whole situation soon.
May 3, 2008
Other articles about the symposium have come from MedPage Today, Citizenlink and Worldnetdaily.
First a couple of corrections and observations about these articles. The MedPage Today article leads by saying the symposium was to have covered “the ethics of ‘therapies’ for homosexuality.” Not so. We were not going to discuss therapy for homosexuality as if homosexuality is a disorder to be treated. In a related statement, the reporter referred to me as “closely identified with therapies to ‘cure’ homosexuality.” Again not so. That would require me to hold a view of homosexuality as a disorder which I do not.
The Citizenlink article makes a similar mistake in reporting that the symposium was to provide a “‘balanced discussion’ on the origins and treatment of homosexuality.” See the above on the treatment issue and the symposium was not going to discuss causal factors relating to homosexuality.
The Worldnetdaily article is interesting as I think it is largely accurate about some of the factors which led to the demise of the program. For instance, the Gay City News article of last weekend was an attack piece and may get a separate post to outline the problems with it. The WND article incorrectly identifies David Scasta as past-president of the APA (he is past-president of the Association of Gay and Lesbian Psychiatrists, a related group). Another point of the WND article is the quote attributed to Peter LaBarbera: “it wouldn’t be correct to ‘paint Warren Throckmorton as the religious right.'”
Peter’s quote highlights something I recently taught in social psychology: The more familiar one is with a group, the more one sees the diversity of that group. Social conservatives are not of the same mind when it comes to homosexuality. Case in point, this blog posts from Derek Keefe at Christianity Today and the Indegayforum regarding the different ways to respond to the Day of Silence. Those outside the social conservative world may very well lump me in with “efforts to cure” as a part of the “religious right” (is there a membership card?). However, those closer to those circles see the differences and experience them as very significant. As I have talked and listened to people of various ideological leanings, I see the same thing on the other side. I continue to hope for opportunities for dialogue, despite the efforts of those who worked to undermine the symposium.

The APA symposium on homosexuality, therapy and religion has been cancelled

What a difference a day makes.

The American Psychiatric Association program Homosexuality and Therapy: The Religious Dimension has been pulled by chair David Scasta. My understanding is that he was asked (by whom, I am still not clear) to pull the program because of increasing concerns about it. I am still hearing more about the reasons and hope to know something more clearly soon.

Dr. Scasta did tell me that the APA’s position is that the program was not pulled because gay activists were unhappy with it. At this moment, I am skeptical.

More to come…