As a follow up to the recent broadcasts by NPR and several posts regarding gender identity, here is a Q & A involving J. Michael Bailey and Ken Zucker recently posted on the SEXNET email list. Dr. Zucker is the Head of the Gender Identity Service, Child, Youth, and Family Program and Psychologist-in-Chief at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Dr. Zucker is the chair of the newly appointed Sexual and Gender Identity Disorders working group for the 5th edition of American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V). Dr. Bailey is Professor of Psychology at Northwestern University, prolific sexual orientation researcher and moderator of the SEXNET list. As the NPR article noted, Dr. Zucker has extensive clinical and research experience with persons who experience gender dysphoria. This interview was conducted by Dr. Michael Bailey via email and has been slightly edited for posting here. Both Drs. Bailey and Zucker have reviewed and approved it.

Bailey: Both NPR shows used the phrase “a girl trapped in men’s bodies.” How common is this concern over body image?

Zucker: I would say that, in general, there has not been a lot of good empirical research on body image issues in pre-pubertal children with GID. In adolescence, the Dutch group has reported clear evidence of body image dissatisfaction as one finds in adults. One of my PhD students has a dissertation that should be defended later this year in which we studied body image in boys with GID compared to clinical and community controls. We did detect significant body image differences among the three groups: body image in general and in relation to gender-specific anatomic dysphoria. The boys with GID had a poorer body image in general and, of course, with regard to gender-specific anatomic dysphoria. It is only a first pass at this issue and I will report on this down the road after the dissertation is defended.

Bailey: The case on the second NPR show is of a child (natal boy) who had extreme temper tantrums when not allowed to engage in feminine behaviors. Is this common in the kids you see, or is there something unusual about these kids?

Zucker: This is not uncommon. Some parents will report that if they try to limit cross-dressing that this can be very distressing for the boys. Some parents describe it as “he needs his fix.”

Bailey: You are more familiar than anyone else I know with the difference between the British and Dutch treatment centers that yielded the findings that only 20% of the British kids but 100% of the Dutch kids pursued sex reassignment eventually. Did the Dutch center focus on older children (who were less likely to change their minds)? To the extent that the samples were comparable, it is a shocking difference in outcome.

Zucker: I don’t think the British group has published their data yet. But, yes, the Dutch group data are on adolescents and I think that the British group is talking about clients first seen in childhood, not adolescents. The Dutch group now has a paper that is close to being “in press” on their first follow-up of GID children and then followed up later. The GID persistence rate for their boys was about 20% and the persistence rate for girls was 50%. Their persistence rate for boys appears to be similar to what I have summarized for the boys seen in my clinic (Zucker, 2005), but higher than the 12% rate for girls that we published earlier this year (Drummond et al., 2008). The Dutch group speculates that their girls were, at initial presentation, more extreme in their cross-gender behavior than the girls that we reported on, but that will require more careful analysis.

Bailey: The NPR show, and some people on it, kept implying that some of these kids are “really” transgender, and others are not. I suspect you don’t agree with this way of thinking about it, although you recognize that some kids are more likely to become transgender adolescents and adults than other kids are. Can you remind us which factors are associated with persistence of GID from childhood?

Zucker: I don’t think we know yet. Two possible candidates are age at initial evaluation (later age associated with greater persistence rates) and quantitative metrics of cross-gender behavior in childhood.

By persistence rate, Dr. Zucker is referring to the percentage of GID children who are still GID at a later assessment. In the Dutch group, as well as in Dr. Zucker’s research sample, most boys who want to be girls in childhood, end up as men who do not want to be women. For women in the Dutch sample, half remain GID. I think the assessments of low persistence of GID provide some helpful information to parents who wonder about puberty delay and behavioral interventions with their GID children.

Thanks to Drs. Bailey and Zucker for permission to post this conversation.

Filed under: Professional issues, Research news, gender identity, sexual orientation by Warren - No Comments →

At last, I am posting some follow up comments made by Danielle, mother of the twin boys featured in the 60 Minutes segment, Science of Sexual Orientation. Part one is here and should be read first.

Danielle said this in her initial email:

I often wonder “if” I had told Adam that “yes” he could be a girl when he became old enough would he have stayed on that track of thought? However, at the urging of his therapist I told him I understood he was a girl yet he was really a boy and couldn’t be a girl.

Wanting to be clear, she wrote to elaborate:

This was my response when he was three years old. We thought it would be confusing for that age of a child to hear he could be a girl but not until he was older. Later in his life I was up late watching a tv show about transgender surgery. Adam had awaken and was watching the show behind me - I didn’t know he was there. I heard a gasp. When I turned around there was my Adam staring intently at the tv. He asked me in a shocked whisper “Can I do that surgery and be a girl?” I told him “yes” he could but not until he was 18 years old. He became very excited. You have to understand the differences in his age. I believe the information I gave him at each step was based on age appropriate responses. He did stare at me for a bit and asked me if I would really let him do something like that if he wanted. I assured him I would if it would make him happy. He wanted to know why I would help him change his body. I informed him because I loved him and I didn’t want him to be sad or hurt. He asked me if I really loved him that much. My response was a very sound “yes!” that seemed to please him very much.

The last time Adam and I talked about him being able to change his body into a girls body Adam was indecisive. Again, I believe it’s the age/stage of his life and awareness of all around him. This conversation occurred after Tyra Banks had issued an invitation to be on her show. At that time Adam advised me he wasn’t sure what he wanted to do. He didn’t know if he should change his body so he could be a girl, stay with a boys body, if he was straight sexually or gay. Again, I believe his answer and confusion to be age appropriate. I declined the show offer because I didn’t want him to expose himself when he was so unclear about his future. I didn’t want to “lock” him into any particular role. That was when I decided to proceed with the hormone therapy to give him more time and maturity to decide what he wanted for himself. However he was already fully into developing so we decided not to go ahead with the treatments.

We are in the process of working on another television project. I am allowing Adam to participate because I believe the show will allow him to show his confusion and be himself as he is for a 12 year old. This lead us to another conversation about the issue. For all of his wise wisdom he informed me he still didn’t know what he wanted to do. “After all Mom, I’m only 12. I’m not suspose to know 100% for sure where my sexuality belongs. I’m suppose to be able to explore and decide later” And that’s where I have left it. For him to be a normal 12 year old child, maturing, developing and exploring the possibilities of his future. I’m here to guide him, support him, and show him all the possibilities of the future. I can love him, hold him, praise him and catch him if he falls. That’s my role as a parent.

I then wrote to her to clarify how these thoughts related to her parenting decisions, specifically with his name and school. She said:

The issue of what name to use during school was never really discussed. I wouldn’t have allowed him to use a girls name at school even if he had pushed me to do so. He was “Adam” and that was that.

During school hours he could wear what he wanted as long as it followed the school dress code. He only asked to wear a dress to school a few times. My response was always that his brother couldn’t wear his fireman clothing so he couldn’t wear his dresses to school however, he did wear them around the house. He did wear a girls black sweater with gold thread for two years. He wore girls tennis shoes all his life because of the color and sparkles and still wears them. He would wear girl shirts; however, in today’s fashion world, sometimes it’s difficult to tell the difference except in color. In his younger years, he wore girl jeans with sparkles but only for about an year then he didn’t want to wear them anymore. But the really feminine clothing was only at home. My life was easier dealing with this issue because I had twins. His twin wanted to be a fireman. He had everything to do with a fireman just like Adam had everything to do with being a girl. My rule was that the girl clothing (dresses, heels, jewelry, skirts, femme blouses, makeup) and the fireman clothing stayed home when we went to the library, grocery store, grandma’s, church, school and so on. My main reason for my restrictions were due to my parents who are totally against Adam’s gender issues. However, his Nana didn’t care what he wore so he could take his dresses to her house and wear them over there. I did have an issue at school once where the principal asked me if I could get Adam a different book bag (his was pink) and buy him different shoes (his were white with a pink logo on them). I advised her that he wasn’t breaking any rules by his choices so I wouldn’t make him give them up. I told her I could give in to him and allow him to wear dresses to school if she really wanted to push me since there isn’t a dress code that says he can’t. She backed off after that. However, I wouldn’t have ever allowed him to wear a dress to school anyway. Yes, I had restrictions about what he wore and did in society but he did have a bit of freedom by his choice of shoes.

I again want to thank Danielle for her candid comments. I have received emails from parents and professionals who are glad for this glimpse into how one parent reasons through these difficult issues.

Filed under: Professional issues, gender identity, sexual orientation, transgender by Warren - 3 Comments →

The other APA (the psychologists) has now commented on the appointment of Ken Zucker to the psychiatrist’s APA DSM task force.

American Psychological Association
Office of Public Affairs
(202) 336-5700
Public.affairs@apa.org

Statement on Gender Identity Disorder and the Planned Revision of the Diagnostic and Statistical Manual

May 2008

There has been some recent confusion regarding the American Psychological Association and work being done on the next version of the Diagnostic and Statistical Manual (DSM). The DSM is a publication of the American Psychiatric Association, not the American Psychological Association (APA). Questions regarding the DSM-V and the Sexual and Gender Identity Disorders Work Group should be directed to the American Psychiatric Association.

For many years, the American Psychological Association has worked to end discrimination, including discrimination based on sex, gender identity and sexual orientation. APA is committed to taking a leadership position among the mental health professionals, scientists and scholars who are addressing the issues surrounding gender identity and transgenderism. APA formed a task force in 2005 to study gender identity and gender variance. This group has been reviewing both the scientific literature and APA policies related to these issues and developing recommendations for education, training, practice, and further research.

The task force has completed a report that is slated to be presented to APA’s governing Council of Representatives in August. It will make a series of recommendations, including that APA call upon psychologists to provide appropriate, nondiscriminatory treatment to all transgender and gender-variant individuals. It is expected that the Council will adopt the report and its recommendations.

The task force did not take a position with regard to the gender identity disorder diagnosis because there was no consensus among its members. Indeed, there is no consensus among professionals working in the field; reputable scientists continue to disagree about GID. Regardless of the disagreement concerning the GID diagnosis, there is a need for greater consensus on treatment of gender dysphoria. The task force strongly supports the development of practice guidelines for transgender clients.

APA believes that no psychological disorder should be stigmatized or used as the basis for discrimination. People who are concerned about issues having to do with their gender identity should have access to appropriate and non-discriminatory treatment. Mental health providers need to educate themselves about how to provide such care.

Responses to Possible Questions:

Q.What is the American Psychological Association’s position with regard to the appointment of Dr. Kenneth Zucker and Dr. Ray Blanchard to the work group reviewing GID? Are you actively working to have them removed?

A. APA is pleased that well-qualified psychologists who are also members of APA have been included in the leadership of this aspect of the DSM revision. We are also aware that there are substantive disagreements in the field over the GID diagnosis and over the treatment of gender dysphoria. We call on this group and others working on the new DSM to apply the highest professional standards in reviewing the science and we encourage the careful consideration of all legitimate perspectives.

Q.Why did the American Psychological Association allow Dr. Kenneth Zucker to be part of its task force on gender identity?

A. APA’s Task Force on Gender Identity was given a very specific charge — to complete a review of the research literature on gender identity and transgenderism and to make recommendations based on that review. Nominations to the Task Force were widely sought and appointments to the task force, including that of Dr. Zucker, were made through a very thorough review process based on an individual psychologist’s research, clinical expertise and experience. As is the case with all APA task forces, the final work product is grounded in the strongest, peer-reviewed science available and undergoes a rigorous review process within the APA governance structure before it can become APA policy. Ultimately, what becomes APA policy must be well-grounded in science not individual opinion.

UPDATE - Elsewhere the American Psychiatric Association issued a statement reviewing the credentials of Dr. Zucker, which are impressive indeed.

Filed under: APA, Professional issues, gender identity by Warren - 6 Comments →

There appears to be a growing schism within LGBT circles regarding the APA appointments of Kenneth Zucker and Ray Blanchard to the Sexual and Gender Identity Disorders Work Group (see the APA statement here). Today, the National Gay and Lesbian Task Force issued a press release calling Zucker and Blanchard “clearly out of step with the occurring shift in how doctors and other health professionals think about transgender people and gender variance.”

The APA and Jack Drescher has stepped up in favor of the appointments.

Thus far, to the best of my knowledge, the opposition has primarily been from transgender advocacy groups and writers. The press release stops short of calling for the appointments of Zucker and Blanchard to be canceled, but rather expresses disappointment. I wonder if any other advocacy groups will follow suit.

Filed under: APA, Professional issues, gender identity, transgender by Warren - 4 Comments →

We have been talking about it just about non-stop here and MSNBC’s Brian Alexander takes a look at the GID-DSM controversy in this piece - “What’s ‘normal’ sex? Shrinks seek definition.”

Filed under: gender identity, transgender by Warren - 51 Comments →

Several commenters have mentioned and quoted from Michael Bailey’s book, The Man Who Would Be Queen.

Click this link to read the first two chapters of the book.

The Man Who Would Be Queen is published by Joseph Henry Press.

PS - Much has gotten in the way of the second part of Danielle’s remarks on gender identity issues, but they are coming soon…

Filed under: gender identity, sexual orientation by Warren - 8 Comments →

Recently, I posted a link to a NPR broadcast outlining two approaches to treating children who are gender non-conforming in their play and activity preferences. In light of that broadcast and the controversies surrounding these different approaches, I provide an update from Danielle, the mother of twin boys first featured in a 60 Minutes broadcast originally aired on March 12, 2006. The segment, titled Science and Sexual Orientation, was by any measure a provocative program. The producer answered numerous questions about the show on the CBS website and many blogs, including this one, provided commentary. I still use the clip in some of my classes to illustrate a variety of issues regarding how the media interprets sexual orientation research.

One of the most interesting aspects of the show was Leslie Stahl’s interview with twin 9-year-old boys, Adam and Jared. Recently, the mother of the twins, Danielle, wrote researcher Michael Bailey with an update regarding her son, Adam. Dr. Bailey and Danielle allowed me to share the note on the blog. She does not preach or lecture but rather reports on her experience. First, to set the stage, I want to reproduce an excerpt of the 60 Minutes segment introducing Adam and Jared:

The bedrooms of 9-year-old twins Adam and Jared couldn’t be more different. Jared’s room is decked out with camouflage, airplanes, and military toys, while Adam’s room sports a pastel canopy, stuffed animals, and white horses.

When Stahl came for a visit, Jared was eager to show her his G.I. Joe collection. “I have ones that say like Marine and SWAT. And then that’s where I keep all the guns for ‘em,” he explained.

Adam was also proud to show off his toys. “This is one of my dolls. Bratz baby,” he said.

Adam wears pinkish-purple nail polish, adorned with stars and diamonds.

Asked if he went to school like that, Adam says, “Uh-huh. I just showed them my nails, and they were like, ‘Why did you do that?’”

Adam’s behavior is called childhood gender nonconformity, meaning a child whose interests and behaviors are more typical of the opposite sex. Research shows that kids with extreme gender nonconformity usually grow up to be gay.

Danielle, Adam and Jared’s mom, says she began to notice this difference in Adam when he was about 18 months old and began asking for a Barbie doll. Jared, meanwhile, was asking for fire trucks.

Not that much has changed. Jared’s favorite game now is Battlefield 2, Special Forces. As for Adam, he says, “It’s called Neopets: The Darkest Faerie.”

Asked how he would describe himself to a stranger, Jared says, “I’m a kid who likes G.I. Joes and games and TV.”

“I would say like a girl,” Adam replied to the same question. When asked why he thinks that is, Adam shrugged.

In this email, Danielle reveals that at one time Adam thought he would like to be a girl. In fact, she considered puberty delaying drugs to allow Adam more time to reflect about his gender identity. At one point, he wanted to be a girl and bear a child via his own body.

With this update, Danielle discloses that Adam is not as definite about wanting to transition as he once was. She reports that he has adopted a male identification, albeit a somewhat unconventional one. Here is her update:

Adam has changed since we did the 60 Minutes show. He is the same yet different. From the research done a gazillon years ago about children like him- he’s basically following the guidelines as they were told to me. One day I would love to get my hands on the actual research papers! Anyway, he turns 12 on [recently]. He still shows a preference for society labeled “girl” items, yet he no longer states he wants to change his body into a girl. He no longer talks about having a baby from his actual body or wanting to know when he will start to grow his breasts. I think most of these changes are due to society (school peers) and his awareness of the actual facts of life. His favorite color is now purple instead of pink and he still prefers to buy “girl” tennis shoes. He dreams of becoming an actor/model and being a professional chef. As I stated, from what I know of this past research, he’s reaching the age where he’s blending in with his peers. I expect the next two years of Middle School to be difficult ones. Then he goes into High School where differences are just a way of life. I’m thinking he may actually find out who he is some time towards the end of High School. Again it follows what I know of this mysterious research paper.

I belong to several email groups with other families that have children like Adam. I don’t participate much because I’m not sure if most of them are following the right path with their children. I often wonder “if” I had told Adam that “yes” he could be a girl when he became old enough would he have stayed on that track of thought? However, at the urging of his therapist, I told him I understood he was a girl yet he was really a boy and couldn’t be a girl. A lot of the parents are allowing their children to grow long hair, dress 100 % as a girl, and go to school with a girl name and girl clothing. Therefore they are totally embracing their child in the opposite sex role. The children are living that role and that life style. So have I done my son an injustice by telling him that he has a boy’s body and even if he wants to be a girl during school hours he had to be the boy as his body was made? Then again, I have allowed him to wear just about anything he was comfortable wearing.

It’s a dilemma that I don’t think we will know the end of until this generation of children grows up. What happens if some of these children that have male bodies but are living life as a girl all through grade school finally reach an age where they decide they really don’t want to have a sex change and be a physical girl? Then what will the ramifications be on that child because of the parents’ actions?

It’s not like my child has Down syndrome and I can go to the library and check out 100s of books to get guidance on how to raise him. There just isn’t much out there for parents who face raising a child like my Adam. I have so many questions about parenting him and very little answers. So I go with my gut and wonder daily if I have made the wrong decision or if these other parents are making the wrong decision. Then again, what may be the wrong decision for one child in this situation may be the right decision for the other. Ah, what a world we live in! Fifty years ago we wouldn’t even be having these types of conversations or email groups.

I have to share something about Adam. I have often wondered how these other kids are developing compared to Adam. Many in the groups have started hormone therapy to stop puberty in the kids. That way the kids have more time to mature and make the final decision about the course of their lives. For the boys they won’t develop the deeper voice and the Adam’s apple and male characteristics. If they decide to transition the theory is that it will be easier without these developments. I made an appointment for Adam to have some baseline tests done. I was seriously thinking about doing the hormone therapy for him to give him more time too. However, much to my surprise he was ready deep into puberty. The doctor said we could still proceed with it but I really couldn’t expect to have undone what was already there. He was developing much earlier than expected. Now his twin, Jared, still hasn’t started into puberty. So, my question is - with boys that follow gender non-conformity - do they start developing earlier than their peers? I realize we won’t have the answer for many, many more years to come.

First of all, I am grateful to Danielle and Dr. Bailey for permission to reproduce this communication. Second, I think it is important for clinicians and advocates alike to reflect on what we can learn from this experience. As far as I can determine from available research, most boys who want to be girls later become men who don’t want to become women. Using the new paradigm with Adam may have altered his future in ways that could have added significant complication to his life.

Given that this email was sent to Dr. Bailey, I asked him for commentary.

Danielle is an admirable and unusual mother. She went to great lengths to protect Adam and to show him that she loved him regardless of his gender-related behavior and self-concept. She let Adam express his femininity (e.g., fill his room with “girls’” toys), while providing him with honest feedback about the likely results of his choices, outside their home. She also hesitated–in my view sensibly so–from encouraging Adam to begin a gender transition during childhood. I have met Adam, and I have read Danielle’s updates. I would be surprised at this point if Adam decides to change his sex. He seems a happy boy, and I expect he will become a happy young gay man.

I wonder, with Danielle, about the implications for gender-atypical children whose parents take the other, emerging, approach: allowing children to change their genders preliminary to biological sex changes in adolescence. Children like Adam start showing their behavior early (Adam at 18 months). All evidence we have suggests that only a minority (20% or fewer) of boys like Adam become women eventually. But if parents let boys become girls at childhood, will this drive up the probability? It seems highly plausible that it would. Sex reassignment is not minor medical intervention. It involves major surgery and lifelong hormonal treatments. All other things being equal, sex reassignment is something to be avoided. Of course, not all other things are equal. If a 6 year old boy wants to be a girl, it will cause him more short-term pain to refuse than to acquiesce. The costs and benefits are hard to estimate, and Danielle has been frustrated in her search for data-supported answers. It would be a fitting reward to her admirable example if people could set aside their differences (and the government could uncharacteristically support research on a controversial topic relate to sex), and begin to collect and share requisite data.

Danielle and Adam should remind us that even if treated liberally, gender-atypical children will not necessarily choose sex reassignment. Indeed, perhaps the most liberal goal of all is to allow gender-atypical children to be comfortable in their own (non surgically altered) skin. By all appearances, that is what Danielle has accomplished.

Since this email, I have corresponded more with Danielle. She has added some additional detail which I will report tomorrow. Specifically, she describes how she has responded to Adam when he has expressed questions about transitioning.

Filed under: Professional issues, gender identity, sexual orientation by Warren - 217 Comments →