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October 28, 2008
Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org
Jazz, a beautiful seven year old girl with long brown hair
and poise beyond her years, explained gender diversity from her porch swing in
a YouTube video this summer:
“If someone asks me why I used to
be a boy and now I’m a girl, I would say that I have a girl brain and a boy
body. I think like a girl, but I just have a boy body and it’s different than
you.” [1]
The American Psychiatric Association might learn a lot from
this young girl. Last year, Jazz and her family appeared with Barbara Walters
in the television news magazine 20/20. They shared how painful her assigned
birth-role had been for her until her family acknowledged her feminine identity
at age five and created safe space for Jazz to be herself. They shared how her
distress was relieved with transition to a female social role and how she has
thrived since.[2]
It is important to note that for preadolescent children,
transition refers to a change in social gender role and not medical or surgical
intervention. The earliest medical treatments, if needed, would come later at
initial stages of puberty. According to endocrinologist Norman Spack, hormone
blockers called GnRH analogues may be prescribed to delay onset of unwanted
puberty and avoid resulting emotional trauma as well as “the physically and psychologically
painful procedures required to reverse puberty's physical manifestations.” [3]
In the context of children, transition is not an assignment
by parents or clinicians. Transition means simply creating an environment where
gender variant or transcendent [4] children may safely define their own roles
that are congruent with their inner sense of gender identity. These roles may
be stereotypically masculine, feminine or uniquely in between and may include
self-expression in clothing and mannerisms and identification in name and
pronouns. However, the APA labels all youth who transition their social gender
roles as mentally disordered in the Diagnostic and Statistical Manual of Mental
Disorders, ed. IV-TR (DSM), [5] regardless of how happy and well adjusted they are in
their new roles. Many of the barriers these youth face in school and society
are exacerbated by these psychiatric labels. In the Byzantine nomenclature of
the current Gender Identity Disorder in Children (GIDC) diagnosis, gender
transcendent children should be closeted and not seen nor heard.
In fact, gender role transition itself is misconstrued as
symptomatic of psychosexual illness in the diagnostic criteria for GIDC. Of the
four criteria for diagnosis, [6] the first is intended to address gender identity
and is the most confusing and controversial:
Criterion A for Gender Identity
Disorder in Children:
A strong and persistent
cross-gender identification (not merely a desire for any perceived cultural
advantages of being the other sex). In children, the disturbance is manifested
by four (or more) of the following:
1. repeatedly
stated desire to be, or insistence that he or she is, the other sex
2. in
boys, preference for cross-dressing or simulating female attire; in girls,
insistence on wearing only stereotypical masculine clothing
3. strong
and persistent preferences for cross-sex roles in make-believe play or
persistent fantasies of being the other sex
4. intense
desire to participate in the stereotypical games and pastimes of the other sex
5. strong
preferences for playmates of the other sex
Of the five characteristics of criterion A, only the first
has anything to do with gender identity and it is not required for diagnosis.
The remaining four are based strictly on nonconformity to social birth-sex
stereotypes, and only four of the five characteristics are required. Thus, a
child may be diagnosed with Gender Identity Disorder without evidence of gender
identity that is incongruent with natal sex -- without ever stating any desire
to be the “other sex.”
The last four characteristics pathologize as mental illness
and sexual disorder behaviors and self-expression that would be considered
ordinary for other children. In the supporting text of the GIDC diagnosis,
these are described to include playing with Barbie dolls, homemaking and
nurturing role play for birth-assigned males and aversion to cars, trucks,
competitive sports and so-called "rough and tumble" play. For
birth-assigned females, pathology is implied by playing Batman or Superman, competitive
contact sports, and aversion to dolls or wearing dresses. Criterion A serves a
punitive role in enforcing these dated, narrow and sexist gender stereotypes
for children, upon penalty of diagnosis of mental disorder. The fifth
characteristic, a "strong preference for playmates of the other sex"
seems to equate mental health with sexual discrimination. [7]
In criterion A, birth-assigned males are inexplicably held
to a much stricter standard of conformity than birth-assigned females in their
choice of clothing and activities. A simple preference for cross-dressing or
“simulating” female attire meets the diagnostic criterion for the former but
not for the latter, who must insist on wearing only male clothing to merit
diagnosis. In modern Western culture where children's clothing is often unisex
and gender roles are as political as social, terms like
"stereotypical" or "normative" clothing seem archaic. [8]
In criterion A, “other sex,” “cross-sex,” and
“cross-dressing,” are defined with respect to assigned birth sex with no
clarification regarding current affirmed gender role. This is evidenced in the
criterion and supporting text, where children are always termed by birth-sex
pronouns, regardless of transition status. For example, an affirmed transitioned
girl, such as Jazz, is maligned as a “boy” and “he” in the DSM. There is no
exit from diagnosis for her or other transitioned youth who are happy and well
adjusted in their affirmed gender roles; they will permanently meet criterion A
as it is currently written.
Criterion B for Gender Identity
Disorder in Children:
Persistent discomfort with his or
her sex or sense of inappropriateness in the gender role of that sex. In
children, the disturbance is manifested by any of the following:
·
in boys, assertion that his penis or testes are disgusting or
will disappear or assertion that it would be better not to have a penis, or
aversion toward rough-and-tumble play and rejection of male stereotypical toys,
games and activities;
·
in girls, rejection of urinating in a sitting position, assertion
that she has or will grow a penis, or assertion that she does not want to grow
breasts or menstruate, or marked aversion toward normative feminine clothing.
The second diagnostic criterion is intended to embody gender
dysphoria, coined by Dr. Norman Fisk in 1973, [9] but profoundly misses its
mark. From a Greek root for distress, gender dysphoria is defined here as a
persistent distress with one’s current or anticipated physical sexual
characteristics or current ascribed gender role. [10] While a dated definition
of gender dysphoria remains in the DSM-IV-TR glossary, [11] its meaning in the
current criterion B is far less clear than in previous editions.
“Discomfort” and “inappropriateness” seem euphemistic in
describing the intense and often debilitating distress that many children
experience with their anatomy or assigned birth-sex role. While the criterion
describes elements of anatomic dysphoria, [12] it lacks clarity for distress
with anticipated physical sex characteristics for preadolescent birth-assigned
males, such as facial hair, voice change and upper body musculature. Most
troubling, criterion B substitutes nonconformity to gender stereotypes for
clear distress with assigned birth-sex role. The phrases following the “or” in
the sentences for “boys” and “girls,” which include “rough-and-tumble play” and
“normative feminine clothing,” make criterion B redundant to criterion A. For
example, children who are profoundly distressed by their birth-sex assignment
and corresponding names and pronouns are not clearly described in criterion B,
while gender nonconforming youth with no clear evidence of anatomic dysphoria
or distress with their birth-sex may be falsely implicated. Like the first
criterion, there is no exit for children whose gender dysphoria has been
relieved by social role transition. Transitioned youth would permanently meet
criterion B as it is currently written, even more so than before transition.
Criterion C for Gender Identity
Disorder in Children:
The disturbance is not concurrent
with a physical intersex condition.
The DSM-IV Subcommittee on Gender Identity Disorders
recommended at one point that individuals born with anatomical or chromosomal
intersex conditions be included in the GID diagnoses for adults, adolescents
and children, [13] as did previous editions of the DSM. However, the final
decision was to exclude them from GID diagnosis and recommend diagnosis of
Gender Identity Disorder Not Otherwise Specified. [14]
Criterion D for Gender Identity
Disorder in Children:
The disturbance causes clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.
A significant change in the 1994 DSM-IV from prior editions
was the addition of a clinical significance criterion to most diagnostic
categories. Its purpose was to establish a definition of mental disorder and
limit false positive diagnosis of those who do not meet that definition. [15] This
policy change was controversial within mental health professions [16] and was
particularly opposed by some members of the DSM-IV Subcommittee on Gender
Identity Disorders. In an article on the Transvestic Fetishism diagnosis, Dr.
Kenneth Zucker, chair of the present DSM-V Sexual and Gender Identity Disorders
work group and Dr. Raymond Blanchard, chair of the DSM-V paraphilias
subcommittee, dismissed the clinical significance criterion as “muddled” and
having “little import.” [17] This view seems to conflict with that of Dr.
Darrel Regier, Vice Chair of the DSM-V Task Force:
“We do not consider something a
disorder unless there is a clearly defined description of this entity and there
is clearly some significant dysfunction and distress associated with it,” [18]
The central flaw in criterion D for the GID in Children
category is that it fails to distinguish distress and impairment caused by
gender dysphoria from those resulting from societal prejudice or intolerance.
Dr. Zucker notes, “the standard of impairment in children with GID has been
their poor same-sex peer relations, with attendant social ostracism.” [19]
Thus, ego-syntonic or self-accepting gender variant children who are victimized
by prejudice at school meet criterion D only because of hate from others.
Gender variant children with healthy peer relations with children of the same
gender identity also meet criterion D, because their friends are not of the
same birth-assigned sex. This lack of clarity serves to promote gender-reparative
psychotherapies that attempt to change gender identity and repress all gender
expression not conforming to birth sex. Zucker continues,
“I hope that the vagaries of the
distress/impairment criterion do not dissuade clinicians from providing early
therapeutic intervention”
Moreover, Drs. Zucker and Susan Bradley, who chaired the
DSM-IV GID Subcommittee, invoked circular logic to cast all children diagnosed
with GID as cognitively impaired. They claimed that diagnosed children were
more likely to “misclassify their own gender, which ... surely must lead to
confusion in their social interactions.” [20] In other words, children who
disagree with their birth-assigned roles were presumed impaired by fiat. But
are these children actually misclassifying their gender or are they certain of
it? Is it more likely that their psychiatric examiners are confused about the
true gender of these children?
The current diagnostic criteria for Gender Identity Disorder
of Childhood are broadly over-inclusive. They encourage false-positive
diagnosis of gender nonconforming children having no significant distress of
gender dysphoria, and they encourage diagnosis of mental illness on the basis
of victimization from prejudice and intolerance. Authors of the GIDC diagnosis
in the DSM-IV acknowledged that nearly 30% of children who did not meet the
DSM-III criteria would meet the current criteria in the DSM-IV, based on
changes to criterion A alone, using data from the Toronto Centre for Addiction
and Mental Health (CAMH), formerly the Clarke Institute of Psychiatry. [21]
While the American Psychiatric Association has emphasized
that the DSM “does not provide treatment recommendations or guidelines,” [22]
the GIDC diagnostic criteria are heavily biased in favor of gender-reparative
therapies that attempt to change gender identity and expression differing from
birth-sex assignment. Children whose gender variant expression is shamed into
the closet by these treatments no longer meet criteria A,B or D, even if they
continue to verbalize unhappiness and rejection of their birth-sex assignment.
(Criterion C, regarding concurrent intersex conditions, would not be relevant
to gender expression or transition status in this example)
Emerging alternatives to gender-reparative interventions have
very recently been termed “Gender Identity Actualization” by therapist Reid
Vanderburgh. [23] Sadly, the diagnostic criteria for Gender Identity Disorder
in Children contradict these affirming treatment approaches, including social
role transition to relieve distress of gender dysphoria. Youth who are happy
and well adjusted after transition to affirmed gender roles and who may
experience intolerance at school continue to meet criteria A, B and D, even if
they are not distressed by their anatomy. In fact they are stereotyped as even
more symptomatic of mental disorder, according to these criteria, than before
transition.
According to the American Psychiatric Association, the
purpose of the DSM includes facilitation of research and communication among
clinicians and researchers. [24] However, the diagnostic criteria for Gender
Identity Disorder in Children arguably bias research on the persistence of
gender identity in youth. Follow-up studies of gender variant children
commonly use GIDC diagnosis to select the study sample and evaluate gender
dysphoria or transsexualism later in adolescence or adulthood. [25,26] Since
children can meet the DSM-IV criteria for GIDC on the basis of gender role
nonconformity with no stated anatomic dysphoria, it follows that rates of persistent
dysphoria at follow-up could be under-reported. The actual impact of this error
on current published literature is unclear, as follow-up studies still
partially rely on data from subjects selected under the DSM-III and III-R.
Drs. Zucker, Bradley and others have acknowledged concerns that the DSM-IV
criteria for GID of Childhood may “’scoop in’ youngsters who show extreme
cross-gender behavior but are not necessarily gender-dysphoric.” For example,
Zucker has suggested that,
“Because of the putative conflation
of gender identity dysphoria and gender role behavior, particularly in the Point
A criterion, one could argue that reform of the criteria is called for.” [27]
With the publication of the DSM-V, there is opportunity to
address very serious shortcomings in the diagnosis of Gender Identity Disorder
in Children. I hope that the Sexual and Gender Identity Disorders Work Group
will clarify distress with physical sex characteristics (including those
anticipated at puberty) and distress with birth-sex assignment as the focus of
diagnostic nomenclature. I urge the Work Group to remove all references to
gender expressions that differ from birth-sex roles from the diagnostic
criteria. Expressions that would be ordinary or even exemplary for all other youth
do not constitute mental illness in gender variant youth.
Back on Jazz’s porch swing, the seven year old concluded,
“It’s ok to be different because it
just matters who you are. It doesn’t matter if you’re different than anybody
else. It just matters that you’re having a good time and you like who you are.”
We all might learn a lot from this young girl.
[1]
Jazz, “7yr. old Jazz's thoughts on being a Transgender Child,” http://www.youtube.com/watch?v=7S5usRgY720
[2] A. Goldberg and J. Adriano, “'I'm a Girl' --
Understanding Transgender Children,” ABC News 20/20, April 27, 2007, http://abcnews.go.com/2020/story?id=3088298&page=1
[3] N. Spack, “Transgenderism,” Lahey Clinic Medical
Ethics Journal, Fall 2005, http://www.lahey.org/newspubs/publications/ethics/journalfall2005/journal_fall2005_feature.asp
[4] I define transgender, gender variant and gender
transcendent in a broadly inclusive community sense: describing those whose
inner sense of gender identity or outer gender expression transcend social
gender stereotypes or differ from those associated with assigned birth sex. I
use the terms roughly synonymously, although I am coming to prefer gender
transcendence for its affirming shade of meaning.
[5] American Psychiatric Association, Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,
Washington, D.C., 2000.
[6] DSM-IV-TR, 2000, p. 581.
[7] K. Winters (under pen-name K. Wilson), “The
Disparate Classification of Gender and Sexual Orientation in American
Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association,
Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This
paper is a revised and expanded version of a previous article of the same
title, published in Psychiatry On-Line, The International Forum for
Psychiatry, Priory Lodge Education, Ltd., April, 1997, www.priory.com/psych/disparat.htm.
[8] Winters, 1998.
[9] Fisk, N. (1973). Gender dysphoria syndrome. (The
how, what, and why of a disease). In D. Laub & P. Gandy (Eds.), Proceedings
of the second interdisciplinary symposium on gender dysphoria syndrome (pp.
7–14). Palo Alto, CA: Stanford University Press.
[10] Working definition of Gender dysphoria by Dr.
Randall Ehrbar and I following our panel presentations at the 2007 convention
of the American Psychological Association.
[11] DSM-IV-TR, 2000, App. C, p. 823. “A persistent
aversion toward some of all of those physical characteristics or social roles
that connote one’s own biological sex.”
[12] K. Zucker and S. Bradley, Gender Identity
Disorder and Psychosexual Problems in Children and Adolescents, Guilford
Press, 1995, pp. 21-22.
[13] S. Bradley, Ray Blanchard, et al., “Interim Report
of the DSM-IV Subcommittee on Gender Identity Disorder,” Archives of Sexual
Behavior, Vol. 20, 4, p. 339.
[14] DSM-IV-TR, 2000, p. 582.
[15] American Psychiatric Association, Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Washington,
D.C., 1994, pp.xxi, 7.
[16] Spitzer R.L., Wakefield J.C. (1999). “DSM-IV
diagnostic criterion for clinical significance: does it help solve the false
positives problem?” Am. J. Psychiatry 156:1856-64 http://ajp.psychiatryonline.org/cgi/content/abstract/156/12/1856.
[17] K. Zucker and R. Blanchard, “Transvestic Fetishism
Psychopathology and Theory,” in D. Lays and W. O’Donohue, eds., Sexual
Deviance: Theory, Assessment, and Treatment, Guilford, 1997, p. 258.
[18] B. Alexander, “What's ‘normal’ sex? Shrinks seek
definition,” MSNBC , May 22, 2008, http://www.msnbc.msn.com/id/24664654/.
[19] K. Zucker, “Commentary on Richardson’s (1996)
‘Setting Limits on Gender Health,’” Harvard Rev Psychiatry, vol 7, 1999,
p. 41.
[20] Zucker & Bradley, 1995, p. 58.
[21] K. Zucker, R. Green, et al., “Gender Identity
Disorder of Childhood: Diagnostic Issues,” in T. Widiger, A. Frances, et al., DSM-IV
Sourcebook, Am. Psychiatric Assoc., 1998, p. 511.
[22] American Psychiatric Association, “APA STATEMENT
ON GID AND THE DSM-V, “
http://www.psych.org/MainMenu/Research/DSMIV/ DSMV/APAStatements/APAStatementonGIDandTheDSMV.aspx
, May 23, 2008.
[23] R. Vanderburgh, “Appropriate Therapeutic Care for
Families with Pre-Pubescent Transgender/Gender-Dissonant Children,” to be
published in Child Adolesc Soc Work J, 2008.
[24] DSM-IV, 1994, p. xxiii.
[25] K. Drummond, S. Bradley, M. Peterson-Badali, K.
Zucker, “A follow-up study of girls with gender identity disorder,” Developmental
Psychology, vol. 44, 1, Jan 2008, p. 34-45.
[26] Zucker & Bradley, 1995, p. 290-301.
[27] K. Zucker, “Gender Identity Disorder in Children
and Adolescents,” Annu. Rev. Clin. Psychol., vol. 1, 2005. p. 17.9.
Copyright © 2008 Kelley Winters, GID Reform Advocates
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