Should we worry?
May 17, 2008 10:40 AM   Subscribe

Mercedes Allen looks at who's in charge of deciding the fate of Gender Identity Disorder in the DSM-IV. The APA (American Psychological Association) has announced it's intention to revise the DSMV (Diagnosis and Statistical Manual of Mental Disorders). The expert they've named to chair revisions on sexuality and gender is Kenneth Zucker. Zucker is the major remaining proponent of Reparative Therapy for LGBT folks.

Zucker has named Ray Blanchard to work with the group that will re-write the section on Gender Identity Disorder. Blanchard is connected with 'ex-gay' organizations, and believes that all transpeople are really sex offenders.
posted by FunkyHelix (86 comments total) 11 users marked this as a favorite

 
Spectacular NPR report profiling two possibly-transgendered children, featuring Zucker as an interviewee. Q&A with Zucker and a therapist with a different view. "In terms of which of these therapies is more prevalent in the United States, Ehrensaft says there is absolutely no doubt. 'Zucker's,' she says."
posted by ibmcginty at 10:55 AM on May 17, 2008


This will not end well. (the DSM revision, not the thread)
posted by msalt at 10:56 AM on May 17, 2008


Nineteen sixty called. It wants it's arrogant, bigoted psychologists back.
posted by Caduceus at 10:59 AM on May 17, 2008 [18 favorites]


Sigh. Nix that apostrophe in "it's."
posted by Caduceus at 11:00 AM on May 17, 2008 [1 favorite]


2008 called, it wants it's goo-goo eyed relativists back -- erm, well, hmm, that's doesn't work as well.
posted by undule at 11:01 AM on May 17, 2008


goo-goo eyed relativists back

Wait, what? Who?
posted by Avenger at 11:05 AM on May 17, 2008


My major issues with psychology are well encapsulated in the arc of this story.

That any single person or group could claim sweeping, half-assed generalizations and observations as fact and hard science.

Even if we knew much more specifically about how the mind and brain work, there's far too much variation in sentient existence to ever be able to reduce it to a set of simple rules or guidelines as contained in the DSM. You have a small statistical sampling, not a complete index of humanity.

Doctors? You hubris is appalling and inhuman. Check your ego. You're not as brilliant as you think you are.
posted by loquacious at 11:07 AM on May 17, 2008 [3 favorites]


I dunno. I don't know enough about this to get outraged yet, even after reading the links -- and I've got a serious case of teh gizay myself. There are ten names in that working group...


Kenneth J. Zucker, Ph.D. (Chair)
Head, Gender Identity Service Clinic, Child,
Youth, and Family Program
Centre for Addiction and Mental Health
Toronto, Ontario, Canada

Irving M. Binik, Ph.D.
Professor
Department of Psychology
McGill University
Montreal, Quebec, Canada

Ray Blanchard, Ph.D.
Professor, Department of Psychiatry
University of Toronto
Head of Clinical Sexology Services
Centre for Addiction and Mental Health
Toronto, Ontario, Canada

Peggy T. Cohen-Kettenis, Ph.D.
Head of the Department of Medical Psychology
VU University Medical Center
Amsterdam, The Netherlands

Jack Drescher, M.D.
Clinical Assistant Professor of Psychiatry,
New York Medical College
Associate Attending Psychiatrist, St. Luke's-
Roosevelt Hospital Center
New York, NY

Cynthia Graham, Ph.D.
Research Tutor
Oxford Doctoral Course in Clinical Psychology
Isis Education Centre
Warneford Hospital
Headington, Oxfordshire, United Kingdom

Richard B. Krueger, M.D.
Medical Director, Sexual Behavior Clinic
Department of Psychiatry
New York State Psychiatric Institute and
Columbia University
New York, NY

Niklas Langstroem, M.D., Ph.D.
Associate Professor
Centre for Violence Prevention
Karolinska Institutet
Stockholm, Sweden

Heino F. L. Meyer-Bahlburg, Dr. rer. nat.
Professor of Clinical Psychology
Department of Psychiatry
College of Physicians & Surgeons
Columbia University
New York, NY

Robert Taylor Segraves, M.D., Ph.D.
Chairperson
Department of Psychiatry
MetroHealth Medical Center
Cleveland, OH


...so if anyone wants to run MeFi dossiers on them all to see if an insidious plot is indeed underway, I'm all for it.

When I was a kid, homosexuality was classified as a mental disorder in the DSM, and punishable by imprisonment and even forced lobotomy in many states. Next month, my spouse and I hope to get a marriage license here in San Francisco. We've come a long way in just a few decades -- I can't get worked up about this yet on the basis of the information here.
posted by digaman at 11:15 AM on May 17, 2008 [1 favorite]


loquacious: Even if we knew much more specifically about how the mind and brain work, there's far too much variation in sentient existence to ever be able to reduce it to a set of simple rules or guidelines as contained in the DSM. You have a small statistical sampling, not a complete index of humanity.

Well, clearly psychologists are just idiots and should give up and go home. I feel sorry for all of the people they've treated for their imaginary 'schizophrenia', 'bipolar disorder', or 'depression'. I'm sure those are all normal variations to the human condition that could never be identified, described, or treated.
posted by Mitrovarr at 11:17 AM on May 17, 2008 [8 favorites]


Any info on why the APA chose a person with such known and relivant bias to chair the group? You might argue that there's value in having him as a member, dissent is useful after all, but the chair seems like a place you'd want someone with less of an obvious bias.

And, also, there's the question: any transpeople in the group? I'll bet there's at least a few transgender members of the APA, and yo'd think their personal experience would be valuable.

But, given the situation as it is it seems likely that we'll see a slew of fundie gloating after the APA classifies homosexuals and transfolk as mentally ill. Joy.
posted by sotonohito at 11:18 AM on May 17, 2008


It's amazing that this kind of bigotry could still exist in an organization like the APA. Amazing enough that I wonder if there aren't more mundane reasons for including "Gender Identity Disorder" in the DSM. Is it possible that if the "disorder" were dropped from the DSM, that it would make it impossible to get insurance companies to pay for gender reassignment procedures?
posted by nixxon at 11:19 AM on May 17, 2008


My X and Y chromosomes are in perfect union. Like some kind of Tibetan image of a deity and his consort.
posted by Burhanistan at 11:20 AM on May 17, 2008


What's the general argument for removing Gender Identity Disorder from the DSM? Isn't GID as a disorder the basic reason that sexual reassignment surgery is considered a medical procedure, and not just plastic surgery for cosmetic reasons? If GID isn't a disorder, what separates sexual reassignment surgery from a boob job?

This might sound trollish, but I'm really not trying to troll, I'm honestly curious. It seems like a lot of attempts to build up sympathy for and understanding of transgender people in the mainstream is based on GID-as-disorder, for instance the common "woman trapped in a man's body", etc.
posted by Joakim Ziegler at 11:22 AM on May 17, 2008


When I was a kid, homosexuality was classified as a mental disorder in the DSM, and punishable by imprisonment and even forced lobotomy in many states. Next month, my spouse and I hope to get a marriage license here in San Francisco. We've come a long way in just a few decades -- I can't get worked up about this yet on the basis of the information here.

I agree that these guys may not be in a position to do significant damage to the state of gay rights. For my money, the big issue here is the standard of care for trans folk.

There's already a lot of frustration with the current system, in which patients often need to meet some arbitrary standard of "masculinity" or "femininity" before they're allowed to transition. People are pushing for a change, but this looks like a step in the wrong direction.

(Sadly, the first link isn't loading for me; I hope I'm not just rehashing TFA, seeing as I didn't get to R it.)
posted by nebulawindphone at 11:24 AM on May 17, 2008 [1 favorite]


I think the key is whether GID is the disorder where you're born with the wrong set of genitals or if it's the disorder where you THINK you're born with the wrong set of genitals. Either way, it doesn't seem like taking GID out of the DSM entirely makes any sense at all.
posted by prefpara at 11:26 AM on May 17, 2008


Just because there's no good therapy that reverses it, doesn't mean that it's not a disorder. As Zucker points out, option B at this point in major surgery, sterility, and a lifetime or hormone treatments with consequences. If you could easily make them not angry at their body, that would obviously be preferable to everyone.
posted by a robot made out of meat at 11:33 AM on May 17, 2008


I think it's a bit funny that people find it offensive that sexual variations are considered disordered... but nobody comments on the fact that simple personality differences that move someone outside the range of "average" are also considered disordered. More than half the world would qualify for some personality disorder if everyone were tested, and nobody seems to find this strange at all.
posted by sonic meat machine at 11:40 AM on May 17, 2008 [2 favorites]


Well, clearly psychologists are just idiots and should give up and go home. I feel sorry for all of the people they've treated for their imaginary 'schizophrenia', 'bipolar disorder', or 'depression'. I'm sure those are all normal variations to the human condition that could never be identified, described, or treated.

Before I burn down your straw man, I'll play.

When was the last time you had a clinical psychologist or psychiatrist acknowledge the role of a mal-adjusted society as part of the problem with depression? That it isn't always simply brain chemistry, or that many brain chemistry imbalances are dietary or environmental at their roots?

That we really aren't evolved or designed to be on-task and at-attention for 40+ hours a week, that the amount of stress we cope with in our daily lives is part of the real problem, and that simply focusing on the smaller elements with little or no regard for the larger picture or holistic issues at hand?

Here, this pill will help you forget all those problems. And this one will help calm you down when you're stressed. And this one will trick your brain into thinking that everything is normal even though your neurochemistry is all fucked up from processed and artificial foods and weird chemicals in your diet and plastic food packaging. And this one will help you sleep - because you sit in a car, an office, and on a couch in front of a TV all day.

Most of the people I've met don't need a therapist. They need a hard job on a vegetable farm, some good food and time away from the goddamn city they live in.

Anyway. No, I don't discount the good things psychology has done. There are a lot of people that it has helped. There's a lot of people that need help. That's not the issue I'm addressing, here. Your counterpoint is orthogonal and unrelated to mine.

*lights a match, throws it into your straw man*

Have you ever read any version of the DSM? I remember being really offended by huge sections of the DSM-IV, as it already seemed laughably out of date, trite and simplistic to me.
posted by loquacious at 11:43 AM on May 17, 2008 [12 favorites]


nebulawindphone: There's already a lot of frustration with the current system, in which patients often need to meet some arbitrary standard of "masculinity" or "femininity" before they're allowed to transition.

Well, to be fair, people have had the surgery and then regretted it later. So I don't really blame doctors for trying to make sure the patient is really transgendered before they go through with the irreversible surgeries.
posted by Mitrovarr at 11:44 AM on May 17, 2008


I think it's a bit funny that people find it offensive that sexual variations are considered disordered... but nobody comments on the fact that simple personality differences that move someone outside the range of "average" are also considered disordered.

In my experience, people comment on this ALL THE TIME. People are always complaining that many ADD diagnoses are applied to perfectly healthy kids, that everything, including normal reactions to extreme situations, is pathologized...

The difference here is that transgendered people are a fairly distinct subset of society that is often seen as a victim class subject to serious discrimination. People with ADD can walk down the street without catching a beating because of that diagnosis.
posted by prefpara at 11:51 AM on May 17, 2008


I think there's a lot in psychology that's hokum. Just because you can reliably test someone for something doesn't mean that 'thing' is real and not simply a subset of some other problem, or a combination of problems, etc. After reading about how the DSM was created, it's kind of hard to take seriously.

My understanding (and correct me if I'm wrong) is you can use the DSM to diagnose, say, depression, but that won't actually help you determine what anti-depressants would help them or how.
posted by delmoi at 11:58 AM on May 17, 2008


loquacious: When was the last time you had a clinical psychologist or psychiatrist acknowledge the role of a mal-adjusted society as part of the problem with depression?

Most psychologists I've seem draw a line between depression with an external non-biological cause and depression with an internal cause, and consider only the second pathological. In other words, if you are depressed because of society, your depression is not a disorder.

That it isn't always simply brain chemistry, or that many brain chemistry imbalances are dietary or environmental at their roots?

The dietary or environmental thing is well known and I don't think I've ever seen a psychologist dispute it. However, a lot of the holistic food types take it far beyond where the research is conclusive. As far as it not being 'simple' brain chemistry, well, that's a tough issue and it is currently in debate.

That we really aren't evolved or designed to be on-task and at-attention for 40+ hours a week, that the amount of stress we cope with in our daily lives is part of the real problem, and that simply focusing on the smaller elements with little or no regard for the larger picture or holistic issues at hand?

This is all debatable. I've seen those studies that claim hunter-gatherers had lots of time to relax and all, but I've also seen studies that dissected them and tore them to bits. Personally, I'd guess that (like most animals) humans are designed to be on-task and at-attention most of the time, and we cope with less stress than our ancestors did. For example, modern health is leaps and bounds better than any previous (yes, even with all the obesity and diabetes and such.) Also, you don't have to worry about predators.

Furthermore, don't forget that modern, western society is a lot nicer than the societies that preceded it. Imagine the level of work of work that, say, an artisan in the roman empire would have had to deal with. Or peasants during the middle ages.

Anyways, you specifically stated that human behavior was so complex that mental disorders could not be usefully summarized. I disagree. Some things are complicated, like transgenderism, but some mental pathologies do present in fairly consistent manners and summarizing them for identification and treatment is not arrogant. For example, schizophrenia - while every case differs substantially, there are many characteristics that most of them share (age of onset, some of the symptoms.) I believe that creating guidelines for recognizing and treating disorders like this is highly beneficial, even if the entire variation cannot always be recorded.

As far as reading the DSM-IV goes, I've read parts. I don't remember finding anything specifically wrong with those, but perhaps I didn't read the parts you dispute.
posted by Mitrovarr at 12:01 PM on May 17, 2008 [3 favorites]


this is somewhat tangential... (though absolutely engrossing and pertinent to the way these decisions are made in the real world)

... for those interested in the politics behind the reclassification
of homosexuality by the APA in the DSM back in 1973, I can't recommend this radio
investigation by Alix Spiegel of This American Life highly enough. One of the most interesting things I've ever heard on radio.
posted by Auden at 12:36 PM on May 17, 2008


Hello, my name is Andrea. I'm one of Metafilter's genderiffic people. Specifically, I have a Y chromosome, but most people can't tell that at a glance. My daughter calls me "Momma," for instance, and she's five.

Lets go all-in with this. Lets remove the GID from the DSM. Then, it is no longer a medical condition. Awesome! That means that the dozens of hoops you need to jump through before getting hormone replacement or The Big Surgery (or surgeries, if you were born female) are simplified to only one hoop: money. Insurance isn't paying for this stuff anyways, so lets just go with that!

...um, no. On the face of it, transgendered people are either born with the wrong body or the wrong brain, or THINK they were born with the wrong body or the wrong brain. If any of those are true, it is a medical condition.
posted by andreaazure at 12:40 PM on May 17, 2008 [7 favorites]


OP and others: the APA that publishes the DSM-IV is not the American Psychological Association - it's the American Psychiatric Association. It's an important difference given that the goals of clinical psychology and psychiatry are not always the same.
posted by drmarcj at 12:50 PM on May 17, 2008 [6 favorites]


An important point to bring up is that a characteristic of most psychiatric disorders is that they involve a component of distress on the part of the patient; someone with a non-normative sexual identity and who is comfortable with it would not be seen to have a 'gender identity disorder' by both DSM and general psychiatric standards. From this, treatment for such a disorder could take one of two tacks. The first shouldn't upset anyone: to help patients become more comfortable with their sexual identity, whatever it may be. The second is what has everyone worried about this definition: change the gender identity. I definitely see the concern that such a label will be misappropriated by anti-LGBT activists to apply to the whole of the transgendered community, but don't see that as an issue with the diagnosis per se.

delmoi: This is definitely correct. The DSM is a tool designed for a specific purpose: to enable reliable interobserver description of patients. It by design is inherently descriptive; in its most recent iterations, it doesn't speak to etiology or praxis, and tries, sometimes unsuccessfully, to be value neutral. It's thus also somewhat trite by design: the diagnosis itself only gains meaning and utility when the rest of the body of knowledge of psychiatry is applied to it. Its success can be measured by comparing the rate at which two psychiatrists will arrive at the same diagnosis for a patient. In the 1950's, this was something like 20%; the rate has risen to around 80% today. Of course, there are serious construct validity concerns with this approach: there are an infinite number of possible boxes to stuff people into, and most of them are unhelpful or even harmful.

loquacious: Your description of psychiatric practice does not jibe with my experience of psychiatry either as a patient or a student of medicine. The psychiatry component of my medical school's second year course was the only one which really took the phrase 'biopsychosocial model' seriously, and although the curriculum included a substantial amount of biology and pharmacy nowhere was it suggested that neurohormonal factors alone are responsible for disease. My patient experience was the same: some pharmacy, along with a great deal of analysis of internal and external stressors and developing skills to deal with them. Granted, this distinction may be lost on a lot of doctors: I'm not a fan of primary care providers handing out psychoactive drugs, for example. However, in my personal experience, I haven't met any doctor, psychiatrist, PCP, or whatever, who subscribes to the model of mental illness you've attributed, and as a result find your description of the profession to be inaccurate and insulting.
posted by monocyte at 12:54 PM on May 17, 2008 [8 favorites]


Thanks drmarcj, I was about to say the same thing. The APA that publishes the DSM is the American Psychiatric Association, not the American Psychological Association.
posted by ALongDecember at 1:12 PM on May 17, 2008


When was the last time you had a clinical psychologist or psychiatrist acknowledge the role of a mal-adjusted society as part of the problem with depression?...
Here, this pill will help you forget all those problems.


Well, considering that clinical psychologists cannot legally prescribe medication and their focus is on various other kinds of therapy, many of them having to do with talking and others having to do with planning changes in lifestyle, pretty often.
posted by hydropsyche at 1:51 PM on May 17, 2008


I'm still waiting for the definitive answer on gay sheep.
posted by parhamr at 1:59 PM on May 17, 2008


I'll have to read through this in depth later... I'm meeting Ray Blanchard next week.
posted by arcticwoman at 3:20 PM on May 17, 2008


Psychiatry is a field that changes rapidly and constantly but an examination of its history reveals that it has been grossly wrong enough times for my skepticism to be justified.

However, it is phenomenally life changing in some of the cases that mitrovarr mentioned. Talk, art, music and massage therapy are terrific although it is a crying shame you have to pay someone to give you their attention.

I think you're dead on about how psychiatry is taught,monocyte, but psychiatric drugs are extremely profitable for pharmaceutical companies and less expensive to insurance companies than paying for extensive interactive therapy.

The problem is getting patients, their loved ones and psychiatrists to take lifestyle change seriously. Some parents just want their kids to grow up already and are willing to pay for piece of mind. I can't state this quantitatively but from working with young adults I believe that drugs are overprescribed and everyone is dropping the ball from parents to GPs to therapists to the young adults themselves.
posted by christhelongtimelurker at 5:01 PM on May 17, 2008


Sorry; I'll retract my general, sweeping statements about psychology and psychiatry. Not all of it is terrible. If you feel you need help - seek it. Counseling and therapy is hard work, but only you can do it.

The comments stem from frustration with the easy-prescription culture towards mental health that has been building and building here in the US, and elsewhere in the world, and I should know better than to let it influence my opinions in this particular debate. Note that prescription drug deaths recently surpassed everything else here in the US as the leading cause of accidental death, and though that isn't an issue limited to psychiatry but belongs more to general medicine.

This is tangential to other frustrations with the DSM and the history behind it and the role that it has played in the suppression, oppression and even outright bigotry against very real facets of humanity, gender and sexuality that aren't diseases in and of themselves.

The DSM may have helped many - but how many has it harmed or how many have been oppressed fraudulently by use of it? I can't imagine how terrible things must have been for some people being treated under the guidelines of the earlier editions of the DSM.

Part of this frustration is how insistent we are as a culture that gender is only binary. It might be mostly binary, but it's not even close to entirely binary. It has been more than a few decades since the Kinsey reports, and more modern research indicates that gender is much more fluid than we're collectively comfortable acknowledging.

In the real world, the current "standards of care" as drawn and interpreted - and most importantly, applied - from the DSM-IV are rigid in continuing to imply that there is two strict gender classes, as well as rather strict gender preferences and sexual archetypes. It's been a while since I've read the relevant entries involved but I remember there not being much room for bisexuality or general pansexuality in their interpretations.

This is a problem for many transsexuals in particular because the US, as informed by the DSM, generally requires a lengthy period of "living full time" for transgenders long before any therapy or beginning to transition. This is supposedly a requirement to prevent people from making mistakes or weeding out "deviants" or "fetishists" but seems like a rather cruel way to go about it - and, really, assuming good values of socialization and general sanity - why would it even matter if it was a "deviant" or "fetishist" in the first place?

In my opinion, not only is this a problem for determining therapy or treatment paths - but the DSM-IV (as used and applied) has already proven to be a very negative issue for intersexed or transgender patients in more mundane and real-world settings. Settings like routine medical treatment, with refusal of treatment or misclassed treatment, above and beyond issues with transitioning therapies. There have also been issues within the corrective system with intersexed or transgender people being inappropriately incarcerated, examined or searched.

Why the continued implied assumption that GLBTQ people are distressed, deviant, abnormal, or otherwise diseased? The tone is all wrong. Why isn't there an entry for "gender inflexibility" or perhaps homophobia? Why did the DSM even originally list these issues of sexuality and gender as disorders in the first place?

If our culture was more flexible, more accepting and less judgemental, many of these "issues" - the root reasons for the real distress of GLBTQ folks - would likely cease to exist. I really wish we'd collectively get over and outgrow these gender issues. It shouldn't be an issue if anyone is a boy, or a girl, or somewhere in between unless you want to get down their pants. And if you already want to get down their pants, why is it even an issue?

All that being said? From what I'm reading about Kenneth Zucker, he's the last person we'd want revising the DSM for this. It feels like a lot like science by fiat and decree, very possibly from a religion-influenced viewpoint.

The following sums up how I feel about it all pretty succinctly, as the issue at hand is much more than skin deep or gender-specific. The issue goes to the core of what it means to be both "free" and "human".
FOR EVERY GIRL WHO IS TIRED OF ACTING WEAK WHEN SHE IS STRONG, THERE IS A BOY TIRED OF APPEARING STRONG WHEN HE FEELS VULNERABLE. FOR EVERY BOY WHO IS BURDENED WITH THE CONSTANT EXPECTATION OF KNOWING EVERYTHING, THERE IS A GIRL TIRED OF PEOPLE NOT TRUSTING HER INTELLIGENCE. FOR EVERY GIRL WHO IS TIRED OF BEING CALLED OVER-SENSITIVE, THERE IS A BOY WHO FEARS TO BE GENTLE, TO WEEP. FOR EVERY BOY FOR WHOM COMPETITION IS THE ONLY WAY TO PROVE HIS MASCULINITY, THERE IS A GIRL WHO IS CALLED UNFEMININE WHEN SHE COMPETES. FOR EVERY GIRL WHO THROWS OUT HER E-Z-BAKE OVEN, THERE IS A BOY WHO WISHES TO FIND ONE. FOR EVERY BOY STRUGGLING NOT TO LET ADVERTISING DICTATE HIS DESIRES, THERE IS A GIRL FACING THE AD INDUSTRY’S ATTACKS ON HER SELF-ESTEEM. FOR EVERY GIRL WHO TAKES A STEP TOWARD HER LIBERATION, THERE IS A BOY WHO FINDS THE WAY TO FREEDOM A LITTLE EASIER.

Crimethinc

posted by loquacious at 5:41 PM on May 17, 2008 [3 favorites]


If you could easily make them not angry at their body, that would obviously be preferable to everyone.

This is the way Zucker seems to approach things. The transgirl at a young age must be stopped from doing girly things, playing with "girly" toys and at girly modes of pretend, and must be dressed in the most "boyish" clothes and made to play with the roughest of boys and in every way overtly masculinized via the worst possible stereotypes of a regressive gender binary in order to make her "not angry at her body" but the fact remains that if this child is truly transgendered all this is going to do is protract her suffering, as she either chafes against extraordinary restriction preventing her from being who she is, or she tamps down the essence of her being and smothers herself for the sake of fitting in -- which she probably won't accomplish very well anyway.

That is to say that I posit that you can no more "easily make" a transgender person "not angry at their body" than you can make a panda want to be a lion.
posted by Dreama at 7:36 PM on May 17, 2008 [5 favorites]


loquacious: This is supposedly a requirement to prevent people from making mistakes or weeding out "deviants" or "fetishists" but seems like a rather cruel way to go about it - and, really, assuming good values of socialization and general sanity - why would it even matter if it was a "deviant" or "fetishist" in the first place?

Because they've slipped through before, had the operation, and regretted it later. Usually suing the living crap out of everyone involved in the process. Also, usually it's not 'deviants' or 'fetishists', it's people who think they're transgendered but aren't.

Also, "good values of socialization and general sanity" are not something you can safely assume.
posted by Mitrovarr at 9:31 PM on May 17, 2008


That we really aren't evolved or designed to be on-task and at-attention for 40+ hours a week, that the amount of stress we cope with in our daily lives is part of the real problem

The amount of effort modern, first-world humans need to engage in their daily lives is minuscule compared to ancient agrarian societies. I mean come on. And humans weren't evolved to be happy in the first place. A lot of people seem to have this idea that if you just live in a way that's copacetic with human evolution, they'll be happy and wonderful, but all evolution selected for was the ability to reproduce and survive long enough to raise your kids. It wouldn't matter if you were in constant pain or stressed out about not getting enough to food to eat, or died at 40, or whatever.

Note that prescription drug deaths recently surpassed everything else here in the US as the leading cause of accidental death, and though that isn't an issue limited to psychiatry but belongs more to general medicine.

Being the leading cause of (accidental) death isn't as big of a problem if it's caused by other things getting safer.
posted by delmoi at 10:23 PM on May 17, 2008 [1 favorite]


Part of this frustration is how insistent we are as a culture that gender is only binary. It might be mostly binary, but it's not even close to entirely binary.

You see, this is what I don't understand. Doesn't these transgender cases imply that gender is binary? I say this because recently I was talking to a guy who was planning on becoming a woman and everything he said to me to involve a very conservative notion of gender as fixed and binary rather than fluid and socially constructed. He said that he needs female hormones to be functional at all -- when he tries to do without them he gets a crippling depression....and then to demonstrate this he showed me photos of himself as a kid wearing pink dresses. But to me a genetic hormonal imbalance can't mean a genetic desire to wear dresses. I also tried to suggest to him that he could have both of these things -- the hormonal balance and the social role -- without operating on his genitalia, since penis/vagina has no intrinsic connection to the social fact of being male or female, but he didn't see it this way. In fact he admitted to having a conservative idea of gender when I pointed this out -- he sees it as a black-or-white category, almost a metaphysical principle. (I have no personal problem with this guy or anyone changing their sex, I'm just confused and genuinely curious about their view of gender.)
posted by creasy boy at 12:43 AM on May 18, 2008 [2 favorites]


Zucker is the major remaining proponent of Reparative Therapy for LGBT folks.

We want forty acres and a tool!
posted by PeterMcDermott at 1:59 AM on May 18, 2008


Part of this frustration is how insistent we are as a culture that gender is only binary. It might be mostly binary, but it's not even close to entirely binary. It has been more than a few decades since the Kinsey reports, and more modern research indicates that gender is much more fluid than we're collectively comfortable acknowledging.

Even if our culture could comfortably acknowledge that gender is more fluid, like we are beginning to do for sexual orientation, I'm not sure I can agree with your other point that it wouldn't matter whether if anyone were a boy or a girl anymore until you want to sleep with him or her.

For sexual orientation, a straight person can have a homosexual experience, or a homosexual desire, and still can continue to identify as straight. We're past the idea of "becoming" gay because you have one gay thought. Given a self-aware choise, people still choose. That's identity, and it's important not for sexual orientation, but just as a part of being human. People segregate themselves into sub-cultures to find others who are like them, and not necessarily for existential, "this is what means to be gay and I am gay" reasons. I mean, there are gay clubs, not to allow people to live a gay life, but principally to allow gay people to find each other.

It would be impractical for a gay person to hit on straight-identified people, in hopes of finding someone who has the occasional homosexual interest. It wouldn't be wrong or disrespectful, but rather I imagine impractical and discouraging.

Gender is even more divided; at least with regards to orientation, the question doesn't come up when the subject isn't sex. With gender, participating in culture at all implies an idenfication, male, female, or andro. Except for sometimes in writing, you cannot avoid picking one. Refusing to choose a gender is, in a way, choosing to be androgynous, at least that's how others will interpret it.

So, even if the underlying gender is fluid, and acknowledged to be fluid, it doesn't matter because the identification is not fluid. I don't think identification can be fluid. If it were, we'd see people, liberated from sexual orientation labels, all being bisexual. Instead, the gay as an identity is stronger now than before Kinsey.
posted by cotterpin at 3:01 AM on May 18, 2008


That is to say that I posit that you can no more "easily make" a transgender person "not angry at their body" than you can make a panda want to be a lion.

Way to miss the point. It was posed as a hypothetical indicating in part that GID is a disorder. And you base this conclusion on nothing whatsoever. We understand neither the why nor how of how gender dysphoria happens. The majority of children with GID go on not to want sex reassignment; as the others in the discussion point out, most children have fluid identities. Both of these leave open the possibility that there may be a therapy that we just don't know about yet. There's also no very effective therapy for male anorexics; it's still a disorder and if we could cure it we would.

I also wouldn't take the fact that some GID children stay GID as indicating the existence of "truly transgendered." That doesn't have any real meaning attached to it; people who stay anorexic aren't "truly anorexic" and we should just leave them alone. I'm picking on anorexia because it's another body dysphoria. Before you say that anorexia causes problems and GID doesn't remember the extraordinary degree of distress that tends to be present. The suicide rate (even compared to homosexuals and cross-dressers who suffer similar social judgment) is extreme.

You don't like Zucker's treatment and don't think that it works very well based on the presentation in a radio show. That's great.
posted by a robot made out of meat at 7:01 AM on May 18, 2008


You don't like Zucker's treatment and don't think that it works very well based on the presentation in a radio show. That's great.

Everything I've seen of Zucker's treatment seems to assume that transition is a process that should be avoided at all costs, to the point where taking away everything that makes a child happy and forcing them to do things that make them unhappy is entirely justified. If you remove the initial assumption - that gender transition is inherently a bad thing - then Zucker's methods start to look, well, cruel and unusual.
posted by ArmyOfKittens at 8:41 AM on May 18, 2008 [1 favorite]


This is a problem for many transsexuals in particular because the US, as informed by the DSM, generally requires a lengthy period of "living full time" for transgenders long before any therapy or beginning to transition. This is supposedly a requirement to prevent people from making mistakes or weeding out "deviants" or "fetishists" but seems like a rather cruel way to go about it - and, really, assuming good values of socialization and general sanity - why would it even matter if it was a "deviant" or "fetishist" in the first place?

It matters because gender reassignment surgery is essentially irreversible. There is a long history of people who are "merely" transvestite believing that they're transgendered, going through the very difficult surgery to get there, and then realizing afterwards that they're not, and that they've taken an extremely expensive, emotionally charged one way door which they regret going back through. Depression and suicide are frequent results.

The "living full time" protocol very often results in people realizing that they just wanted the sex/play/deviance part without the hard work parts. Given the penalty for not obtaining this realization, it's completely worth the presumed "inconvenience" (??!) for the truly transgendered who have to wait.
posted by felix at 11:23 AM on May 18, 2008


There is a long history of people who are "merely" transvestite believing that they're transgendered, going through the very difficult surgery to get there, and then realizing afterwards that they're not, and that they've taken an extremely expensive, emotionally charged one way door which they regret going back through. Depression and suicide are frequent results.

Not saying you're wrong or right, but do you have figures?
posted by ArmyOfKittens at 11:38 AM on May 18, 2008


a robot made of meat: Just because there's no good therapy that reverses it, doesn't mean that it's not a disorder. As Zucker points out, option B at this point in major surgery, sterility, and a lifetime or hormone treatments with consequences. If you could easily make them not angry at their body, that would obviously be preferable to everyone.

Well, reading the interview responses with the other therapist profiled by NPR, it's clear that "option B" isn't necessarily full transition. It's giving the kid a safe place to explore and come to his or her own ideas as to what gender means. Of all of the things that could happen to a kid, growing up as a 'feminine' man or a 'masculine' woman doesn't seem that big of a deal to me.

Of course, I'm biased in that I'm a member of that class of somewhat feminine queer men who would have been subjected to all kinds of medical torture that attempted to enforce conformity to gender norms.

Way to miss the point. It was posed as a hypothetical indicating in part that GID is a disorder. And you base this conclusion on nothing whatsoever. We understand neither the why nor how of how gender dysphoria happens. The majority of children with GID go on not to want sex reassignment; as the others in the discussion point out, most children have fluid identities.

From reading the articles, it seems that it's the parents who are more distressed and disordered when bobby plays dress-up with barbies. If children have fluid identities, then why not let them express those identities as they change over time? And can it not be argued, that at least half of the problem is the same kinds of prejudice and bias that killed Lawrence King?

creasy boy: There is a lot of debate within transgender communities on these issues. Ranging from very conservative views of gender to genderqueer people who don't identify with existing gender categories.
posted by KirkJobSluder at 11:55 AM on May 18, 2008


From my queer, trangender LGBT-issues specialist friend in the APA:

"Blanchard is NOT on the Gender subcommittee, he's heading up the paraphillia subcommittee. And Zucker is not actually evil, despite the way he is sometimes portrayed. He recognizes that in adolescents and adults gender identity is pretty much set and supports gender transition and sex reassignment services for adult and adolescent trans-folk.

"He sees kids as being at risk for developing stable 'cross-gender' identites and thinks it's worthwhile to try and help them to develop gender identities consistent with the sex assigned at birth. Not how I would treat kids (if I treated kids) but not malicious or evil. Plus, Zucker has been part of the DSM process for the gender section since the DSM-III-R, so I would be suprise if there are radical changes, although I've heard him publically say that it might be a good idea to shift the criteria of GID for kids to be more focused on gender dysphoria rather than gender non-conformity: I think that would be a really good thing.

"I've actually worked with him on a different task force -- it was an interesting experience. And NOBODY is trying to put homosexuality back in the DSM. Dresher (who is on the gender subcommittee) is a strong LGBT advocate and has been a strong voice against 'reparative therapy.' Cohen-Kentenis, the chair of the gender sub-committee, is one of the people who has been an early advocate for social and medical transition for adolescents and has collected solid data on how well that works. So actually, the gender subcommittee is a pretty good collection of people.

"Sorry for going on about this at such length, but it's been kind of amazing to see the cyclone of misinformation and fear that's been brewing."
posted by kyrademon at 12:33 PM on May 18, 2008 [4 favorites]


Oh, I'll agree that he's probably not evil. On the other hand, I think that a therapy emphasizing gender role conformity isn't in the best interest of kids, while political action emphasizing gender flexibility is.
posted by KirkJobSluder at 12:38 PM on May 18, 2008


Gender and identity are tricky topics. I'm a little sad that people aren't more individualistic but you've got the whole world telling you to consistently act one way or another or in a few, rarely long term cases act a third way(but hopefully not if you're a guy!). Even in the most progressive places, defying convention is looked down upon. That said, people are hardwired to do the nasty.

Homosexuality is common among animals within both genders(but primarily dudes, go figure) and it is historically very common if not constant with humans despite a long sweeping trend of being looked down upon. When you consider that wealth transitioned primarily through heredity during most of our history of possessions, it is little wonder that homosexuality would be viewed so negatively; you've got your son or daughter pissing away everything you and your ancestors worked for because they like to hump one of their best friends.

Also, jealousy plays a factor. If you'd rub your crotch against another chick, why not rub it against me? Binary gender and gender roles establish neutral territory in the war to perpetuate our genes. They also reinforce the idea that love and sexuality are inclusive and you have to be affectionate of someone to let them inside you.

Political action emphasizing gender flexibility is a great idea for liberating folks but I don't trust politicians. Campaign for certain universal rights but also talk about these items with anybody willing to keep an open mind while listening.

Another point that I find interesting is paraphilia. When I was young, I considered sexuality mainly from the vantage point of love(ha!) and thought the same arguments could be used to justify homosexual couplings could be applied to pedophilia, bestiality, really any kind of sex. While this is certainly true in the case of sex for love and age, pedophilia and bestiality are institutions in some places in the modern world.

Consider Melanesia, where boys are encouraged to eat the semen of older males before producing their own. Or consider animal husbandry. There are people here in uptight America who professionally get animals rocks off! I don't know about you but if I could earn millions of dollars a year jerking Secretariat or Lassy off I'd be doing it!

As I've aged I began to consider lust its own justification but this doesn't sit well with me. Lust could be used to justify all sorts of terrible behavior(rape) that I cannot possibly condone. The role that lust plays in your own life ought to be considered very very carefully.

Bottom line: if you don't want to rock the boat, stick to convention. This pertains to homosexuals in particular. Lisp and epitomize stereotypes. Homer Simpson's line about how he likes his gays flaming is particularly telling in this instance. If you do want to rock the boat, defy convention and be subversive and educational about it; hold your boyfriend's hand at dinner parties while flirting with the hostess. We are all soldiers in the fight for sexual liberation and equality.

Wrote too much...
posted by christhelongtimelurker at 2:01 PM on May 18, 2008


Also, the line about getting animals off was in bad taste. For that I apologize most sincerely.
posted by christhelongtimelurker at 2:02 PM on May 18, 2008


Well, reading the interview responses with the other therapist profiled by NPR, it's clear that "option B" isn't necessarily full transition. It's giving the kid a safe place to explore and come to his or her own ideas as to what gender means. Of all of the things that could happen to a kid, growing up as a 'feminine' man or a 'masculine' woman doesn't seem that big of a deal to me.

This is a point worth considering. In follow-up articles by Zucker, the much more common outcome from gender cross identification (aside from normal) is homosexuality rather than full trans-gender. If the goal is to avoid the complications of sex reassignment by working with children, then it's important to identify who's at risk for severe body dysphoria and who's probably going to be fine. You're not going to start unpleasant and unnecessary work with kids just because they like feminine things. If it's to the point where the child definitely asserts being the opposite gender, then the risk assessment shift.
posted by a robot made out of meat at 2:42 PM on May 18, 2008


When how you think or what you feel convinces you to cut off and replace your sexual organs, then, well, I gotta side with the organs.

I'm convinced by the evidence that there are "gender oriented" brains. I'm just not convinced that the best psychological solution to a mismatch is going under the knife.
posted by ewkpates at 3:28 PM on May 18, 2008


"He sees kids as being at risk for developing stable 'cross-gender' identites and thinks it's worthwhile to try and help them to develop gender identities consistent with the sex assigned at birth.

And who decides what the "appropriate" gender expression is? Should boys not be allowed to play with dolls or have long hair? Should girls be kept out of shop class (do they even have those anymore?) and be made to wear skirts? If your five-year-old son goes through a time when he really likes to wear a sparkly pink skirt, do you rip it away from him because it's "inappropriate," or let him wear it, because in all likelihood he'll get bored with it in a week anyway?

Anybody here read Daphne Scholinski's book The Last Time I Wore a Dress? She was institutionalized as a teenager (from 1981-84) for Gender Identity Disorder; her "treatment" included being forced to learn how to walk "like a girl" and put on makeup. It's been a while since I read it, but if IIRC, she wasn't transgender - she was a tomboy (with a whole mess of problems, of which the tomboy part was the least of it, but that was the focus of the "treatment.")

When I read it, I remember thinking, Christ, that could have been me - except I didn't have parents who thought it was sick that I liked wearing jeans and thought Barbie was boring. I've never wanted to be male, or thought I was male, but my gender presentation doesn't exactly conform to what society says is typically female. I wonder, if Zucker had met me when I was five, would he have determined that I was sick and in need of treatment?
posted by rtha at 8:41 PM on May 18, 2008 [1 favorite]


I'm just not convinced that the best psychological solution to a mismatch is going under the knife.

I'm sure your vast wealth of experience in this area has lead you to form this opinion.

When how you think or what you feel convinces you to cut off and replace your sexual organs, then, well, I gotta side with the organs.

When these thoughts and feelings have been present your entire life, when they've been a feature of every memory since your first and most distant, when they're not even really thoughts or feelings but a background hum to your existence, an everpresent fact that whispers quietly to you in every situation that this is wrong, this is broken, you are broken, then why on earth do some little flaps of skin and flesh get the deciding vote?
posted by ArmyOfKittens at 11:05 PM on May 18, 2008 [1 favorite]


I'm convinced by the evidence that there are "gender oriented" brains. I'm just not convinced that the best psychological solution to a mismatch is going under the knife.

I agree that conclusion, but I don't buy the "gendered brain" part. It's just so 1950's boys play with trucks/girls play with dolls. It's flat-out sexist.

And that's my main beef with transgender people: They claim to be side-stepping gender roles, but in actual fact no one buys into gender roles with as much vigour as TG's. "This is a woman. This is a man. Which one am I?" It's such a black-and-white (or pink-and-blue) way of thinking. If a boy "feels like a girl," what does that even mean? What does a girl "feel like," and how would he know?

To dress like the opposite sex, or act as such (whatever that means) -- that doesn't bother me in the slightest. But there's a big, bold line between effeminate and emasculate.

At the end of the day, it's none of my business and, as far as I'm concerned, people should absolutely have the right to do with their body whatever they please, but what's so wrong about helping someone to become comfortable as they are?
posted by Sys Rq at 6:44 AM on May 19, 2008


To those posters who are saying transgender people should accept the genitals they're born with -- imagine that you woke up this morning in a body with the opposite gender from your present one. You're still you in every way, but there's a vagina where your penis was (or vice versa). Do you think that the best thing for you to do in that situation would be to accept that state of affairs and live as that gender?
posted by prefpara at 8:10 AM on May 19, 2008


And that's my main beef with transgender people: They claim to be side-stepping gender roles, but in actual fact no one buys into gender roles with as much vigour as TG's. "This is a woman. This is a man. Which one am I?" It's such a black-and-white (or pink-and-blue) way of thinking.

You should read some Kate Bornstein, who is transgender and has written extensively about this.
posted by rtha at 8:32 AM on May 19, 2008


If a boy "feels like a girl," what does that even mean? What does a girl "feel like," and how would he know?

This is one of the largest problems to overcome in transsexual psychiatry. There isn't an objective, external way to decide if an individual "feels like a boy" or whatever; after all the questions have been asked, after every childhood and adolescent memory has been picked over, in the end it all comes down to two questions the individual must answer: am I a boy or a girl? and do I feel strongly enough about this to take action?

However, your statment,

in actual fact no one buys into gender roles with as much vigour as TG's

really isn't true. Even if it were possible to have a sweeping generalisation be accurate (and, god knows, we transgendered are martyrs to the art of the sweeping generalisation, as well as to the backhanded compliment), it ignores the vast amount of discussion that goes on within the transgendered community on the nature of gender. In fact, there's something of a split right now between transpeople, with people on one side (who want to reclassify themselves as suffering from Harry Benjamin Syndrome*) very much in support of the sex/gender binary; ooh, the arguments and the flamewars between them and everyone else, they'll tear the internet apart, they will!

But there's a big, bold line between effeminate and emasculate.

I'm glad you have a dictionary and that it brings you such joy, but please don't attempt to apply one-line definitions to a thing that is at this point a horrible/joyful cross between a medical condition, a social movement, and a never-ending argument.

* I know very little of the arguments or the philosophy of the HBS movement, as it's never really interested me; thus my characterisation of their support for the gender binary is based entirely on third party information. Any HBS-knowledgeable people, please feel free to correct me if I'm doing the movement a disservice.

Finally, and I'm not sure why I'm addressing your comment in reverse,

I agree that conclusion, but I don't buy the "gendered brain" part. It's just so 1950's boys play with trucks/girls play with dolls. It's flat-out sexist.

I would certainly refer to a gendered brain only in context of the owner of that brain knowing what gender they are (see: me; woman), and wouldn't use that to try to imply particular traits.
posted by ArmyOfKittens at 8:40 AM on May 19, 2008 [1 favorite]


my main beef with transgender people

In retrospect, my "beef" is with the concept of transsexualism rather than with any individual or group, and, more directly, with the outmoded societal and cultural norms from which the concept is carved.

I mostly just long for a post-gender society.

...all of which is rather irrelevant to the topic at hand, which is some pretty scary shit.

The Human Biodiversity Institute (of which Blancherd was a member) is a conservative-run eugenics thinktank headed by Steve Sailer. According to Sailer, "The Human Biodiversity Institute promotes the study of biological differences among humans and their impact on society. Major areas of interest include race, sex, and sexual orientation."

This man should not be allowed anywhere near a typewriter, let alone hired to rewrite any part of the DSM.
posted by Sys Rq at 9:37 AM on May 19, 2008


And that's my main beef with transgender people: They claim to be side-stepping gender roles, but in actual fact no one buys into gender roles with as much vigour as TG's. "This is a woman. This is a man. Which one am I?" It's such a black-and-white (or pink-and-blue) way of thinking.

We clearly know different transgender people. In my experience, few people have thought as long and hard about gender, what it means, and how it operates in society, as transgender individuals. Most of the transgender people I know are acutely aware of the nuances of gender, gender presentation, and where they fit on a continuum of gender identities. And as Army of Kittens points out, there is absolutely no consensus within the TG communities on what gender and sex mean and whether it is binary or a continuum.
posted by gingerbeer at 9:44 AM on May 19, 2008 [1 favorite]


In retrospect, my "beef" is with the concept of transsexualism rather than with any individual or group, and, more directly, with the outmoded societal and cultural norms from which the concept is carved.

I don't think you really understand transsexualism. It's not purely social or purely physical. A common question asked of trans people is, "In a post-gender society, would you still transition and/or have SRS?" Some answer yes, some answer no. Overall, we don't come entirely from society any more than we come entirely from biology; we're a mix of both.

(Above paragraph entirely IME and IMO.)
posted by ArmyOfKittens at 10:06 AM on May 19, 2008


You're right; I don't understand it--not even remotely.

I was a rather girly Barbies and nail polish kid, never quite feeling like a boy, to the point that I did often wish I was a girl, well into high school. At some point I chose to play the cards I was dealt, because the alternatives just seemed silly and childish and would ultimately cause more problems than they solved.

It's from that perspective that it seems to me that taking such impulses beyond mere role-reversal or transvestism and into the realm of actual transsexualism would require a whole lot of obsession and/or delusion, informed by grass-is-greener comparisons of deep-rooted misconceptions of what it means to be male or female.

This is, of course, entirely prejudicial on my part and for that I apologize. I must concede to anyone with any actual insight, and gratefully accept any given.
posted by Sys Rq at 12:23 PM on May 19, 2008


It's from that perspective that it seems to me that taking such impulses beyond mere role-reversal or transvestism and into the realm of actual transsexualism would require a whole lot of obsession and/or delusion, informed by grass-is-greener comparisons of deep-rooted misconceptions of what it means to be male or female.

From my perspective (I'm a transwoman many years post-transition) it was very different. Neither an obsession nor a delusion, and involving no real idea of what it meant to be a woman, I simply needed to stop being something I wasn't. I wasn't a man. Not, "I'm not a masculine man," or, "I wish I was a woman." Simply, "I am a woman." Everyday life as a woman who wasn't was, quite literally, killing me. Banal and trite as the time-old saying is, I really was a woman trapped in a man's body.

We're in danger of turning this into a personal anecdote thread (and I'm certainly in danger of over-posting again in a trans topic); you can memail me if you want to talk about this further, or follow the website link in my profile.
posted by ArmyOfKittens at 12:35 PM on May 19, 2008


There are costs and benefits to bringing questions like these to the personal level, and once there it can be difficult to discuss these questions without the appearance of personal criticism. Nevertheless, ArmyofKittems makes my point with the comment that gender identity disorder was "...quite literally, killing me".

Clearly not. Mental anguish is a common element in mental illnesses. From paranoia to obsessive behavior, those suffering from mental illness often feel life threatening distress. But there is no physical danger.

This thread also slipped very quickly into "you don't understand it unless you are going through it" very quickly, and that is always a sign of error. Again, with paranoids and obsessives, you don't have to have experienced it to identify it as mental illness.
posted by ewkpates at 2:21 PM on May 19, 2008


those suffering from mental illness often feel life threatening distress. But there is no physical danger.

There certainly is if the (mental) anguish causes the person to self-medicate with drugs and/or alcohol; to engage in risky behavior to support those habits (or because the person doesn't feel like they deserve any better); or to attempt suicide. Those are all physical dangers in my book.
posted by rtha at 2:29 PM on May 19, 2008


ewkpates: "it's really hard to talk about this now without being insulting. having said that, here are some baseless and insulting thoughts i'd like to share."

I agree that you can't see into aok's secret truth, so perhaps diagnosing her over the internet is not wise? Beyond sort of acting like you know what's in her head better than she does, I'm not sure what point you were making.
posted by prefpara at 2:51 PM on May 19, 2008


Nevertheless, ArmyofKittems makes my point with the comment that gender identity disorder was "...quite literally, killing me".

Brevity is my enemy. The depression, panic attacks and agoraphobia that I experienced in my late teens and early twenties were a direct result of my untreated GID. I would cut myself very deeply (and harm myself in other direct, physical ways), drink alone and to excess, and I survived one suicide attempt. Fortunately I was lucid enough to recognise that if I didn't get help then, in the black despair that often overtook me, I really would do something there was no going back from; whether death or permanent injury.

During that time I was determined not to pursue gender therapy; any other option! I was convinced that there was no way I could live as a woman because I felt disgusting, deformed, and obvious: everyone would see through me. I would be a laughing stock. Only when I stopped seeking treatment for the symptoms and started seeking treatment for the cause did the despair begin to recede.

I also experienced something experienced by many transpeople: once on the "correct" hormones it became a lot easier to think straight, to recognise what behaviour was from the despair, to control myself, and to understand my emotions. Sort of like a diesel engine that's been run on petrol for 20 years finally getting the correct fuel. Of course, this is purely anecdotal and, despite coming from a hundred mouths, not really admissible data because we're all deluded and making it up. Unfortunately, data on brain structure in transpeople is so absurdly limited that anyone claiming to know for certain one way or the other is lying or ignorant.

Whether from suddenly having a direction, or from suddenly having the right chemicals in my body, or from slowly feminising in my face, figure and voice - or from a combination of the three - once treatment began I was on the road to eradicating the depression and despair that had dominated my life for years.

Again, with paranoids and obsessives, you don't have to have experienced it to identify it as mental illness.

As I hope is obvious from what I've typed above, I would characterise GID as a cause of mental illnesses. I'm not sure I would call GID a mental illness in itself, as to me that implies treatment to the mind, and not to the body. Of course I know next to nothing about professional standards of diagnosis and treatment, but I've seen an awful lot of evidence that treatment to the body works for many people, and know for certain that in my case, treatment to the mind would not. Of course, delving into the latter point is another essay and, believe it or not, considering how much of myself I've just revealed, rather too personal for such a public website.
posted by ArmyOfKittens at 3:02 PM on May 19, 2008 [3 favorites]


The last thing I read related to GID was a study that suggested that some people have brain development suggestive of one gender and other physical development suggestive of the other. Kittens opens the door to an excellent area for research: how does hormone therapy in GID affect other behavioral problems? There are obvious grounds for looking into this: testosterone problems can cause a variety of craziness and other physical problems.

While prefpara and rhta miss my point entirely and almost seem to miss the point of science in general, they underscore the sensitivity of personalizing mental health discussions, while Kittens, hats off to you, you've saved the discussion.

It should be clear though that given a patient with many mental health challenges, surgery shouldn't really be a consideration. Hormone treatment aside, cosmedic surgery and its relationship to mental illness is very uncertain ground.
posted by ewkpates at 4:19 AM on May 20, 2008


The last thing I read related to GID was a study that suggested that some people have brain development suggestive of one gender and other physical development suggestive of the other.

That sounds very much like the study I read, which is as far as I'm aware the only one, and worked with an incredibly small sample. It's not currently possible to say with certainty that, say, transwomen have female brain development, or how much of the brain this applies to. Of course, when/if this is shown to be the case, there are bound to be transpeople who show up without said development.

It should be clear though that given a patient with many mental health challenges, surgery shouldn't really be a consideration.

Which is why the RLT (Real Life Test) requirement exists under the current guidelines. Only after hormone therapy and at least one full year (often more; two in the case of the UK) spent living "in role" (with additional situation requirements such as employment or voluntary work; you can't have spent the two years hiding behind a closed door) is surgery approved, and at least two psychiatrists must sign their approval before a referral for surgery is made. The whole process is centred around confirming that no mental illness or fetish or space aliens are responsible for the "cross-gender" feelings experienced by the patient, and about confirming that the patient really is better off. I've been post-transition for 6 years (and on HRT for almost 8) and have only just been approved for surgery (although this was because I didn't seek the referral for surgery on the NHS until around a year ago, having previously been treated privately; I've been fast-tracked because I'm very very obviously a happy, healthy woman who just needs this weird growth between her legs excised, and even then I've still required the two signatures and extensive interviews with professionals).

Long-term HRT is another justification for surgery: remove the testicles and the HRT dose can be lowered, which is unambiguously a good thing for any number of obvious health reasons.

I don't think that anyone in this latter discussion has missed the point of science in general; to treat GID as a clinical puzzle to be solved is to see only a small portion of the picture. I'm having trouble coming up with any other condition classified as a mental disorder that is subject to quite as many prejudices, fetishes and exotifications, that results in such extreme apparent changes to the patient from the point of view of an observer, that is home to such a varied set of communities, and that is the focus of whole political movements. Thus a wider viewpoint is necessary and focusing on aspects other than the purely clinical is entirely appropriate.
posted by ArmyOfKittens at 4:59 AM on May 20, 2008


Some people see the world very differently than it is. What is the role of mental health providers? Twofold: 1) help the patient to see the world more accurately, as it is; 2) to help the patient accept that the world they see, that they want to see, isn't the world that exists. When surgery enters the picture, we should consider those people who don't like their body shape, can't accept a disability or injury, or want to achieve some ideal that they think is necessary for their happiness. Mental health providers' role, arguably, is to increase acceptance and decrease perception distortion.

When, instead, we look at surgical changes, I wonder what we have accomplished.

The case for treating GID as something other than a clinical problem is tied inextricably to the case of seeing so much else as a clinical problem, the closest example being voluntary amputation. The model of therapy isn't to change the world, but to change the patient's perception and acceptance of the world. What would be the consequences if we adopt a new model, one that aims to conform the world to the patient's desire? Under this new model, would the patients who can conform the world not be mentally ill? Is this kind of "world conforms to patient" strategy essentially what medicating mental illness accomplish?
posted by ewkpates at 5:57 AM on May 20, 2008


ewkpates, that is one way of defining the role of mental health providers, but it is not the only way. I also think you rely too much on the assumption that mental health providers are always going to be able to "see the world as it is." You don't define "the world," and that is incredibly question-begging in this context. You can't just assume that "the world as it is" means you "are" the gender your genitals dictate when that is one of the points of contention in the discussion.
posted by prefpara at 7:21 AM on May 20, 2008


When, instead, we look at surgical changes, I wonder what we have accomplished.

Happier people.
posted by ArmyOfKittens at 7:31 AM on May 20, 2008 [1 favorite]


When surgery enters the picture, we should consider those people who don't like their body shape, can't accept a disability or injury, or want to achieve some ideal that they think is necessary for their happiness. Mental health providers' role, arguably, is to increase acceptance and decrease perception distortion.

When, instead, we look at surgical changes, I wonder what we have accomplished.


Should we tell that to people born with cleft palate?
posted by get off of my cloud at 1:04 PM on May 20, 2008


I'm concerned with the disingenuousness, or appearance of it, in some of the arguments related to GID that I've come across. Also, in reading about other cases of elective surgery and mental illness, I've been surprised at degree to which this debate hasn't progressed.

Cleft palate is a fine example of this. Cleft is a congenital deformity. If you were to seriously put this analogy forward as an argument, then we would have to consider brain surgery as a way to reverse GID as well. How often is this discussed as a possible treatment option? It seems that GID is a debate mired in misconception and poor reasoning. It seems that much of the current debate is driven by a lack of interest on the part of scientists and a ferocious lobby on the part of sufferers.
posted by ewkpates at 4:00 AM on May 21, 2008


Speaking of poor reasoning, ewkpates, seriously, you make a lot of assertions, but you seem unable or unwilling to articulate the reasoning behind the positions that you take, some of which seem to me to be patently absurd, e.g.:

If you were to seriously put this analogy forward as an argument, then we would have to consider brain surgery as a way to reverse GID as well. How often is this discussed as a possible treatment option?


What brain surgery do you envision? What are you even talking about? You have thrown out there that people who are mentally ill (according to you) shouldn't be allowed to modify their bodies through surgery, you've made broad claims as to what the purpose and nature of mental health intervention ought to be, but you've never really explained why you think you're right about any of this or why you thinks the organs should get the final word.

You talk a lot about what other people don't understand and how lacking the debate is because of their intellectual sloppiness. Beam in your own eye, dude.
posted by prefpara at 4:47 AM on May 21, 2008


Cloud's argument
1. People born with cleft should be able to get surgery.
2. Cleft and GID are (in some way) similar conditions.
3. Therefore, GID patients should be able to get surgery to change genders.

My counter argument is that this argument also works given Cloud's assumptions:
1. People born with cleft should be able to get surgery.
2. Cleft and GID are (in some way) similar conditions.
3. Therefore, GID patients should be able to get surgery to alter brain formations responsible for gender-identity-based-rejection of their physical gender.

If surgery is a treatment variable, as the cleft argument suggests, that doesn't necessarily limit or compel arguments for a particular kind of surgical solution. The brain surgery I'm referring to involves the study about GID and the brain formation connection that was referenced earlier.

No beams in here. When you find the reasoning unclear, first request a clarification. There will be time for the attacks ad hominem later. There always is.

I note also that your previous comments shows some... weaknesses in the structure of the arguments. To wit:

you rely too much on the assumption that mental health providers are always going to be able to "see the world as it is."
Why go to a therapist if they aren't more objective (e.g. accurate) observers? You've raised an argument that invalites therapy as a model, not my model for therapy.
You can't just assume that "the world as it is" means you "are" the gender your genitals dictate when that is one of the points of contention in the discussion.
"You" is an open question here. Some say it's brain chemicals, some say brain formations, some say physical self, including the genitals. I'm not saying it is one or the others, I'm saying that the mental health provider's role is to get the patient to an acceptance of their circumstances, even if the circumstances involve missing/broken parts or parts that don't fit together the way the patient wants.
posted by ewkpates at 6:06 AM on May 21, 2008


This thread has gone to a deeply weird place.

I'm saying that the mental health provider's role is to get the patient to an acceptance of their circumstances, even if the circumstances involve missing/broken parts or parts that don't fit together the way the patient wants.

You still haven't said why. Why is personality alteration a better option than physical alteration?

You could also do with saying how. Take a genetic/assigned male who says he's a woman, really, deep down inside. We know that aversion therapy won't make him happy to be a man. We know reparative therapy won't make him happy to be a man. We know pumping him full of testosterone won't make him happy to be a man. We know antidepressants won't make him happy to be a man. We know hours and hours of conventional therapy won't make him happy to be a man. How would you fix her?

If you don't have an answer, then try to accept that no-one in the field does. If you do have an answer, be sure to compare it to the deeply suspect answers given by people with morality motives.

As far as I can see, there's no way to change her personality; to change who she is. And there's no reason to go looking for one anyway, because that's who she is. So what, exactly, is your point?
posted by ArmyOfKittens at 8:34 AM on May 21, 2008 [1 favorite]


So, we now at least understand that the question posed in the beginning: Who should write the DSM? is really a question about "what is the model for treatment that should underlie the DMS?"

Clearly if you think that a) a person who is depressed because of a history of abuse; or b) a person who has trouble controlling irrational fears or repetitive behaviors - go through a "personality alteration" when, through a cognitive behavioral course of treatment, they learn how to set aside the past, their fears, etc. and focus on today and growth as a person, then you have a conception of therapy that doesn't match most of the mainstream.

Most of the mainstream would say that such patients lack the ability to be objective and to direct their thoughts rationally. Most of the mainstream would say that the person isn't altered, that they are learning to use new cognitive tools. These people cannot change who they are, but they can improve their lives by learning how to live better.

There are some people who seem to be born with a brain/body gender mismatch. Then again, there are some people who are born with both sets of sex organs. Then again, there are some people who are treated horribly by their parents and have learned not to trust other people, ever. Based on the therapeutic model I've discussed, treating these people is helping them to, in their given set of circumstances, live the best lives they can.

I'm saying that people can learn how to be happy regardless of their circumstances. I'm saying that being happy doesn't go with any particular physical condition or personal history. I'm saying that you don't have to change what you are to be happy being who you are. Happiness is not about getting what you want, it's more about accepting who you are.

Perhaps there is a different model for treatment that should drive the DSM. Perhaps pills or surgeries are the best answer in some cases, although I can think of none that have stood the test of time so far.

But when we talk about the treatment model underlying the DSM, we are generally not talking about "helping" people who are cognitively functional by altering their life circumstances, but by altering their ability to perceive them and adapt to them.

What other model for the DSM would you suggest?
posted by ewkpates at 9:55 AM on May 21, 2008


The story of David Reimer is interesting, and, I think, apt.

Due to a medical accident (an inadequate word) when he was an infant, his penis was removed. His parents agreed to raise him as a girl, and he was given hormonal treatment to make him (more) female. He was not told he had been born a boy until he was 14, after he had undergone years of hormone and psychological treatment. He killed himself when he was 38.

His social and physical identity were in deep conflict with his own identity. The treatments (medical and psychological) he received as a child were apparently very damaging, according to John Colapinto's book As Nature Made Him.

I'm saying that you don't have to change what you are to be happy being who you are. Happiness is not about getting what you want, it's more about accepting who you are.

Other people say differently, ewkpates.
posted by rtha at 10:23 AM on May 21, 2008 [1 favorite]


Clearly if you think that a) a person who is depressed because of a history of abuse; or b) a person who has trouble controlling irrational fears or repetitive behaviours - go through a "personality alteration" when, through a cognitive behavioural course of treatment

I'll keep this short because I'm supremely bored with this conversation as it seems to be going nowhere. The people you describe a) have had something inflicted on them, and b) unambiguously would be helped by conventional therapy of the sort you advocate. Transsexuals are in a different position: cross-gender feelings arise so early in life - and in environments that have produced children with no cross-gender or even homosexual feelings - that the natural conclusion is that this is something that is in-born; further, it is simply not possible to "therapise" someone out of transsexual feelings; further still, there exists a physical alteration which is most cases completely eliminates the problem at hand.

Find me another condition classified as a mental illness that can be treated similarly, successfully. GID is unique. You can't treat it like it's not.

We're talking at cross purposes. I'm talking about GID. You're talking about other conditions and applying their treatment methodology to GID. It's daft.
posted by ArmyOfKittens at 11:38 AM on May 21, 2008


Is this where I insert my lame joke about the conference being full of fruits and nuts?
posted by Pollomacho at 11:43 AM on May 21, 2008


There are some people who seem to be born with a brain/body gender mismatch. Then again, there are some people who are born with both sets of sex organs. Then again, there are some people who are treated horribly by their parents and have learned not to trust other people, ever. Based on the therapeutic model I've discussed, treating these people is helping them to, in their given set of circumstances, live the best lives they can.

But those aren't comparable at all. There is no physical treatment that can give an abused kid a healthy childhood. There are a variety of physical treatments that can make transpeople happier in their bodies.*

The comparison to brain surgery doesn't really make sense either. We've no idea how or whether the physical structure of the brain determines gender. That study suggests that [some] trans brains [may] be more like the brains of the other biological sex. That doesn't mean we know how to change them. It's possible that at some point in the far future we may be able to go into someone's brain and rearrange things a little. But even if so--why? The sense of self comes from the mind, not the body. Surely there would still be many people who would prefer to bring their physical being into line with their self-image, the core of their identity and how they've known themselves since birth, than vice versa and accept a fundamental alteration in their own mind. It's not the same at all as obsessive-compulsive disorder, for example.

I guess...I'm still not seeing why you think surgery is a worse option than therapy. For many people, it works. It may change the functioning of the body slightly, but only in ways the person wants, so that's not a problem. It's permanent (mostly), but their are massive guidelines in place to make sure people don't do it lightly, so that's not a problem. It's expensive, but so is years and years of therapy, so that's not a problem.

So what's the problem?

*I also think it's important to keep in mind that not all transpeople choose the same options. Some have "top" surgery, some have "bottom" surgery, some take hormones, some use clothes, voice, or mannerisms to present as their gender. Y'know, just so we're keeping in mind that these are individuals.

On preview: what ArmyOfKittens said. Again.
posted by hippugeek at 11:49 AM on May 21, 2008


So let me some up. GID people, who exhibit symptoms of "crazy" should not be evaluated in the same way as other people manifesting the same symptoms. Unlike people who want their limbs removed or have "perceptual impairments", GID people should not be included in the DSM because they have an incompletely understood physical condition that is best treated through chemical and surgical intervention.

Oh, and this physcial condition is a problem because of the social construct that defines what "gender" is.

But wait: If there was a a colony where there are no gender norms, where "man" and "woman" were not based on sex organs but were simply elective life style choices, would surgery be as necessary? Why is it that a woman can't have a penis?

And there's the problem: If being a woman is just a matter of saying "I would prefer to be considered a woman", then why is surgery necessary? Because women have "certain characteristics?" Which society determines them?

Once we start talking about social constructs, we drift back into DSM land...
posted by ewkpates at 12:15 PM on May 21, 2008


ewkpates, I'm patiently attempting to understand your point in your last comment. I'm not succeeding. Where did anyone say that gender was only a social construct? What does your imaginary nonhuman colony demonstrate?

So let me some up. GID people, who exhibit symptoms of "crazy" should not be evaluated in the same way as other people manifesting the same symptoms.

This is, wow, quite an oversimplification of...every symptom of every disorder in the DSM. Nice use of 'crazy,' though. Army of Kittens said that GID wasn't comparable to the other mental disorders in the DSM in treatment (and in some cases origin), but where did anyone even advocate for removing GID from the DSM wholesale?
posted by desuetude at 1:29 PM on May 21, 2008


Happiness is not about getting what you want, it's more about accepting who you are.

YES.

But "who you are," in this situation, is ambiguous. It can mean "the body you have." It can also mean "the way you experience yourself."

Here's the thing: bodies are easy to change, and many, many people undergo bodily changes without trauma. And I'll grant you, some aspects of a person's inner life are mutable too: their moods, their system of concepts, the way they approach challenges, and so on.

But some aspects of a person's inner life don't seem to be mutable. Gender identity, experience tells us, is on that list; if you try to turn a woman into a man, the result will be a traumatized, confused and unhappy woman. The attempts at change do damage, and they don't work.*

So which kind of acceptance is most important? Accepting the body that's yours to control and change? Or accepting the reality of your own experience, which in this case is beyond deliberate control?

*This, by the way, is what's at the root of all the comparisons with sexual orientation. After all, if you try to turn a gay man straight, the result is a traumatized, confused and unhappy gay man. People by now are well familiar with the latter phenomenon; I think as transfolk become more visible, the former will become more familiar in its own right.
posted by nebulawindphone at 2:12 PM on May 21, 2008


I wish I had more time to respond in depth, but I am having a crazy week at work, so I am just going to comment on a few points and for the rest second hippugeek, desuetude, nebulawindphone, and aok.

ewkpates, you insist that the role of a therapist is to help a patient accept themselves as they are. This strikes me as absurdly narrow. Isn’t it fairly obvious that in many cases, the role of the therapist is to help the patient change themselves or their circumstances? If I am in an abusive relationship, I would hope that my therapist would help me get out of it and away from my abuser. I would not expect them to try to help me accept my situation. If I were living in constant pain because of a poorly-set bone, I would expect my therapist to encourage me to have the bone re-set, surgically if need be, and not to help me accept the pain.

My problem with most of what you wrote is that I don’t think you ever answer the question that I think is fundamental to the conversation: is GID the disorder that makes you think you have the wrong set of genitals, or is it the disorder in which you in fact do have the wrong set of genitals? I’m sure that people exist in both categories, and you seem to either disbelieve in the former or advocate that surgery should never be an option for either without explaining fully why someone who can fix the genuine problem with their body should try to learn to live with it instead.

In other things, I’m with you so far as accepting the things you cannot change goes, but why should people accept things that they CAN change? And why should people who are born into a body with the wrong set of genitals be penalized for being difficult to quickly distinguish from people who are merely confused?

I think the analogy to cleft palate was very apt. Like cleft palate, it seems increasingly likely that GID is often a congenital deformity as well. Why not operate? And what does brain surgery have to do with that question? I mean, whatever, if someone wants to have brain surgery, I have to say – it’s their body, and I’m not going to try to prohibit them from doing what they feel they must to do become healthy and whole, but neither am I going to prohibit them from other kinds of sexual reassignment surgery. I really think you’re just ducking the question, again, of what the basis is for your absolutist stance against allowing surgical intervention in these cases.

Yes, the question of whether or not you “are” the gender your genitals dictate remains open in our culture, and I’m glad you agree, but why then do you insist that the therapist ought only to foster acceptance? I mean, you explicitly admit the possibility that these people are born with the wrong genitals, that fact causes them extreme distress, and your solution is: learn to live with it even though a surgical intervention is possible. WHY?
posted by prefpara at 3:23 PM on May 21, 2008


UM, in my third paragraph, I meant disbelieve in the latter.
posted by prefpara at 3:57 PM on May 21, 2008


1. Who should write the DSM? This depends on a) what the model for treatment underlying the DSM is; b) Whether or not the symptoms identified under any particular disorder can be treated by the DSM. The current prevailing model for treatment is a) develop objective thinking; b)increase (self) acceptance.

2. Gender is a social construct. This means that when you change societies, you change gender standards. Gender standard behaviors are less flexible than the gender standards for physiology.

3. If GID is a physiological problem where the brain and body are not compatible, than chemical and surgical intervention to modify the brain and/or the body are possible treatments. ("Cleft model" theory of GID)

4. If GID is a mental health problem, then using the current model for treatment, then the treatment plan would involve helping the patient develop flexible concepts of gender identity and increase self acceptance. ("BIID model" theory of GID).

5. Under the cleft model , GID should be treated with a combination of chemicals, brain surgery, and body surgery. It would be unethical to put these patients in the DSM.

6. Under the BIID model, GID should be treated with therapy, and it would be unethical to treat these people with chemicals/surgery.


I don't have a personal postition. I have "hunches" but I give them no weight. What I do see is that there is no clear consensus on what model of treatment should be used with GID. Is it possible that GID is both an adjustment disorder and a physiological problem? Not really. Not under any model I am aware of. What if we give GID patients hormones and therapy, and this solves all their problems? This would mean that GID should be treated under the cleft model. What if GID patients who undergo surgery are happier afterward? Doesn't resolve the question of what model GID works under. Just as with BIID, surgery may relieve the symptoms but doesn't identify or treat the underlying problem.
posted by ewkpates at 4:05 AM on May 22, 2008


What if GID patients who undergo surgery are happier afterward? Doesn't resolve the question of what model GID works under. Just as with BIID, surgery may relieve the symptoms but doesn't identify or treat the underlying problem.

I think you're making this more complicated than it needs to be.

We treat illnesses all the time without understanding why they happen. (Less often now that we have some understanding of DNA and of carcinogens, but still.) When that's the case, we go ahead and treat the symptoms because the alternative is letting the patient suffer. It'd be interesting to know the origins of gender variance, and maybe someday we will, but in the meantime there's no reason to postpone effective treatment.

You're right that there isn't a clear consensus about how to treat the symptoms. But I think a lot of that is because many people are still uncomfortable with the idea of gender variance and ascribe a moral value to traditional genders. And many other people want to abolish socially constructed gender roles altogether. Which as far as I'm concerned is a noble aim, but it ignores the reality that right now, transpeople have to live in a world where there are very strong social pressures related to gender. And frankly we don't know enough to predict that a hypothetical genderless society, which has never existed, would eliminate feelings of bodily wrongness.

So given that we don't know why transgenderism happens or how to eliminate socially constructed genders, it seems to me that we ought to observe how different treatments work and make the standard the one that allows transpeople to function fully in the world, well-integrated, happy, and with little conflict between their internal reality and external reality.

And that is precisely in line with the goals of the DSM.
posted by hippugeek at 10:26 AM on May 22, 2008 [1 favorite]


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