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DSM controversy could overshadow opportunities

by Zak Szymanski

Bay Area Reporter

Monday June 2, 2008

When Julia Serano first heard of psychologist Kenneth Zucker's appointment to the Diagnostic and Statistical Manual of Mental Disorders (DSM) revisions group, she saw it as an opportunity to strategize.

Zucker's work at Toronto's Clarke Institute for Psychiatry (now the Centre for Addiction and Recovery) has been hailed by ex-gay groups for his claims that too-tolerant parents enable gender disorders in children and that gender-conforming therapies - forbidding boys from playing with dolls, for instance - are effective treatments for young people.

After the American Psychiatric Association's May 1 announcement that Zucker would chair the workgroup for the DSM-V's Sexual and Gender Identity Disorders section, Serano was one of many transgender activists who began dialoguing with concerned therapists and LGBT advocates. The conversation focused on how to raise awareness about complex issues of concern, so that the new DSM - due in 2012 - accurately represented the community.

Then, the Internet firestorm hit.

Just about every well-connected LGBT message board saw a flurry of posts - some of them confusing, others transparently false - about Zucker's appointment to the APA group.

Zucker believes that most people with gender variance should not change their sex, said some online posts (So, too, do many members of the trans communities).

Zucker's appointment would guarantee that Gender Identity Disorder would remain a mental disorder, said some posts. (The controversial diagnosis is actually considered useful by many transgender people who have no other way of getting care).

Zucker, a champion of "reparative therapy," said other posts, would help to reclassify homosexuality as a mental disorder and would advocate that gay people get treatment to be "cured." (This was never a possibility, many activists and the APA agree. Additionally, the DSM does not contain treatment guidelines).

In the ensuing weeks, Zucker and the APA responded to these accusations.

"My work has been incorrectly portrayed as reparative or conversion therapy," Zucker said during a conference call on May 19. "I've never, ever said the goal of any therapy I do is to try to prevent a child from being gay or lesbian ... in some ways, my goal is the opposite of conversion therapy ... I consider a well-adjusted transsexual, gay, lesbian, or bisexual youth to be a therapy success."

During the same interview, the APA's Dr. William Narrow said that the field itself is controversial, but that many of the calls and e-mails coming in are based on misinformation.

"I understand the concerns ... and we do hear them," said Narrow, who acknowledged that while he can understand why people would see similarities between Zucker's and ex-gay therapies, "the comparisons are not accurate."

Zucker's role will actually be less about providing content and more about keeping other workgroup members organized and on deadline, according to the APA.

"I really want to emphasize that this entire revision process is scientifically based," added Narrow. "It requires literature reviews, and, where possible, that data be analyzed to answer any questions about the revisions."

But the extreme and confusing protest posts that circulated online, said activists like Serano, meant that Zucker and the APA "were pitched a softball."

"Some of the language used ... allowed the APA to simply respond to the extreme charges," said Serano. "They could say, 'Of course we're not putting homosexuality back into the DSM' and come across as very reasonable. But then, because of that, a lot of the actual concerns that people have get completely overlooked."

Arlene Istar Lev, a therapist from Albany, New York and member of the World Professional Association for Transgender Health, agrees.

"I've spent much of my career criticizing Zucker's clinical strategies," said Lev, a lesbian whose 2004 book "Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families", took many of Zucker's claims to task. "The fact that I now find myself defending him against inaccurate portrayals is ironic."

This week, as the initial uproar subsided, many LGBT advocates said that the more complex issues within the DSM debate have been overshadowed by inaccuracies. But they also emphasized that the DSM's approach to trans people, queer communities, and yes, homosexuality itself, means that the LGBT community does indeed have much at stake in the upcoming DSM-V.

GID concerns

"If the DSM committee stays exactly as it has been proposed, I don't actually think that anything will change for the worse. I think everything will stay the same," said Lev. "My concern is that nothing will change, and we will be left with a rigid, sexist, pathologizing document."

It's not too surprising that Zucker is in the DSM workgroup, said transgender activist Jamison Green, because the process relies on evidence, and Zucker is one of a very few number of clinicians (besides Peggy T. Cohen-Kettenis, Ph.D., considered a "trans-positive" psychologist, also on the DSM workgroup) who has documented any evidence about gender-variant youth at all.

Zucker can publish a lot, said Green, because the Canadian health care system supports his work.

"We don't have anybody doing that kind of writing in the U.S., because we're under intense stress in our health care system," said Green. "We've got all these great people doing amazing things and really helping people, but we can't prove it. Nobody has the time to organize it and put it into a comprehensible package."

Green's concerns are less about Zucker - "his role isn't what people think it is," he said - and more about Gender Identity Disorder as it is already written, a diagnosis that inaccurately conflates issues and unfairly stigmatizes gender variance in a range of populations.

"There is disagreement within the community about the value of having GID in the DSM. But most of us working on the issue agree that there are some serious issues in the DSM-IV that need to be looked at," said Green. "For example, I worry that GID doesn't really separate the stress that a person feels about their gender versus the stress a person feels from the social problems that arise because they are gender-variant. It's all pushed into one big ball, so it makes people responsible for the way others react to them."

Although mental illness by definition must include suffering and distress, the diagnosis itself can create "a whole other level of stress," said Green. "It's easy to give the diagnosis and say, 'These people are socially impaired because they don't fit in.' But wait a minute. Whose fault is that? Didn't we make that up?"

Sarah Hoffman, a journalist who coined the term "Pink boys" in the 2007 San Francisco Chronicle article "Let Them Be," agrees.

"One of the people I interviewed for the article said we should change the name [of GID] to 'Persecuted Minority Syndrome,'" said Hoffman, a heterosexual mother of a gender-variant son.

Hoffman added that the online listserv she belongs to - run by the Children's National Medical Center in Washington, D.C., for parents who tend to be supportive of their gender-variant children - has been abuzz over news of Zucker's appointment.

It's not necessarily Zucker's conservative approach to gender transition that concerns LGBT advocates and allies. Indeed, most would agree with his view that young children not make any permanent decisions about their bodies.

"A 4-year-old boy may say 'I like Barbies. Girls like Barbies. Maybe that can mean I'm a girl,'" Zucker told the Bay Area Reporter. "But if they can think more flexibly they may come to the realization that there are different ways to be a boy."

Where there seems to be a disconnect is in Zucker's next step: forbidding the doll even as he tries to get boys to be comfortable with expanded definitions of gender.

Treatment may be absent from the DSM, but many people agree that therapeutic approaches still can influence how and why a GID diagnosis might be used around the world. Gender variance - always subjective according to local customs - can mean a variety of things, including same-sex attractions.

"GID as it stands has been used to hospitalize kids that most likely are gay," said Lev, referring to more politically conservative areas. "These are kids who were too 'butch' or too 'nellie' and have been treated with reparative therapy."

In some articles, Zucker has seemed to suggest a link between treating gender dysphoria and averting homosexuality, though by press time he did not respond to inquiries about the accuracies of these reports. In other articles, Zucker has been quoted as saying that treating gender dysphoria has lessened the incidence of transsexuality and resulted instead in more children growing up to be gay. Neither opinion necessarily jibes with the variety of ways in which trans and gay people live their lives.

Gay disorders

While the relationship between gender and sexuality is not always clear, the way clinical language around gender and sexuality gets interpreted means that gays and lesbians often qualify for mental disorders that are designed for hetero-normative individuals to evade.

GID serves as a case in point.

"Gender Identity Disorder in childhood can be related to what some people have called pre-homosexual behavior," said Green. "If a boy is too feminine, or if a girl is too masculine, people are often really afraid that the child is going to turn out to be gay.

"They got rid of homosexuality in the DSM," added Green, "but they still got to treat children to prevent homosexuality because it falls under GID. It's not explicitly stated, but that's what's there."

But GID is not the only coded language for homosexuality in the DSM, according to Lev.

"People often think there is no diagnosis for homosexuality in the DSM, but that's not true," said Lev. "A residual category for homosexuality still remains in the fourth revised edition of the DSM, under the category of Sexual Disorders Not Otherwise Specified (NOS). This category includes three items, and the last one is, 'Persistent and marked distress about sexual orientation.' It's coding. Clearly it's meant for gay people."

For Serano, a queer trans woman who partners with other women, homophobia as well as sexism threatens to further pathologize women like herself, she said.

The reason: Zucker's mentor, Ray Blanchard, Ph.D., is chairing the "Paraphilias" committee of Zucker's Sexual and Gender Identity Disorders workgroup.

It's Blanchard who championed the theories of "autogynephilia," the questionable science behind J. Michael Bailey's highly controversial 2003 book "The Man Who Would Be Queen". According to Blanchard, autogynephilia describes a man's sexual arousal at the thought of himself as a woman. It is a label mostly applied to cross-dressing men who partner with women and who may seek sexual reassignment later in life.

Bailey used this information to promote his theory that there are two types of MTF transsexuals: the "gay man," who had a mostly effeminate childhood, partners with men, and changed his sex to female due to gender identity, and the "autogynepheliac," who is motivated to change sexes by erotic desire.

Serano points out that many queer-identified trans women actually are not motivated to transition by the kind of fantasies Blanchard describes. Still, it's queerness that could target many MTFs for an "autogynephilia" diagnosis (though Blanchard and Bailey would probably refer to these patients instead as "heterosexual males").

"It really endangers trans women who are attracted to women, because there's the potential for them not to be considered real women; it's just a 'perversion,'" said Serano.

While trans activism has allowed GID to gain legitimacy, she said, few people are comfortable standing up for someone defined as a paraphiliac.

"[Autogynephilia] gives people an excuse not to take our female identities seriously," she said.

Blanchard has said that he does not believe fetishism is an illegitimate reason to change sex.

But Serano said the culture is such that "autogynephilia" - an often-inaccurate diagnosis - will allow a certain subset of trans women to be further marginalized.

"In practice that's the way it gets used - it affects queer transwomen," said Serano. "Women often have their opinions and personalities delegitimized by being sexualized, and trans women are no exception."

And under such circumstances, it doesn't really matter that DSM revisions won't contain specific treatment guidelines.

"Certainly just having this diagnosis can create situations where trans people can't get access to care," she said. "It could have profound negative effects on our social and legal status as women and our ability to access the means to transition."


Diagnostic manuals have historically been racist, sexist, and homophobic, said Lev, whose book notes that crossdressing is only pathologized in "heterosexual males," because DSM authors think these patients are emulating the "the weaker and more despised sex."

Other listings in the Sexual and Gender Identity Disorders section of the DSM, a recent MSNBC piece noted, include sadomasochism and klismaphilia, or the erotic use of enemas.

"I would like to see that whole section really redone," said Lev, whose long-term goals are to see all trans identities removed from the DSM. Gender-related issues would still be dealt with in therapy, but trans people seeking medical intervention could rely on a medical diagnosis instead. (Transsexuality does already exist as a poorly-crafted medical diagnosis, she notes, and can be used for medical treatments.)

"It has to happen, for all of the same reasons homosexuality had to be removed," said Lev. "I don't think you can create a civil rights moment around a psychiatric pathology."

But such goals require strategizing beyond angry e-mails and online petitions.

Though the online campaigns have been useful, said Green, engaging only in protest and appearing as "uncooperative, impossible people with no rational capacity," does not necessarily bode well for trans people's status in the DSM.

"[APA members] own the DSM. We depend on it one way or another. We have to cooperate with them to get it to do what we want and need," said Green.

He proposes that the LGBT communities begin reaching out to savvy therapists and asking them to speak with APA appointees.

"Those are the people - the ones actually providing treatment - who they are going to be listening to," he said.

The revision process, said the APA's Narrow, includes internal discussion and deliberations, with periodic updates to the community. In a recent phone call with concerned members of LGBT advocacy groups, he said, the APA also agreed "it would be a good idea to have some sort of forum ... where we could present our progress in a way that wouldn't put premature closure on the process."

The DSM process, he said, also includes "advisers," who are solicited for input by workgroup members, and there is always room for public suggestions.

Currently, published research is still being gathered, and Green expects that discussions about the GID definition will begin next year.

In the meantime, "we have an opportunity," said Green, who will co-facilitate a town hall meeting for people to discuss their concerns, at Philadelphia's annual Trans Health Conference, held this week from May 29-31.

Similarly, Lev has spoken with therapists she knows, asking them to get involved, and she has written to the APA expressing concern that the sex and gender workgroup does not represent the diversity of clinical viewpoints on trans issues.

To a certain extent, a "queer" politic can be at odds with clinical terminology, and many queers who oppose pathologizing GID might also opt out of a culture that invests in being "normal."

But changing the DSM does require a level of investment in clinical language, and Lev said now is the time for people from all communities "to unite regarding how we address this issue, and I do think we need to speak the language of science and research."

"We can work out the queer stuff on our own," she added. "Once the [GID] diagnosis is gone, we will be a lot more free."

Whatever one's goals for the DSM, it's going to take a long-term commitment. Lev said it's getting more difficult to add and remove things from the DSM.

"If we had not gotten homosexuality out of the DSM in 1973, I assure you it would not have come out," said Lev, who attributed that move to a "political coup."

But without that removal, she said, "as a lesbian, I would not have had domestic partner benefits. There would not be two women's names on my child's birth certificate."

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