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…

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…

PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococci

I recently became aware of this condition where a variety of emotional and psychiatric symptoms arise due to an adverse reaction to the strep virus. I hope to raise awareness and note the import of understanding this condition for mental health professionals and consumers.
Years ago, I specialized in child mental health and saw cases of anxiety with no apparent precursor. Despite my psychodynamic training, it became clear to me that family dynamics played little to no role in the etiology of these conditions. However, in some of the cases, I could find no clear explanation. I suspect I was dealing with PANDAS. Some background:

PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The term is used to describe a subset of children who have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette’s Syndrome, and in whom symptoms worsen following streptococcus infections such as “Strep throat” and Scarlet Fever.
The children usually have dramatic, “overnight” onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones. This abrupt onset is generally preceeded by a Strep throat infection.

How does Strep throat lead to PANDAS?

What is the mechanism behind this phenomenon? At present, it is unknown but researchers at the NIMH are pursuing a theory that the mechanism is similar to that of Rheumatic Fever, an autoimmune disorder triggered by strep. throat infections. In every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However in Rheumatic Fever, the antibodies mistakenly recognize and “attack” the heart valves, joints, and/or certain parts of the brain. This phenomenon is called “molecular mimicry”, which means that proteins on the cell wall of the strep. bacteria are similar in some way to the proteins of the heart valve, joints, or brain. Because the antibodies set off an immune reaction which damages those tissues, the child with Rheumatic Fever can get heart disease (especially mitral valve regurgitation), arthritis, and/or abnormal movements known as Sydenham’s Chorea or St. Vitus Dance.
In PANDAS, it is believed that something very similar to Sydenham’s Chorea occurs. One part of the brain that is affected in PANDAS is the Basal Ganglia, which is believed to be responsible for movement and behavior. Thus, the antibodies interact with the brain to cause tics and/or OCD, instead of Sydenham Chorea.

In other cases, the child with PANDAS can become fearful, especially surrounding separations from parents. Mood swings have an abrupt onset and are more extreme than prior to the strep infection. There is a clear and dramatic change.
The best treatment seems to be antibiotics to address the strep infectiom. However, even after the infection is ended, the antibodies can remain in the child with negative impact.
I suspect many counselors have seen children with PANDAS without knowing it. The following description seems quite plausible:

Typically, a child with undiagnosed PANDAS may be taken to the Psychologist and/or Paediatrician for treatment of an onset or exacerbation of ADHD symptoms, oppositional behaviours or OCD. Stimulant or anti-depressant medication may be prescribed and/or a behavioural intervention or counselling initiated. As the infection passes and the strep antibodies reduce, the symptoms gradually subside and parents and clinicians believe that the intervention was successful. However then there is another strep infection, the symptoms return and the process is repeated. The problem is that the brain is being continuously damaged by the repeated attacks by streptococcus antibodies; and after each attack the recovery of damaged brain tissues may not be as complete as we would hope. Eventually the child may develop a chronic psychiatric disorder

This condition should cause health professionals to reconsider models of personality and psychopathology development. Counselors advising parents who have a child with PANDAS might be tempted to propose environmental theories for sudden anxiety states. However, such hypotheses would be far off. Counselors should take detailed health histories even with adult clients given how this biological causal factor gradually coould compromise mental health and lead to a psychiatric condition. Rather than hunt for psychic trauma, a bacterial trauma may be implicated.
This disorder came up on another thread regarding causes of same-sex attraction. There is no evidence as yet that a virus/bacteria could create a similar autoimmune reaction which would effect brain development or perhaps glutamate levels in the developing brain. However, it appears that behavior and emotional experience are effected in PANDAS. Is it a stretch to think other experiences (e.g., sexual attraction) might be altered in some similar manner?
Part 2 discusses a paradigm shift in treatment stimulated by PANDAS.

Year in review: Top ten stories of 2008

As in year’s past, I have enjoyed reviewing the posts from the year and coming up with the top ten stories.

1. Cancelation of the American Psychiatric Association symposium – Amidst threat of protests, the APA pressed to halt a scheduled symposium dedicated to sexual identity therapy and religious affiliation. Whipped up by a factually inaccurate article in the Gay City News, gay activists persuaded the APA leadership to pressure symposium organizers to pull the program. Gay City News later ran a correction.

2. The other APA, the American Psychological Association, released a task force report on abortion and mental health consequences. Basing their conclusions on only one study, the APA surprised no one by claiming abortion had no more adverse impact on mental health than carrying a child to delivery. I revealed here that the APA had secretly formed this task force after a series of research reports in late 2005 found links between abortion and adverse mental health consequences for some women. New research confirms that concern is warranted.

3. Golden Rule Pledge – In the wake of Sally Kern saying homosexuality was a greater threat to the nation than terrorism, I initiated the Golden Rule Pledge which took place surrounding the Day of Silence and the Day of Truth. Many conservative groups were calling for Christian students to stay home. This did not strike me as an effective faith-centered response. The Golden Rule Pledge generated some controversy as well as approval by a small group of evangelicals (e.g., Bob Stith) and gay leaders (e.g., Eliza Byard). Some students taking part in the various events were positively impacted by their experience.

4. Exodus considers new direction for ministry – At a leadership training workshop early in 2008, Wendy Gritter proposed a new paradigm for sexual identity ministry. Her presentation was provocative in the sense that it generated much discussion and consideration, especially among readers here. It remains to be seen if Exodus will continue to move away from a change/reparative therapy focus to a fidelity/congruence ministry focus.

5. New research clarifies sexual orienatation causal factors – A twin study and a study of brain symmetry, both from Sweden and a large U.S. study shed some light on causal factors in sexual orientation.

6. Letter to the American Counseling Association requesting clarification of its policies concerning counseling same-sex attracted evangelicals. Co-signed by over 600 counselors (many of whom were referred by the American Association of Christian Counselors), I wrote a letter to the ACA requesting clarification regarding how counselors should work with evangelicals who do not wish to affirm homosexual behavior. The current policy is confusing and gives no guidance in such cases. Then President Brian Canfield replied affirming the clients self-determination in such cases. He referred the matter back to the ACA ethics committee. To date, that committee has not responded.

7. Paul Cameron’s work resurfaces and then is refuted – resurrected Paul Cameron’s work in an article on their website about gay lifespans. The article was later altered to reflect more on HIV/AIDS than on homosexual orientation. Later this year, Morten Frisch produced a study which directly addressed Cameron’s methods.

8. Mankind Project unravels – This year I posted often regarding the Mankind Project and New Warriors Training Adventure. Recently, I reported that MKP is in some financial and organizational disarray.

9. Debunking of false claims about Sarah Palin’s record on support for social programs – I had lots of fun tracking down several false claims made about Sarah Palin during the election. Her opponents willfully distorted her real record to paint her as a hypocrite. I learned much more about Alaska’s state budget than I ever wanted to know but found that most claims of program cuts were actually raises in funding which not quite as much as the agencies requested. However, overall funding for such programs increased.

10. During the stretch run of the election, I became quite interested in various aspects of the race. As noted above, I spent some time examining claims surround Sarah Palin’s record. I also did a series on President-elect Obama’s record on housing, including an interview with one of Barack Obama’s former constituents.

I know, I know, number 10 is an understatement. (Exhibit A)

Happy New Year!