Regret in Medical Transition: Research from the Amsterdam Gender Dysphoria Study

One of the significant issues in treating gender dysphoria is an examination of regret, if any, experienced by patients who engage in surgical interventions. In a remarkable paper published recently in The Journal of Sexual Medicine, a report of cases seen from 1972-2015 in the largest gender identity clinic in Amsterdam is presented. The sample was large and as a group showed very little regret.

6,793 people (4,432 birth-assigned male, 2,361 birth-assigned female) visited our gender identity clinic from 1972 through 2015. The number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015. The estimated prevalence in the Netherlands in 2015 was 1:3,800 for men (transwomen) and 1:5,200 for women (transmen)*. The percentage of people who started HT within 5 years after the 1st visit decreased over time, with almost 90% in 1980 to 65% in 2010. The percentage of people who underwent gonadectomy within 5 years after starting HT remained stable over time (74.7% of transwomen and 83.8% of transmen). Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.

The idea that regret is common is promoted by Christians who disapprove of gender transition.*** One such website “Sex Change Regret” (sexchangeregret.com) carries articles by Ryan Anderson, Walt Heyer, and Michelle Cretella.** Whether one agrees with transition or not, one should not promote a tendentious reading of research to promote one’s views. While a very small number of people have expressed regret, most don’t. In this study, some experienced social losses after transition, while others did not experience relief from their dysphoria.
If anything, the appropriate stance for a Christian is love and curiosity. Let’s keep our minds and hearts open.
**UPDATE:
After I published this post, Ryan Anderson took exception with my characterization of his position. See his tweet below:


Although Anderson quoted Walt Heyer’s article Regret Isn’t Rare in his new book When Harry Became Sally, I removed this phrase in the post:

all of whom promote the idea that regret is may be widespread

Anderson denies that he believes anything about regret. I also asked him to characterize his position which I will include in a separate post. There was no intent to misrepresent him. Given the section in his book on the subject of regret, his approving citation of Walt Heyer, and an essay in the Daily Signal, I felt I fairly and non-controversially represented his position.
 
*In the study, the authors defined “transwomen as having a male birth assignment and transmen as having a female birth assignment who might receive medical treatment to adapt their physical characteristics to their experienced gender.”
***edited to change “disapprove of transgender people” to “disapprove of gender transition.” To transgender people, there is little difference, but to be as fair as possible to those who have moral misgivings about transitioning, I made the change.

A Real Life Reason to Reject the Nashville Statement

Nashville logoLast week I wrote some reactions to the Nashville Statement on sexual orientation and gender identity.  The statement was written by the Council on Biblical Manhood and Womanhood and has been the focus of much controversy since it was released a week ago.  I thought the statement missed the mark in several ways, but the one I want to highlight with this follow up post is the Nashville Statement’s claim about disorders of sex development.
After my post on the Nashville Statement came out, I received the following email from Lianne Simon. Lianne is an intersex individual who tells her story on her website and also accompanies Dr. Megan DeFranza (PhD, theology, Marquette University) on speaking engagements regarding intersex conditions and theology. They manage the website intersexandfaith.org. Simon gave me permission to use her email:

In your Patheos post you said, “Practically, the Nashville signers don’t give us a clue how people Jesus referred to here can “embrace their biological sex.”
I think their intention is fairly clear. Sex is strictly binary to the signatories. Gender identity is entirely ‘adopted’ rather than rooted in biology. Therefore, intersex people must have a biological sex (i.e. male or female) that is confused or obscured by their disorder. So. the statement
“…and should embrace their biological sex insofar as it may be known.”
means that intersex people should embrace the sex assigned them by doctors and accept the medical treatment involved.
This is the way I, as a Christian intersex person, understand their position. As do my intersex friends.
We are castrated by doctors, undergo cosmetic sex assignment surgeries without our consent, are given hormones, lied to, have secrets kept from us, and made to live in shame–all in the name of their bloody binary view of sex.
That’s what their statement means to us.
They not only approve, they’re demanding that we embrace the evil that’s being done to us.
And if we object to the binary sex forced upon us, then we’re rejecting God’s plan and departing from the faith.
Kind regards,
Lianne Simon
www.intersexandfaith.org
www.liannesimon.com

Simon’s story is fascinating and well worth reading. She wrote a detailed response to the Nashville Statement at her website. She provides a human face to the topics covered in the Nashville Statement. I hope the signers will reconsider their pronouncements about disorders of sex development in light of Lianne’s life.
The part of the Nashville Statement Lianne referred to is below:

WE AFFIRM that those born with a physical disorder of sex development are created in the image of God and have dignity and worth equal to all other image-bearers. They are acknowledged by our Lord Jesus in his words about “eunuchs who were born that way from their mother’s womb.” With all others they are welcome as faithful followers of Jesus Christ and should embrace their biological sex insofar as it may be known.
WE DENY that ambiguities related to a person’s biological sex render one incapable of living a fruitful life in joyful obedience to Christ.

Lianne’s story provides a real life foundation for my criticism that the guidance offered by the Nashville Statement is uninformed and inadequate. She concludes her blog post with this:

I’m grateful that the Nashville Statement says that we who are intersex are “created in the image of God and have dignity and worth equal to all other image-bearers.” But I’m troubled that this affirmation appears to require us to give up our bodily integrity and embrace some doctor’s guess at what sex God meant us to be.
Understand this—your Nashville Statement drives intersex people away from the Gospel.

The real world of sexuality is not as neat and clean as portrayed by the signers of the Nashville Statement. I hope Lianne’s story provides a caution to those who marginalize those who have been dealt a hand they didn’t ask for.

The New Atlantis Study on Sexual Orientation and Gender Identity That's Not a Study

UPDATE: In a post out on 8/27/16, Adam Keiper, editor at The New Atlantis magazine responds to this post with a rebuttal to my points below. I urge you to go read it. I in turn respond to him. I also make a correction in my original post below based on his communication to me.
————————————————- (original post below)
Over the past year, hot discussions of sexual orientation have been pushed aside by controversies over gender identity and bathrooms. A new article from The New Atlantis shows that both topics have plenty of life. Yesterday, social media was buzzing about a new “study” of sexual orientation and gender identity by Lawrence Mayer and Paul McHugh. Actually, the article was not a study but a review and summary of empirical studies. As far as I can tell, it is being touted most by conservative leaning and anti-gay organizations.
The New Atlantis describes itself as a “Journal of Technology and Society.” However, the article did not receive peer review and it shows. Lawrence Mayer, the first author, is not well known in sexuality research circles but the second author is. Paul McHugh is retired from Johns Hopkins and was responsible for discontinuing the sex reassignment program there. He also was an advisor to the Repressed Memory Foundation in the 1990s.
Quickly, the National Organization for Marriage touted the paper as “Groundbreaking New Research.” Even calling the paper a new study isn’t accurate, there are no new studies in the paper. A bunch of old ones are missing as well.
In this post, I want to include some initial reactions and then some notes from Michael Bailey, professor at Northwestern, who was cited several times in TNA paper. I am going to focus on their points about sexual orientation and leave the gender identity points for a future post.
Here is their summary of research regarding sexual orientation:

● The understanding of sexual orientation as an innate, biologically fixed property of human beings — the idea that people are “born that way” — is not supported by scientific evidence.
● While there is evidence that biological factors such as genes and hormones are associated with sexual behaviors and attractions, there are no compelling causal biological explanations for human sexual orientation. While minor differences in the brain structures and brain activity between homosexual and heterosexual individuals have been identified by researchers, such neurobiological findings do not demonstrate whether these differences are innate or are the result of environmental and psychological factors.
● Longitudinal studies of adolescents suggest that sexual orientation may be quite fluid over the life course for some people, with one study estimating that as many as 80% of male adolescents who report same-sex attractions no longer do so as adults (although the extent to which this figure reflects actual changes in same-sex attractions and not just artifacts of the survey process has been contested by some researchers).
● Compared to heterosexuals, non-heterosexuals are about two to three times as likely to have experienced childhood sexual abuse.
● Compared to the general population, non-heterosexual subpopulations are at an elevated risk for a variety of adverse health and mental health outcomes.
● Members of the non-heterosexual population are estimated to have about 1.5 times higher risk of experiencing anxiety disorders than members of the heterosexual population, as well as roughly double the risk of depression, 1.5 times the risk of substance abuse, and nearly 2.5 times the risk of suicide.
● Members of the transgender population are also at higher risk of a variety of mental health problems compared to members of the non-transgender population. Especially alarmingly, the rate of lifetime suicide attempts across all ages of transgender individuals is estimated at 41%, compared to under 5% in the overall U.S. population.
● There is evidence, albeit limited, that social stressors such as discrimination and stigma contribute to the elevated risk of poor mental health outcomes for non-heterosexual and transgender populations. More high-quality longitudinal studies are necessary for the “social stress model” to be a useful tool for understanding public health concerns.

First, here is Michael Bailey’s quick reaction:

1. Their review of sexual orientation is not up to date (A major omission is that it neglects to cite our recent magnum opus on this topic: http://psi.sagepub.com/content/17/2/45.full.pdf+htmlf). The idea that sexual orientation is fluid has some plausibility for women, but not for men.
2. I agree with the authors that discrimination alone is unlikely to completely explain differences between heterosexual and homosexual people in mental health profiles, although it may contribute.
3. They are right on that the idea of innate, fixed gender identity is not consistent with empirical evidence. I differ from them, however, in believing that sex reassignment is still the best option for some individuals.
4. Most importantly, I agree that all of these issues should be openly discussed and researched. There is little government support for open-minded investigation for these controversial issues. That is unfortunate and exactly backwards. Support should be directed to resolve the most contentious issues.

As I reviewed the sexual orientations sections, I agree with Bailey. I especially agree that readers should read this major review of research on sexual orientation published earlier this year. Mayer and McHugh’s paper is missing any serious discussion of epigenetics, they overlook the new genetic linkage paper involving gay brothers, (they do address it, see the follow up post) as well as work on “gay rams.” The TNA authors minimize the neural differences between gays and straights, calling them “minor differences in brain structures.” How do these authors know what differences are minor and which are not? In fact, the differences in symmetry and brain activity are quite provocative and have not been accounted for by any environmental theory. Of course, we need more research with larger sample sizes but Mayer and McHugh just shrug these studies off as inconsequential.
Regarding sexual abuse, the authors review several studies which demonstrate higher rates of sexual abuse among GLB people as opposed to heterosexuals. For the most part, they report the relevant details but they failed to catch the mistakes in the Tomeo study and report it incorrectly (see this post for the problems with using Tomeo). Even though some who are touting the study miss this, the authors provide caution for those wanting to see homosexuality as the result of sexual abuse:

In short, while this study suggests that sexual abuse may sometimes be a causal contributor to having a non-heterosexual orientation, more research is needed to elucidate the biological or psychological mechanisms. Without such research, the idea that sexual abuse may be a causal factor in sexual orientation remains speculative.

They say “sometimes.” I would say infrequently or rarely and would add that we really don’t know. What we do know is that most people who are GLB were not abused. The TNA paper affirms that observation.
On the “born that way” claim, I find it contradictory that the authors express uncertainty about the causes of orientation but then say with great certainty that the “born that way” theory isn’t supported by scientific evidence. This line is apparently meant to hook the social conservatives which indeed it has. I mentioned the misleading “Groundbreaking New Research” headline from NOM, and then I just saw Liberty Counsel’s email which leads: “Scientific Research Debunks LGBT Propaganda.”
For readers wanting a more thorough review of the literature, please see the paper from Bailey and colleagues linked here.
 

Iowa Civil Rights Commission Releases Revised Sexual Orientation and Gender Identity Public Accommodations Brochure

This just in from the Iowa Civil Rights Commission:

Iowa Civil Rights Commission Releases Revised Sexual Orientation & Gender Identity Public Accommodations Brochure
The Iowa Civil Rights Commission announced today the publication of its Revised Sexual Orientation & Gender Identity Public Accommodations Brochure.  The revision replaces the previous version which had not been updated since 2008 and clarifies that religious activities by a church are exempt from the Iowa Civil Rights Act.
“The Iowa Civil Rights Commission has never considered a complaint against a church or other place of worship on this issue,” said director Kristin H. Johnson. “This statute was amended to add these protected classes (sexual orientation and gender identity) in 2007 and has been in effect since then. The Iowa Civil Rights Commission has not done anything to suggest it would be enforcing these laws against ministers in the pulpit, and there has been no new publication or statement from the ICRC raising the issue. The Commission regrets the confusion caused by the previous publication.”
The revised brochure may be found at this link: https://icrc.iowa.gov/sites/default/files/publications/2016/2016.sogi_.pa1_.pdf

This new language is more clear:

P L A C E S O F W O R S H I P
Places of worship (e.g. churches, synagogues, mosques, etc.) are generally exempt from the Iowa law’s prohibition of discrimination, unless the place of worship engages in non-religious activities which are open to the public. For example, the law may apply to an independent day care or polling place located on the premises of the place of worship.

By independent day care, the Commission means a day care renting or leasing a place of worship and not being conducted by the church as a part of the church’s ministry. Ms. Johnson clarified that to me earlier in the week.
For background on this issue see these posts: Link, link

Information and Misinformation on Gender Dysphoria from Wallbuilders and the American College of Pediatricians, Part One

Tuesday on Wallbuilders Live, Dr. Michelle Cretella represented tiny pediatric breakaway group the American College of Pediatricians. She briefly discussed the organization’s position paper on responding to gender identity issues. In doing so, she said something which caught my irony sensor. It also occurred to me, as it repeatedly has in the discussion of gender dysphoria, how difficult it is to avoid taking extreme positions.
Listen to her response to a question from host Rick Green about how much harm gender dysphoria is causing.

I want to address two claims that came up in this segment. In this post, I address the claim that 80% of gender dysphoric children will accept their biological sex with therapy. In a future post, I will write about the claim about suicide rates.
Cretella says:

They’re [advocates for transgender children] cooperating with, at least, mental confusion.  You know, initially, we know that there is psychiatric literature that shows if you work with these children one on one and with their families, the vast majority, over 80% will come to accept their biological sex after puberty before adulthood. So yes, to put these children to reaffirm their confused thinking, to put them on puberty blockers, and then cross-sex hormones to make them quote unquote the other gender, you are permanently sterilizing children. It’s insanity.

Cretella is correct that persistence rates are low (gender dysphoria continuing into adulthood) among gender dysphoric children, but this is not the case with adolescents who remain gender dysphoric or those who experience it with an adolescent onset. In their paper, ACP uses the American Psychiatric Association’s DSM-V as an authority. The section of the DSM-V cited by ACP supports the claim about persistence but does not fully support Cretella’s claim about the role of therapy.

Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. In one sample of natal males, lower socioeconomic background was also modestly correlated with persistence. It is unclear if particular therapeutic approaches to gender dysphoria in children are related to rates of long-term persistence. Extant follow-up samples consisted of children receiving no formal therapeutic intervention or receiving therapeutic interventions of various types, ranging from active efforts to reduce gender dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence, since such children have not yet been followed longitudinally in a systematic manner. For both natal male and female children showing persistence, almost all are sexually attracted to individuals of their natal sex. For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually attracted to males) and often self-identify as gay or homosexual (ranging from 63% to 100%). In natal female children whose gender dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%). (APA, DSM-V, p. 455)

To the DSM-V, I can add the description of persistence developed by the World Professional Association for Transgender Health (WPATH) in their standards of care.

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.V Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003). (WPATH, p. 11).

The irony of Cretella’s confidence in psychiatric intervention relates to the expulsion from ACP membership of George Rekers who was infamous for his own personal decline and his discredited treatment approach to what was then called gender identity disorder. In fact, we don’t know the role, if any, therapy plays in influencing the current persistence rates. While there is reason to think parental permission to transition in childhood might increase the persistence rates, there isn’t sufficient research to say for sure.
After listening to Cretella and reading the ACP paper, I wonder what the ACP recommends for the 10-20% of people with gender dysphoria persisting into the late teens. Do they favor reassignment for those persons? They focus on the data which make their point but don’t seem to have an answer for the rest of the people involved.
Another problem with ACP’s confidence in psychiatric interventions for gender dysphoria is that they also oppose a frequent end point in the trajectory of many gender dysphoric children: homosexuality (see image at the end of the post). One of the reasons George Rekers tried to re-orient gender dysphoria was to prevent homosexuality. Furthermore, one of the prime objectives of reparative therapists like Joseph Nicolosi is to prevent homosexuality via the alteration of parenting behaviors toward gender nonconforming children. ACP should stop pretending to sympathize with gender dysphoric children when they also write letters to school personnel promoting reparative change therapy for gay people.
Summary
Cretella is right that studies of gender dysphoric children (mostly with boys) find low rates of persistence of gender dysphoria into adulthood. However, she should have distinguished between prepubescent children and teens. The outcomes for these two groups do not appear to be the same. No doubt her listeners will not make that distinction.
Cretella was wrong to invoke psychiatric treatment as the reason for low persistence rates. If anything, some treatments have been shown to be harmful in some cases while others may not be harmful but may not cause a reduction in gender dysphoria. From her presentation, one could get the impression that advocates for gender dysphoric children know these treatments work but are motivated to undermine the natural family and therefore withhold appropriate medical care. While there is strong disagreement among experts and some advocates might oppose traditional families, it is simply not true that gender dysphoria could be easily treated if only activists would get out of the way.
Another important factor is that the treatment advocated by Cretella and the ACP is an outdated, discredited, psychoanalytically based approach which has not shown success. Even among those in the mainstream who are skeptical of puberty blocking drugs, the treatments advocated by ACP are rejected.
Gender Dysphoria After Childhood
The following image comes from a 2012 study by Devita Singh on gender dysphoric boys. Note the columns titled “sexual orientation in fantasy” and “sexual orientation in behavior.” By far, the most common end point for gender dysphoric children across studies is some level of same sex attraction. Gay advocates have in the past confided to me that they are ambivalent about supporting interruption of puberty because such interventions may interfere with a natural homosexual outcome. Please see this common sense article by Michael Bailey and Eric Vilain on the dilemma many parents of gender dysphoric children face.
Singh table

Ted Cruz and Bobby Jindal Headline David Barton's ProFamily Legislative Conference

Ted Cruz and Bobby Jindal will headline David Barton’s ProFamily Legislative Conference in early November. Cruz and Jindal are both running for the GOP’s presidential nomination.
In all seriousness, how can this be a good thing when the person sponsoring the conference can’t get his facts straight? Just in the last two days, Barton has made false claims about gender identity in the military and the Obama administration’s record on prosecution of child porn.
Watch this video to see if your state senator or representative endorses the conference.
[vimeo]https://vimeo.com/134212588[/vimeo]
 
 

David Barton Doubles Down on His Gender Identity Nonsense

Before you exclaim, “Not another David Barton post!” I want you to remember that at least two men running for the GOP presidential nomination (Ted Cruz and Mike Huckabee) take Mr. Barton seriously and encourage others to do the same.
Recently, David Barton said on a Mission Radio podcast that churches had to hire pedophiles to run their nurseries because you can’t discriminate on the basis of sexual orientation. Nearly everything he said about that topic was incorrect.
Now, Right Wing Watch discovered that Barton is telling evangelicals (click the link for the audio) that the military can’t discharge soldiers for bestiality and/or pedophilia.

“There’s 82 official gender identities now and they all have equal status and protection here,” Barton said, “so we’re talking pedophiles. If you’re a military member and you have an inclination for young children, you can’t be kicked out of the military for that anymore because that is your gender identity. If you are into having sex with animals, bestiality, that is one of the 82 gender identities, you cannot be kicked out for your lack of judgment and your very perverse taste on that.”

If Barton protests that he is only talking about inclinations, then he is making things up just to generate unfocused outrage. You never could be kicked out of somewhere for thinking something unknown to anyone but yourself.
The Uniform Code of Military Justice addresses these matters.
Media covering Cruz and Huckabee: When you have some down time and you are not talking about weighty matters like Iran and abortion, ask the candidates about their praise for a pundit who didn’t know that ENDA hasn’t passed yet and thinks that, by law, churches have to hire pedophiles. Oh, and ask them if the Constitution quotes the Bible verbatim. Ask if violent crime in the nation is going up or down. And how about asking if HIV/AIDS research is a pointless effort since God won’t allow an HIV vaccine.
 

Are Rachel Dolezal and Caitlyn Jenner Alike? Conflict over Ethnic Identity and Gender Identity Examined (VIDEO UPDATES)

UPDATED: Dolezal as a white woman sued Howard University for racial discrimination. See video on that point at the end of this post. Video of her interview with Matt Lauer is also at the end of the post.
Rachel Dolezal has become an object of media and public attention because she has identified as a black woman for years even though both of her biological parents are white. She recently was outed by her parents but told Matt Lauer on the Today Show today: “I identify as black.”
In May 2008, I asked Ken Zucker, a psychologist best known for his work in gender dysphoria, for permission to reprint a post from the SEXNET listserv, an internet group of people who research and write about sexuality research. The post addressed the question: are ethnic identity conflict and gender identity conflict similar in any meaningful ways? Although Zucker’s illustrations primarily examine the case of darker skinned people wanting to pass as white, his post addresses some of the current issues raised by Rachel Dolezal’s public statements about her ethnic identity.
Dr. Zucker:

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.
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Ken Zucker

Zucker’s provocative post is timely now. Rachel Dolezal’s and Caitlyn Jenner’s stories have caused people to question and examine categories which seem to most people to be discreet categories. One is either a part of one group or another. However, gender is increasingly being questioned by scientists and activists alike. Race and ethnicity has been seen as more fluid but for different reasons than are posed by Dolezal. Can a person simply declare an ethnicity based on psychological affinity for that ethnicity? Is Zucker correct to wonder about an analogy between ethnic identity disorder and gender identity disorder?
Regarding Dolezal, it will be interesting to see how this plays out. Will the decreasing plasticity Zucker describes demonstrate itself here. She certainly has taken a very public step by declaring herself to be black. Social psychological research tells us that it may be harder for her to walk back from that now that she has made a public declaration. If she does revert to a “white identity” then I will be interested in the social and psychological factors which could bring that about.
ABC News has the story of Dolezal’s discrimination suit.

ABC US News | World News
Interview with Matt Lauer (embed not working, click here for video)

What Kind of Woman is Caitlyn Jenner? Part Two of a Q&A on Autogynephilia with Michael Bailey

Yesterday, I posted part one of my interview with Michael Bailey on the topic of Caitlyn Jenner and autogynephilia. In that segment, Bailey covered the basics about autogynephilia and why he thinks Jenner manifests autogynephilic characteristics. In this segment, Bailey tackles what is known about outcomes for autogynephilic individuals, issues relating to minors with gender dysphoria and addresses critics of the concept. He also mentions one case where autogynephilia disappeared with the administration of leuprolide.
I also wrote GLAAD three times and asked for comment on autogynephilia generally and yesterday’s interview specifically with no response. GLAAD produces a tip sheet for journalists that doesn’t mention autogynephilia. Bailey addresses the media silence at the end of the interview.
I want to thank Michael for sharing his time and knowledge.

WT: What are the long term trajectories for autogynephilic individuals? What is the proper therapeutic response?
MB: Persons with autogynephilia often struggle, because of shame, lack of understanding, and the disapproval of others. Also, there is a real tension between achieving autogynephilic goals and maintaining conventional romantic relationships. Autogynephilic males who cross dress often go through binge-purge cycles, in which their cross dressing increases periodically, they get fed up and throw away their female clothing, and then later begin the cycle again. Some are fortunate to find partners (generally women) who accept their autogynephilia-driven behavior–some women even cooperate and participate. Some autogynephilic individuals never acquire partners, and they avoid the aforementioned struggle.
Some persons with autogynephilia are content to remain male. Those who get their gratification primarily from cross dressing are less likely to want to progress than those whose fantasies involve having female bodies, especially genitalia. Those, of course, can acquire female genitalia via surgery. Those who go that route generally undergo electrolysis and hormonal therapy prior to genital surgery.
As for “proper therapeutic response,” this is surely best considered at the individual level. But gender dysphoria due to autogynephilia doesn’t merely go away. Again, autogynephilia is like a sexual orientation, and that doesn’t change. I suspect that if there were more honesty about autogynephilia, then those who have it would understand themselves sooner, be less likely to commit to romantic interpersonal relationships, and would be more likely to pursue earlier sex reassignment. Evidence suggests they would be happier doing so, and there would be fewer wrecked families; quite parallel with the case of men hiding their homosexuality and getting heterosexually married.
WT: In your answer about proper therapeutic response, you said autogynephilia doesn’t change. Is this based on research or on the classification of autogynephilia as a sexual orientation? 
MB: Many men with autogynephilia would like not to have it. But I have never met a man who said his autogynephilia went away. Some transwomen say that it diminishes or vanishes after a sex change. Remember, the sex change also removes testosterone, which fuels male sex drive.
I should mention one other therapeutic approach that has not been widely used, to my knowledge. Still, I know one autogynephilic man who was on the verge of changing sex. He was, however, conflicted because he would have lost everything: his family fortune, his job, and his family. He was put on a course of leuprolide, a powerful drug that removes testosterone from the body. His desire to change sex virtually vanished. He’s happy and somehow able to have sex with his wife (viagra helps).
WT: I assume you are talking about adults. In other words, do you have different advice for minors? 
MB: The controversy over how and whether to treat preadolescent children experiencing gender dysphoria is irrelevant to controversies concerning autogynephilia. These preadolescent children are not autogynephilic. Autogynephilia almost never manifests in an obvious way before adolescence.
Lots of autogynephilic transsexuals wish they’d transitioned earlier. I can imagine this would have been better for them. If only people were more open about autogynephilia and people were more honest about it–and here I include journalists along with people with autogynephilia among those who have conspired to keep it secret–we could collect better data and ideally learn the optimal treatment for autogynephilic individuals of various subtypes.
I worry when autogynephilic transsexual activists (this includes all who were born male who have not always been exclusively attracted to men) advise families of preadolescent gender dysphoric children. The older activists have completely distinct conditions from the children, and the activists’ experiences are not an accurate guide to what the youngsters feel or how they will turn out. As we have argued, most preadolescent gender dysphoria does go away, and it is at least questionable whether it is in preadolescent children’s interests to change sex, socially (because this may lead to persistence requiring serious medical treatment).
WT: Why is there so little media coverage of the autogynephilia angle? 
MB: I think it’s a mixture of ignorance, political correctness, and fear. Most journalists know what they know from the media and from transgender activists — who do not mention autogynephilia. In fact, a few activists have managed to convince a lot of people that autogynephilia theory has been disproved (when in fact, it has substantial scientific support) and that anyone who agrees with it is anti-transgender (when in fact its major proponents, including me, have been quite supportive of transgender rights). As for fear, transgender activists (especially Lynn Conway, Andrea James, and Deirdre McCloskey) were so enraged by my writing about these ideas in my book that they tried to ruin my life. They were unsuccessful–their major success was to help Alice Dreger write a terrific article (and recently, a book) about the controversy–but I’m sure few people want to risk that. We will have made progress when Conway et al. are more ashamed of what they did to me than of autogynephilia.
WT: Is there anything else you would like to mention?
MB: I’ve noticed disapproval among some journalists–even Jon Stewart on the Daily Show went there–of the focus on Caitlyn Jenner’s attractive photographs in Vanity Fair. I can assure you (and Stewart): Caitlyn’s thrilled with that attention. It’s an autogynephilic fantasy.

Again, thanks to Michael for this information. Readers can leave follow up questions in the comments section which may form the basis for a return to the issue at a later time.

What Kind of Woman is Caitlyn Jenner? Part One of a Q&A on Autogynephilia with Michael Bailey

The transition of Bruce Jenner to Caitlyn Jenner has raised many questions about transgender issues. One that has not been widely discussed is autogynephilia as a trajectory for males who experience gender dysphoria. My impression of Jenner’s story is that she manifests aspects which are often associated with autogynephilia so it seems odd to me that the topic has not come up.
Michael Bailey is professor of psychology at Northwestern University and one of the more prolific sex researchers in the world. He kindly accepted my invitation to discuss autogynephilia in light of Caitlyn Jenner’s transition.

Throckmorton: What is autogynephilia? And how do autogynephilic individuals differ from androphilic men who become women?
Bailey: Before explaining what autogynephilia is, let me begin by explaining what it looks like. It occurs in natal males (those born male, regardless of whether they switch gender later), and it generally first manifests in adolescence, with the onset of puberty and sexual feelings. In the large majority of cases, it begins with erotic crossdressing. Generally, a boy discovers it’s sexually exciting to put in female clothing, especially lingerie, in private, look at himself in a mirror, and masturbate. People who know these boys don’t usually see them as feminine. Males like this usually are attracted to females, though some are not attracted to other people. A subset will discover other, related erotic fantasies, sometimes including the idea of having female anatomy (such as breasts and a vulva). If the anatomical fantasies predominate, then gender dysphoria is most likely to be intense. Males who eroticize the fantasy of having women’s bodies are most likely to get sex changes, for obvious reasons.
The phenomena I’ve talked about so far don’t make much sense if we take the conventional approach that these males have women’s brains. They make much more sense explained via autogynephilia. Autogynephilia might best be thought of as an unusual sexual orientation that occurs in natal males (those born male, no matter what they become). It’s very similar to male heterosexuality, because the erotic target is a woman. The difference is that in autogynephilia, the target is a self-constructed internal image–it’s like inwardly-turned heterosexuality. These males eroticize and fall in love with a woman they create within themselves
WT: Do you believe that Caitlyn Jenner is autogynephilic? If so, why?
MB: I believe it is very likely that Caitlyn Jenner’s transition was motivated by intense autogynephilia. I believe this because the best science suggests there are two completely different reasons why natal males become women: because they are feminine androphiles (lovers of men) or because they are autogynephilic. Jenner’s history shows none of the former and is very consistent with the latter. I refer specifically to his previous heterosexual marriages and secretive crossdressing.
WT. She says she always had gender dysphoria and that there was no erotic component. Would she say this if she were autogynephilic? Why?
MB: Autogynephilic individuals experience gender dysphoria, typically beginning in adolescence, when their intense erotic longing for female characteristics almost always begins. There is evidence (John Bancroft published an article long ago) showing that after changing sex, some show memory distortion. They begin to assert that their gender dysphoria began in early childhood and was far more overt than they had alleged before. They also deemphasize the erotic component, even if they admitted it before. I think they do this for at least two reasons: shame (because: sex is involved) and the desire to believe they really have the brains of women (as Jenner suggests she does–um, how does she know that?). I think also that Jenner (and others in the spotlight) likely enjoys the media spotlight, and the mainstream media loves the “was always a woman trapped in a man’s body” story and can’t deal with the “experienced intense sexual arousal when crossdressing or imagining I had a woman’s body” story.
WT: If Jenner doesn’t want people to think her transition was due to autogynephilia, why shouldn’t we just go along? 
MB: This inaccurate denial of autogynephilia is not for the good, because being honest could help lots of males struggling with their autogynephilia. (And there are lots who are.) It might help them understand themselves. It might help them accept themselves. It would at least say “Autogynephilia is nothing to be ashamed of.” I would say that people who admit and deal with their autogynephilia are even admirable.
Falsely misrepresenting one’s gender issues is also bad for science. It’s not good for people to believe false things merely because journalists don’t want to go certain places. Even among scientists, too many don’t bother to learn about the relevant literature and just listen to transgender people’s explanations (“I have the brain of a woman.”). This leads to bad scientific studies and ideas.
I think that Jenner’s brain has nothing more in common with the brain of a natal woman than mine does. She’s not that kind of woman. Her gender dysphoria was much more akin to times in my life when I had erotic and romantic longings for someone I couldn’t have.
WT: Do autogynephilic individuals have attraction to other people? 
MB: Usually, they are also attracted to women in the world (i.e., women besides their inner creation) as well. Some of these individuals marry–some tell their wives and some don’t. Wives who know often feel like they are married both to their husband and to the other woman. And the men (many–probably most–never become women) sometimes struggle between their love for their families and their desire to become women. This desire is like a typical man’s midlife crisis.
A subset of autogynephilic males report that they are bisexual, but knowledgeable scientists think this is not true bisexuality. Rather than attraction to men’s bodies, these individuals enjoy the fantasy of being courted by, desired by, or even engaging in sex with men, as women. This makes them feel quite feminine, and is thus exciting. Another subset identifies as asexual. These have plenty of sexual fantasies–it’s just that the sexual fantasies are all about the internal woman, and there’s nothing left for women in the world.
WT: What research support does this phenomenon have? 
MB: There is a great deal of support originating in Toronto in the important clinic formerly run by Ray Blanchard, the scientist most responsible for the study of autogynephilia. Blanchard observed that erotic arousal at the idea of having a female body was uncommon among natal male gender patients who said they were exclusively attracted to men (he referred to these as “homosexual” because with respect to their birth sex, that is their sexual orientation). In contrast, it was very common among natal male gender patients attracted to women, those who identified as bisexual, and those who identified as asexual–he referred to these three subtypes as “non homosexual” because they were not exclusively attracted to men. Homosexual natal male gender patients tended to have been extremely feminine since childhood. Nonhomosexual patients, not so much. (In follow up studies of preadolescent boys so feminine they wanted to be girls, not a single one was attracted to women as an adult.) Non homosexual natal male gender patients’ gender dysphoria is rarely evident in childhood but begins in adolescence. Homosexual patients request sex reassignment surgery much younger than non homosexual patients do–at least they have in the past. This partly reflects the fact that many non homosexual patients form families that delay them from pursuing such surgery.
A good resource summarizing this science (up to 2003) is the third section of my book (free pdf). A more scholarly and updated treatment is Anne Lawrence’s book.

Tomorrow, I will post the second part of my Q&A with Michael Bailey. In that part of the interview, Bailey opines about the proper therapeutic response to autogynephilic individuals, minors and transgender issues, media reporting about autogynephilia and his critics.
Part two of this Q&A is here.