As a follow up to the recent broadcasts by NPR and several posts regarding gender identity, here is a Q & A involving J. Michael Bailey and Ken Zucker recently posted on the SEXNET email list. Dr. Zucker is the Head of the Gender Identity Service, Child, Youth, and Family Program and Psychologist-in-Chief at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Dr. Zucker is the chair of the newly appointed Sexual and Gender Identity Disorders working group for the 5th edition of American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V). Dr. Bailey is Professor of Psychology at Northwestern University, prolific sexual orientation researcher and moderator of the SEXNET list. As the NPR article noted, Dr. Zucker has extensive clinical and research experience with persons who experience gender dysphoria. This interview was conducted by Dr. Michael Bailey via email and has been slightly edited for posting here. Both Drs. Bailey and Zucker have reviewed and approved it.
Bailey: Both NPR shows used the phrase “a girl trapped in men’s bodies.” How common is this concern over body image?
Zucker: I would say that, in general, there has not been a lot of good empirical research on body image issues in pre-pubertal children with GID. In adolescence, the Dutch group has reported clear evidence of body image dissatisfaction as one finds in adults. One of my PhD students has a dissertation that should be defended later this year in which we studied body image in boys with GID compared to clinical and community controls. We did detect significant body image differences among the three groups: body image in general and in relation to gender-specific anatomic dysphoria. The boys with GID had a poorer body image in general and, of course, with regard to gender-specific anatomic dysphoria. It is only a first pass at this issue and I will report on this down the road after the dissertation is defended.
Bailey: The case on the second NPR show is of a child (natal boy) who had extreme temper tantrums when not allowed to engage in feminine behaviors. Is this common in the kids you see, or is there something unusual about these kids?
Zucker: This is not uncommon. Some parents will report that if they try to limit cross-dressing that this can be very distressing for the boys. Some parents describe it as “he needs his fix.”
Bailey: You are more familiar than anyone else I know with the difference between the British and Dutch treatment centers that yielded the findings that only 20% of the British kids but 100% of the Dutch kids pursued sex reassignment eventually. Did the Dutch center focus on older children (who were less likely to change their minds)? To the extent that the samples were comparable, it is a shocking difference in outcome.
Zucker: I don’t think the British group has published their data yet. But, yes, the Dutch group data are on adolescents and I think that the British group is talking about clients first seen in childhood, not adolescents. The Dutch group now has a paper that is close to being “in press” on their first follow-up of GID children and then followed up later. The GID persistence rate for their boys was about 20% and the persistence rate for girls was 50%. Their persistence rate for boys appears to be similar to what I have summarized for the boys seen in my clinic (Zucker, 2005), but higher than the 12% rate for girls that we published earlier this year (Drummond et al., 2008). The Dutch group speculates that their girls were, at initial presentation, more extreme in their cross-gender behavior than the girls that we reported on, but that will require more careful analysis.
Bailey: The NPR show, and some people on it, kept implying that some of these kids are “really” transgender, and others are not. I suspect you don’t agree with this way of thinking about it, although you recognize that some kids are more likely to become transgender adolescents and adults than other kids are. Can you remind us which factors are associated with persistence of GID from childhood?
Zucker: I don’t think we know yet. Two possible candidates are age at initial evaluation (later age associated with greater persistence rates) and quantitative metrics of cross-gender behavior in childhood.
By persistence rate, Dr. Zucker is referring to the percentage of GID children who are still GID at a later assessment. In the Dutch group, as well as in Dr. Zucker’s research sample, most boys who want to be girls in childhood, end up as men who do not want to be women. For women in the Dutch sample, half remain GID. I think the assessments of low persistence of GID provide some helpful information to parents who wonder about puberty delay and behavioral interventions with their GID children.
Thanks to Drs. Bailey and Zucker for permission to post this conversation.
The other APA (the psychologists) has now commented on the appointment of Ken Zucker to the psychiatrist’s APA DSM task force.
American Psychological Association
Office of Public Affairs
Statement on Gender Identity Disorder and the Planned Revision of the Diagnostic and Statistical Manual
There has been some recent confusion regarding the American Psychological Association and work being done on the next version of the Diagnostic and Statistical Manual (DSM). The DSM is a publication of the American Psychiatric Association, not the American Psychological Association (APA). Questions regarding the DSM-V and the Sexual and Gender Identity Disorders Work Group should be directed to the American Psychiatric Association.
For many years, the American Psychological Association has worked to end discrimination, including discrimination based on sex, gender identity and sexual orientation. APA is committed to taking a leadership position among the mental health professionals, scientists and scholars who are addressing the issues surrounding gender identity and transgenderism. APA formed a task force in 2005 to study gender identity and gender variance. This group has been reviewing both the scientific literature and APA policies related to these issues and developing recommendations for education, training, practice, and further research.
The task force has completed a report that is slated to be presented to APA’s governing Council of Representatives in August. It will make a series of recommendations, including that APA call upon psychologists to provide appropriate, nondiscriminatory treatment to all transgender and gender-variant individuals. It is expected that the Council will adopt the report and its recommendations.
The task force did not take a position with regard to the gender identity disorder diagnosis because there was no consensus among its members. Indeed, there is no consensus among professionals working in the field; reputable scientists continue to disagree about GID. Regardless of the disagreement concerning the GID diagnosis, there is a need for greater consensus on treatment of gender dysphoria. The task force strongly supports the development of practice guidelines for transgender clients.
APA believes that no psychological disorder should be stigmatized or used as the basis for discrimination. People who are concerned about issues having to do with their gender identity should have access to appropriate and non-discriminatory treatment. Mental health providers need to educate themselves about how to provide such care.
Responses to Possible Questions:
Q.What is the American Psychological Association’s position with regard to the appointment of Dr. Kenneth Zucker and Dr. Ray Blanchard to the work group reviewing GID? Are you actively working to have them removed?
A. APA is pleased that well-qualified psychologists who are also members of APA have been included in the leadership of this aspect of the DSM revision. We are also aware that there are substantive disagreements in the field over the GID diagnosis and over the treatment of gender dysphoria. We call on this group and others working on the new DSM to apply the highest professional standards in reviewing the science and we encourage the careful consideration of all legitimate perspectives.
Q.Why did the American Psychological Association allow Dr. Kenneth Zucker to be part of its task force on gender identity?
A. APA’s Task Force on Gender Identity was given a very specific charge — to complete a review of the research literature on gender identity and transgenderism and to make recommendations based on that review. Nominations to the Task Force were widely sought and appointments to the task force, including that of Dr. Zucker, were made through a very thorough review process based on an individual psychologist’s research, clinical expertise and experience. As is the case with all APA task forces, the final work product is grounded in the strongest, peer-reviewed science available and undergoes a rigorous review process within the APA governance structure before it can become APA policy. Ultimately, what becomes APA policy must be well-grounded in science not individual opinion.
UPDATE – Elsewhere the American Psychiatric Association issued a statement reviewing the credentials of Dr. Zucker, which are impressive indeed.
There appears to be a growing schism within LGBT circles regarding the APA appointments of Kenneth Zucker and Ray Blanchard to the Sexual and Gender Identity Disorders Work Group (see the APA statement here). Today, the National Gay and Lesbian Task Force issued a press release calling Zucker and Blanchard “clearly out of step with the occurring shift in how doctors and other health professionals think about transgender people and gender variance.”
The APA and Jack Drescher has stepped up in favor of the appointments.
Thus far, to the best of my knowledge, the opposition has primarily been from transgender advocacy groups and writers. The press release stops short of calling for the appointments of Zucker and Blanchard to be canceled, but rather expresses disappointment. I wonder if any other advocacy groups will follow suit.
We have been talking about it just about non-stop here and MSNBC’s Brian Alexander takes a look at the GID-DSM controversy in this piece – “What’s ‘normal’ sex? Shrinks seek definition.”
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.