Month: January 2009

The Dr. Phil Show on gender identity, Part 3 – Should puberty be delayed?

Near the end of the Dr. Phil Show on gender identity, two guests who were not on stage provided a mini-introduction to the controversy of using hormones to delay puberty. Dr. Jo Olson and Dr. Eva Cwynar are two prominent doctors who work in the field of gender disorders and endocrinology. And action!

From the Dr. Phil website, here is a rough transcript of their comments.

Dr. Phil turns to two more medical professionals in the audience. Endocrinologist Dr. Eva Cwynar says parents need to wait and see what happens with puberty and not give in to their child’s fantasy of wanting to become the opposite sex. Dr. Jo Olson, pediatrician with the Transgender Clinic of Children’s Hospital Los Angeles, says children are born this way, and she helps kids make the transition through hormone therapy.
“Dr. Olson, at what point do you begin that?” Dr. Phil asks.
“It’s a different process for each child. It’s really important to recognize that young people and their families come in at very different stages of this process. Many of the people we see have actually already gone through puberty, but we do have some patients who are young, in the 12- to 16-year-old age range as well,” Dr. Olson says. “However, I want to say that we don’t just provide hormone therapy for young people, and not all young people who want to transition get hormones. We have a multi-disciplinary approach in our clinic, where they are assessed by a psychologist who is extremely familiar with gender-questioning youth, gender identity disorder and the issues that these young people face, as well as the case manager who understands what these young people go through. And hormones are not the end of the story for every young person.”
“And you work with the family members as well. It’s not just something you do to the child in isolation,” Dr. Phil says.
“Absolutely, and we have many parents who experience this same kind of mourning,” she says, referring to Toni.
“Dr. Cwynar, do you think there’s ever a point when hormone-blocking therapy is appropriate?” Dr. Phil asks.
“I do,” Dr. Cwynar says. “I think that, as everybody mentioned before, there’s a spectrum of this transgender, and I do believe as well that gender is a definition between the eyes and not between the legs, and that there are certain chemical phenomena, chromosomal phenomena, that occur both in utero and as we develop that make us appear as one sex, but is actually a different sex. I prefer waiting through puberty to see what actually happens when the hormones kick in. There are situations where you have distress and suicidal ideations and because of that, hopefully the family will be there for the child to help them get through that process. So, I like to see the whole adolescence be complete, essentially, before I do anything permanent.”

This is among the most controversial of issues and one with which I have had some professional involvement. I will give one example and then some links from past blog posts which address similar gender identity concerns.
Among several similar cases, I recall a family in conflict where the mother wanted to delay puberty for a GID child but the father did not. In short, the child now post-puberty is strongly identified with the biological gender. Delaying puberty would have been a mistake and the earlier wish to consider it vanished. Other cases are not so clear cut and hence the controversy.
Here are some relevant links to past posts:
–Two families, two approaches to gender preferences
–Gender identity disorder research: Q & A with Kenneth Zucker
–Ken Zucker compares ethnic identity conflict and gender identity conflict
–APA issues statement regarding GID and the DSM-V
–The Man Who Would Be Queen – Chapters 1 & 2
–American Psychological Association comments on DSM gender identity issue
–60 Minutes Science of Sexual Orientation: An update from the mother of twins
–60 Minutes Science of Sexual Orientation mother of twins, part 2 (this 2 part series is highly recommended)

More on the Dr. Phil episode on gender identity: Reparative drive theory

I have some video clips of yesterday’s Dr. Phil Show on gender identity. In this segment, Toni, the mother of a three boys, one of whom is transgender, expresses strong disagreement with Dr. Joseph Nicolosi and Mr. Glenn Stanton. Prior to this clip, Nicolosi outlined his views on response to gender identity issues. From the Dr. Phil website:

“So, what is a parent to do?” Dr. Phil asks. “You’re at home with your little child, they don’t do what other little boys do — and I’m using a little boy as an example. It happens with girls too, but statistics say it’s about five to one boys over girls who have this, but what is a parent to do at that point? Their question is, ‘Do we support his interest, or do we say, “No, no, no. You can’t play with that. You must play with this”?’”
“We see certain patterns, very typical patterns, of an over-involved mother, where the mother and son have a symbiotic relationship,” Dr. Nicolosi explains. “It’s very close, their identities are merged, and the father is out of the picture, and the work that we’re doing is to get the mother to back off, get the father more involved, get that boy to dis-identify with the mother and bond with the father, and in the bonding with the father, he develops that masculine identity.”

Most therapists have encountered families like this. However, they often come in for reasons other than a child’s gender identity. As Dr. Siegel said in a later part of the show, there is no evidence that a mom being close with a son leads to gender identity problems.
In this clip, Nicolosi and Stanton lay out their view of what happens to create a son like Toni’s. Roll the tape for the segment.

If I am following the mother’s explanation, she says she was not close to her son and her fiance became close to him after she backed off. She also notes that she was a single mom to her first son who would be expected to be closer to mom. Apparently, that child has no gender identity issues. And she says, the fiance/father-figure was less involved after the boy transitioned to a female role, but very involved prior to the transition. She further says that she wasn’t enmeshed with him. In other words, the reparative theory predicts a certain constellation but this women disconfirms it.
As noted in my first post on this episode, no middle ground views were presented. Near the end of the show, two reseachers seated in the audience were given a chance to speak. This segment was too short. I hope to post the clip of that exchange in a future post.
For now, I want to point out again the problem with confirmation bias in thinking through highly controversial topics. In this clip, the comments presented by Nicolosi and Stanton were not consistent with the experience of the mother and this son. Is it possible she was in denial? Is it possible that the reparative theorist was in denial? Sorting through this is difficult since both mom and the psychologists have powerful incentives to seek evidence favoring their commitments and views. In an area, like this one, where the science is developing, I advocate a very loose hold on theoretical commitments.
While the scientist can and should take a critical stance, it is true that parents need advice now. I tend to favor waiting until puberty to make decisions about transitioning since the existing research indicates most children do not opt for transition after puberty. However, even that finding is not as clear as Dr. Phil presented. See this interview with Ken Zucker for more on persistence of GID into adulthood.
Stay tuned…

Gender issues debated on Dr. Phil Show today

Glenn Stanton from Focus on the Family and Joe Nicolosi square off with Dan Siegel and Michele Angello over how to raise gender variant kids today on the Dr. Phil Show. Check local listings for times in your area.
The problem with episodes like this is how polarized it is likely to be with these guests. One side will say gender variance is all environment (well, I hope Glenn doesn’t say that) and the other side will say gender variance is all inborn in every case.
UPDATE: Did anyone else view the show? It was not terribly helpful for the purpose stated which was to help parents who had gender variant children. I will have more to say about it later but the social conservatives offered the close mother-detached father theory of gender variance to open scorn – deserved scorn I might add. The segment was awkwardly edited so that comments were probably not really related to each other as the show was taped.
Thinking about the episode, I have decided not to say much more about it until I can find some video clips. If you didn’t see it, then my descriptions won’t help much. The extreme positions presented left me very frustrated, knowing that most cases of GID do not end up in gender reassignment but also knowing that parenting dynamics in GID situations are not that much unlike families that have no GID kids. Indeed, the woman on the Dr. Phil episode had two other children without gender identity issues. I reported here several months on a mother of twin boys, one with GID and one without any such issues.
Both sides did not address the data points which falsify their perspective. Phil McGraw asked Dr. Siegel why 85% of GID kids do not go on to request gender reassignment. Siegel answered by saying that was a good question and the science isn’t clear but never gave a plausible answer as to why puberty changed these kids in so many cases. On the other hand, Nicolosi is so committed to his theory that he glosses over the problems with parenting theory. As noted above, GID children are often found in families with siblings who are quite gender conforming. Parents report that they do the same things with the GID children as they do with their other children with vastly different results. Most parents with more than one child can relate to this. Kids respond differently to the same environment thus helping to shape different parent and child relationships. Parents cannot be faulted when a GID male hates his gender typical Christmas presents or out of the blue at age 4 says, I want to be a mom and have babies when I grow up. Even if the reparative proponent says we are not blaming the parents just pointing out the causes, the “explanation” fails to account for the fact that the other children in the family did not respond to the parents with gender confusion. Also, as in the case of Dr. Phil’s parent, the mother was not especially close to the son. The reparative proponent is left with a need to assert untestable hidden dynamics which must be true because no exceptions to the theory are allowed. This kind of response from Nicolosi was in clear view on this episode of Dr. Phil. If all you have is a hammer, everything must be a nail.
So both sides of the theoretical debate can be faulted for confirmation bias. Holding tightly to a theory of causation in the face of incomplete science can create a situation where the client in front of you becomes secondary to the felt need to verify the theory.
I soon will be meeting with a group of parents some of who (perhaps all, I am not clear on this as yet) have felt great hurt from the application of reparative drive theory to their children. It must be quite surreal to go to someone who everyone says is an expert only to have that person be so wrong in their guesses about your lives. I am quite sure that those who hold tightly to a theory underestimate the intense anger and frustration this creates in parents. At one point in the Dr. Phil show, Nicolosi criticized the GID mom for getting “emotional.” As Dr. Siegel pointed out, the woman had reason to be emotional. She was on national television talking about the greatest hurt of her life with people who were essentially blaming her for the trauma. I believe I would be upset as well.

Ted Haggard says sexuality labels "just don't work"

Ted Haggard could have been in my study last summer. Over 190 same-sex attracted men who are heterosexually married took my survey to describe their sexuality. Many of them said the same thing – that labels didn’t fully capture their experience.
Haggard told the Denver Post that labels don’t work. Read the rest at the link.
Haggard’s description is consistent with the results I found. I am still collecting data involving same-sex attracted women in straight marriages. Just a few points on the men:
-191 men completed the survey; referrals came from ex-gay ministries, bisexual groups, mixed orientation couple support groups and via this website.
-Regarding the labels issue, 33% of all respondents qualified their sexual orientation self-description because they felt the labels were not adequately descriptive.
-We found 6 groups of such men with different attaction patterns. Haggard may fit into the “spousosexual” group if his general attractions are for men, but he experiences attraction for his wife. We found 20% of the total group in that category.
-The smallest group was the “ex-gay” group. Just over 6% said they once were attracted to the same-sex primarily and are now primarily attracted to the opposite sex.
-The largest group (40%) were bisexual in their attraction patterns and about one-quarter of the men were primarily attracted to the same sex in the present.
There are many more interesting findings that I am saving for the paper on this research. It should be ready by the end of February for submission. Stay tuned…

Genetics and environment: Interaction in a different key

In previous posts, I wrote about PANDAS, the streptococcus related autoimmune disorder which involves obsessions, compulsions and perhaps more broad anxiety and movement problems. Discussion has been vigorous about the role of pathogens in creating mood and mental health issues.
Genetics as an influence is another biological factor often considered as a causal factor in mental health and behavior. Today, Brain Blogger discusses the influence of genetics and depression in a post with the provocative title, “Stressed by his short allele.” Brain Blogger is an interesting read in that he attempts to bring neurological research to a lay audience in a magazine format.
Regarding depression, stress and genetics, BB writes:

Individual differences in the genetic makeup of the serotonin system have been shown to increase one’s vulnerability to depression, anxiety and other psychiatric conditions, particularly if individuals are exposed to stressful events in their lives. Studies are showing that certain people (those that have the short allele of the serotonin transporter gene) have a greater biological reactivity to stressful events, including a larger hormonal response to stress and a greater brain reactivity to threat. In other words, both the hormonal and brain systems (amygdala) involved in fear and anxiety are more active in response to stress in those individuals who have a certain genetic makeup (short allele). This genetic difference may also account for individual differences in personality; those people who have a short allele for the serotonin transporter have been suggested to exhibit more “anxious” personality traits. This means our differences in gene function may bias our brains and our personalities to create a tendency to be more “negative,” “anxious” or reactive to stress.

Bringing together the PANDAS research with the observations regarding short serotonin gene alleles, one can envision several scenarios. A child with a stubby allele gets strep throat. This child is unfortunate in that the antibodies created to seek and destroy the strep bacteria find and bind with dopamine receptors in the basal ganglia. At that point, the cells designed to kill strep bacteria which are supposed to be hooked up with strep antibodies find this unholy alliance of strep antibody and dopamine receptors and launch their holy war of immunity. Dopamine cells fall in friendly fire thus sending the dopamine-serotonin balance into disarray. This child, being completely unaware of this of course, begins to feel nervous and irritable (mood change). This creates stress in the family and parents who may also have stubby alleles get stressed too. As BB notes, the short-allele brain already primed to be more reactive in the event of stress (the illness itself, the mood change and reaction of parents and sibs) goes into full fledged alert, generating lots of chemicals which basically provide that child with thoughts suggesting something is wrong here (anxiety and depression).
We can also imagine a child with a full sized allele going through the same thing. When the dopamine-serotonin balance is disrupted via an autoimmune disorder, one may see the typical rapid onset of PANDAS symptoms but these will likely not turn into a chronic problem. Furthermore, it is possible that the symptoms will be less intense or that the child will be more easily soothed with even modest parental inputs, thus preventing an escalation of panic.
Active readers will probably imagine a few hundred more scenarios.
I recently spoke with Susan Swedo at the NIMH who provided invaluable information regarding PANDAS. She agreed with me that we are at the beginning of this line of research and thinking. There is no doubt that psychological trauma is stressful and thus impacts mental health. However, the mechanisms of extended impact may be much different than psychodynamic theorists imagine.
The more of this kind of information we can get to patients the better in my view. It is helpful for people to understand the tricks their brain is playing on them when they get the intuition that they must engage in a compulsive action in order to relieve anxiety. Or when everything is really going well and they constantly fear the worst. Our active, monitoring minds play tricks on us and we are learning more about how those tricks are constructed in part via pathogens in the environment interacting with a genetically prepared host.