American Psychiatric Association 2003 Annual Meeting

Sexual and Gender Identity Disorders:
Questions for DSM-V
Copyright June L Roberts 2003, All rights reserved.

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Participants:

Co-Chairs: Dan Karasic, MD , chair; Jack Drescher, MD

Presenters:

Darryl B. Hill, Ph.D., GID in Children and Adolescents: A Critical Review
Katherine Wilson, Ph.D., Disordering Gender Identity: Issues of Diagnostic Reform
Charles A. Moser, M.D. DSM-IV-TR and the Paraphilias: An Argument for Removal

Discussants: Paul J. Fink, M.D., and Robert Spitzer, M.D.Dan Karasic, MD

My name is Dan Karasic. I am Associate Clinical Professor of Psychiatry at UCSF. I was originally mostly going to confine myself to introducing the speakers, but last night I was at our association of gay and lesbian psychiatrists opening session and I was chatting with Ron Winchel (sp), who 10 years ago in San Fransisco had done a similar symposium on the eve of DSM-IV coming out, and he was interested that 10 years later we are again doing a symposium about GID – this time for DSM-V – and he asked me, "What's changed in 10 years?" and I think you'll hear a little bit about what's changed in terms of some people's thinking on this subject in the last 10 years.
I just had a couple of thoughts particularly about GID. One of the things that's changed about GID of children, the treatment of which has been well known to be a surrogate treatment for pre-homosexual boys, basically. GID of girls is not diagnosed very much because tomboys are usually not particularly distressed and their families are not distressed in the same way as feminine boys. But, in the this past 10 years since this presentation, the APA has come out against reparative therapy with Dr. Munioz been quoted here as saying "It is fitting that this position opposing reparative therapy as adopted on the 25th anniversary of the removal of homosexuality as a mental disorder from the DSM. Although there is no scientific evidence that reparative or conversion therapy is effective in changing a person's sexual orientation, there is, however, evidence that this type of therapy can be destructive."
Well, this is five years later at the 30th anniversary of homosexuality being removed from the DSM and we have some of the same folks who have been in favor of the practice of reparative therapy shifting gears a bit towards promotion of cumulative gender identity disorder in effeminate boys with the hope of preventing homosexuality. Actually all the reviews over here basically kind of views GID of children and pre-homosexual boys kind of interchangeably. In terms of GID of adults, one of the things that has changed has been the development of a much more visible TG community and a sense of a TG society / culture / sub-culture, that has parallels to gay and lesbian culture and more and more has been joined into a LGBT culture.
The APA, in viewing somebody as a cultural group has come out with [?] practice guidelines for social / cultural diversity that the practice of psychiatric evaluation must take into consideration / respect the diversity of subcultures. “Respectful evaluation involves an empathic non-judgemental attitude towards the patient's explanation of illness, concerns, and background – and awareness of one's possible biases or prejudices about patients from different subcultures and an understanding of limitations in our knowledge and skills in working with such patients may lead to identification of situations calling for a consultation of experts and the potential effect of the psychiatrist's social cultural identity on the attitude and behavior of the patient should be taken into account in forming a diagnostic opinion.”
My experience in coming to this workshop has been somebody who both spends part of my time supervising mental health clinicians who are administering [SPID's ?] Dr. Spitzer's.... one of his big contributions to psychiatry, the structured psychiatric exam, and where I'm very, very attuned to psychiatric diagnosis of depressive and anxious disorders. Because it's very important that these be precise for our research project. Another part of my work is working for the TG Lifecare Project at UCSF and on some days I go from one place to the other where with this approach – where thinking of a very diverse TG'd population of patients strictly in terms of GID really isn't as useful as respecting that the patient is a member of a subculture and trying to be understanding of where that ... of how that patient fits in that way.
Okay. I just wanted to say that – as people are filling into the room. The other thing I wanted to say there are... Kathy Wilson has a handout – they're on both those chairs. And there's also a pamphlet from the Children's National Medical Center on a guide for parents of gender variant children [that I've] put out at their request.
So next, I'm going to introduce our first speaker, Dr. Darryl Hill, who's an Assistant Professor of Social and Personality Psychology at Concordia (sp) University in Montreal. He is not [a clinician,] but since 1995 has been working on the Life History project for adult TS's, TGists, and crossdressers in Toronto where he's heard first-hand from many of their experiences as children and youth. He is now working on a study of the history of GID and the subjectivities of children and adolescents diagnosed with GID. He is co-editor of a new book just released called "About Psychology," which is a critical examination of the practices of psychologists. This [begins?] a new position as Assistant Professor of Psychology of Women's Studies at the the College of Staten Island at City University of NY.Gender Identity Disorder in Children and Adolescents: A Critical Review
Darryl B. Hill, PhD
Good afternoon and thanks for coming out to this talk. Today what I would like to do is basically cover some of the literature since the publication of the DSM-IV on gender identity disorders in childhood and adolescents and my aim here is to provide you here with some arguments about why this is generally a problematic diagnosis. I would like to acknowledge the help of two paid research assistants and funding from two research sources. So basically my method here is a critical evaluation of the diagnosis, assessment and treatment of GID – in children and adolescents. I reviewed published controversies, evidence, and arguments in psychological, psychiatric, and lay discourse since the publication of the DSM-IV.
Just to give you a little bit of background and warm you up for the topic here, GID become an official diagnoses with the DSM-III in 1980 and the most recent DSM points out that there are two main components to GID: A strong and persistent crossgender identification and discomfort about one's assigned sex or gender. So if I can just point out a couple of features here from scans of the DSM.
Criteria A then, is a strong and persistent cross gender identification. In children, you need 4 of 5 main criteria. Criteria 1 is a repeated stated desire to be or insistence that he or she is the other sex. And the other 4 criteria basically crossgender interests or preferences for clothing, for role play or fantasies, pastimes, play activities, and playmates.
Criteria B is a persistent discomfort with his or her sex or [other?] inappropriateness in gender role about sex. For children, this is.... boys have problems with their penis or testes, they have aversion towards rough and tumble play, they reject male stereotypical toys, games, and so on. For girls they avoid urinating in a sitting position, assert that they will have a penis eventually, that they do not want breasts or to menstruate, etc.
And of course there is an exclusionary category here, criteria C is the exclusion of all those who have intersex conditions – physical IS conditions – and of course good old criteria D: the distress criteria. So the person also has to exhibit some sort of impairment or distress. So this diagnosis, GID in children and adolescents, has been the target of criticism since the late 1970's and I'm going to follow in that tradition today.
It really began in the mid 1970's over controversy about behavior modification techniques used to alter gender identity in children and adolescents. This is what we would call reparative therapy nowadays – generally the trying to convince these kids to go back to being ordinarily gendered children – going back to their natal or birth gender. In the last decade the debate has been heating up. Just to give you a range of the positions on this issue: some argue that GID is necessary given that the adult consequences of GID of childhood and adolescents i.e. homosexuality and TSity are undesirable. And others argue on the other end of the debate that it's simply a homophobic and sexist diagnosis so just get rid of it.
So I'm gonna try and cover the range of those positions and try and give you some sense of what some of the arguments are. This debate has also been invigorated by a wide coalition of TG activists, feminists, gay & lesbian and human rights organizations. All are seeking reform of the GID diagnosis.
You know, just a couple of caveats before we get going, this debate is full of twists and turns – those in favor of the diagnosis readily admit fundamental problems. So, I am going to be [citing?] those people who admit hey, we don't know everything about this diagnosis. And opponents, people opposed to this diagnosis, admit that there is some use to this diagnosis. So it's a confusing discourse and I should point out that proponents persist with diagnosis and treatment – treatments that the critics find quite offensive. So this is a hot area of research to talk about.
There is often a moral tone to much of the discourse too. Those not dismayed by the absence of good science underlying GID in children and adolescents are often moved by humanistic arguments against it.
So if I can't convince you about the bad science that underlies this diagnosis, maybe I can sway you on its purely humanistic level here. So... and again, careful about this – this is moral discourse – so values, gender politics, are right at the heart of what I'm talking about today.
I have lots of issues I could talk about and I'm going to focus my issue because I have limited time here, so today I'm going to focus on the problems with the criteria used to diagnose GID – the validity and reliability of the diagnosis in clinical practice, whether GID is a mental disorder at all view, in particular, and I'm going to look at some of the debates on the rational of treatment, including the issue of distress of a child and the adult consequences of GID.
So lets start off with the first issue – problems with the criteria. I make the general point that gender roles are a not clearly dichotomized – why am I making that point? Well the language of the diagnostic criteria and the preamble section of diagnostic features section of the DSM, portray gender roles as uniformly and clearly dichotomized – you are either male or female – masculine or feminine. To give you a sense of this they describe boys with GID as preferring traditionally feminine activities – these are quotes from the DSM, “Boys prefer traditionally feminine activities, girl's or women's clothes, they may reject stereotypical boy's activities and they give an example of rough and tumble play in favor of stereotypical girl's toys such as Barbie.” Yeah, Barbie makes it into the DSM. <some laughter> “And boys with GID might insist on sitting to urinate. Girls with GID are characterized as shunning dresses or other feminine attire – wear boys clothing and short hair. They dislike menstruation, they have boys as playmates. They enjoy contact sports, rough and tumble play, and traditional boyhood games. And they identify with powerful male figures such as...” Yeah, Batman and Superman are also in the DSM.
Now if I haven't made my point yet, I'll make it clear – what exactly are feminine and masculine attire and activities according to youth today? What are stereotypical games and pastimes for either sex? What do length of hair, urinating position, preferences for playmates and activities indicate about gender roles? I just want you to think about this – I don't have an answer and I'm certainly not going to answer any of these questions and I'm not sure that any of us in this room know the answers to any of these questions. I think we assume in our society that gender roles are clearly dichotomous, but aren't most of us in the middle of all this.
So, I'll move on. It seems increasingly difficult in modern Western culture to classify such a wide range of behaviors into neatly distinct male and female / masculine and feminine forms – most behaviors – as I can point out {in the} Intro to Gender Psych textbook that I use – say most behaviors are normally distributed for each gender with small differences between the genders emerging only for very specific abilities and contexts. The research on this says that we are not clearly and distinct dichotomized gendered forms as humans. There is clearly a lot of overlap.
My next main point about problems with the criteria – there are cultural and historical variances in gender role expectations. Different cultures and classes in N. America may have different standards for gender behavior. Gender descriptions outlined in the DSM-IV-TR may be irrelevant to other cultures. To give you an example, Neuman has pointed out that gender non-conformity might be a disorder in Arabic cultures but not in Buddhist cultures. So, what am I saying here? I'm saying that we really need to pay attention to gender variance not just amongst our own cultures but also immigrant cultures who come to this country, but also different areas or sub-cultures within our culture. You know, rural vs. urban communities have different expectations for gender. Your parents have different expectations than you do and certainly as I might have. And your children will have different expectations again. Well, this is just all gender studies 101 here. And I'll just summarize by saying we need clinical categories and assessments based on more sophisticated and contemporary conceptualizations of gender.
Another problem with the criteria: crossed-sex desire or identification must be necessary for a diagnosis of GID. I'll go back to criteria A here. One of the 4 main criteria and you'll remember that only 4 of the 5 parts were necessary for a diagnosis. And part one of that diagnosis was a repeatedly stated desired to be or insistence that he or she is the other sex. And this is obviously the most restrictive of the five criteria. The other 4 parts refer to cross-gender activities and interests. So a good question might be to ask, who might be exhibiting parts 2-5 only? As well as meeting criteria B, C, and D? And I would argue that these are non-TS gender non-conformists. And these people then can be diagnosed with GID.
Zucker argues that these cases should be diagnosed as GID-Not Otherwise Specified and of course he admits that this risks an inflated a false positive rate because you're clearly including people who have not stated a desired that they are the other sex or want to be the other sex. Bower hopes the the DSM-V will reflect the fact that the desire for hormones or surgery must be present in addition to an intense desire to be the other sex. So Bower hopes that we'll change the language here to make this an even more restrictive criteria. Richardson points out that criteria A must be further modified to require that crossgendered behavior must not simply be present but used in a pathological sense: extreme or rigid crossgender behavior – a lack of flexibility – or even a source of great distress for that child.
The 4th problem with the criteria as they're written right now is that distress is a necessary criterion as it's listed and stated... but this has been criticized. Zucker and his colleagues and Bower say that they are not in favor of including distress as a criteria. Zucker writes, “I hope that the vagaries of the distress impairment criteria do not dissuade clinicians from providing early therapeutic intervention. Because I believe this would be a grave disservice to our child's patients, {parents?} and their families.” Well, what's he saying here? He's saying forget about distress. Give them the diagnosis anyway. So that means that kids who are ego-syntonic with respect to their gender variance could be given this diagnosis. So just forget about it – but of course the problem here is then you're simply inflating the diagnosis rate. There are further concerns about how to operationalize distress and whether or not the distress of GID is ego-dystonic or syntonic.
Richardson argues the the distress that these kids might be feeling might be a result of the fact that people don't accept them or it might be the result of some other trouble. They're not distressed about their gender, other people are distressed about their gender. And that causes them pain and anguish. He points out that criterion D should state that distress is not attributed solely or principally due to rejection or harassment because of his gender atypicality.
I might take a moderate stance on distress. I'll say you can ignore distress, but only if you require all 5 parts of criteria A. So that is that children not distressed about their gender non-conformity should not be candidates for reparative therapies. And I ask the question "Why force a happy gender non-conforming child to go against their chosen gender"? So, GID diagnosis and treatment should be available only for adolescents who are ego-dystonic about their gender, i.e. the so-called pre-TS youth that clinicians see, and not for any other child.
Now, I'll move on to my 2nd main group of problems, the reliability and validity of the GID diagnosis. First off, there is very little evidence of diagnostic specificity. I'll go back aways before DSM-IV and point out that Zucker was finding that about 1/5 of the referrals fell into an uncertain category. They didn't clearly meet all the criteria and yet they were being referred for GID. So we think that there's something... a group of kids out there who are getting referred for GID who may not meet all the criteria. This coincides nicely with a recent paper by Zucker who pointed out that there are basically three paths past childhood and adolescents out of GID. For boys he writes – but I'm wondering if this happens for girls also – and that is, “A few become TS adults, some become heterosexual without GID, but most become gay adults.” So now the question about diagnostic specificity is can our criteria distinguish between these different phenomenologies? Can we identify and separate out these different groups of people?
Richardson argues basically “No, we can't.” He says that what the diagnostic criteria are doing are picking up gender non-conformists, sissies and tomboys, gay, lesbian, bisexual or gender disordered youth. He argues that we cannot yet conclude that gender identity disorder is categorically distinct from gender non-conformity. So we have a diagnosis according to Richardson that is simply making people sick because of their gender non-conformity. Corbet talks about feminine boys – both hetero and homo – who should not be pathologized by GID. He argues that basically this diagnosis is being used to pathologize and then convert feminine boys back to being ordinarily gendered boys.
Lets look at some of the research on this. Zucker and Bradley in '95 said that they could correctly classify children who met all of the DSM-III criteria 83% of the time. But if they ignored part one of criteria A, they could correctly classify 69% of the children. Well one thing that's obvious here, as a statistician, is the false positive rate doubles when you do that. So basically if you ignore – if you don't include all the criteria, you're doubling the false positive rate. Again, an argument to really tighten up criteria A. Zucker and Bradley point out that all the research that's been done on reliability so far has been with the GID DSM-III criteria. None have been done on the GID DSM-IV criteria. So there are no known studies on the reliability and validity on the diagnostic features that we have right now for us.
My third main issue with GID in children and adolescents is that GID is not a mental disorder. Let me give you a sense of the debates here – I'm not gonna be able to cover all the information – this is a big issue. But let me look at the parents and the role of parents in GID. First off, parents of GID youth are often distressed – the parents are distressed. Granted, [Grant?] points out that this my be that they're distressed about their child being GID. And this is quite simply often the case. They maintain secrecy about their GID child, they pressure their child to change – to drop their crossgender behaviors, they hope GID will go away, {and} they become preoccupied with the negative possibilities of TGism. We can expand this critique even further when we look at what Zucker and Bradley have been giving us.
When they look at [the] evidence for psychopathology, they find that boys referred for gender problems come from families with greater parental and familial dysfunction than normal controls. In fact, they point out that the strongest predictor of the child behavior checklist psychopathology ratings of the child is maternal psychopathology.
Many GID adolescents experience disagreements with their parents, serious relationship problems between parents, poor parenting skills or combinations of these factors. Parents may inadvertently create GID children because the parents themselves have pervasive conflict that revolves around gender issues. So, there's an emerging picture in the literature that maybe the parents are involved and... that there's some familial issues going on here. And this has led people recently last year and even this year to suggest that psycho-educational approaches with parents may be effective ways of dealing with GID in children and adolescents. Notice what's going on here. The kids are sick, but the parents are getting treatment. So how are the parents getting treatment?
Myer Ballburg (sp) points out that what we need to do is teach the parents how to teach their children how to better dichotomize gender. So the parents are taught how to train their kids to be better boys – traditionally, stereotypically, trained boys and better girls. Rosenburg suggests a softer approach – a parents centered approach that encourages acceptance of the child, support for the child – for the way they are – and in fact in her study she notes that all the children she's treated have gone back and accepted their natal gender. This is a remarkable finding. Gender non-conforming kids present themselves – she does treatment with the parents to lessen the pressure, lessen the aggravation that they might give these children, and the kids go back to their ordinary gender.
Menvial (sp) and Turk, whose program is described in the pamphlet that's available here, say that we need group therapy with the parents. We can help the child understand that they may simply be non-stereotypical boys and girls. We can help the child with coping strategies for violent attacks, or for teasing, or for stigma due to their non-conforming behavior. But moreover they suggest some specific ways that we can help parents cope with having a gender non-conformist child. Again the intervention here is aimed at the parent.
More concern about parents: Most of the research that we have on pathology comes from parents, most of the referrals for treatment come from parents, and certainly this is true when we look at Zucker and Bradley's work, Recours (sp) and Kilgas. (sp) Some of the best evidence of disorder in GID children and adolescents comes from parent and teacher ratings on the child behavior checklist. The child behavior checklist asks the parent to make ratings about their child, very simply, and then we see then if the child is pathological or not.
What are some problems with this? Well, from a strict research point of view parental ratings in the assessment of GID are problematic because well first off, observational ratings suffer from a wide range of problems like anchoring and [?] contrast effects. What typically happens is the parent uses their own sense of gender to make judgements about their child so if their child has a different gender than they do, they are going to judge that child as pathological. Furthermore ratings of gender behavior are often biased by the beliefs of the rater. So the parents own gender beliefs will then bias their ratings of the child's gender. And more generally, research has been coming out that shows that parents are often biased against their children and parental attributions of the child's disorder behavior may indicate more about the parent than the child. Koe and Kontanus (sp) and vanGusen, (sp) supporters of the GID diagnosis, point out that it could be that these parents felt so hopeless, helpless, or angry that they tended to over-report the number of problems in their children.
So, this culminates, this data and other data, reviewed by others such as Bartlett and colleagues really throw open the whole question. GID in children and adolescents is not a mental disorder they argue – they look at the basic definition of mental disorder in the DSM and they find that it meets none of these criteria [?] that we're dealing with [in the] literature. And they conclude quite simply that the category of GID in children in its current form should not appear in future editions of the DSM.
My last main group of criticisms center on the rational for treatment for these kids. First off, there is very little evidence that these kids are suffering from any pathology. Advocates of GID reform note that gender variant children are at risk for stigma and isolation and need special support. If that's true, I think that most clinicians who work with these kids would acknowledge that. Yet, what evidence is there to substantiate the idea that children and adolescents diagnosed with GID have a reduced capacity to live a healthy and successful live. We can turn back to the CVCL (sp) data mostly from Zucker and Bradley and Zucker and his colleagues. Researchers are really only able to identify minor sources of distress in specific domains.
Boys referred to a clinic for gender problems were no different from matched clinical controls, they scored higher on their CVCL internalizing disorders that their male siblings. So, they're different from their brothers, but not from other psychiatric patients. Few young girls referred to a clinic were different from their siblings, the older girls had higher ratings on 4 of the 9 CVCL scales. More recent and comprehensive evaluation of this literature by Zucker and colleagues shows basically of 25 years of referrals to Zucker's clinic shows that 85% of the adolescents and 47% of the children fall within the clinical ranges of maternal ratings on the CVCL. So, you're saying okay, well there's evidence of pathology but again remember back... my criticisms of the CDCL ratings. This is basically according to their mother and they're sick. These are not actual objective ratings of these children.
In fact, they find that the best predictor of CVCL pathology are 3 items on the child behavior checklist: maternal ratings, doesn't get along with other kids, gets teased a lot, and not liked by other kids account for most of the pathology that was observed in these children. This suggests then that it is simply a problem of socialization and these kids getting along with other kids that accounts for most of their pathology. Cohen and colleagues did a study of adolescent TS's – compared them to psychiatric outpatients in university student control groups and they did not show any marked degree of psychopathology. They conclude that the argument that gross psychopathology is a required condition for the development of TSism appears indefensible.
Koe and Kontanus (sp) and vanGusen (sp) in 2002 did also a follow-up with 29 of their adolescent TS's. They found that 9 of the 29 cases had elevations into the clinical range. So a third of their population is exhibiting some pathology. Bartlett and colleagues then conclude that generally when looking at this research, GID children are similar to other children who experience peer rejection and victimization. The only probable out come of GID in children is homosexuality and this is not of course a pathological outcome.
My next main concern with treatment of these kids involves reparative therapies targeted at converting these kids back to ordinarily gendered children. Some believe that reparative treatments can be therapeutic – they reduce social ostracism by helping gender non-conforming children mix more readily with same sex peers, and they prevent long-term psychopathological development which Bower considers adult TSism or homosexuality. However, I should point out that critics argue that reparative therapies very simply disrespect the youth's subjective sense of gender, challenges the youth's self-esteem, make both parents and therapists the gender police {and} encourage the youth to go under-ground with their cross-gender feelings.
Finally there is very little controlled research supporting the idea that therapy can help these children accept their born sex and gender. There is weak evidence that treating children for gender variance assists in any co-morbid conditions that they present. There is no evidence that GID children are [at] increased risk to grow up to be TS or TV. There is no evidence that adult TS's or cross-dressers are worse-off psychologically than others. So most GID youth do not develop into adult pathologies. This is Zucker and Bradley's own work. They provide evidence – follow-up data – on about 50 GID referrals and they found that as adolescents or young adults only 20% continued to be dysphoric – most were heterosexual. So again, what happens to these kids? Not much. Some become gay. Some become a little dysphoric, but in general, in Zucker's populations anyway there's not much going on here in terms of pathology.
Now, you need to be careful here because Zucker is arguing here that we need to do treatment early with these kids. These kids are very troubled and the prognosis of any treatment is extremely guarded after puberty. So he's suggesting jump on it now, basically the earlier the diagnosis and treatment the better. Well, what's the problem with this? Well, Mimeburg (sp) and the DSM itself in the language of the preamble says that most GID children abandon gender variant behavior by adolescence without intervention. So early intervention is a waste of time – let them go, and they may just cure themselves.
My last main concern is that early reparative therapies contravene the standards of care for gender identity disorders established the the Harry Benjamin Society. Some support early interventions. Koe and Kokenis (sp) and vanCussen's (sp) early study evaluating 22 adolescents given hormone therapy and SRS report improvements in their lives. They surveyed these kids after they spent a little bit of time in the other gender. [Both] report generally fairly good results. However, lets be careful about evaluating this study. They provided no statistical analysis, they had no control comparison group, the evaluations of how well these kids were doing were provided by the staff that treated them. And the sample were in their own words, "the best cases for surgery". Smith concurs that adolescents accepted for sex reassignment are less pathological than those refused sex reassignment. So, these are the best case scenarios. So, we shouldn't be surprised that they're happy and having fun.
So, the Standards of Care – I'll focus in on the issue here that they say that there are only fully reversible interventions for those under 16. So they recommend that we should only do therapy that can be reversed for those who are under 16. Now, they're talking about physical interventions here, about pubertal delay, hormones, surgery. I might argue that the effects of early psychotherapy might also be irreversible. If you provide psychotherapy to a child to convert them back to a gender that they didn't want to be, isn't that also irreversible, or if it's not irreversible, "why are you doing that?" sort of a question. Moreover, if the child is too young to get treatment to change their sex or gender, then why are they old enough to receive reparative therapy?
So, in conclusion, I have a couple of recommendations. And they're based on the if GID stays / if it doesn't kind of breakdown. If GID stays basically I recommend tightening up the language. Reconsider the language used to describe GID, get rid of the stereotypical dichotomizing language. Make sure that all 5 parts of criterion A need to be present for the diagnosis. Make a statement as Richardson suggests that crossgender behaviors must be pathological in nature, Part 1 of criteria A should include desire for gender reassignment, GID-Not Otherwise Specified should not be used for children who meet all but part 1 of criteria A. And criteria D should be clarified such that youth who are distressed due to harassment are excluded from the diagnosis.
Now, however, given the other evidence that I reviewed, given the limited evidence of reliability and validity, concerns as to whether GID among children and adolescents meets the conditions of a mental disorder. Given the role of parents in the pathology of the child, and given the possibility that reparative therapies contravene the standards of care, we support a moratorium on GID diagnosis and treatment with children and adolescents until further research can establish or answer any of the questions raised in this paper. Thank you. <applause>
Dr. Karasic:
Our next speaker, and I'll introduce her as she picks up her laptop is ***** Ph.D., who under the pen-name Katherine Wilson, is a writer on issues of transgender medical policy, former Director of Outreach for the Gender Identity Center of Colorado, founder of GID Reform Advocates and an Adjunct Professor of Interdisciplinary Studies at the Union Institute and University in Cincinnati, Ohio. She has presented papers at the annual conventions of the American Psychiatric Association in 1998, the American Counseling Association and the Association of Women in Psychology. Kathy received the Equality Colorado Pride Award in 1999. Disordering Gender Identity: Issues of Diagnostic Reform
Katherine Wilson, Ph.D.
Thank you so much for coming. Thirty years after the American Psychiatric Association first removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, the category "gender identity disorder" in adolescents and adults remains controversial. This issue has divided the transgender community and mental health care professions alike on the premise that the social stigma associated with psychosexual diagnosis must inevitably be traded against access to sex reassignment procedures for those who require them.
In truth, the GID category poorly serves transgender and especially transitioning transsexuals on both counts. Gender variant people face barriers to social legitimacy under medical policy that labels their gender identity as mental disorder and otherwise ordinary gender expressions as sexual deviance. At the same time, transsexuals who suffer distress with their physical sex characteristics face obstacles to sex reassignment treatment posed by a diagnosis that contradicts the treatment goals. We would like to propose today that replacing GID with a diagnosis unambiguously defined by distress rather than social nonconformity would help to reduce the harm of stigma and to establish at the same time the medical necessity of sex reassignment procedures for those who require them.
The purpose of diagnostic nosology according to the Harry Benjamin International Gender Dysphoria Standards of Care is to guide treatment and research: “The use,” they say, “of formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments.”
However, if the purpose of GID is to guide treatment and establish medical necessity for insurance coverage of sex reassignment, then key questions arise: Is the current diagnosis consistent with treatment goals and procedures? Is the diagnosis relevant to the distress and impairment that are relieved by sex reassignment? Is it congruent with recognized definitions of mental disorder? Does the diagnosis differentiate gender variant individuals who require treatment from those who do not, or even from those who have successfully completed it? Is the diagnosis limited to those for whom it serves a thera-peutic purpose? Are there unintended consequences of the diagnosis that undermine the treatment goals?
Psychology has a long history of using diagnostic systems to pathologize human diversity around race, ethnicity, sex, gender, class, disability, and of course, sexual orientation and this has had a direct impact on the civil rights of minority peoples. For example, Benjamin Rush, known as the father of American psychiatry, believed that people who had a fervent commitment to mass participation in democracy suffered from a mental illness called Anarchia – I like that one. And there's a whole list of others here that were directed at a variety of groups: for slaves in the Americas, for women – of course the hysteria for women at the turn of the last century – and until 30 years ago, homosexuality.
The diagnostic Criteria that we are speaking of and Daryl already covered these in depth, and our paper here is limited to a discussion on adults and adolescents. So let's start with stigma. By the way, there are faces attached to these issues and these portraits are provided courtesy of the Colorodo Coalition for the Homeless – with the permission of the subjects. We'll talk more about them in just a little bit.
Transgender people suffer from societal intolerance, discrimination, violence, undeserved shame, and denial of civil rights. There is little question that the characterization of gender nonconformity among sexual mental disorders worsens the burden of stigma that gender variant individuals face.
Among countless examples of the consequence of the stigma is the following recent statement by the Congregation for the Doctrine of the Faith on behalf of the Vatican – and they say: "Transsexuals suffer from 'mental pathologies', are ineligible for admission to Roman Catholic religious orders and should be expelled if they have already entered the priesthood or religious life,” the Vatican says in new directives this January. Notably, the Vatican distinguished transsexuals from intersex people in an apparent reference to criterion C of the Gender Identity Disorder diagnosis.
The issue of stigma associated with overly broad classification of gender variance as mental illness is remarkably parallel to that regarding same sex orientation thirty years ago this month. The following statement by our own Bob Spitzer at the 1973 annual meeting of the American Psychiatric Association remains as true in 2003 for transgender people as it was for gay and lesbian people then. And he said: “In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer a 'mental illness' the burden of proof is upon them to demonstrate their competence, reliability, and mental stability.” Perhaps all mental health policy should be measured against this, what I'm calling "a Spitzer standard." Does the policy or diagnosis place the burden of proof upon individuals to demonstrate their compe-tence with a consequence of denied civil rights? Does it ultimately harm those it was intended to help?
The very name, Gender Identity Disorder, suggests that cross-gender identity is itself disordered or deficient. It implies that gender identities held by diagnosable people are not legitimate in the sense that more ordinary gender identities are, but represent perversion, confusion or defective development. This message is reinforced in the diagnostic criteria and supporting text that emphasize difference from cultural norms over distress, and Daryl talked about many of those a minute ago. Under the premise of "disordered" gender identity, self-identified transgender women and transgender men are reduced to mentally ill "men" and "women" respectively. This intent is underscored throughout the supporting text in the GID section, where the subjects are offensively referred to by their natal sex and not by their own experienced gender.
Distress and impairment became central to the definition of mental disorder in the DSM-IV, when a generic clinical significance criterion was added to most categories, including criterion D of Gender Identity Disorder.
Unfortunately, no specific definition of distress and impairment is given in the GID diagnosis. The supporting text in the DSM-IV-TR lists relationship difficulties and impaired function at work or school as examples of distress and disability with no reference to the role of societal prejudice as the root cause. Prostitution, HIV risk, suicide attempt, and substance abuse are described as associated features of GID, rather than consequences of discrimination and shame. The DSM does not acknowledge the existence of healthy, well-adjusted transsexual or gender variant people or differentiate them from those who could benefit from medical treatment. GID currently makes no distinction between the distress of gender dysphoria and that caused externally by prejudice and discrimination.
Conflicting language in the DSM serves to conflate cultural nonconformity with mental illness and pathologize ordinary behaviors as symptomatic. The Introduction to the DSM-IV-TR states: “Neither deviant behavior .... nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction.”
However, in the supporting text of the GID diagnosis, behaviors that would be ordinary or even exemplary for natal women and men are presented in Criterion A as symptomatic of mental disorder. These include passing, living and a desire to be treated as ordinary members of the preferred gender. And I'll stress the word "ordinary". Adopting ordinary behaviors, dress and mannerisms of one's own experienced gender is termed "preoccupation" for diagnosable adults and adolescents. It is not clear how these same behaviors can be pathological for one group of people and not for another.
So, in this presentation, we would like to define gender dysphoria as a persistent distress with one's physical sex characteristics or their associated social roles. And speaking as a person who experiences this in the 1st person, the word distress is much more accurate than euphemisms like discomfort. Don't ya hate it when dentists do that... Furthermore, gender dysphoria is obfuscated by broader language in criterion B that is not limited to ego-dystonic subjects. Ego-syntonic people who do not need medical treatment or have completed it can remain permanently implicated by the phrase, "belief that he or she was born the wrong sex."
The focus of treatment for transsexuals described by the current Harry Benjamin Standards of Care is on congruence with one's gender identity not on attempting to change it: “The general goal,” it says, “of psychotherapeutic, endocrine, or surgical therapy for persons with gender identity disorders is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment.”
However, therapeutic achievement of this goal would not release a subject necessarily from GID diagnosis subject to interpretation. To the contrary, sex reassignment would serve to reinforce the "symptoms" described in criterion A. An experience of "typical feelings and reactions of the other sex," is enhanced and not diminished by triadic therapies. Moreover, the current GID diagnosis is described as having a "chronic course." There is no clear exit clause, not even for post-operative transsexuals however well adjusted. The supporting text lists postsurgical complications as "associated physical examination findings" of GID. This implies that postoperative transsexual people are by interpretation forever diagnosable, regardless of successful treatment outcome or their lack of pathology, distress or dysfunction.
Emphasizing cross-gender identity and expression rather than the distress of gender dysphoria as the basis for diagnosis, GID contradicts the treatment goals for transsexuals who require sex reassignment procedures. This incongruity has undermined the legitimacy and medical necessity of sex reassignment, for example Paul Fedoroff, of the Centre for Addiction and Mental Health in Toronto, cites the diagnosis itself in arguing for the elimination of sex reassignment procedures. He says: “TSism is also unique for being the only psychiatric disorder in which the defining symptom is facilitated, rather than ameliorated, by the 'treatment.' ” And later he says: “It is the only psychiatric disorder in which no attempt is made to alter the presenting core symptom.”
Consequently, medical coverage for sex reassignment surgery procedures are extremely rare in the U.S. today. Since gender dysphoria is not unambiguously defined as a condition to be treated, procedures that relieve its distress are all too easily dismissed as cosmetic and elective by insurers, employers, HMO's, and governments. In order to receive medical and surgical treatments, gender dysphoric people must first receive a referral from a mental health specialist who has completed a psychosocial evaluation. Referral for medical services require a diagnosis of GID. Consequently, GID has become a desired "admission ticket" for transgender and transsexual people seeking medical treatment.
It is quite difficult to develop an authentic therapeutic relationship with a client when the initial diagnostic evaluation casts the clinician in the role of gatekeeper who controls access to medical treatments. In response to this, they're are emerging treatment philosophies based on a model of educated self-determination, where gender variance is respected and clinicians serve as advocates and educators as well as evaluators of mental health. For example, in the early 1990's the Tom Waddell Health Center here in San Francisco, developed a new culturally competent approach to the treatment of gender dysphoria for homeless individuals. It incorporated the following principles, which were adopted by the Denver based Colorado Coalition for the Homeless Stout Street Clinic in 1999. And they are:
· Assuming that most TG people are sane and responsible
· Recognizing cultural/social factors that affect care
· Promoting a respectful, non-pathologizing approach
· Rejecting a label of TG Identity as sexual perversion
· Adopting a model of informed consent and harm reduction for treatment
In conclusion, we would like to propose that GID be replaced in the nosology of mental disorders with a diagnosis based on distress, and having the following characteristics:
· Defined unambiguously by distress with one's physical sex characteristics or their associated social roles.
· Excludes social gender nonconformity and ordinary, normal behaviors and expressions as symptomatic of mental illness.
· Excludes consequences of societal prejudice or intolerance as symptomatic
· And excludes reference to sexual orientation as symptomatic
· It should clearly differentiate those who are diagnosable and may benefit from treatment from those who are not
Just as DSM reform reduced stigma and fear surrounding same sex orientation thirty years ago, reform of the Gender Identity Disorder diagnosis holds similar promise today. It is possible to define a diagnosis that both reduces the stigma of gender difference while legitimizing the medical necessity of sex reassignment treatment for gender dysphoria with criteria that are clearly and appropriately inclusive. Thank you so very much. <applause>
Before I go, I promised to say one thing. So, my co-author Arlene Istar Lev is coming out with a book later this summer from Hayworth Press entitled Transgender Emergence, Therapeutic Guidelines for Working with Gender Variant People and Their Families. Thank you.
Dan Karasic:
As Charles picks up his laptop, I will introduce him. Frederick Charles Moser, PhD. & MD. is Professor of Sexology at the Institute of Advanced Study of Human Sexuality. He's a licensed clinical social worker, he's board certified in internal medicine, he's in private practice in internal and sexual medicine at California Pacific Medical Center here in San Fransisco. DSM-IV-TR and the Paraphilias: An Argument for Removal
Charles A. Moser, M.D.
{He refers to a slide presentation here which of course we cannot see}
First I want to just credit my co-author, Peggy Kleinflatze (sp), who dearly wanted to be here today but could not and this is the work that we both worked on for quite some time.
I'm gonna to say some things that are really not very complimentary of the DSM. And... you can throw arrows at me, but the real reason is I think the concern should go to the DSM-V committee and I'll say a little bit more about that at the end. And I'm sure I don't have to tell the people in this room what paraphilias are, but, since this is a concept that we are trying to critique, I thought it was interesting to look at... I would just like to point out that it was interesting to point out some of the little differences in this.
On the first column you see fetishism. Fetishism is an interest in inanimate objects. We have partialism which is an interest in a part of the body. So you are technically a shoe fetishists and a foot partialist if that's you're interest. I find that interesting that this is the only place I've known that it's been distinguished like that. And at least in the US among men, many of us, or many men are breasts partialists or some people are buttock partialists. So, I just point that out.
Pedophilia is technically an interest in pre-pubescent children. Though I think if you go to most of the sex offender treatment programs, you'll find most people were actually with either pubescent or slightly post-pubescent children. That existence – there is no other term for that here – that's technically a hebophile. I point out that telephone scatology – that's making dirty phone calls. And scatology is actually a term that means the study of fossilized feces – the anthropologists get into this. They have down here coprophilia which is the interest in feces, and why they used a "copro" here and a "scat" here is not known to me.
The paraphilia edition has changed with every edition, and I want to actually compliment the editors for that. There is criticism with every edition and a number of these critiques are in the literature. I'm not going to talk about any of that. This is the first critique to question the internal consistency of the DSM at least as far as I've been able to find out. Does the DSM do what it says it's going to do? And then apply it to paraphilias.
And I've been given actually less time, so I'm going to go through this quickly, but this just shows that in every edition, there was some changes to what is now what we would call a paraphilia. There is a lot of reasons why the paraphilia diagnosis is either retained or removed, or changed. The most important reasons are politics, both inside the APA and politics in the world. Science does play a part and hopefully it will play a larger part, and societies changing plays a part. And if you think about what happened with homosexuality and how homosexuality was removed from the DSM, I think you can see those factors at work.
Now, this is the DSM's own standards. These are not my standards and all the quotes that you see are from DSM-IV-TR – and those are the page numbers. They say they want to correct any factual errors, they want ensure all the information is up to date, they want to reflect new information available, changes had to be supported by empirical data, and the changes were limited to the text sections. All of which I think are reasonable. Let's see how well they do.
They did a review process. They did a comprehensive and systemic review, the utility and credibility required be supported, the majority of the paragraphs had not been revised indicating the original text is up to date. Those are their statements. So I ask three questions: Do the paraphilias meet the DSM definition of a mental disorder? Do the individuals diagnosed with paraphilias constitute a discrete class of patients which is required? And are the facts presented up to date, and supported by the empirical research?
This is the definition of a mental disorder. I would like to point out that the editors admit that this is not an adequate definition. But this is the one that they're working with. It has to be clinically significant, present distress is important here, because if it's not present as the other people [have said?], you know, [you're still?] labeled with this diagnosis for life. And then they have this, you know, the various distress and impairment [and] increased risk of death – we'll talk about that. But they point out very clearly, “Neither deviant behavior, sexual, nor conflicts primarily between the individual and society are mental disorders.” It [is] important to understand where that came from. I believe psychiatry has been used in many countries to imprison dissidents. And this is a statement from the APA saying we don't want to use it that way, which I commend the APA on.
So let's look at those factors one at a time. Present distress: They admit paraphiles rarely are self-referred, they deny distress. They don't say whether distress has to come from the interest or the discrimination. It's one thing to be upset and distressed because you have a certain paraphilia, it's another thing to be upset because they're taking you're children away because you have a certain paraphilia. That is, I think, a crucial point which is missed. There is some data – actually a lot of data – that support groups will diminish the distress. Doesn't work for everyone, but if it does do the people now loose the diagnosis because they're no longer distressed? And then is the distress different from sexual disorder – not otherwise specified?
Persistent and marked distress about sexual orientation. Now, as was said earlier, there was an ego-dystonic homosexuality diagnosis in DSM-III-R. That was the terminology. They just took out the ego-dystonic and called it sexual disorder – not otherwise specified. Some slight changes, but that's a basic point. The diagnosis is in there – they just changed the name. How about dysfunction. Well if in fact I was a paraphile and I wasn't going to my job, and I wasn't attending to my relationship, then I think there's a point. But if in fact the dysfunction comes because people are firing me from my job because of my sexual interests, or people are bringing me to therapy saying if you don't go to therapy, I'm leaving you, then I don't think you can call that dysfunction – at least not by the person with the behavior.
There's another statement that pops up. It's been in every DSM from 3-R, 4 and 4-TR. There is often impairment in the capacity for reciprocal affectionate sexual activity. Considering the divorce rate among heterosexuals, I'm not sure any of use would survive this. But this is a clearly value-laden statement that as far as I know does not have an empirical base.
Death, pain, disability, and lose of freedom. Now I point out the first step, the DSM is supposed to be employed by individuals with appropriate clinical training and experience. I would argue that there are very few of psychiatrists, psychologists, {or} social workers who have had both experience and clinical training. Even so, there are a whole bunch of people who risk death, pain, disability, and lose of freedom. And so, I don't understand why we think that sex is a special category that deserves a diagnosis. I mean... scuba diving – I'm a scuba diver, I mean, I know that it's dangerous. Should I be diagnosed? Alright. So, are the paraphilias mental disorders? The DSM does not define health.
Remember I can't prove a negative, logically you can't prove a negative. So why categorize it according to distress and dysfunction according to the behavior? We're going to talk about that at length – the distinction between the cause and effect, data to support that paraphilia is a cause – I have not seen any data in my review of the literature. I have written to the people who are on the workgroup and they have not responded. Does discrimination and social pressure cause distress and dysfunction? If we allow distress and dysfunction caused by social pressure, then African Americans, Women, Wiccans, {and} a whole bunch of other people are going to be diagnosed with a psychiatric diagnosis.
My last point is why is this not a "V" (sp) code? That's my signal to take a deep breath. And everyone is sitting back and saying "Alright, come on... these guys are crazy – we all know they're crazy. Who wants to have sexual relationships with a shoe. Alright – come on!" But, criminals are not necessarily mentally disordered, people who stick to religious beliefs are not necessarily mentally disordered, political criminals, terrorists... You know when they bombed... when they flew in and destroyed the WTC, my first... said "They're crazy!" Well, on further thought, you have to understand and see them within their context and understand their perspective. It may be crazy, but it's not necessarily diagnosable.
Now, I point out that they have been psychiatric follies about sex in the past. Promiscuity – having sex with more partners than I do, excessive masturbation – masturbating more that I do, nymphomanias and satyrizers – having sex more than I do. Homosexuality and possibly paraphilias – having sex in a different way than I do. This is all related to the view of the diagnoser. Alright, we're moving on.
So, let's look back... go back now to the specific definition of a paraphilia. They say, “Recurring intense, sexually arousing fantasy, sexual urges, or behaviors that occur over a period of at least six months.” Now, the issue here is the term intense. They don't say compulsive, impulsive, or obsessive. Those are defined elsewhere in the DSM – that's not it. I have to tell you, I think this is healthy. When you're not intense enough you have sexual arousal disorder, hypoactive sexual arousal disorder... I think intense is good. I think thats what we want our patients to have. I don't know why it's in there.
So they go further. The definition continues: “Generally involving non-human objects, the suffering or humiliation of oneself or one's sex partner, or children or other non-consenting persons.” So, what I think this says – [is] it's the behavior. This is not about the intensity, this is about the behavior. So what's wrong with specifying the behavior? Well, the behavior is not evidence of psychopathology. Alright. You can be paranoid and you can be schizophrenic, you can have a paranoid personality disorder, you can have a delusional disorder, bi-polar disease – a number of different things. So not the symptom, not... the behavior is the problem – by the way, they could really be after you as well.
Leads to discrimination against behavior. So if in fact we say, you know, liking... having sex with shoes is the behavior then everyone who has an interest in shoes is somehow affected as well and maybe we look at them a little askance. But it infers that other behaviors are not problematic – the people that I left off the list.
Focus is treatment on the behavior. If you're having a problem because you're having sex with shoes, than lets deal with shoes. When in fact I think the real issue is something else that's causing the problem and the behavior is not it. It clearly is confounded with cultural values and the therapist's beliefs, socialization, and theoretical perspective will affect their judgements because there's no data to support anything else – you have to go with your gut. And you'll hear a therapist saying, "That's how it felt – in my gut".
Now this is the B criteria. In the paraphilias they all have an A criteria and a B criteria – This is the B criteria of all the diagnoses in the paraphilia section in DSM-IV. The bottom is the DSM criteria in some of the paraphilia diagnoses in DSM-IV-TR. This is what I call the illegal ones. If it was illegal, you got this one... exhibitionism, voyeurism, pedophilia – you get this one.
Now, they add, the person has acted on these sexual urges... This allows for the person who acts and isn't distressed or dysfunctional about it. But what this really adds is criminals. Alright, this adds criminals. That's a whole new class of patients. And I can't understand why they changed "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" to "cause marked distress or interpersonal relationships difficulty." I don't even know which one's worse.
No explanation, just change. So should the paraphilias be pathologized? We don't pathologize heterosexuality or homosexuality now. We don't have a diagnosis for people having difficulty with their heterosexual interests. Non-consensual sex is rape, but there's no sexual diagnosis for it. Why do other non-consensual sex interests have a sexual diagnosis? And then this is a cute one: If sexual masochism is a mental disorder could a masochist give informed consent, or is it part of their mental disorder? So it's all confused.
[Let me] go a little bit further. In the DSM there are statements of fact. Alright, and I remind you these are all supposed to be supported by data. Now some of these statements: Frequent unprotected sex may result in the infection with or transmission of a sexually transmitted disease – absolutely true. Why it's in the paraphilia section I have no idea. It has nothing to do with paraphilias. It implies that paraphilics have some higher group of sexually transmitted diseases – none of which I know to be true.
Sadistic or masochistic behaviors may lead to injuries ranging in extent from minor to life threating. Again, absolutely true, but also true of every other sexually behavior I know of. And I do not – I researched the emergency medicine literature – I cannot find a rash of cases of masochists or sadists showing up in the emergency room with injuries. By the way, do you know what the most common cause... common reason for going to the emergency room is? – Injuries while playing sports. So if you... you know, maybe we should not let people see baseball magazines or something because it will increase the attendance at emergency departments.
As specific culture and gender features, except for sexual masochism where the sex ratio is estimated to be 20 males for each female, the other paraphilias are almost never diagnosed in females although some cases have been reported. This is very interesting. I went through the literature. I can't find 20 to 1. I can't... I didn't know that existed. I publish more articles on S&M than anyone else and never heard this. So I wrote the people and I basically I got an answer that said, "uh... sounded right to us." <some laughter>
I went back to the literature, and in fact – now this in non-clinical literature – I can't find any clinical literature that shows numbers. But if you combine, I think [you get?] about 4 males to each female, and thats really skewed because most of these people go to S&M groups – to sex groups, and sex groups tend to have more men then women in it anyway. But there's data out there, remember they were going to work on data – the data's there, they... didn't seem to read it.
Prevalence; approximately half of the individual with paraphilias seen are married. Now, whats really interesting – first of all there is a paper that shows this, and it's a paper of 50 men: 26 transvestites and 24 others. Okay, if you add all the married, divorced, separated, widowed, you get to the 50%. But, I don't understand why it's there. Marriage is not mentioned in the other diagnostic categories. I don't know why it's important. I don't know if 50% is high or low.
The behaviors may increase with increased opportunity to engage in the behavior – absolutely true, I don't know what it has to do with paraphilias. It's true in general of humans – especially behaviors which we find pleasurable. They say – one particularly dangerous form of sexual masochism is called hypoxilia. (sp) This is the arousal... to be choked or lack of oxygen – autoerotic asphyxilia (sp) is another name for this. And indeed Blanchard and Hucker, in 1991, looked at 117 cases and couldn't find any relationship to masochism. Sadism or masochism.
So, how did they say this? How did they figure out this was a form of masochism? Now, the DSM tries to help the clinician make a differential diagnoses. And this [green?] is bolded in the DSM in all the editions – it's bolded. It allows for the fact that there's non-pathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement – in individuals without a paraphilia. I think that's double-talk. If you're interested in the sexual fantasies, behaviors, or objects and it's one of those listed behaviors, you have a paraphilia. If you don't, then it's okay. Again – distinguishing on the basis of the behavior. And I'm gonna rush through this, because all this is is – it tells you what these different categories are and how they're distinguished and so we're gonna take each category by itself.
Causes clinically significant distress. We know that's rare and we've discussed it already.
Cause clinically significant impairment. I can not find any studies in the literature that shows that paraphilias cause impairment. Now there are some studies that show in the paraphilia population – studies which are clinical – these people are often diagnosed with other disorders.
Alright, [you know,] depression, obsessive compulsive... wide variety of other things. So how do you know it's the paraphilia that causes the dysfunction and not the depression or other diagnosis? It's obligatory. Longerman (sp) showed that it's not obligatory for most paraphiles or at least sex offenders – and of interest – how does that define most heterosexuals who are obligatorily heterosexual? I mean, doesn't... don't we have to have an even basis here?
Results in sexual dysfunction. And that's their word: results. Alright... Not, it's associated with it – it results – it causes sexual dysfunction. Now there's absolutely no data I can find, we'll go [through] a little bit in a minute that shows that it results in sexual dysfunction. And, more importantly, the rates of sexual dysfunction reported in the general population are huge: over 40% for women, over 30% for men. So if that's true, these people must have an enormous amount of sexual dysfunction to be statistically significant.
Requires participations of a non-consenting individual. I thought that was a crime, and I thought that we went back to the definition – crimes are not part of this.
Leads to legal complications. And this is actually does happen. The reason I started doing this and started looking into this is I was an expert witness in numerous cases of people whose children were being taken away from them because they had a diagnosed sexual disorder... paraphilia, and therefore were deemed unfit to be a parent. And my opposing 'expert' would say, "the fact that we're here in this courtroom shows that it leads to legal complications."
Interferes with social relationships. Well, this is true, there are many partners who bring their partner in by the hand and say to the psychiatrists, psychologist, {or} social worker, fix that person. But the question is whose issue is that? I mean, could we not just as easily sit the other partner down and say, you know, what's your problem with accepting this behavior? I'm going to go – this is really quick, but if you go back over it, this is the same sort of criteria fit people who seek sex therapy for sexual dysfunctions. Alright. So, how do you distinguish a paraphilia from healthy sexuality? There's no clear guidelines in the DSM. There's a paper that shows crossdressers are virtually indistinguishable from non-crossdressers – and that non-clinical paraphiliacs are indistinguishable from the general population. One can only conclude that says paraphilia is a diagnosis of social and sexual control. I don't think you can state that diagnosis at this point.
Now, this is the DSM slide that we saw earlier. I do not believe they have corrected their factual errors. Their data is not up to date – I think I've shown you that. It does not reflect new information available – changes had to be supported by empirical data is not true. And, let me just go for a second here. If you want to remove the paraphilia section from the DSM you have to show empirical data. Since you can't prove a negative, it's an impossible hurdle.
Changes were limited to the text sections – you already saw they were not limited to the text sections. They changed the B criteria and they changed it in a significant way – this was not a minor change.
Now, these two women are reminding me that, I don't think that the editors and the workgroup for the DSM are bad people. I think that they have really tried to do a good job. And I really have said some things today that are quite critical of them, and I don't mean to criticize them either professionally or personally. I think that it is a tough job to write this section, and they tried, and I think have not done it very well.
But sometimes it's up to someone to say the Emperor has no clothes. And this is a woman... these are both women have their clothes painted on. And since you're... I know I was talking to a group of psychiatrists I could not resist this – there is a sense that people look at things differently. And sometimes people see vegetables, and sometimes people see all sorts of disgusting sexual acts. And I think that it's the view of the person that needs to be separated because after all we're trying to be scientists. And I think that we have to look for objective data and not our impression of dirty pictures. Thank you very much. <applause>Discussants: Paul J. Fink, M.D. and Robert Spitzer, M.D.
Dr. Karasic:
We're going to go directly to our discussants. Would you prefer to come up here? Dr. Robert Spitzer is Professor of Psychiatry at Columbia University and chief of the Biometrics Research Department at the NY State Psychiatric Institute. He is well known for his role in removing homosexuality from the DSM- II, and his leadership role in the development of DSM-III, published in 1980 – and the DSM-III-R published in 1987. He's a special adviser to the workgroup that developed DSM-IV. He is the senior author of several assessment instruments widely used in psychiatric research, including the Research Diagnostic Criteria, the SPID (SP), and the Prime MD (SP). Dr. Spitzer...Robert Spitzer, M.D
I looked at my watch and I saw I just have an hour and a half to go and I'll be done with this bloody symposium. I've never wished for an end to a symposium so much. <some laughter> That's my beginning. I'm glad there's nothing personal that Dr. Moser has, I... <Dr. Moser: "No, nothing at all."> I'm really happy to hear that.
This is tough. I had one thought of having a little quick vote, you know, to see where my audience stood. I think I know what the vote would be – these are very persuasive guys. And Moser, in addition, is funny – that's hard to beat. And he points out all kinds of little things that make the poor DSM-IV and Ms. Michael Furst (SP) who worked on the text of DSM-IV... and you have to listen to all that stuff. I mean, that's tough going.
So, I'm not sure this is the best way that we could have organized this symposium, maybe it would have been better if the chairperson had said, you know, "First let's discuss this, then let's discuss this," but that is not the way we have it. So I am not going to discuss all the little details. And there are several things that I am not gonna to talk about. I'm not gonna to talk about what kind of treatment, say, kids who are given the GID should get. I'm not going to talk about that. I'm not going to talk about whether mental disorders should be discreet categories – Actually Dr. Moser said that we have to show that paraphilias are distinct – we don't have to show that at all.
Almost all mental disorders it's now recognized are not distinct, there's no clear boundaries – so we're not going to argue that. I'm not going to argue that the particular criteria are written in the best way. I am not gonna to argue that there are no false positives, of course there are, there are false positives [in] all. And I'm certainly not gonna to argue that patients... kids with GID are not treated very nicely and they get very upset, and I guess there [are] people with paraphilias who get into legal trouble and maybe they shouldn't and maybe they don't get custody. And so we're not going to talk about that.
There's really just one thing that I think is the basic issue, at least for me: What we have heard is really a pretty dramatic proposal. In fact, I was saying to Ken Houseman (sp), I mean, this is really quite something – no GID and no paraphilias. I mean, that's news, that's why Ken Houseman, Psychiatric News, is here. So the real issue is not where do we put the boundary, the real issue is are there any cases of kids or adults for which these diagnoses are appropriate.
There's no question he thinks there's no such thing as pathological sexual behavior – that's rather remarkable. Because it's hard to think of any other kind of behavior or function that can't go wrong. But for some reason for Dr. Moser, all there is is statistical variations. Some things are very unusual. Now, Dr. Hill doesn't go quite that far – actually he wants to get rid of GID, but he sees a way of changing it that would be acceptable. The way it would be acceptable is the kids have to require – they have to ask for hormones or surgical change which kids never do; so in essence he also wants to get rid of the category.
So what I have to do is try to tell you what I think is the big issue on how do you know when something is a normal variation, which is what these guys are saying. How do you decide that something is just unusual or something is disordered. I mean that's really the issue, okay. Now let's think... almost everybody who has eyes can see, right? Some people [that] have eyes can't see. Okay, now that's a variation – that's unusual. What do we think about that? Well, I think you don't have to be, you know, a philosopher of science. Everybody intuitively knows there's something wrong with the eyes. What does that mean, there's something wrong with the eyes?
It means that we have an intuitive sense that the eyes were designed. Now, we use the word designed only as a kind of shorthand. We mean – and some people would say it's designed by God – other people, like me, would say it's designed by natural selection, evolution. But however it is, the eye has a certain function. It's supposed to do something. And somebody who has an eye that can't see – there's some mechanism that's not working.
Somebody has an heart, and there's congestive heart failure, and it's pumping, but the blood isn't really going around – the heart's not doing what it's supposed to do. That's what the heart is there for. You could go through all kinds of, you know, examples. Whenever you think of a disorder, a medical disorder, you're really thinking of some physical something that is expected, that's in the nature of being human that's not working. Okay, now does that apply to human behavior? There are really two viewpoints about human behavior. There are people like me and others who believe there are certain human qualities, certain behaviors, that is part of being human. It's part of the normal development. Let me give you an example of one of those.
Humans tend to be social – they're not taught to be social. Kids are interested in other kids. It's not because parents tell them "You'll be better off if you're interested in other kids," no, it's natural for almost all kids to be interested in kids. So what do we call that? Well, there's some socialization development. Almost everybody... part of being human is to have the ability to empathise – to sense what somebody else is feeling. And we expect that. But there are some kids who don't have that. Maybe that's autism, maybe it's anti-social personality, but it's something.
So, there are certain things that we expect to happen. Actually in philosophy, I guess that's called the essentialist viewpoint. There are some things that are essential to the organism. And those essential things you expect to see in all cultures... virtually all cultures, although the shape of it may vary. But you [would] expect to see that in all cultures.
The other view is the social deconstructionist – which is what I think the presenters, or at least 2 of the 3 here are – which is everything is social. Everything is how you view it. Everything is social and, you know, one culture says one thing, another culture says another thing. Masturbation is once ok, masturbation now is not okay – homosexuality in '73, now we get rid of... now it's 2003... [?] paraphilias. That's the social deconstruction view.
Okay, now let's talk about the two issues here, which is gender identity and paraphilias. So let me first deal with the paraphilias. What are paraphilias all about? Now Dr. Moser says it's about sexual interests. It's not the interests – it's sexual arousal. It's what we're attracted to. Now, we're not taught when we're teenagers to be interested in sex. I think we all know that. In every culture almost all boys and girls show an interest in sex, and a capacity for sexual arousal. So that's part of being human. Now that sexual arousal – does it have a function? You know, we said the heart pumps blood, and the eye sees.
Why do we have sexual arousal? Well I think, if you think a little bit about it, it becomes kind of obvious. Sexual arousal brings people together and they have sex. And that interpersonal sex certainly has [a] survival value. Now I'm not going to get into the issue of homosexuality, but certainly sexual arousal has the function of bringing a pair bonding. And pair bonding is best when there is reciprocal affectionate relationships which Dr. Moser thinks is just, you know, middle class ideals or something. So my view is that there is a normal development of sexual arousal and sometimes it can go wrong.
And when Dr. Moser says, “Well, there's nothing different about these things from normal” – that he can see. Well, I see it. It seems to me if you're turned on by undergarments and you're more interested in undergarments than in people, yeah, I think something has happened to the sexual development. I was thinking of [a] fantasy that it's uh... the year 2023 and my grandson comes up to me and says “Dad, I understand you were once a famous psychiatrist. So I got a problem,” – what's the problem. “Well, I can have sex with Julie, my wive, but what really turns me on is 7-10 year old girls.” And I'm so turned by these girls, that sometimes when I see these girls, I get the thought maybe I should really grab one of them. So what do I tell my grandson?
I say well, we used to think that was pathological, now we know, we've known since DSM-V-2010, that's just normal variation. But if you do it it's criminal – it's got nothing to do with psychology – don't come to me. I mean I think that's what were really talking about. Now, so, it seems to me, you know, sure, these categories they change from time to time, but... and sure there's a boundary problem. You know, somebody finds sex is a little bit more fun if they fantasy a little rough stuff or maybe being humiliated. I don't know at what point it becomes pathological. But certainly at some point it does.
And to say that it... I mean Dr. Moser says there's no evidence there's any impairment in reciprocal relationships and there's a big divorce rate amongst heterosexuals. But heterosexuality does not – in it's most severe form; well, what is it? It's exclusive heterosexuality, it doesn't... that's not [important?/ apparent?] But,the paraphilias, when they are extreme, they do impair – it's just... it's obvious. If you're more interested in 7 year old boys and girls, you're not interested in...[?]
Now, let me also say that it's also interesting to think, most... very few men struggle with the issue of being attracted to children. And it's not because it's just, you know, you're taught that. It's just most men, they're just not interested in children. Now why is that? Well the evolutionary psychologists say there's probably... it has evolutionary significance. Because being interested in children is not going to have survival value. There are probably inhibitory mechanisms. So somebody who really has pedophilia, seems to me something's not working.
Now what are the consequences if we go Dr. Moser's route. It's not gonna happen because it would be a public relations disaster for psychiatry. There was already a little disaster when DSM-IV – the initial DSM-IV, not the TR – put in that clinical significance and everybody – not everybody but a lot of people said "What? the APA now says that if you're a pedophile but you're not upset by it it's not a mental disorder?" Well, the APA wisely corrected that, in DSM-IV-TR. So, it's not gonna to happen but at least in this symposium, let's think about it.
What Dr. Moser is really saying is let's end psychiatric research into the treatment of sex offenders. Let's just regard it as a criminal activity. Well, okay, I don't think that's a very good thing to do. Okay, let me switch to – I think I've done my business with Dr. Moser... let me... <Dr. Moser: Would you like me to respond?> No,no,no,... you'll get your chance. Oh yeah! oh, no, there is one point. When he had the DSM definition of mental disorder, what I was thinking of, you know, Dr. Moser, and Dr. Hill they both quote the DSM definition of mental disorder. And you know the phrase, the devil can quote scripture. I wrote that definition and I know that they're not quoting it... But anyway, when he put up that definition he left out one very – the key phrase: The condition must be due to a psychological or behavioral dysfunction in the individual – that's the key issue. Not the distress and the harm – that's the key issue.
And I would argue, as I've tried to, that the paraphilias do represent a dysfunction of sexual arousal.
Okay, let's talk about gender identity. Now Dr. Hill said, and he was wise in acknowledging, you know, he's gonna make a humanistic appeal to you, and he did. But let's not deal with that issue. He says gender is not dichotomous. We're all somewhere in between. Are we? That's news to me. What we're talking about is gender identity.
First of all, gender itself – well we're all not in between. We're pretty much all male or female biologically. There are a few very small number of intersex. So we're not all in between biologically. Are we all in between in terms of gender identity? Is it the fact that there's a small number of males who are really sure they're male and then there's a large number in the middle that are not quite sure what they are, and then at the extreme they think they're females? Come on, give me a break. Almost all males know they're males and it's self obvious to them and there's a very small number of males who feel uncomfortable being males.
Now the other thing is the dichotomy issue is really the behaviors and as Zucker has pointed out – and it's a pity Zucker can't be here, I'm here in his stead cause they're out to get that guy – Zucker said call me up after this symposium and... call me... <some laughter> Well, what Zucker points out is that if you look at the behaviors that are in those A criteria and you do a distribution of those in the GID'ed kids who are referred to his clinic, and you look at those behaviors in a control group for the same sex – there is almost no overlap. Very few young boys want to play with young girls. They want to play with their... boys. Now [that's?] what's so interesting; in terms of evolution, why is it it is certainly the case that... I mean, I think you have to acknowledge that in all cultures, pretty much young boys want to play with boys, primarily – young girls want to play with girls. They're not taught that. That seems to be part of the human condition.
And I think if you're interested in evolution, you ask yourself, could that have some survival value? And I think the answer is yes. Because in all, not in all, but in many mammals play to learn skills that will be necessary. And boys rough tumble and I supposed that's because 1000's and 1000's of years ago when men were more likely to be into hunting and women were more likely to be in the nurturing role, you did better if you spent your time with kids who are gonna hunt with you and rough and tumble play.
Now the other point that is important is Dr. Hill said, you know in all cultures gender expression changes – absolutely true. But in all cultures gender is recognized as a dichotomy – pretty much as a dichotomy. In all cultures there are gender specific ways of identifying gender, so it may change. In our culture for example, very few men wear lipstick. There are some women who don't wear lipstick, but almost all the lipstick wearers are men {Obviously misspoke there}. So that's a very gender specific behavior. Now there are other cultures nobody wears lipstick. But there is no culture in which a basic dichotomy is not gender. Kids, we all know, kids develop a sense of identity, of gender identity, and again it's not taught it just happens.
So I would argue that that is why sexual arousal it's part of the human condition and as I said, I think there's good reason why... for evolution that makes a lot of sense. I would argue that by itself, the failure of gender identity – that is the child who is uncomfortable in their sex – that is a dysfunction. It seems to me that is a dysfunction. Now how severe it has to be, how much you treat it, exactly what behaviors in any given culture... but it seems to me you can't argue that that is a dysfunction.
There was a case – Dr. Zucker provided me with a case – this is an actual case that he saw just a few weeks ago or a month ago. Ben is a 2 year 10 month old boy referred for assessment. When asked his name, he says [he's] Snow White. Since the age of 24 months he has either insisted that he was a girl or that he wants to be a girl. He is adamant that he will grow up to be a mummy. When told by his parents that he will grow up to be a daddy, he burst into tears, he's inconsolable – he wants to grow up to be a mummy. He likes to wear dresses in nursery school and have his hair put into a ponytail. He only plays with girls in his school and has had no male playmates on the street. He sits to urinate.
For the 10 months preceding the referral, and after the onset of the crossgender behaviors, his parents had assumed the behavior was a phase that he would grow out of. His increasing distress about being told that he was a boy led them to consult their family doctor who recommended a referral. Now, this is just non-conforming behavior? I mean it seems to me there's something wrong there. Now Dr. Hill sometimes uses the phrase gender choice. This is not a question of choice – it's not a question of choice at all.
So in conclusion, despite the attempts to get your sympathy for the oppressed people... And it's also interesting – not a single case – why don't we hear about cases of kids, you know, who suffered with this diagnosis or cases of people with paraphilic diagnosis [and that suffered?] We didn't hear a single case. So I would say the argument for eliminating these categories is weak at best. Thank you. <applause>Dr. Karasic
Paul J. Fink is Professor of Psychiatry at Temple University School at Madison, past President of the APA, the American College of Psychiatrists, the National Association for Psychiatric Health Care, and the American Association of Chairmans of Department of Psychiatry, um... do you want more? He's done a lot...Paul J. Fink, M.D
Well I agree with Bob that this is a tough panel to discuss so the first thing I'll do is say to Bob, I... was one thing I disagreed with – there are lots of cases where boys play with girls cause there ain't no boys in the neighborhood. So we don't know enough about how the kids choose etc. but I don't want to get into that because I agreed with a lot of what you said.
I come here not as a logician, and since 4 of these people have been logicians, I want to make a distinction – I'm a clinician and I come here to talk about the question of these conditions and whether they should be called diseases or have diagnoses. I mean, that's really the issue that's on the table. I read very carefully these 3 papers. And we should acknowledge first of all that it's hard for someone to discuss three papers that are on three different topics.
The first one, Daniel Hill wrote about childhood GID. Uh... the 2nd paper by Kathleen Wilson was on adult TSS I believe and GID problems and the 3rd one was on paraphilias – and whether or not they belong in the DSM. And I guess as a clinician I am loathe to relegate these conditions to legal problems and have these folks go to jail wily-nilly. That's not what I'm looking for.
The largest mental hospital in America was the [LA?] Jail. There are over 1,000 or 2,000 inmates that may or may not get treated for their condition. It certainly won't get treated the way I hope we in this field and in other mental health fields would treat them. Some of the conditions that we've discussed today are treatable and some are not, some have shown success in treatment and some have not. A lot depends on the treater, the conditions of the system, what's going on with the child, or the adult, etc.
In my life I have worked with and helped 40 transsexuals go from sex A to sex B, because I feel that it's an appropriate thing to treat them surgically and chemically, etc. – although I think it's also important for the psychiatrist to be the ombudsman and be manager of the case. I guess partially that's because I'm the psychiatrist, so I like to be the manager. But partially, because I think the surgeon has no interest in the lifestyle and difficulties of the patient. And the endocrinologist only wants to grow breasts. And, you know, there's just nobody there except us to take a total person, humanistic view of the patient.
And so whether or not... how we treat should be differentiated from how we diagnose. And I think transsexualism is a diagnosis. It is not something that it's by choice and therefore you don't want it in the book. And it certainly doesn't stigmatize anybody worse than the stigma they get every single day.
Currently I'm working on a... with a male to female transsexual who has – in addition to everything else – a tremendous shyness. She became a nurse when she was a male. We are finally getting her license turned into female. She has had to go through a difficult acceptance by all of the people in her life, her children, her co-workers, lots of folks... she's gone through a tremendous amount of distress, if that's what you're addressing. But she is going for her aim, which is to become a female, and she's not a bad looking female. She's doing well in her adjustment, and she seems to have less anxiety as a female than a [male]. But I still think the diagnosis is appropriate. I don't think that we throw out that diagnosis for any reason that it's more legitimated .
Now there's an undercurrent that I'm concerned about and that is using the history of homosexuality and DSM to address other diagnostic categories of a sexual nature. And to say ergo, we need to do with the other diagnoses what we did with homosexuality. And I think that no matter how you slice it, there is an illness involved in an adult man who gets his greatest sexual pleasure from going out on the street, opening up his coat, and demonstrating his erection to little girls, and getting... and ejaculating at the moment of their terror.
The fact is we can treat that and I've treated a number of exhibitionists who have been cured. It's treatable. It's not... you know, I think lumping all of the paraphilias into a silly diagnoses that we shouldn't be including in DSM trivializes DSM in a way that is improper. I would also like to make sure everybody understands DSM is a work in progress – psychiatry is a work in progress. We may be a work in progress that's snuffed out in 20-30 years but we're a work in progress.
And we have a lot of trouble, and the fact is that we help a lot of people who otherwise would automatically go to jail. Now, there is an attempt in this society to make... legitimize and justify what we are calling paraphilias. And the one that's most interesting and has gone the furtherest in it's legitimization is transvestism.
There are TV clubs, almost all transvestites are married, they eventually confess their transvestite tendencies to their wife, and instead of getting treated for the anxiety that underlies the transvestism, they go with their wife both dressed as women to this place where 50% have penises and 50% don't have penises, but 100% of them are dressed as women. And some of the men dressed as women are prettier than the women dressed as women.
But that's not the point – the point is by having these clubs we end up legitimizing transvestism as a normal sexual variant. And I would say to you as Bob Spitzer has said, that there has to be some way of differentiating how people get aroused, excited, and fulfilled; and whether or not, underlying that are psychological difficulties that bring the person to the point of using this methodology as a way of satisfying and gratifying #1 their fantasy life, and #2 some inner urge that is in my mind, primitive – I'll use a Fruedian word – I hate to do it, Pre-Oedipal. I mean, the reality is we're dealing with a group of people who have a difference that I think can be diagnosed.
Now I want to say... I want to go back to Dr. Hill's paper. And Dr. Hill uh... reminded me of a story that Bob Stoler (sp) used to tell about a patient he had when he did the intensive research, psychoanalytic research on ultra-effeminate boys. And he... he said that he had this kid in child analysis and he was working with him – he was 6 yrs. old – had been crossdressing since the age of 2 or 3, which we know is not uncommon. And he was trying to get him to have essentially a more acceptable way of behaving in the community and in his home and at school. And in Los Angeles in Halloween there's a park where kids get dressed up in there costumes and go to the park apparently. And it's across from Stoler's office. So during his lunch he went over and he saw his 6 yr. old patient dressed in a full-length gold-lame gown with a tiara and a beautiful pocketbook and beautifully coiffed. And uh... he became a little non-analytic. And he said to the mother "What's going on here!". And the mother said "Well, this is how he wanted to dress for Halloween".
So how much support there is in the house for crossdressing children, how much urge there is in the house among parents to have somebody of a different sex... there's so many variables in the determination. Is it purely biological? Is it bio-psychosocial? Is it purely sociological in terms of what happens in the family? We don't know – I agree with the panelists. We don't have a lot of research on this. On the other hand I think that we ought not to try to correct it by legitimizing behaviors that are not necessarily going to be useful.
I will help you recall a letter that Frued wrote to an American mother in which he said "There is nothing pathological about homosexuality, but it is certainly no advantage". It is no advantage to a effeminate boy to go to school every day and get beat up. So you change schools – and try to explain to him, maybe this is not good behavior.
Green did a study on the outcome of ultra-effeminant boys, years after it happened, and he found that of all of the boys one was TS, one was heterosexual, and all the rest were homosexual. We don't know what good or damage the therapy did in the interim to help change whatever, those kids. We don't have research on that – we have the data about the treatment and we have the data about the outcome later in terms of their sexual orientation, but I would pose the question that as clinicians, using the DSM as a guideline, and being confronted with kids who may not know they're in distress – they may not – they may want to do this. They desperately want to do this. In the case that Bob read to us, that kid desperately wanted to... he had a tantrum if he wasn't allowed to do it. But I'm not sure of the rightness or wrongness of that behavior in children. And we have to look at all the other behaviors of children that we correct, that we might say well, we should let them do what they want.
A patient came to me the other day, a six-year old child defecated on the floor, picked up the feces, and put it in the bathtub. I think the father was legitimately outraged. He was very, very upset. What made it worse for the father was that when he scolded the child, the child laughed. Now, I don't know what that means, I haven't examined the child, but I know there's no good parenting going on there if there's no control over behavior that's unacceptable.
And I don't know the answers to some of these questions. I'm only speaking about this from the clinical point of view. You're right, parents bring children in and say "What are we gonna do about this kid?" And if you say well – first of all, this business of it's a stage drives me crazy – because almost every... the pediatricians and the family physicians... everything is a stage. And that's not good. Cause we don't know if it's a stage. We know there are times which you should intervene. And as somebody who works in the field of reducing youth violence, I know that what I want to do is find the children who are potentially going to be trouble in 1st, 2nd, and 3rd grade, and do some interventions that will help them cool down and stop the behaviors that are going to take them down into a vicious, negative, cycle of life. I don't agree with just letting it happen. I think we need to find the right outlets for these kinds of problems.
Now, the other thing that was mentioned was that ego-syntonic... I say... almost all transsexuals that I've seen – this is adult transsexuals – the transsexuality is ego-syntonic. There's no room for psychotherapy. Their only interest in me is to get them the operation and get them over the... If I said to them: You know, I really... I know that you want to be a man, but – you can't. They can't make penises – let me do psychotherapy. Twice a week, for 6 years, we'll try to help you [out].
If they came back twice I would be amazed. Why the hell would they come back to somebody who's not going to give them what they want and the intensity of their need to change sex is great. Now as a psychiatrist, I don't know what led to that intensity, I don't know where it came from. They always say to me I felt this all my life. Is it biological, is it psychological, I don't know.
I only know that when they come to me they are ego-syntonically desiring a change in their sexual identity... [or] their sexual organs. I have a lot of trouble finding surgeons who will do this. I had a lot of surgeons in my life say to me, this is mayhem – you can't take out normal organs. I say to them this organ is not normal for this patient. You know, do something to help the patient, forget about normal organs. I've been able to convince a few surgeons to do that. But the point is in our society this is seen as pathological, crazy, somebody [would have to be] crazy to do it... I don't' know – I don't know the answer – I only know that I'm there as a clinician to help them and having the diagnosis helps me. So, have I said more than I should?
And again I want to come back to this issue of whether we let it be a sickness or a crime. And in particular I would speak to pedophilia. I think pedophilia is a sickness and a crime. I think we need to help a pedophile overcome the behaviors that lead to their doing sexual things with children. Can we get rid of the fantasies? I don't know. I doubt it – having worked for 45 years with fantasies, I don't think that we can just wipe them out.
But I think you can teach people controls, I think you can teach them inhibitions, I think you can help them to learn the right way to behave. I think there are things that people can learn in therapy and I think that that's an important variation on this theme. We as psychiatrists have multiple roles. And even though the diagnosis may be offensive to some, it's still important that we maintain the diagnosis in order for us to do our job and find a way to save some of these people from jail, and some of these people from themselves. Thank you. <applause>
Dan Karasic, MD
I'm gonna next turn the mic over to Dr. Jack Drescher who's chairman of the APA committee on Lesbian, Gay, and Bisexual Issues and editor of the Journal of Gay and Lesbian Psychiatry. I will just say one thing: we did lump some disparate, uh... conditions / discussions of conditions into one symposium but DSM does that too <laughter> this was a discussion of a chapter on DSM and we actually had submitted papers on other things like dyspareunia in that same chapter that we decided, you know, [would] be really too much to cover in three hours. So, but with that I give this over to... / in defense of that and I'll give this over to Jack.Jack Drescher, MD
I wanted to thank all the panelists – those who presented papers and those who did discussions. Just want to make just a couple of brief comments. One is to say I find myself in the interesting position of being both a psychiatrist who believes in [you know] the value of diagnosis and the value of the diagnostic system and also as a gay man who has an interest in rights, you know, in the realm of queer theory – clinical queer theory anyway. And so, you know, uh... there are those I think, you know, Bob Spitzer thinks I want to take these diagnoses out because I invited people to talk about taking them out but I actually don't know what I think about this and one of the perks of having the authority to sort of put these kinds of things together is you can invite people to sort of explain their ideas to you so you can sort of think about them more.
And there's a lot to think about and I don't want to take up to much time for discussion but the one thing I want to say is I think it's very important that this conversation does takes place because it brings together people who are approaching the subject and both sides are invoking different kinds of authority as they do this. And on one side we have, you know, those on my left but really on my right <laughter> who invoke the authority of medicine, historical tradition, evolution – and on my right but of course on my left are those who, you know, invoke the authority of humanism, of cultural diversity, and in Dr. Moser's case irony.
And uh... but I think both sides are appealing, you know, in some ways to our compassion – both sides are arguing that their view is, in fact, the view that is more helpful to people, and I think it's real important in having this conversation as the questions come up, that really both sides are really interested in helping people even though they disagree strongly about the right way to do that. And so I think with that in mind the panelists might want to respond to each other before we go to the audience. But I think we can hopefully can keep the tone... Bob [?]
Robert Spitzer, M.D.
Sure. You know I realize that I didn't do justice to Kathy's presentation and the reason for that is that we had actually had two very long conversations on the telephone and there were two points where I learned a lot. And I like to think of myself as kind of doing noselogic and diplomacy – trying to think of ways of solving problems and I think there are two things which concerned her which is the way the criteria are it sound like the disorder is in the identity and and the disorder really is in the mismatch and maybe even the name of the disorder could be gender incongruent disorder – I don't think that that's gonna happen but it might... something worthy of thinking about.
Dr. Drescher?
Would any of the presenters like to respond? Charles...
Dr. Moser:
You know, I think that I was mis-understood because I want to be very clear. I don't have any hope, you know, not a snowball's chance in hell of this... of paraphilias being removed from the DSM. And I think that, in fact, what I would hope is what Dr. Furst and some of you guys would say is "You know, Dr. Moser was really right – he picked apart some problems with our internal consistency and we should really fix that". You know, I mean I don't think that's an unreasonable thing for the premier, most respected volume in psychiatry / in mental health in the world to be consistent with its own ideals.
And I think that, you know, that's a reasonable thing, and I want to be very clear – I think that sex can be a focus of treatment, and believe me – I treat lots of sex offenders in my office – and I think that there's a lot of / and I did it when I was a therapist as well as an internist and endocrinologist. I think there's lots of important work that should be done. Of course I want research to go on.
<unintelligible> Sure, all the time. Patients come in and say "I'm attracted to kids and I can't control myself", and I give them anti-androgens, I give them SSRI's, I... <unintelligible> I'm gonna call it an Impulse Control Disorder- Not Otherwise Specified. <[So, it's not a social disease?]> You know, now you're asking me for / to do something which is not known. I don't know – the best I can do is help the patients with the information I have and be honest about it. I don't write in a book that says: "Here's some things 20 to 1 – here are some other things.", that really you can't support. I don't do that. I say we don't know – here's the best I can do for you – and I try and help 'em. And I think that's what everyone does in their offices.
But, let me just go on a little bit more. Uh... I think that evolution – which has been reported as science – I believe in evolution – I was trained in it. I'm an evolutionist myself. These people have been with us all through time. It must be something in evolution that keeps them here. There must be. And the fact that they're there says they play some role – I don't know what that role is – I don't understand it, but I'm also not about to dismiss it.
Just a couple more quick comments. Dr. Fink said these people have underlying psychological difficulties. He['s] probably right – I just want to know what they are. I just wanna get at some studies out there that really look at this and not just put it in a book that says see they must have psychological difficulties – I'm going to do psychotherapy. And what we should point out is both of you are obviously master clinicians and do wonderful work – I don't mean that / I'm not being gratuitous here, but there are a lot of – pardon the expression – hacks out there who do really awful things in their offices.
And we need to use the best evidence we have to try and give people guidelines of what they can do and what they can't do. And when people do bad things, they can't point to the DSM and say "Yeah it's a diagnosis, it's in there, yeah... I'm just doing what every other psychiatrists does", without training without whatever? I'm not gonna get too excited – my own Dr. told me my blood pressure was too high.
Dr. Fink:
If I can just comment for a moment. What are the psychological difficulties? It's not a circular reasoning. I do believe – first of all, let me go back to my first question, {whether} paraphilias should be lumped into a single category. And I think we really need to talk about which ones we can in fact treat and treat successfully, {and} which ones do have real problems. I would say that exhibitionism, voyeurism, transvestitism, and I wont try to do it all – have a common base of anxiety underlying them, and need to be addressed as some kinds of anxiety disorders in which this is the manifestation of how they deal with their anxiety. That's my training and my background.
Am I gonna write a paper on that? I'm not gonna collect data, I'm not going to have a controlled study and I am not going to have – uh... I just can't do that. I'm too old. Anyway, if we divide up the paraphilias and we begin to say which ones make sense to be included and which ones don't or which ones have more closer to normal, uh... a normality to it and which ones don't, then I think we begin to look at this and try to dissect the situation. A guy came to me once and said "I uh... I have a problem. I like to be spanked before I have sex – it gives me an erection. And my wife wont do it." So I said, well, that's sadomasochistic on your wife's part – no I didn't... <some laughter> – But basically the whole point was how pathological is that and what we would call that. And whether that is a normal variation or foreplay and so forth.
{These are} very complicated questions, I mean I'm not arguing with you, but I think we make a problem in making global statements that we should somehow change the entire process when the process does have some extraordinary value to [it].
Dr Karasic:
I think there is a task here though. The title of the symposium – the 2nd part of the title is "Questions for DSM-V" and – there is a DSM-V that's going to come out and it may or may not be the same – well, it's not going to be exactly the same as the DSM-IV-TR, they will call it DSM-V, so there is a task of rethinking these diagnoses. And are there refinements or radical change or whatever, you know, or something in between that are justified by anything from clinical practice to the science? So ...
Dr. Spitzer:
Can I just – my last response to Dr. Moser – "There must be some evolutionary value because these things persist." A lot of things keep persisting, tuberculosis, diabetes... that doesn't... that's not... does not indicate any evolutionary value. But I thought your reluctance to diagnose this case, the fellow that you were treating who was attracted to children, and you want to call it an impulse disorder not a sexual disorder, is very interesting. The guy doesn't have any problem with other impulses – his problem is with that particular impulse. What you don't want to do is say that arousal is pathological. I'm saying it's pathological – that's the difference.
Dr. Karasic:
I think I want to move on the the next couple of panelists to see if they have a response to the discussion and then to the discussants, then we can get to the audience. Kathy...
Dr. Wilson:
Well one clarification, my co-author Arlene Lev and I are not proposing to remove GID recklessly from the noseology but to replace it with a diagnosis based on distress and not o