Wednesday, 28 May 2008

Informed dissent - DSM, Zucker and Aice Dreger


Read Alice Dreger's "informed Dissent" here

Stephen Whittle, 27th May 2008: Activist,

Blanchard, CAMH, DSM IV, DSM V, FTM, ICD 10, Lawrence, MTF, T, Trans, WPATH, Zucker, ..... I currently wake up in in an alphabet soup sweat from a regurring nightmare, firmly embedded in the current Trans Activists vs Psychotherapeutic Professions debate around the writing of version V (5) of the Diagnostic Manual of the Amercian Psychiatric Association.

This week, Alice Dreger, published a polemic blog against the trans activists campaigning against the appointment of Dr's Ken Zucker and Ray Blanchard to the committee responsible for writing the new diagnostic statements of childhood and adult 'gender identity disorders' for DSM V , Alice Dreger says
"For dissent to be effective, for it to be sustainable, for it to be ethical, it has to be factually right". (See
Informed Dissent)

I totally agree with her ... but as she steams through her vicious, if not quite transphobic, something quite close to it blog, the arguments she uses are very clever, but not true when considered through the realities of trans and trans / or not trans kids' lives, and are consequently disingenuous and therefore unethical. I quote, in full:
"Zucker also said that, if he could make a child feel comfortable with the genitals she or he was born with, without causing harm, then that would be best. As someone who has been a long-time advocate of keeping children’s genitals intact and using psychologists to help parents to accept their “different” children, I admit I was sympathetic to these arguments. In fact, as I thought about it more, I realized that pushing gender-atypical kids towards eventual transition (as some “progressive” therapists seem to do) could be another case of ultimately changing the child surgically to satisfy parental discomfort with the child’s atypicality. ."
Informed Dissent)

Let us get the facts straight. No one, including, and especially trans activists is advocating doing anything but keeping children's genitals intact. There is nothing on the table from either party to this heated discussion suggesting that gender atypical children should have their genitals surgically operated on to change them to look more like the genitals of children of the opposite birth sex . So why does Alice Dreger raise this point?

Firstly, she is making it quite clear to us that she is an expert on this matter - which of course she is not. She is an academic who has specialised and gained some expert perspectives on the history of intersex lives and the surgical interventions used on intersex children, and according to a recent interview helped lead the Intersex Society of North America for ten years. But she is not an expert of any sort on gender identity issues, she simply knows very little about trans lives.

Secondly, she is saying that Dr's Zucker and Blanchard are not wrong in not advocating such surgery - and that anybody who is advocating it is wicked. As I have said, however, she speaks falsely by failing to tell the whole truth and nothing but the truth; she fails to point out that in all the Internet activity from trans folk expressing anger at Dr's Zucker's and Blanchard's appointments that the trans activists also think such surgery would be wicked. Instead she leaves the question hanging so that all right minded people will thank that is not the case.

Thirdly, she refers to the pushing of gender atypical children to eventual transition as wicked. Of course, as anyone who has been working with the trans community for as long as myself (33 years) or even as long as Dr's Zucker and Blanchard, knows it is not possible to push a non-transperson to transition. The only exceptions are the easily diagnosed schizophrenic disorders which might just make a person that. But they are not trans people, and their diagnosis has nothing to do with diagnosing trans people.

I did stop and wonder whether this last statement was accurate. Could non-trans children be pushed to transition? I feel it is important here to consider the small but whole set of medical literature and case law reflecting 'mistakes'.1 There are:

  • some people who are trans feel that transitioning and surgery cost them too much, in terms of health, family, work, and other social networks, but they do not to 'change back'.

  • other trans people who have felt that the social stigma surrounding trans identities led their transition and later life being a nightmare, but only a very few of them want to change back.

  • an even smaller number trans people (I have known 12 out of the thousands of trans people I have met) who feel that their doctor pushed them through the process too quickly when they were not quite ready to decide whether it was yet right for them, and so took a wrong route, but most choose not to 'change back'.

  • a tiny number of cases (I know 4 out of the thousands of the trans community) of non-trans people who feel they were pushed to transition and surgery at a time when they were just mixed up about their identity, feeling wrongly that they were trans, most of these want to 'change back'.
Overall, the long term studies show that between 5 and 14% of (mtf) trans women are not happy with the consequences of their transition; however almost all of these relate it to social stigma or poor surgical results. Between 0 and 6% of (ftm) trans men are not happy with the consequences of their transition; however almost of these relate it to poor surgical results. VERY, VERY few of both groups feel they were not trans, should not have transitioned, and if they did surgically transition - now want to transition back.

However, in relation to young people, the most telling evidence comes from the follow up studies from the team of another member of the DSM V committee, Dr Peggy Cohen-Kettenis, whose role it will be to lead the sub-working group who are responsible for writing (or choosing not to write) the specific diagnostic statements on gender identity disorders. Her co-written paper "Psychiatric Comorbidity Among Children With Gender Identity Disorder"2 states that that:
"children with GID are at risk for developing co-occurring problems. Because 69% of the children do not have an anxiety disorder, a full-blown anxiety disorder does not seem to be a necessary condition for the development of GID. Clinicians working with children with GID should be aware of the risk for co-occurring psychiatric problems and must realize that externalizing comorbidity, if present, can make a child with GID more vulnerable to social ostracism." (p. 1307, abstract)
as such physicians seeing children with GID should be very careful to diagnose and treat co-morbid illnesses, before or alongside interventionist treatments for GID so as to ensure that transition is not seen by the child as the cure for anxiety and unhappiness, when in fact it rarely is.
But, another paper "Sex Reassignment of Adolescent Transsexuals: A Follow-up Study"3 co-authored by Dr Cohen-Kettenis concludes in the abstract that:
"Starting the sex reassignment procedure before adulthood results in favorable postoperative functioning" but the team also say that this success is only possible:
"provided that careful diagnosis takes place in a specialized gender team and that the criteria for starting the procedure early are stringent."

Alice Dreger has chosen to villify and mock the trans communty - both in her blog, but more importantly in her paper recently published in the Archive's of Sexual Behaviour, in which she condemns the trans people involved in the Michael J. Bailey (him of "The Man who would be Queen") Crisis as liars and frauds without taking the time to speak to them properly. She behaved as if a cub reporter on the National Enquirer or the Daily Star, calling the trans people without introduction, and demanding they answer here questions. If she had rung me I would have politely told her not to be so rude and to get off my line, with as many 4 letter words as it took. There are certain standards when academics write - it is the ethics of doing research, and everytime we must remember those people we seek answers from are research subjects to be treated with respect and not to be hounded into giving information until they had given fully informed consent. I could not credit that it was ultimately publihsed by the archives of sexual behavior - though written to look like an academic paper, it was not formed from the basis normally required - that of ethical academic research. ..... Oh, but wait, guess who is the editor - why no other than Mr. Zucker himself.

So, Alice Dreger considers herself above the normal ethics of research as we saw then and as we see now in this particular blog. In it, she condemns trans activists for not wanting a guy who is not an MD or other medical professional, and who would rather make gender variant children 'normal' than allow them to grow up as trans in the future, chair a committee which will decide the basis on which trans youth and adults will be treated by the medical professions in the future. I tell you something , I don't want him deciding my life, or treatment, either.

Clearly the APA process is flawed, surely and only sensibly, they would ask a medical professional, at least a psychiatrist in the field of trans treatment, to lead a group whihc is going to decide on treatment routeways in the future. Instead we have to settle for this guy (who is so short he looks like a [ftm] trans man, but is so arrogant he couldn't possibly be), who works at a clinic which is notorious amongst trans people for the disastrous, rude and arrogant way they are treated there. I accept that might not be the full picture of the Clarke Institute. But it is a persistant picture (in the past I have received many letters asking for help from it's desperate patients.) Nevertheless, I do acknowledge that there may well be satisfied trans patients from the clinic, but I do wonder whether they knew they were entitled to get better respect from clinical staff.

Anyhow , what is done is done and we will now have to await the outcome, but I, for one, will not be wasting breath waiting for it. As for Ms Dreger, I think she should go back the her university's research gudies, manuals etc and look up ethics.

1 I'm not going to cite all of these, this is a blog not an academic paper.
2 Wallien,Madeleine.; Swaab, Hanna.; Cohen-Kettenis, Peggy.:
Psychiatric Comorbidity Among Children With Gender Identity Disorder J Am Acad Child Adolesc Psychiatry. 2007 Oct ;46 (10):1307-1314
3 Cohen-Kettenis, Peggy T. Ph.D.; Van Goozen, Stephanie H.M. Ph.D.:
Sex Reassignment of Adolescent Transsexuals: A Follow-up Study