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.

New SAMHSA Report Calls for End to Change Therapy for LGBT Youth

I may have more to say about this report in the coming days, hopefully with some commentary from Mark Yarhouse, but for now, I am going to link to it.
Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth was released today by the Substance Abuse and Mental Health Services Administration. The report recommends the end of change therapies for minors via professional advocacy and legal strategies.
Mark Yarhouse, co-author with me of the Sexual Identity Therapy framework and professor at Regent University, was an evangelical presence on the panel of experts who produced the consensus statements.
The most controversial parts of the report, in my opinion, deal with gender identity. I think most therapists now understand that sexual orientation is durable and rarely, if ever, changes dramatically as the result of change therapy. However, the recommendations on gender identity are more controversial. Despite the use of the word consensus, I question whether there is a consensus among professionals of all ideologies about how to respond therapeutically to youth dealing with stress over gender expression.
As for the goal of ending change therapy for youth, I am a supporter. Despite years of research and effort, no safe, effective and ethical approach to sexual orientation change has emerged. The very few people who still claim effectiveness are small operations with no research of their own methods. The anecdotes of harm are convincing and the candid admissions of people like Alan Chambers that the change they claimed didn’t happen is enough to cause significant skepticism. My own professional experience researching change efforts in clients and research participants informs me that any claimed change is unlikely to be lasting or complete. The biological research, while not conclusive, supports a very early establishment of sexual desires (especially for males). The available options for attempting change are often bizarre and carry potential to create psychological problems. Thus, limiting these efforts in a free society to adults seems like a reasonable professional position.
 

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.
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

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)

Common Sense on Treatment of Gender Dysphoria

Given the controversial nature of the subject matter, I think this Globe and Mail article does a good job of representing the type of treatment offered at the Centre for Addiction and Mental Health in Toronto.
According to this article, gender identity clinic director Ken Zucker is not allowed to speak to the media. However, clinic founder Susan Bradley gave her views along with parents of children treated by the clinic. Quite appropriately, the clinic evaluates each situation and creates an individualized treatment plan. Some kids later transition and some don’t.
The writer, Margaret Wente, provides several illustrative cases. Here’s one:

“They never tried to force my son into something he wasn’t,” one mother told me. Her son had been a hyper-anxious child since birth. In kindergarten he became obsessed with dressing like a girl. The CAMH therapists determined that anxiety, not gender, was the key issue, and advised the parents to discourage their son’s obsession with girls’ clothing. Today, he is a well-adjusted young adult with a girlfriend and no interest in women’s clothes. The mother, who describes herself as “quite liberal” says she would have supported gender change if that had been the right thing to do.

This fits my experience working with such children. In some cases, it is very clear that gender is not the primary issue. Clinical response should not be “one size fits all.”
I hope the legislative effort to stop the work of the clinic is not successful.
For prior posts on Zucker and gender issues in children, see:
Gender identity disorder research: Q & A with Kenneth Zucker
Two families, two approaches to gender identity
60 Minutes Science of Sexual Orientation: An Update from a Mother of Twins
60 Minutes Science of Sexual Orientation: An Update from a Mother of Twins, Part 2
 

CNN: Sissy Boy Experiment, Part 2; Nicolosi to be on tonight

At the end of Part 2 posted below, Ryan Kendall was on giving a preview of his appearance in Part 3 of the Sissy Boy series, on tonight. After Kendall was on, Anderson Cooper said that Kendall’s therapist would also be on. According to Kendall, his therapist was Joe Nicolosi. We’ll see…
Here is Part 2 of the series:

You can read some of Kendall’s testimony in the Prop 8 CA gay marriage case here.

Barton: Gender bending honorable during Revolutionary War

On Glen Beck’s show on Friday, David Barton said:

BECK: On that program, what took a lot of viewers by surprise was that some women actually served in the military during the American Revolution.
(BEGIN VIDEOTAPE)
BECK: I have to ask you about this handsome lady.
BARTON: 1782, she wanted to do something for her country. She dressed like a man and went and enlisted.
Now, what’s interesting is she’s 22 years old at the time and other guys in the army, I always kid her about, you never shave. You’re just a kid. Of course, she didn’t shave. She’s a lady.
She got wounded in a battle up at West Point and she treated the wound herself so no one would find out what her gender was.
BECK: Holy cow.
BARTON: She later, in Philadelphia, came up with a really high fever, almost unconscious and so the physician had to check her and at that time, find out what her gender was. So, when they found out her gender, they quietly moved her out of Army. But General Henry Knox is the one that gave her an honorable discharge out of the Army at West Point.
BECK: Wow.
BARTON: She ends up with a military pension because she served as a soldier. And if you were a soldier, you got the pension so pretty cool story.

But let’s not have any of that now…

Fetal Testosterone Predicts Sexually Differentiated Childhood Behavior in Girls and in Boys

This is an important study from the Psychological Science journal’s early view:

Fetal Testosterone Predicts Sexually Differentiated Childhood
Behavior in Girls and in Boys

Bonnie Auyeung, Simon Baron-Cohen, Emma Ashwin, Rebecca Knickmeyer, Kevin Taylor, Gerald Hackett, and Melissa Hines
ABSTRACT—Mammals, including humans, show sex differences in juvenile play behavior. In rodents and nonhuman primates, these behavioral sex differences result, in part, from sex differences in androgens during early development. Girls exposed to high levels of androgen prenatally, because of the genetic disorder congenital adrenal hyperplasia, show increased male-typical play, suggesting similar hormonal influences on human development, at least in females. Here, we report that fetal testosterone measured from amniotic fluid relates positively to male-typical scores on a standardized questionnaire measure of sextypical play in both boys and girls. These results show, for the first time, a link between fetal testosterone and the development of sex-typical play in children from the general population, and are the first data linking high levels of prenatal testosterone to increased male-typical play behavior in boys.

Here’s the money quote:

Thus, our data are the first documentation that androgen exposure prenatally relates to sexually differentiated play behavior in boys and in girls. In addition, the current results support an organizational, as opposed to current, activational role of testosterone, because play behavior is measured in childhood, when concurrent testosterone levels are low.

Gender non-conformity is the strongest predictor of same-sex attraction in adulthood. This study links prenatal testosterone with later gender typical behavior. The brains of children are organized in ways that react to their environment in socially typical or atypical ways. How such behavior shapes the family environment is unclear, however, it does not appear that the behavior is exclusively a response to parental bonding or modeling.

60 Minutes Science of Sexual Orientation mother of twins, part 2

At last, I am posting some follow up comments made by Danielle, mother of the twin boys featured in the 60 Minutes segment, Science of Sexual Orientation. Part one is here and should be read first.
Danielle said this in her initial email:

I often wonder “if” I had told Adam that “yes” he could be a girl when he became old enough would he have stayed on that track of thought? However, at the urging of his therapist I told him I understood he was a girl yet he was really a boy and couldn’t be a girl.

Wanting to be clear, she wrote to elaborate:

This was my response when he was three years old. We thought it would be confusing for that age of a child to hear he could be a girl but not until he was older. Later in his life I was up late watching a tv show about transgender surgery. Adam had awaken and was watching the show behind me – I didn’t know he was there. I heard a gasp. When I turned around there was my Adam staring intently at the tv. He asked me in a shocked whisper “Can I do that surgery and be a girl?” I told him “yes” he could but not until he was 18 years old. He became very excited. You have to understand the differences in his age. I believe the information I gave him at each step was based on age appropriate responses. He did stare at me for a bit and asked me if I would really let him do something like that if he wanted. I assured him I would if it would make him happy. He wanted to know why I would help him change his body. I informed him because I loved him and I didn’t want him to be sad or hurt. He asked me if I really loved him that much. My response was a very sound “yes!” that seemed to please him very much.
The last time Adam and I talked about him being able to change his body into a girls body Adam was indecisive. Again, I believe it’s the age/stage of his life and awareness of all around him. This conversation occurred after Tyra Banks had issued an invitation to be on her show. At that time Adam advised me he wasn’t sure what he wanted to do. He didn’t know if he should change his body so he could be a girl, stay with a boys body, if he was straight sexually or gay. Again, I believe his answer and confusion to be age appropriate. I declined the show offer because I didn’t want him to expose himself when he was so unclear about his future. I didn’t want to “lock” him into any particular role. That was when I decided to proceed with the hormone therapy to give him more time and maturity to decide what he wanted for himself. However he was already fully into developing so we decided not to go ahead with the treatments.
We are in the process of working on another television project. I am allowing Adam to participate because I believe the show will allow him to show his confusion and be himself as he is for a 12 year old. This lead us to another conversation about the issue. For all of his wise wisdom he informed me he still didn’t know what he wanted to do. “After all Mom, I’m only 12. I’m not suspose to know 100% for sure where my sexuality belongs. I’m suppose to be able to explore and decide later” And that’s where I have left it. For him to be a normal 12 year old child, maturing, developing and exploring the possibilities of his future. I’m here to guide him, support him, and show him all the possibilities of the future. I can love him, hold him, praise him and catch him if he falls. That’s my role as a parent.

I then wrote to her to clarify how these thoughts related to her parenting decisions, specifically with his name and school. She said:

The issue of what name to use during school was never really discussed. I wouldn’t have allowed him to use a girls name at school even if he had pushed me to do so. He was “Adam” and that was that.
During school hours he could wear what he wanted as long as it followed the school dress code. He only asked to wear a dress to school a few times. My response was always that his brother couldn’t wear his fireman clothing so he couldn’t wear his dresses to school however, he did wear them around the house. He did wear a girls black sweater with gold thread for two years. He wore girls tennis shoes all his life because of the color and sparkles and still wears them. He would wear girl shirts; however, in today’s fashion world, sometimes it’s difficult to tell the difference except in color. In his younger years, he wore girl jeans with sparkles but only for about an year then he didn’t want to wear them anymore. But the really feminine clothing was only at home. My life was easier dealing with this issue because I had twins. His twin wanted to be a fireman. He had everything to do with a fireman just like Adam had everything to do with being a girl. My rule was that the girl clothing (dresses, heels, jewelry, skirts, femme blouses, makeup) and the fireman clothing stayed home when we went to the library, grocery store, grandma’s, church, school and so on. My main reason for my restrictions were due to my parents who are totally against Adam’s gender issues. However, his Nana didn’t care what he wore so he could take his dresses to her house and wear them over there. I did have an issue at school once where the principal asked me if I could get Adam a different book bag (his was pink) and buy him different shoes (his were white with a pink logo on them). I advised her that he wasn’t breaking any rules by his choices so I wouldn’t make him give them up. I told her I could give in to him and allow him to wear dresses to school if she really wanted to push me since there isn’t a dress code that says he can’t. She backed off after that. However, I wouldn’t have ever allowed him to wear a dress to school anyway. Yes, I had restrictions about what he wore and did in society but he did have a bit of freedom by his choice of shoes.

I again want to thank Danielle for her candid comments. I have received emails from parents and professionals who are glad for this glimpse into how one parent reasons through these difficult issues.