Category: sexual orientation

Information and Misinformation on Gender Dysphoria from Wallbuilders and the American College of Pediatricians, Part One

Tuesday on Wallbuilders Live, Dr. Michelle Cretella represented tiny pediatric breakaway group the American College of Pediatricians. She briefly discussed the organization’s position paper on responding to gender identity issues. In doing so, she said something which caught my irony sensor. It also occurred to me, as it repeatedly has in the discussion of gender dysphoria, how difficult it is to avoid taking extreme positions.
Listen to her response to a question from host Rick Green about how much harm gender dysphoria is causing.

I want to address two claims that came up in this segment. In this post, I address the claim that 80% of gender dysphoric children will accept their biological sex with therapy. In a future post, I will write about the claim about suicide rates.
Cretella says:

They’re [advocates for transgender children] cooperating with, at least, mental confusion.  You know, initially, we know that there is psychiatric literature that shows if you work with these children one on one and with their families, the vast majority, over 80% will come to accept their biological sex after puberty before adulthood. So yes, to put these children to reaffirm their confused thinking, to put them on puberty blockers, and then cross-sex hormones to make them quote unquote the other gender, you are permanently sterilizing children. It’s insanity.

Cretella is correct that persistence rates are low (gender dysphoria continuing into adulthood) among gender dysphoric children, but this is not the case with adolescents who remain gender dysphoric or those who experience it with an adolescent onset. In their paper, ACP uses the American Psychiatric Association’s DSM-V as an authority. The section of the DSM-V cited by ACP supports the claim about persistence but does not fully support Cretella’s claim about the role of therapy.

Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. In one sample of natal males, lower socioeconomic background was also modestly correlated with persistence. It is unclear if particular therapeutic approaches to gender dysphoria in children are related to rates of long-term persistence. Extant follow-up samples consisted of children receiving no formal therapeutic intervention or receiving therapeutic interventions of various types, ranging from active efforts to reduce gender dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence, since such children have not yet been followed longitudinally in a systematic manner. For both natal male and female children showing persistence, almost all are sexually attracted to individuals of their natal sex. For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually attracted to males) and often self-identify as gay or homosexual (ranging from 63% to 100%). In natal female children whose gender dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%). (APA, DSM-V, p. 455)

To the DSM-V, I can add the description of persistence developed by the World Professional Association for Transgender Health (WPATH) in their standards of care.

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.V Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003). (WPATH, p. 11).

The irony of Cretella’s confidence in psychiatric intervention relates to the expulsion from ACP membership of George Rekers who was infamous for his own personal decline and his discredited treatment approach to what was then called gender identity disorder. In fact, we don’t know the role, if any, therapy plays in influencing the current persistence rates. While there is reason to think parental permission to transition in childhood might increase the persistence rates, there isn’t sufficient research to say for sure.
After listening to Cretella and reading the ACP paper, I wonder what the ACP recommends for the 10-20% of people with gender dysphoria persisting into the late teens. Do they favor reassignment for those persons? They focus on the data which make their point but don’t seem to have an answer for the rest of the people involved.
Another problem with ACP’s confidence in psychiatric interventions for gender dysphoria is that they also oppose a frequent end point in the trajectory of many gender dysphoric children: homosexuality (see image at the end of the post). One of the reasons George Rekers tried to re-orient gender dysphoria was to prevent homosexuality. Furthermore, one of the prime objectives of reparative therapists like Joseph Nicolosi is to prevent homosexuality via the alteration of parenting behaviors toward gender nonconforming children. ACP should stop pretending to sympathize with gender dysphoric children when they also write letters to school personnel promoting reparative change therapy for gay people.
Summary
Cretella is right that studies of gender dysphoric children (mostly with boys) find low rates of persistence of gender dysphoria into adulthood. However, she should have distinguished between prepubescent children and teens. The outcomes for these two groups do not appear to be the same. No doubt her listeners will not make that distinction.
Cretella was wrong to invoke psychiatric treatment as the reason for low persistence rates. If anything, some treatments have been shown to be harmful in some cases while others may not be harmful but may not cause a reduction in gender dysphoria. From her presentation, one could get the impression that advocates for gender dysphoric children know these treatments work but are motivated to undermine the natural family and therefore withhold appropriate medical care. While there is strong disagreement among experts and some advocates might oppose traditional families, it is simply not true that gender dysphoria could be easily treated if only activists would get out of the way.
Another important factor is that the treatment advocated by Cretella and the ACP is an outdated, discredited, psychoanalytically based approach which has not shown success. Even among those in the mainstream who are skeptical of puberty blocking drugs, the treatments advocated by ACP are rejected.
Gender Dysphoria After Childhood
The following image comes from a 2012 study by Devita Singh on gender dysphoric boys. Note the columns titled “sexual orientation in fantasy” and “sexual orientation in behavior.” By far, the most common end point for gender dysphoric children across studies is some level of same sex attraction. Gay advocates have in the past confided to me that they are ambivalent about supporting interruption of puberty because such interventions may interfere with a natural homosexual outcome. Please see this common sense article by Michael Bailey and Eric Vilain on the dilemma many parents of gender dysphoric children face.
Singh table

Top Ten Posts in 2015

The ten top posts during 2015 are as follows with the most popular first:
1. Open Letter to Gateway Church Pastor Robert Morris from a Former Member of Mars Hill Church – This was posted on November 2, 2014 but remained popular throughout 2015. Driscoll recently joined Jimmy Evans as a director to form The Trinity Church in Phoenix.
2. Former Chief Financial Officer at Turning Point Claims David Jeremiah Used Questionable Methods to Secure a Spot on Best Seller Lists – This story about David Jeremiah’s questionable tactics from a former insider was a scoop but not one which stuck to Jeremiah like  a similar scandal did to Mark Driscoll.
3. Hillsong’s Brian Houston Interviewed Mark and Grace Driscoll After All (VIDEO) (AUDIO) – First, he said he would interview Driscoll, then he said he wouldn’t, then Brian Houston aired an interview with Mark and Grace Driscoll. It was great theatre but didn’t draw good reviews from former Mars Hill leavers.
4. A major study of child abuse and homosexuality revisited – This post from 2009 is one of the most popular articles in the history of the blog. In it, I demonstrate a key mistake in a journal article often used to link homosexuality and child abuse.
5. Southern Baptists Say Enough to Perry Noble and NewSpring Church – I am surprised that this post got so much attention.
6. Gospel for Asia Faces Allegations of Misconduct; GFA Board Investigation Found No Wrongdoing – The GFA story received the most attention from me this year.
7. Pastor of Willow Creek Presbyterian Says Church Reaction to Hiring Tullian Tchividjian is “Overwhelmingly Positive” – I briefly covered Tullian Tchividjian’s comeback as a development minister at a PCA church in FL.
8. A Few Thoughts on The Village Church Controversy – Village Church’s leadership apologized for their response to a young woman who sought a divorce from her husband who had admitted having child porn.
9. Hillsong Founder Brian Houston Issues Statement On Mark Driscoll at the Hillsong 2015 Conference – Mark Driscoll’s return to the spotlight garnered much reader attention.
10. Gospel for Asia’s K.P. Yohannan and the Ring Kissing Ritual – While the financial scandals were of interest to readers, this article ranked higher than the money problems.
To fully capture activity on the blog, one should consider the Gospel for Asia scandals (Patheos considered my coverage as a part of one of their top ten Evangelical stories of 2015).
It has been a good year and I thank my readers and those who support the blog with their comments and regular visits.

Robert Spitzer, Father of Modern Psychiatric Diagnosis, Dies at 83

Robert Spitzer at his home in 2004, screencap from I Do Exist.
Robert Spitzer at his home in 2004, screencap from I Do Exist.

According to the New York Times, psychiatrist and author of the third edition of the American Psychiatric Association’s diagnostic manual Robert Spitzer died on Christmas Day. Spitzer is credited with changing the way mental health professionals view diagnosis of mental disorders. By basing the assessment of mental disorder on personal distress and diminished functioning, Spitzer promoted a more rigorous approach to diagnosis.
More famously, Spitzer’s modifications also paved the way for reconsidering homosexuality as a mental disorder. After meeting gay psychiatrists who did not experience distress over homosexuality, Spitzer, in the early 1970s, led the effort to remove homosexuality from psychiatry’s list of mental disorders.
I first talked to Bob Spitzer when he invited me to take part in a debate over sexual orientation change efforts at the American Psychiatric Association meeting in 2000. The debate was canceled when, near the beginning of the conference, the two psychiatrists arguing against sexual orientation change backed out. Bob later told me that the psychiatrists who declined to participate wanted out because they heard that I was a member of the National Association for the Research and Therapy of Homosexuality (NARTH). While I had been a NARTH member for one year in 1997, I had allowed my membership to lapse by 2000. An irony is that I later became one of NARTH’s biggest critics. Bob knew I tracked NARTH’s actions and about once a year asked about any news on their activities.
Although I was unable to attend, the following year Bob invited me to speak as a part of a symposium where he presented results of his research on ex-gays. Eventually, that study was published in 2003 in the Archives of Sexual Behavior and was one of the most controversial studies in modern psychiatry. At the time, due to his conversations with people who described themselves as ex-gay, Spitzer believed that some gays had been able to modify their sexuality toward the straight side of the continuum. Later, in 2012, Spitzer retracted that interpretation of his research, denounced his earlier beliefs, and apologized to gays.
In 2004, I met Bob Spitzer in person and spent a few hours at his home near New York City while filming for the video I Do Exist, a video with the testimonies of five people who told me they changed from gay to straight. Because one of the main participants retracted his statements and two others had significant changes, I later retracted the video in January 2007. My views were also altered by the emergence of new data on sexual orientation and the failure of change therapy supporters to produce evidence in their favor.
After he published his study, Bob’s collaboration with social conservatives was something he later regretted. On one occasion in November 2008, I sent him a link to Focus on the Family’s website where they had misrepresented his study. He wrote back and said, “That is awful. Whoever wrote it must have known it to be incorrect. Can you do something about it?” Focus later modified the statements slightly but still did not fully represent Bob’s views. 
In 2007, Spitzer told me in a phone call that he endorsed the sexual identity therapy framework that I developed with Mark Yarhouse. The endorsement was later published on the SIT framework site:

I have reviewed the sexual identity framework written by Warren Throckmorton and Mark Yarhouse. This framework provides a very necessary outline to help therapists address the important concerns of clients who are in conflict over their homosexual attractions. The work of Drs. Throckmorton and Yarhouse transcend polarized debates about whether gays can change their sexual orientation. Rather, this framework helps therapists work with clients to craft solutions tailored to their individual situations and personal beliefs and values. I support this framework and hope it is widely implemented.
Robert L. Spitzer, M.D., Professor of Psychiatry, Columbia University, New York State Psychiatric Institute, New York City, NY. Co-editor of the Diagnostic and Statistical Manual of Mental and Emotional Disorders, 3rd Edition and 3rd Edition (Revised).

On a personal level, I liked Bob immediately. He was friendly and very approachable. While he seemed to like the controversy, in my hearing he communicated no malice toward any side of the gay change debate. He seemed to be a genuine truth seeker and wanted to follow the evidence no matter what. I will miss him.
Bob Spitzer, R.I.P.

Interview with Mark Yarhouse on SAMHSA Report Calling for an End to Sexual Orientation Change Efforts for Minors

On October 15, I linked to a report published by SAMHSA which called for an end to sexual orientation change efforts for LGBT minors. At the time, I wrote:

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth was released today by the Substance Abuse and Mental Health Services Administration. The report recommends the end of change therapies for minors via professional advocacy and legal strategies.

Mark Yarhouse, co-author with me of the Sexual Identity Therapy framework and professor at Regent University, was an evangelical presence on the panel of experts who produced the consensus statements.

I also said I hoped to have commentary from Mark. Today, I have an interview with him on his committee experience and his views of the consensus. Mark is professor of psychology at Regent University and Director of the Institute for the Study of Sexual Identity. He is co-author with me of the Sexual Identity Therapy Framework, which is a model for ethically and effectively helping clients with distress surrounding their sexual orientation and religious beliefs. For more on SITF, see the website which supports the framework. This will be cross–posted there.
This interview comes amid a bit of a controversy involving Mark and a speaking engagement in Canada. I hope those who assume they know Mark’s views will also read this and the SITF.

Warren Throckmorton: In general, what was your experience like being on the consensus committee? Did you feel the rest of the committee members took religious concerns seriously?
Mark Yarhouse: Overall, it was a good experience. I am always grateful for the opportunity to engage with others around complex issues, to learn from other experts, and to share from my own lines of research. We reviewed existing research and past policy statements, as well as shared from our professional experience working with children, adolescents, and families. In answer to your question about religious concerns, I think committee members wanted to take religious concerns seriously, although the primary focus was the well-being of minors who are navigating sexual identity and gender identity. As you know all too well, the beliefs and values of religious families are important considerations when working with families whose teen may be navigating gender identity or sexual identity concerns. In any case, my experience was that other committee members were interested in the experiences I’ve had – and others had – working with conventionally religious families.
WT: Even though the sexual identity therapy framework (SITF) wasn’t mentioned or cited, do you feel the report is supportive of the approach we take in the framework?
MY: Yes, I think so. We had the opportunity to review many documents, including the SITF and the 2009 APA task force report on appropriate therapeutic responses to sexual orientation, which, as you know, cited the SITF favorably. The kind of practice we saw as helpful would emphasize identity exploration without an a priori fixed outcome. I think the framework does that in the area of sexual identity. However, the framework does not address in much detail working with minors, and that may be something we consider if we offer a revision in the future.
WT: Do you have any comments, reservations about the consensus reported in the paper?
MY: As the SAMHSA report notes, we decided at the outset that we would define consensus as a reasonably high percentage of agreement rather than unanimous consensus. We all agreed to that, but that meant that what counted as consensus in at least a few occasions was not reflecting unanimity. We worked hard for unanimity in all cases, but that did not always happen. I at times found myself in disagreement with some of the wording, for example, but the threshold for consensus was met in those instances, and I understood and respected that process.
WT:It seems to me that the consensus surrounding sexual orientation is more settled than gender identity. How do you see that?
MY: There are fewer professional debates about sexual orientation, which likely reflects the consensus you are referring to. There seem to be more professional discussions about a range of clinical options with gender dysphoria. However, I was impressed by how little research is published on minors – particularly efforts to achieve congruence between gender identity and biological sex.  I was under the impression that more studies of higher quality had been published in some areas, and as the committee looked at them together, we found them lacking. Also, while research was one consideration, we drew on other sources, too, such as committee members’ professional experience and prior reports. In any case, I would have preferred to frame and word various aspects of the consensus report differently, but again that in some cases goes back to what counted as consensus. Without going into too much detail, you could imagine someone favoring the language of  ‘insufficient evidence’ in discussions of effectiveness and harm, to reflect how little published research is available in a given area of inquiry. Other topics, such as how to conceptualize sexual and gender identities and expressions in a diverse and pluralistic culture raise important philosophical and theological questions that were beyond the scope of the discussion.
WT: In general, do you support the recommendations of the paper (or asked another way). Is there anything in the recommendations you have concerns about?
MY: It is important to distinguish the consensus statement from the SAMHSA report. I did provide feedback on portions of the SAMHSA report, especially around family, community, and religious considerations, but it was written by designated persons from that agency. I think it reflects a little more regard for conventionally religious persons and families and provides for more resources than otherwise may have been available. But many committee members provided input and suggestions, and I imagine the author of the report had to balance various considerations in putting together the final document.
As far as concerns, I indicated at the outset that I did not think the government should be involved in legislating around the complexities of clinical practice in these two areas. I prefer to see government support the regulatory bodies that provide oversight to mental health professions in a given jurisdiction. I shared more of my thoughts on that in an interview with First Things. My opinion has not changed on that matter.

New SAMHSA Report Calls for End to Change Therapy for LGBT Youth

I may have more to say about this report in the coming days, hopefully with some commentary from Mark Yarhouse, but for now, I am going to link to it.
Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth was released today by the Substance Abuse and Mental Health Services Administration. The report recommends the end of change therapies for minors via professional advocacy and legal strategies.
Mark Yarhouse, co-author with me of the Sexual Identity Therapy framework and professor at Regent University, was an evangelical presence on the panel of experts who produced the consensus statements.
The most controversial parts of the report, in my opinion, deal with gender identity. I think most therapists now understand that sexual orientation is durable and rarely, if ever, changes dramatically as the result of change therapy. However, the recommendations on gender identity are more controversial. Despite the use of the word consensus, I question whether there is a consensus among professionals of all ideologies about how to respond therapeutically to youth dealing with stress over gender expression.
As for the goal of ending change therapy for youth, I am a supporter. Despite years of research and effort, no safe, effective and ethical approach to sexual orientation change has emerged. The very few people who still claim effectiveness are small operations with no research of their own methods. The anecdotes of harm are convincing and the candid admissions of people like Alan Chambers that the change they claimed didn’t happen is enough to cause significant skepticism. My own professional experience researching change efforts in clients and research participants informs me that any claimed change is unlikely to be lasting or complete. The biological research, while not conclusive, supports a very early establishment of sexual desires (especially for males). The available options for attempting change are often bizarre and carry potential to create psychological problems. Thus, limiting these efforts in a free society to adults seems like a reasonable professional position.