Academic Freedom Under Review at Brown University

On August 16, peer reviewed journal PLOS One published “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports” by Lisa Littman, an Assistant Professor at Brown University. In essence, Littman surveyed over 250 parents of children who expressed gender dysphoria with an onset in adolescence or later. She also found that the onset of gender dysphoria took place in the context of peer groups where others in the group became gender dysphoric. On August 22, Brown University published a press release (archived) regarding the study. Then on August 27, Brown removed the news item from the school website, stating:

Brown University Statement — Monday, Aug. 27, 2018

In light of questions raised about research design and data collection related to Lisa Littman’s study on “rapid-onset gender dysphoria,” Brown determined that removing the article from news distribution is the most responsible course of action.

As a general practice, university news offices often make determinations about publishing faculty research based on its publication in established, peer-reviewed journals considered to be in good standing. The journal PLOS ONE on the morning of Aug. 27 published a comment on the research study by Lisa Littman, who holds the position of assistant professor of the practice of behavioral and social sciences at Brown, indicating that the journal “will seek further expert assessment on the study’s methodology and analyses.” Below is the comment posted on the study in the journal PLOS ONE:

“PLOS ONE is aware of the reader concerns raised on the study’s content and methodology. We take all concerns raised about publications in the journal very seriously, and are following up on these per our policy and COPE guidelines. As part of our follow up we will seek further expert assessment on the study’s methodology and analyses. We will provide a further update once we have completed our assessment and discussions.” — PLOS ONE August 27, 2018

Then today, Brown’s Dean of the School of Public Health Bess H. Marcus issued a statement explaining the decision to remove the news item. After repeating the above statement, Dr. Marcus added the following:

Independent of the University’s removal of the article because of concerns about research methodology, the School of Public Health has heard from Brown community members expressing concerns that the conclusions of the study could be used to discredit efforts to support transgender youth and invalidate the perspectives of members of the transgender community.

The University and School have always affirmed the importance of academic freedom and the value of rigorous debate informed by research. The merits of all research should be debated vigorously, because that is the process by which knowledge ultimately advances, often through tentative findings that are often overridden or corrected in subsequent higher quality research. The spirit of free inquiry and scholarly debate is central to academic excellence. At the same time, we believe firmly that it is also incumbent on public health researchers to listen to multiple perspectives and to recognize and articulate the limitations of their work. This process includes acknowledging and considering the perspectives of those who criticize our research methods and conclusions and working to improve future research to address these limitations and better serve public health. There is an added obligation for vigilance in research design and analysis any time there are implications for the health of the communities at the center of research and study.

The School’s commitment to studying and supporting the health and well-being of sexual and gender minority populations is unwavering. Our faculty and students are on the cutting edge of research on transgender populations domestically and globally. The commitment of the School to diversity and inclusion is central to our mission, and we pride ourselves on building a community that fully recognizes and affirms the full diversity of gender and sexual identity in its members. These commitments are an unshakable part of our core values as a community.

In an effort to support robust research and constructive dialogue on gender identity in adolescents and youth, the School will be organizing a panel of experts to present the latest research in this area and to define directions for future work to optimize health in transgender communities. We believe that more and better research is needed to help guide advances in the health of the LGBTQ community. We welcome input from faculty, staff and students about the composition of this panel and scope of the discussion.

Researchers Come to Littman’s Defense

In response to Brown’s actions, a group of sexuality researchers signed a letter in support of Littman. Written by J. Michael Bailey, professor of psychology at Northwestern University, the letter cautions Brown to consider the source of criticism:

We are aware of the very loud opposition to Dr. Littman’s article from some transgender activists. This was predictable to anyone who has followed transgender issues during the past few years. However, you should not overreact to this criticism, for several reasons. First, these activists do not represent all transgender persons. There is no one transgender community that speaks as one. Second, those who are protesting the loudest are trying to silence Dr. Littman by intimidation and false or irrelevant accusations. They are not engaging in good faith scientific criticism. Some of us know this strategy all too well, having been targets of it. Third, and most importantly, ROGD is a very serious public health concern. You should be proud that Brown University has opened the door to its study, and hopefully someday, to its successful treatment.

The study has been criticized on several methodological points summarized in an article by transgender activist Julia Serano. These critiques have been answered by Roberto D’Angelo and Lisa Marchiano of the Pediatric and Adolescent Gender Dysphoria Working Group.

From my perspective, the study is a preliminary examination of a syndrome which was once rare but is now increasingly seen by clinicians. I have heard about these cases more frequently over the past decade and seen several such situations. As such, the study is worthwhile and true to the stated purpose (“A study of parent reports”).

It should go without saying that more data are needed and interviews with the teens who are in the groups identifying as transgender need to follow this study. Even so, that is no reason to walk back on this preliminary effort to examine what parents are seeing in their children.

 

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A Problem I See with the DOE/DOJ Guidance on Transgender Students

At the outset, let me be clear that I believe transgender students should not be discriminated against when it comes to public accommodations. I have no problem with the Obama administration issuing guidance to schools about how the Departments of Justice and Education interpret the law regarding sex discrimination. While I don’t agree with all aspects of the DOJ/DOE documents (more on that below), I think schools benefit from knowledge of how the Departments interpret the law.
The guidance isn’t new law.*  The May 13 letter says:

ED and DOJ (the Departments) have determined that this letter is significant guidance. This guidance does not add requirements to applicable law, but provides information and examples to inform recipients about how the Departments evaluate whether covered entities are complying with their legal obligations.

While I don’t object to equal treatment under the law for transgender students, I question the DOE/DOJ on their interpretation of how a student should be regarded as transgender. According to the DOE/DOJ, no professional assessment of the student is required.

The Departments interpret Title IX to require that when a student or the student’s parent or guardian, as appropriate, notifies the school administration that the student will assert a gender identity that differs from previous representations or records, the school will begin treating the student consistent with the student’s gender identity. Under Title IX, there is no medical diagnosis or treatment requirement that students must meet as a prerequisite to being treated consistent with their gender identity.6  Because transgender students often are unable to obtain identification documents that reflect their gender identity (e.g., due to restrictions imposed by state or local law in their place of birth or residence),7 requiring students to produce such identification documents in order to treat them consistent with their gender identity may violate Title IX when doing so has the practical effect of limiting or denying students equal access to an educational program or activity.

All that is required for schools to treat students in keeping with their asserted gender identity is a student’s word (presumably for adult students) or a parent’s word (presumably for minors).
In my experience, parents often disagree over what is best for children. What is a school to do when one parent asserts a change in gender identity and the other doesn’t? In my clinical experience, I have seen just such cases. For instance, some parents interpret gender non-conforming interests as a signal that a child’s gender identity is different than what was assigned at birth. Such interpretation may not be in the child’s interest.
Evaluating the broad spectrum of children where gender identity is an issue often requires professional assistance. Particularly when children and teens are involved, getting competent help can be key in coming up with the best course of action in keeping with professional guidelines. To me, it makes sense for schools to require a supportive statement from a treating physician and mental health professional.
What is the basis for the DOE/DOJ claim?
As an authority (footnote #6) for the contention that schools can’t require a diagnosis, the DOE/DOJ letter uses a case of a transgender female employed by the Army who won an EEOC complaint alleging a civil rights violation in part because she was not allowed to use a common women’s bathroom. The Army’s defense involved a concern that the complainant had not fully physically transitioned from male to female. The EEOC ruled that an employer cannot require a medical procedure in order to deny civil rights to a transgender employee.
However, in that case, the complainant had legally changed her records and was legally female. While she had not had surgical reassignment, she had made significant steps toward transition. The facts of the case involve an adult and are much different than a school where a parent or student may not have consulted a professional.
Of course, students should not have to prove full reassignment to be treated fairly, but it seems to me that schools would be within their rights to require evidence from mental health professionals and physicians that accommodation would be appropriate. Schools regularly require professionals to provide opinions on lesser matters.
When the DOE/DOJ says “there is no medical diagnosis or treatment requirement that students must meet as a prerequisite to being treated consistent with their gender identity,” I think they go beyond the facts of the case they used as a basis for their interpretation. Perhaps there are other relevant cases, but the letter doesn’t list them.
Schools should be safe for all students, including transgender students. My concern is that this guidance will hamper schools in reacting for the good of all students on a case by case basis.
 
*When I first posted this article, I wrote that the DOE/DOJ letter wasn’t an edict. While I still don’t see it as heavy handed as some opponents do, I will concede that some school districts may experience it negatively. Furthermore, I removed that reference because I don’t want to distract from the main point of the post.

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.

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
 

Weekend Roundup: White Power Demo In TN, Transgender Prof Transitions From Christian College, IOTC At Liberty U., Senate Takes Lead In Shutdown Talks

 
Local public radio appropriately calls the League of the South rally in TN, a “white power demonstration.
Azuza Pacific theology prof, H. Adam Ackley leaves the school via a mutual statement.  Ackley is transitioning from female to male.
John Lofton of the Institute on the Constitution presents the theocratic God and Government Project at Liberty University.
Looks like the adults have gotten involved in the Shutnado standoff. Maybe the Senate and the President can keep us from going over the cliff.
Update: The League of the South look pretty puny in this pic…

 

WMOT says about 50 LoS protesters attended the event.

The Dr. Phil Show on gender identity, Part 3 – Should puberty be delayed?

Near the end of the Dr. Phil Show on gender identity, two guests who were not on stage provided a mini-introduction to the controversy of using hormones to delay puberty. Dr. Jo Olson and Dr. Eva Cwynar are two prominent doctors who work in the field of gender disorders and endocrinology. And action!

From the Dr. Phil website, here is a rough transcript of their comments.

Dr. Phil turns to two more medical professionals in the audience. Endocrinologist Dr. Eva Cwynar says parents need to wait and see what happens with puberty and not give in to their child’s fantasy of wanting to become the opposite sex. Dr. Jo Olson, pediatrician with the Transgender Clinic of Children’s Hospital Los Angeles, says children are born this way, and she helps kids make the transition through hormone therapy.
“Dr. Olson, at what point do you begin that?” Dr. Phil asks.
“It’s a different process for each child. It’s really important to recognize that young people and their families come in at very different stages of this process. Many of the people we see have actually already gone through puberty, but we do have some patients who are young, in the 12- to 16-year-old age range as well,” Dr. Olson says. “However, I want to say that we don’t just provide hormone therapy for young people, and not all young people who want to transition get hormones. We have a multi-disciplinary approach in our clinic, where they are assessed by a psychologist who is extremely familiar with gender-questioning youth, gender identity disorder and the issues that these young people face, as well as the case manager who understands what these young people go through. And hormones are not the end of the story for every young person.”
“And you work with the family members as well. It’s not just something you do to the child in isolation,” Dr. Phil says.
“Absolutely, and we have many parents who experience this same kind of mourning,” she says, referring to Toni.
“Dr. Cwynar, do you think there’s ever a point when hormone-blocking therapy is appropriate?” Dr. Phil asks.
“I do,” Dr. Cwynar says. “I think that, as everybody mentioned before, there’s a spectrum of this transgender, and I do believe as well that gender is a definition between the eyes and not between the legs, and that there are certain chemical phenomena, chromosomal phenomena, that occur both in utero and as we develop that make us appear as one sex, but is actually a different sex. I prefer waiting through puberty to see what actually happens when the hormones kick in. There are situations where you have distress and suicidal ideations and because of that, hopefully the family will be there for the child to help them get through that process. So, I like to see the whole adolescence be complete, essentially, before I do anything permanent.”

This is among the most controversial of issues and one with which I have had some professional involvement. I will give one example and then some links from past blog posts which address similar gender identity concerns.
Among several similar cases, I recall a family in conflict where the mother wanted to delay puberty for a GID child but the father did not. In short, the child now post-puberty is strongly identified with the biological gender. Delaying puberty would have been a mistake and the earlier wish to consider it vanished. Other cases are not so clear cut and hence the controversy.
Here are some relevant links to past posts:
Two families, two approaches to gender preferences
Gender identity disorder research: Q & A with Kenneth Zucker
Ken Zucker compares ethnic identity conflict and gender identity conflict
APA issues statement regarding GID and the DSM-V
The Man Who Would Be Queen – Chapters 1 & 2
American Psychological Association comments on DSM gender identity issue
60 Minutes Science of Sexual Orientation: An update from the mother of twins
60 Minutes Science of Sexual Orientation mother of twins, part 2 (this 2 part series is highly recommended)

More on the Dr. Phil episode on gender identity: Reparative drive theory

I have some video clips of yesterday’s Dr. Phil Show on gender identity. In this segment, Toni, the mother of a three boys, one of whom is transgender, expresses strong disagreement with Dr. Joseph Nicolosi and Mr. Glenn Stanton. Prior to this clip, Nicolosi outlined his views on response to gender identity issues. From the Dr. Phil website:

“So, what is a parent to do?” Dr. Phil asks. “You’re at home with your little child, they don’t do what other little boys do — and I’m using a little boy as an example. It happens with girls too, but statistics say it’s about five to one boys over girls who have this, but what is a parent to do at that point? Their question is, ‘Do we support his interest, or do we say, “No, no, no. You can’t play with that. You must play with this”?’”
“We see certain patterns, very typical patterns, of an over-involved mother, where the mother and son have a symbiotic relationship,” Dr. Nicolosi explains. “It’s very close, their identities are merged, and the father is out of the picture, and the work that we’re doing is to get the mother to back off, get the father more involved, get that boy to dis-identify with the mother and bond with the father, and in the bonding with the father, he develops that masculine identity.”

Most therapists have encountered families like this. However, they often come in for reasons other than a child’s gender identity. As Dr. Siegel said in a later part of the show, there is no evidence that a mom being close with a son leads to gender identity problems.
In this clip, Nicolosi and Stanton lay out their view of what happens to create a son like Toni’s. Roll the tape for the segment.

If I am following the mother’s explanation, she says she was not close to her son and her fiance became close to him after she backed off. She also notes that she was a single mom to her first son who would be expected to be closer to mom. Apparently, that child has no gender identity issues. And she says, the fiance/father-figure was less involved after the boy transitioned to a female role, but very involved prior to the transition. She further says that she wasn’t enmeshed with him. In other words, the reparative theory predicts a certain constellation but this women disconfirms it.
As noted in my first post on this episode, no middle ground views were presented. Near the end of the show, two reseachers seated in the audience were given a chance to speak. This segment was too short. I hope to post the clip of that exchange in a future post.
For now, I want to point out again the problem with confirmation bias in thinking through highly controversial topics. In this clip, the comments presented by Nicolosi and Stanton were not consistent with the experience of the mother and this son. Is it possible she was in denial? Is it possible that the reparative theorist was in denial? Sorting through this is difficult since both mom and the psychologists have powerful incentives to seek evidence favoring their commitments and views. In an area, like this one, where the science is developing, I advocate a very loose hold on theoretical commitments.
While the scientist can and should take a critical stance, it is true that parents need advice now. I tend to favor waiting until puberty to make decisions about transitioning since the existing research indicates most children do not opt for transition after puberty. However, even that finding is not as clear as Dr. Phil presented. See this interview with Ken Zucker for more on persistence of GID into adulthood.
Stay tuned…

Gender identity disorder research: Q & A with Kenneth Zucker

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.

National Gay & Lesbian Task Force questions the APA on DSM choices

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.