Guest Blogger

The Burden of Proof: The Politics of Gender, Science, and the DSM

Filed By Guest Blogger | October 24, 2008 2:00 PM | comments

Filed in: Living, Transgender & Intersex
Tags: APA, DSM V, gender dysphoria, gender identity disorder, gid, Kenneth Zucker, science, transgender, transitioning

Editors' note: Kelley Winters, Ph.D. is a writer on issues of transgender medical policy, founder of GID Reform Advocates and an Advisory Board Member for the Matthew Shepard Foundation and TransYouth Family Advocates. She has presented papers on the psychiatric classification of gender diversity at the annual conventions of the American Psychiatric Association, the American Counseling Association and the Association of Women in Psychology.

kelley winters.jpgIn the movie Ghostbusters professor Peter Venkman, played by Bill Murray, deflected questions with a quip,

Back off, man. I'm a scientist.

In the reality of human gender diversity, the current diagnostic categories of Gender Identity Disorder (GID) and Transvestic Fetishism in the Diagnostic and Statistical Manual of Mental Disorders (DSM) convey a presumption that internal gender identity or social gender expression that vary from assigned birth sex roles are intrinsically pathological and sexually deviant. Their authors and supporters have defended this axiom by disparaging skeptical criticism and indignation as "attack" on science and academic expression. Thus, the premise of "disordered" gender identity has ascended to the level of dogma in American psychiatry and psychology, imposing a near-impossible burden of proof upon contrary evidence, dissenting opinion and especially upon transitioned individuals to demonstrate our legitimacy in our affirmed roles.

In an interview with MSNBC this year, Dr. Kenneth Zucker, chairman of the current DSM-V Sexual and Gender Identity Disorders work group and a chief author of the current GID diagnosis, stated that there "has to be an empirical basis to modify anything in the DSM." But has the appropriate burden of proof been reversed here? Should his work group be equally committed to review the validity of the current diagnostic categories? What is the basis, where is the science to substantiate the premise of "disordered" gender identity that underlies them?

Lilienfeld, Lynn and Lorh, editors of Science and Pseudoscience in Clinical Psychology, noted that

the burden of proof in science rests invariably on the individuals making a claim, not on the critic.

At the core of the GID diagnosis is the presumption that social or medical transition contrary to birth sex is always a negative outcome and acquiescence to birth sex role is a positive one. This is reflected in the diagnostic criteria, which tar even the happiest, most well adjusted post-operative transsexual men and women as disordered, and absolve closeted or concealed gender dysphoria (distress with current physical sex characteristics or ascribed gender role) from diagnosis of mental illness. This doctrine of "disordered" gender identity is underscored throughout the supporting text, where persistent gender identity differing from birth sex is termed a "chronic course" of disorder and the need for gender congruence is disparaged as "preoccupation."

In the Treatment Companion to the DSM-IV-TR Casebook, also published by the APA, gender-conversion or gender-reparative therapies, which attempt to change gender identity or expression that differ from birth sex, are recommended to clinicians for birth-role nonconforming and gender-dysphoric children to the exclusion of supporting and affirming treatment approaches. In a chapter authored by Dr. Kenneth Zucker, clinicians are advised to suspect parents in the "genesis and/or perpetuation of GID," and parents are told to "set limits" on gender role expression or even fantasy play nonconforming to birth sex. Successful outcome is only described in terms of "fading of... cross-gender identification" and of being "helped so that the desire to change sex does not persist into adolescence and adulthood." Persistent (or un-closeted) gender identity or expression that differs from birth sex is cast as failure, with alarming predictions of social withdrawal and rejection by "both boys and girls."

Zucker repeated these dire warnings to parents of gender variant children in an interview on National Public Radio last May:

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.

Was this prediction based on science or just substitution of opinion as fact? In the same National Public Radio interview, Dr. Zucker's patient, "Bradley," was contrasted with a young girl, Jona, whose transition from male birth-role to female affirmed-role was supported by her parents and therapist, Dr. Diane Ehrensaft. Far from outcast or withdrawn, Jona's father described her as thriving:

She's so comfortable with her own being when she's simply left to be who she is without any of these restrictions being put on her. It's just remarkable to see.

Jona's case is far from unique. A growing number of parents and their affirming care providers are rejecting derogatory diagnosis and punitive conversion psychotherapies and are working with schools and communities to create safe spaces for their gender variant children and adolescents to simply be themselves. TransYouth Family Allies (TYFA), an education and support organization for gender variant youth and families, provided assistance to 15 families nationwide in 2007 and more than double that number early this year. These children offer dramatic counter-examples to the DSM-IV-TR and its Treatment Companion text. For example, Boulder, Colorado pediatrician Dr. Jeff Richker recently described a very positive outcome for an affirmed girl (MTF), who began her social role transition at age eight:

Lucia is 90 percent happier than Luc ever was ... I think the transition has gone a long way to alleviating so much of the unhappiness in her life.

Yet, the very existence well adjusted, transitioned children is denied in the DSM-IV-TR Treatment Companion and subsequent literature, which denigrate real-life experience in affirmed gender roles as "fantasy solution". In their 1995 book, Drs. Zucker and Susan Bradley, previous Chair of the DSM-IV Subcommittee on Gender Identity Disorders, condemned affirming support of gender variant children as therapeutic "nihilism," invoking a double-negative statement to justify gender-reparative psychotherapies: "we have found no compelling reason not to offer treatment to a child with gender identity disorder." Moreover, Zucker and Bradley insulted the intelligence of all parents who reject or question gender-reparative therapies for their gender-nonconforming children: "Some parents, especially the well-functioning and intellectually sophisticated ones, are able to carry out these recommendations relatively easily and without ambivalence."

Although Dr. Zucker concedes "that contrasex hormonal and surgical sex change may well be the best methods of treatment" for gender dysphoric adolescents, he casts this in a negative context of "much poorer" prognosis and failure of gender-conversion in earlier childhood. A derogatory view of nonconformity to assigned/birth sex roles is repeated in recent literature, coauthored by Zucker and Bradley, where "typical" and "normative" gender behavior are defined as synonymous. The authors incorrectly term persistence of masculine identity as "persistence of gender dysphoria," obscuring the proven roles of social transition and medical treatment (the latter for adolescents and adults) in relieving distress with ascribed gender role and anatomical sex.

For adolescents suffering gender dysphoria, there is growing clinical evidence that social transition and postponement of adverse puberty (development of birth-sex characteristics incongruent with inner identity) enable positive outcomes. In a presentation last year to the Wold Association for Transgender Health (WPATH), Dr. Annelou De Vries reported significant reduction of behavior and socialization problems for transitioned adolescents given puberty-blocking treatment, based on the Child Behavior Checklist (CBCL) and Youth Self-Report (YSL) assessment. He noted "stable, improved psychological functioning" for these youth in contrast to the typecast of "much poorer" prognosis.

For adults, the myth of "disordered" gender identity is also contradicted by co-morbidity studies that find a notable absence of psychopathology among transsexual individuals. In a large-scale 1997 study of 435 gender dysphoric subjects (318 MTF women and 117 FTM men), Cole, et al., concluded,

This study should help to clear up certain misperceptions about gender dysphoria per se. Specifically, individuals presenting with gender dysphoria often do not have problems indicative of coexisting psychiatric illness such as schizophrenia or major depression. Instead, these finding suggest that gender dysphoria is usually an isolated diagnosis.

While analogous findings about the mental health of gay men by Dr. Evelyn Hooker were instrumental to the reform of the homosexuality diagnosis in the DSM-II and III, these analogous studies of gender variant people have been largely disregarded by DSM policy makers. As noted in an earlier essay, studies of postoperative transsexual individuals from non-clinical populations also suggest positive outcomes for social role transition and corrective medical procedures that relieve distress of gender dysphoria in adults. These data are corroborated by numerous positive post-transition narratives in print and online. Yet, counter-examples to presumptions of "disordered" gender identity and negative transition outcome have had no impact on DSM policy.

In fact, clinicians and scholars with dissenting opinion and criticism of the GID and TF diagnoses have been met with hostility and personal insult themselves. In her 1996 book Gender Shock: Exploding the Myths of Male and Female author Phyllis Burke described how the GID diagnosis was used to facilitate reparative therapy and hospitalization of gender non-conforming youth suspected of being "prehomosexual." She quoted Dr. Kenneth Zucker that parents bring children to gender clinics mostly "because they don't want their kid to be gay." In an interview for Brain, Child magazine, Zucker responded by attacking Ms. Burke ad hominem:

He dismisses her book as "simplistic" and "not particularly illuminating," the work of a journalist whose views shouldn't be put into the same camp as those of scientists like Richard Green or himself.

Such personal attacks are not limited to journalists. In a 1999 letter to the Journal of Sex and Marital Therapy, Dr. Zucker fired scathing insults at Richard Isay, M.D., who had raised similar concerns about the GID diagnosis for children in Psychiatric News. Zucker stated, "one must raise the thorny and difficult question of Isay's professional credentials to comment on the validity of the diagnosis of gender identity disorder." Zucker called Dr. Isay's opinion "uninformed, both clinically and empirically" and his work "a cheap imitation of his predecessors."

Negative stereotypes about transition outcomes are also refuted by the magnitude of post-transition and post-operative populations that have integrated into society so completely that they are undetectable to the psychiatric research establishment. At the 2007 WPATH conference, Professors Femke Olyslager and Lynn Conway presented evidence of mathematical flaws in earlier studies, suggesting that vastly more people have transitioned with corrective surgeries than figures cited in the DSM. Although their conclusions were independently corroborated in a health benefit cost analysis by Dr. Mary Ann Horton, mental health policy makers in both APA organizations have ignored these challenges to longstanding belief about the prevalence of transsexualism. A 2008 report from the American Psychological Association Task Force on Gender Identity and Gender Variance rejected Olyslager and Conway's work in a footnote, without bothering to examine the math or even list a citation to their paper. Just as disappointing, the APA (psychological) invoked a guilt-by-association tactic to discredit Olyslager and Conway by claiming that their analysis was endorsed by "transgender activists."

Suppressing dissent by labeling critics of derogatory psychiatric policies as transgender or transsexual "activists" is an unfortunate trend in recent literature. For example, Dr. J. Michael Bailey, psychologist and author of, The Man Who Would be Queen: The Science of Gender-Bending and Transsexualism, and coauthor Kiira Triea panned critics of his controversial book and its underlying theory of "autogynephilia." Both the book and the theory, that all male-to-female transition is motivated by either homosexuality or narcissistic sexual paraphilia, have evoked outrage among a great number of gender transcendent people. In an article entitled, "What Many Transgender Activists Don't Want You to Know and Why You Should Know It Anyway," the authors maligned Bailey's critics ad hominem with labels of "nonhomosexual MTF transsexuals" and "autogynephiles in denial." Bailey and Triea exceeded the bounds of professionalism so far as to publicly speculate about the sexual orientations and private medical histories of people they had never met, including Becky Allison, M.D., Christine Burns, M.B.E., Professor Lynn Conway, Andrea James, Deirdre McCloskey, Ph.D., Nancy Nangeroni, and Joan Roughgarden, Ph.D. Their scorn also extended to clinicians who disagree with these derogatory depictions of transsexual women, describing supportive care providers as "colluding with autogynephiles in denial."

Dr. Alice Dreger, a colleague of Bailey's at Northwestern University, voiced similar derogatory presumptions about the private sex lives and transitions of dissenting "transgender activists" in the Archives of Sexual Behavior (ASB): "women such as they might be labeled autogynephilic--individuals with paraphilias whose cross-sex identification was not about gender but eroticism." Although published as a peer-reviewed work in a scientific journal, Dreger's paper seemed astonishingly acrimonious, remarking that,

trans activists ... have behaved so crazily, the entire population they "represent'' has been marked by researchers as being too unstable and dangerous to bother with.

The editor of the Archives of Sexual Behavior is Dr. Kenneth Zucker of the DSM-V Sexual and GID Work Group, and its editorial board includes Dr. Bailey himself, as well as Dr. Ray Blanchard, author of the "autogynephilia" theory and Chair of the DSM-V Paraphilias Subcommittee.

Perhaps the most frightening abuse of scientific authority against dissenting opinion has come from sexologist Dr. Anne Lawrence, also an editorial board member of the Archives of Sexual Behavior, who has strongly supported Blanchard's theories of "autogynephilia." In a commentary article in ASB, Dr. Lawrence once again repeated personal speculation about sexual orientations of opponents of Bailey's book. Moreover, she diagnosed critics with "narcissistic disorders." Lawrence invoked a label of "narcissistic rage" to disparage, as further mental illness, the indignation expressed by transpeople in response to psychiatric stereotypes of sexual deviance. She stated,

Meanwhile, clinicians and scholars should perhaps be more aware that angry reactions they elicit from nonhomosexual MtF transsexuals might represent narcissistic rage, rather than mature, instrumental anger.

This tactic to discredit dissent has been termed "medicalization of critics" by psychiatrist Dan Karasic, M.D. of U.C. San Francisco, co-editor of Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation.

In an interview for the New York Times, Dr. Dreger condemned outrage and dissent from the trans-community with alarming hyperbole, as "problems not only for science but free expression itself." This begs the question, do oppressed people speaking in protest of their own oppression honestly threaten free expression for policy makers? In the discourse of psychiatric policy, who holds the power to bias either scientific enquiry or its dissemination -- the authors of the DSM and its allied literature or the subjects of their classification?

At the 1973 annual meeting of the American Psychiatric Association, Dr. Robert Spitzer noted,

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a "mental illness" the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

Under the current doctrine of "disordered" gender identity in American psychiatry and psychology, this remains as true today for gender transcendent people and their supportive clinicians as it was for gay and lesbian people then. Writer √Člise Hendrick explained it this way at the 2008 National Women's Studies Association conference,

It is not the butterfly's place to lecture the entomologist; it may feel pain whilst being pinned to a corkboard, but it had best keep that to itself.

The current diagnostic categories of Gender Identity Disorder and Transvestic Fetishism in the Diagnostical and Statistical Manual of Mental Disorders and their supporting literature perpetuate a doctrine of "disordered" gender identity and expression in American psychiatry and psychology. This axiom imposes an unreasonable burden of proof upon gender variant people who defy this stereotype, upon researchers and scholars who present opposing data, and upon change to the status quo in the DSM. Given harsh consequences that the current diagnoses of mental illness and sexual deviance inflict on human dignity, civil justice and access to somatic medical treatment, should the burden of proof instead be guided by reduction of harm to people? In drafting the Fifth Edition of the DSM, members of Sexual and Gender Identity Disorders Work Group have a fresh opportunity to examine all of the evidence and question the premise that gender identities and expression that differ from birth-sex roles are inherently disordered.

For full citations, please check out the original version of this blog post at Kelley's site. For more information about her project, visit GID Reform Advocates.

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Angela Brightfeather | October 24, 2008 2:59 PM

Dear Kelley,

Thank you for explaining so clearly that options concerning our being mentally healthy seem to rapidly be spinning out of our own control.

To boil all this down, is it time that the Transgender Community as we know it, stop complaining about the obvious and engage more directly in the arguement, and are we being pushed back into the corner so far that the only way to eventually get out of it is to push our way out more physically? How far does this have to go before we stop allowing people like Zucker and Baker to define us and stop using us as their own vehicles of experimentation?

Do you feel that it has reached a point where our physical presence and force is the only thing that will convince them that they are wrong? Similar to the GLB movement that showed up and pressured and threatened them to change their diagnosis?

I was thinking exactly that when I read this post, Angela. Whatever happened to a good, old-fashioned zap?

Dr. Winters.

I totally agree with everything you wrote about Ken Zucker and his attitude towards the treatment of transsexual children. On my own blog I had to rip someone else for denying the existence of transsexual children. The idea that transsexual children do not exist and are simply pre-homosexual is observationally false. A number of them have been on 20/20.

However I do not like the false coupling of Ken Zuckers point of view on TG children with the pov of Bailey on "non-homosexual transsexuals". Bailey and Zucker would not be in agreement on how to treat such a person based on Bailey's writings. True in his book he writes about Danny Ryan growing out of early childhood effeminacy. That can and does happen and any child treated for GID below the age of reason (about 7-10 years old) should not have any irreversible medical procedures/treatments for that reason. Wouldn't you agree?

There is also a question of diagnosing such a condition in a person who's brain is still growing and changing. A kid who wants "to be a girl" could just grow up in to someone like Chris Crocker. Who while very feminine is not trans and could be very unhappy if they felt the only way they could get approval was by being trans. I mean for example If "Danny Ryan" really was a transsexual no amount of reparative therapy would have prevented eventual transition at some point in early adulthood.

I have no doubt that you yourself have thought of these things but perhaps some of your readers haven't.

Marja Erwin | October 25, 2008 3:57 PM

I detest Zucker's support for gender programming; however, I have my own doubts about childhood transsexualism.

I draw on my own experience. I knew that something was wrong in childhood but was happy to do boy things and identify as a boy. I changed my attitudes as I approached adolescence. I knew I wanted to grow up as a woman, and wondered what that meant. And then I went through the all-too-common cycles of confusion and denial.

Newspaper stories about trans kids usually read like stories about kids who like "boy things" even though they were assigned "girls" and vice-versa.

My trans identity was hidden, and not strongly felt, in childhood; I'm afraid that someone's cis identity might be hidden, and not strongly felt, in the same way.

I think that until we approach puberty, we define our gender identity in terms of our gender roles and/or butchness/femmeness, but as we approach puberty, many of us redefine our gender identity in terms of our deeply-felt subconscious sex. (It may be different if its not so deeply felt).

Tracking feminine assigned-male kids for transition, and masculine assigned-female kids, strikes me as being as misguided as tracking feminine assigned-male adults, especially gay ones, was. Keeping things open either way may be the best option, also for the masculine assigned-male kids and feminine assigned-female kids.

You need to wait until subconscious sex replaces gender roles as the basis for their identification. I'd put that sometime around age 10-12. It may help to use hormones to delay puberty for adolescents who aren't sure, a well as ones who are trans.

Kelley Winters | October 27, 2008 11:47 AM

Marja Erwin and H. Farmer raise a good point about childhood transition. For preadolescent children, transition refers to a change in social gender role and not medical or surgical intervention. The earliest medical treatments would come later at initial stages of puberty, and only if needed according to the child. Endocrinologist Norman Spack notes that hormone blockers may be prescribed to delay puberty and extend the time for evaluation and for the youth to continue to develop reasoning skills. Their effects are fully reversible. In the context of children, transition means simply creating an environment where gender variant or transcendent children may safely define their own roles that are congruent with their inner sense of gender identity. These roles may be stereotypically masculine, feminine or uniquely in between.

Retrospectively, we can be sure that transsexual children exist, as we transsexual adults were all children and not hatched full-grown. A great many of us vividly remember the horrors of hiding our identities in deep closets throughout our childhoods. However, I am very hesitant to assign a label of transsexuality to children prospectively. They should be free to discover for themselves whether or not they fit that definition or whether they choose to describe themselves with that term. Again, it's all about creating safe space for children to simply be themselves.

If I may speak to one small microcosm, or two. I happen belong to both worlds, that of adult transsexuals and that of trans kids.

I am the parent of a trans child.

I am also a transsexual.

Transgender kids exist.

And some exist long before any development of sexuality.

Some are pre-gay kids. They seem to prefer the aesthetics of the opposite gender but do not identify as such unless given no other way to enjoy their preferences.

Some are effeminate boys or masculine girls. In addition to the aesthetics of the opposite gender these kids also seem to have the innate mannerisms and reactions but have a congruent identity.

And some are transsexuals. We are reluctant to use the term since it still has sexual connotations in our culture, but it is the most applicable label. The distinguishing characteristic is a cross gender self identity as young as four or five years old, the age of normal gender identity development. They do not use phrases such as, "I like girl things". They do say things like, "I am a girl". Many but not all have already begun to exhibit body dysphoria, sometimes quite strong.

Some fit into all of the above categories, and more. Some only fit one or two. They are every bit as diverse as the adult transgender population, to no great surprise. The DSM criteria are nearly worthless in describing, let alone diagnosing these kids correctly.

If allowed to transition socially with little fanfare as much or little as they wish, they simply live out their childhoods without gender being an issue. I have yet to meet a single parent that pushes their child to conform to some transition track; rather it is the children doing the pulling in whatever direction they need to go.

Explain to me, Mr. Bailey and friends, how exactly is my daughter autogynephillic at five years old? The burden of proof, you see, is on you. Ah, that's right; they are GID children until puberty, at which point they become autogynephillics. Ptolemy would be proud.

Marja, from what I've seen I have no doubt that some transsexuals only "become" so at puberty. That is after all, when the sex dimorphism of our species develops far beyond primary characteristics. Would it be any great surprise that dimorphic areas of the brain diverge to a much greater degree at that point as well? From what I've seen the divergence is a continuum, a set of greatly overlapping bell curves. It is conceivable and I would say even likely that some transsexuals may be close to congruence until the sex dimorphic divergence occurs in both their brain and body during their teen years.

Again, the diversity is awe-inspiring and beautiful and bears little resemblance to how the experts describe and deride it. Natural variation is not disorder.