Academic Freedom Under Review at Brown University

On August 16, peer reviewed journal PLOS One published “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports” by Lisa Littman, an Assistant Professor at Brown University. In essence, Littman surveyed over 250 parents of children who expressed gender dysphoria with an onset in adolescence or later. She also found that the onset of gender dysphoria took place in the context of peer groups where others in the group became gender dysphoric. On August 22, Brown University published a press release (archived) regarding the study. Then on August 27, Brown removed the news item from the school website, stating:

Brown University Statement — Monday, Aug. 27, 2018

In light of questions raised about research design and data collection related to Lisa Littman’s study on “rapid-onset gender dysphoria,” Brown determined that removing the article from news distribution is the most responsible course of action.

As a general practice, university news offices often make determinations about publishing faculty research based on its publication in established, peer-reviewed journals considered to be in good standing. The journal PLOS ONE on the morning of Aug. 27 published a comment on the research study by Lisa Littman, who holds the position of assistant professor of the practice of behavioral and social sciences at Brown, indicating that the journal “will seek further expert assessment on the study’s methodology and analyses.” Below is the comment posted on the study in the journal PLOS ONE:

“PLOS ONE is aware of the reader concerns raised on the study’s content and methodology. We take all concerns raised about publications in the journal very seriously, and are following up on these per our policy and COPE guidelines. As part of our follow up we will seek further expert assessment on the study’s methodology and analyses. We will provide a further update once we have completed our assessment and discussions.” — PLOS ONE August 27, 2018

Then today, Brown’s Dean of the School of Public Health Bess H. Marcus issued a statement explaining the decision to remove the news item. After repeating the above statement, Dr. Marcus added the following:

Independent of the University’s removal of the article because of concerns about research methodology, the School of Public Health has heard from Brown community members expressing concerns that the conclusions of the study could be used to discredit efforts to support transgender youth and invalidate the perspectives of members of the transgender community.

The University and School have always affirmed the importance of academic freedom and the value of rigorous debate informed by research. The merits of all research should be debated vigorously, because that is the process by which knowledge ultimately advances, often through tentative findings that are often overridden or corrected in subsequent higher quality research. The spirit of free inquiry and scholarly debate is central to academic excellence. At the same time, we believe firmly that it is also incumbent on public health researchers to listen to multiple perspectives and to recognize and articulate the limitations of their work. This process includes acknowledging and considering the perspectives of those who criticize our research methods and conclusions and working to improve future research to address these limitations and better serve public health. There is an added obligation for vigilance in research design and analysis any time there are implications for the health of the communities at the center of research and study.

The School’s commitment to studying and supporting the health and well-being of sexual and gender minority populations is unwavering. Our faculty and students are on the cutting edge of research on transgender populations domestically and globally. The commitment of the School to diversity and inclusion is central to our mission, and we pride ourselves on building a community that fully recognizes and affirms the full diversity of gender and sexual identity in its members. These commitments are an unshakable part of our core values as a community.

In an effort to support robust research and constructive dialogue on gender identity in adolescents and youth, the School will be organizing a panel of experts to present the latest research in this area and to define directions for future work to optimize health in transgender communities. We believe that more and better research is needed to help guide advances in the health of the LGBTQ community. We welcome input from faculty, staff and students about the composition of this panel and scope of the discussion.

Researchers Come to Littman’s Defense

In response to Brown’s actions, a group of sexuality researchers signed a letter in support of Littman. Written by J. Michael Bailey, professor of psychology at Northwestern University, the letter cautions Brown to consider the source of criticism:

We are aware of the very loud opposition to Dr. Littman’s article from some transgender activists. This was predictable to anyone who has followed transgender issues during the past few years. However, you should not overreact to this criticism, for several reasons. First, these activists do not represent all transgender persons. There is no one transgender community that speaks as one. Second, those who are protesting the loudest are trying to silence Dr. Littman by intimidation and false or irrelevant accusations. They are not engaging in good faith scientific criticism. Some of us know this strategy all too well, having been targets of it. Third, and most importantly, ROGD is a very serious public health concern. You should be proud that Brown University has opened the door to its study, and hopefully someday, to its successful treatment.

The study has been criticized on several methodological points summarized in an article by transgender activist Julia Serano. These critiques have been answered by Roberto D’Angelo and Lisa Marchiano of the Pediatric and Adolescent Gender Dysphoria Working Group.

From my perspective, the study is a preliminary examination of a syndrome which was once rare but is now increasingly seen by clinicians. I have heard about these cases more frequently over the past decade and seen several such situations. As such, the study is worthwhile and true to the stated purpose (“A study of parent reports”).

It should go without saying that more data are needed and interviews with the teens who are in the groups identifying as transgender need to follow this study. Even so, that is no reason to walk back on this preliminary effort to examine what parents are seeing in their children.

 

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A Problem I See with the DOE/DOJ Guidance on Transgender Students

At the outset, let me be clear that I believe transgender students should not be discriminated against when it comes to public accommodations. I have no problem with the Obama administration issuing guidance to schools about how the Departments of Justice and Education interpret the law regarding sex discrimination. While I don’t agree with all aspects of the DOJ/DOE documents (more on that below), I think schools benefit from knowledge of how the Departments interpret the law.
The guidance isn’t new law.*  The May 13 letter says:

ED and DOJ (the Departments) have determined that this letter is significant guidance. This guidance does not add requirements to applicable law, but provides information and examples to inform recipients about how the Departments evaluate whether covered entities are complying with their legal obligations.

While I don’t object to equal treatment under the law for transgender students, I question the DOE/DOJ on their interpretation of how a student should be regarded as transgender. According to the DOE/DOJ, no professional assessment of the student is required.

The Departments interpret Title IX to require that when a student or the student’s parent or guardian, as appropriate, notifies the school administration that the student will assert a gender identity that differs from previous representations or records, the school will begin treating the student consistent with the student’s gender identity. Under Title IX, there is no medical diagnosis or treatment requirement that students must meet as a prerequisite to being treated consistent with their gender identity.6  Because transgender students often are unable to obtain identification documents that reflect their gender identity (e.g., due to restrictions imposed by state or local law in their place of birth or residence),7 requiring students to produce such identification documents in order to treat them consistent with their gender identity may violate Title IX when doing so has the practical effect of limiting or denying students equal access to an educational program or activity.

All that is required for schools to treat students in keeping with their asserted gender identity is a student’s word (presumably for adult students) or a parent’s word (presumably for minors).
In my experience, parents often disagree over what is best for children. What is a school to do when one parent asserts a change in gender identity and the other doesn’t? In my clinical experience, I have seen just such cases. For instance, some parents interpret gender non-conforming interests as a signal that a child’s gender identity is different than what was assigned at birth. Such interpretation may not be in the child’s interest.
Evaluating the broad spectrum of children where gender identity is an issue often requires professional assistance. Particularly when children and teens are involved, getting competent help can be key in coming up with the best course of action in keeping with professional guidelines. To me, it makes sense for schools to require a supportive statement from a treating physician and mental health professional.
What is the basis for the DOE/DOJ claim?
As an authority (footnote #6) for the contention that schools can’t require a diagnosis, the DOE/DOJ letter uses a case of a transgender female employed by the Army who won an EEOC complaint alleging a civil rights violation in part because she was not allowed to use a common women’s bathroom. The Army’s defense involved a concern that the complainant had not fully physically transitioned from male to female. The EEOC ruled that an employer cannot require a medical procedure in order to deny civil rights to a transgender employee.
However, in that case, the complainant had legally changed her records and was legally female. While she had not had surgical reassignment, she had made significant steps toward transition. The facts of the case involve an adult and are much different than a school where a parent or student may not have consulted a professional.
Of course, students should not have to prove full reassignment to be treated fairly, but it seems to me that schools would be within their rights to require evidence from mental health professionals and physicians that accommodation would be appropriate. Schools regularly require professionals to provide opinions on lesser matters.
When the DOE/DOJ says “there is no medical diagnosis or treatment requirement that students must meet as a prerequisite to being treated consistent with their gender identity,” I think they go beyond the facts of the case they used as a basis for their interpretation. Perhaps there are other relevant cases, but the letter doesn’t list them.
Schools should be safe for all students, including transgender students. My concern is that this guidance will hamper schools in reacting for the good of all students on a case by case basis.
 
*When I first posted this article, I wrote that the DOE/DOJ letter wasn’t an edict. While I still don’t see it as heavy handed as some opponents do, I will concede that some school districts may experience it negatively. Furthermore, I removed that reference because I don’t want to distract from the main point of the post.

What Kind of Woman is Caitlyn Jenner? Part Two of a Q&A on Autogynephilia with Michael Bailey

Yesterday, I posted part one of my interview with Michael Bailey on the topic of Caitlyn Jenner and autogynephilia. In that segment, Bailey covered the basics about autogynephilia and why he thinks Jenner manifests autogynephilic characteristics. In this segment, Bailey tackles what is known about outcomes for autogynephilic individuals, issues relating to minors with gender dysphoria and addresses critics of the concept. He also mentions one case where autogynephilia disappeared with the administration of leuprolide.
I also wrote GLAAD three times and asked for comment on autogynephilia generally and yesterday’s interview specifically with no response. GLAAD produces a tip sheet for journalists that doesn’t mention autogynephilia. Bailey addresses the media silence at the end of the interview.
I want to thank Michael for sharing his time and knowledge.

WT: What are the long term trajectories for autogynephilic individuals? What is the proper therapeutic response?
MB: Persons with autogynephilia often struggle, because of shame, lack of understanding, and the disapproval of others. Also, there is a real tension between achieving autogynephilic goals and maintaining conventional romantic relationships. Autogynephilic males who cross dress often go through binge-purge cycles, in which their cross dressing increases periodically, they get fed up and throw away their female clothing, and then later begin the cycle again. Some are fortunate to find partners (generally women) who accept their autogynephilia-driven behavior–some women even cooperate and participate. Some autogynephilic individuals never acquire partners, and they avoid the aforementioned struggle.
Some persons with autogynephilia are content to remain male. Those who get their gratification primarily from cross dressing are less likely to want to progress than those whose fantasies involve having female bodies, especially genitalia. Those, of course, can acquire female genitalia via surgery. Those who go that route generally undergo electrolysis and hormonal therapy prior to genital surgery.
As for “proper therapeutic response,” this is surely best considered at the individual level. But gender dysphoria due to autogynephilia doesn’t merely go away. Again, autogynephilia is like a sexual orientation, and that doesn’t change. I suspect that if there were more honesty about autogynephilia, then those who have it would understand themselves sooner, be less likely to commit to romantic interpersonal relationships, and would be more likely to pursue earlier sex reassignment. Evidence suggests they would be happier doing so, and there would be fewer wrecked families; quite parallel with the case of men hiding their homosexuality and getting heterosexually married.
WT: In your answer about proper therapeutic response, you said autogynephilia doesn’t change. Is this based on research or on the classification of autogynephilia as a sexual orientation? 
MB: Many men with autogynephilia would like not to have it. But I have never met a man who said his autogynephilia went away. Some transwomen say that it diminishes or vanishes after a sex change. Remember, the sex change also removes testosterone, which fuels male sex drive.
I should mention one other therapeutic approach that has not been widely used, to my knowledge. Still, I know one autogynephilic man who was on the verge of changing sex. He was, however, conflicted because he would have lost everything: his family fortune, his job, and his family. He was put on a course of leuprolide, a powerful drug that removes testosterone from the body. His desire to change sex virtually vanished. He’s happy and somehow able to have sex with his wife (viagra helps).
WT: I assume you are talking about adults. In other words, do you have different advice for minors? 
MB: The controversy over how and whether to treat preadolescent children experiencing gender dysphoria is irrelevant to controversies concerning autogynephilia. These preadolescent children are not autogynephilic. Autogynephilia almost never manifests in an obvious way before adolescence.
Lots of autogynephilic transsexuals wish they’d transitioned earlier. I can imagine this would have been better for them. If only people were more open about autogynephilia and people were more honest about it–and here I include journalists along with people with autogynephilia among those who have conspired to keep it secret–we could collect better data and ideally learn the optimal treatment for autogynephilic individuals of various subtypes.
I worry when autogynephilic transsexual activists (this includes all who were born male who have not always been exclusively attracted to men) advise families of preadolescent gender dysphoric children. The older activists have completely distinct conditions from the children, and the activists’ experiences are not an accurate guide to what the youngsters feel or how they will turn out. As we have argued, most preadolescent gender dysphoria does go away, and it is at least questionable whether it is in preadolescent children’s interests to change sex, socially (because this may lead to persistence requiring serious medical treatment).
WT: Why is there so little media coverage of the autogynephilia angle? 
MB: I think it’s a mixture of ignorance, political correctness, and fear. Most journalists know what they know from the media and from transgender activists — who do not mention autogynephilia. In fact, a few activists have managed to convince a lot of people that autogynephilia theory has been disproved (when in fact, it has substantial scientific support) and that anyone who agrees with it is anti-transgender (when in fact its major proponents, including me, have been quite supportive of transgender rights). As for fear, transgender activists (especially Lynn Conway, Andrea James, and Deirdre McCloskey) were so enraged by my writing about these ideas in my book that they tried to ruin my life. They were unsuccessful–their major success was to help Alice Dreger write a terrific article (and recently, a book) about the controversy–but I’m sure few people want to risk that. We will have made progress when Conway et al. are more ashamed of what they did to me than of autogynephilia.
WT: Is there anything else you would like to mention?
MB: I’ve noticed disapproval among some journalists–even Jon Stewart on the Daily Show went there–of the focus on Caitlyn Jenner’s attractive photographs in Vanity Fair. I can assure you (and Stewart): Caitlyn’s thrilled with that attention. It’s an autogynephilic fantasy.

Again, thanks to Michael for this information. Readers can leave follow up questions in the comments section which may form the basis for a return to the issue at a later time.

What Kind of Woman is Caitlyn Jenner? Part One of a Q&A on Autogynephilia with Michael Bailey

The transition of Bruce Jenner to Caitlyn Jenner has raised many questions about transgender issues. One that has not been widely discussed is autogynephilia as a trajectory for males who experience gender dysphoria. My impression of Jenner’s story is that she manifests aspects which are often associated with autogynephilia so it seems odd to me that the topic has not come up.
Michael Bailey is professor of psychology at Northwestern University and one of the more prolific sex researchers in the world. He kindly accepted my invitation to discuss autogynephilia in light of Caitlyn Jenner’s transition.

Throckmorton: What is autogynephilia? And how do autogynephilic individuals differ from androphilic men who become women?
Bailey: Before explaining what autogynephilia is, let me begin by explaining what it looks like. It occurs in natal males (those born male, regardless of whether they switch gender later), and it generally first manifests in adolescence, with the onset of puberty and sexual feelings. In the large majority of cases, it begins with erotic crossdressing. Generally, a boy discovers it’s sexually exciting to put in female clothing, especially lingerie, in private, look at himself in a mirror, and masturbate. People who know these boys don’t usually see them as feminine. Males like this usually are attracted to females, though some are not attracted to other people. A subset will discover other, related erotic fantasies, sometimes including the idea of having female anatomy (such as breasts and a vulva). If the anatomical fantasies predominate, then gender dysphoria is most likely to be intense. Males who eroticize the fantasy of having women’s bodies are most likely to get sex changes, for obvious reasons.
The phenomena I’ve talked about so far don’t make much sense if we take the conventional approach that these males have women’s brains. They make much more sense explained via autogynephilia. Autogynephilia might best be thought of as an unusual sexual orientation that occurs in natal males (those born male, no matter what they become). It’s very similar to male heterosexuality, because the erotic target is a woman. The difference is that in autogynephilia, the target is a self-constructed internal image–it’s like inwardly-turned heterosexuality. These males eroticize and fall in love with a woman they create within themselves
WT: Do you believe that Caitlyn Jenner is autogynephilic? If so, why?
MB: I believe it is very likely that Caitlyn Jenner’s transition was motivated by intense autogynephilia. I believe this because the best science suggests there are two completely different reasons why natal males become women: because they are feminine androphiles (lovers of men) or because they are autogynephilic. Jenner’s history shows none of the former and is very consistent with the latter. I refer specifically to his previous heterosexual marriages and secretive crossdressing.
WT. She says she always had gender dysphoria and that there was no erotic component. Would she say this if she were autogynephilic? Why?
MB: Autogynephilic individuals experience gender dysphoria, typically beginning in adolescence, when their intense erotic longing for female characteristics almost always begins. There is evidence (John Bancroft published an article long ago) showing that after changing sex, some show memory distortion. They begin to assert that their gender dysphoria began in early childhood and was far more overt than they had alleged before. They also deemphasize the erotic component, even if they admitted it before. I think they do this for at least two reasons: shame (because: sex is involved) and the desire to believe they really have the brains of women (as Jenner suggests she does–um, how does she know that?). I think also that Jenner (and others in the spotlight) likely enjoys the media spotlight, and the mainstream media loves the “was always a woman trapped in a man’s body” story and can’t deal with the “experienced intense sexual arousal when crossdressing or imagining I had a woman’s body” story.
WT: If Jenner doesn’t want people to think her transition was due to autogynephilia, why shouldn’t we just go along? 
MB: This inaccurate denial of autogynephilia is not for the good, because being honest could help lots of males struggling with their autogynephilia. (And there are lots who are.) It might help them understand themselves. It might help them accept themselves. It would at least say “Autogynephilia is nothing to be ashamed of.” I would say that people who admit and deal with their autogynephilia are even admirable.
Falsely misrepresenting one’s gender issues is also bad for science. It’s not good for people to believe false things merely because journalists don’t want to go certain places. Even among scientists, too many don’t bother to learn about the relevant literature and just listen to transgender people’s explanations (“I have the brain of a woman.”). This leads to bad scientific studies and ideas.
I think that Jenner’s brain has nothing more in common with the brain of a natal woman than mine does. She’s not that kind of woman. Her gender dysphoria was much more akin to times in my life when I had erotic and romantic longings for someone I couldn’t have.
WT: Do autogynephilic individuals have attraction to other people? 
MB: Usually, they are also attracted to women in the world (i.e., women besides their inner creation) as well. Some of these individuals marry–some tell their wives and some don’t. Wives who know often feel like they are married both to their husband and to the other woman. And the men (many–probably most–never become women) sometimes struggle between their love for their families and their desire to become women. This desire is like a typical man’s midlife crisis.
A subset of autogynephilic males report that they are bisexual, but knowledgeable scientists think this is not true bisexuality. Rather than attraction to men’s bodies, these individuals enjoy the fantasy of being courted by, desired by, or even engaging in sex with men, as women. This makes them feel quite feminine, and is thus exciting. Another subset identifies as asexual. These have plenty of sexual fantasies–it’s just that the sexual fantasies are all about the internal woman, and there’s nothing left for women in the world.
WT: What research support does this phenomenon have? 
MB: There is a great deal of support originating in Toronto in the important clinic formerly run by Ray Blanchard, the scientist most responsible for the study of autogynephilia. Blanchard observed that erotic arousal at the idea of having a female body was uncommon among natal male gender patients who said they were exclusively attracted to men (he referred to these as “homosexual” because with respect to their birth sex, that is their sexual orientation). In contrast, it was very common among natal male gender patients attracted to women, those who identified as bisexual, and those who identified as asexual–he referred to these three subtypes as “non homosexual” because they were not exclusively attracted to men. Homosexual natal male gender patients tended to have been extremely feminine since childhood. Nonhomosexual patients, not so much. (In follow up studies of preadolescent boys so feminine they wanted to be girls, not a single one was attracted to women as an adult.) Non homosexual natal male gender patients’ gender dysphoria is rarely evident in childhood but begins in adolescence. Homosexual patients request sex reassignment surgery much younger than non homosexual patients do–at least they have in the past. This partly reflects the fact that many non homosexual patients form families that delay them from pursuing such surgery.
A good resource summarizing this science (up to 2003) is the third section of my book (free pdf). A more scholarly and updated treatment is Anne Lawrence’s book.

Tomorrow, I will post the second part of my Q&A with Michael Bailey. In that part of the interview, Bailey opines about the proper therapeutic response to autogynephilic individuals, minors and transgender issues, media reporting about autogynephilia and his critics.
Part two of this Q&A is here.

Common Sense on Treatment of Gender Dysphoria

Given the controversial nature of the subject matter, I think this Globe and Mail article does a good job of representing the type of treatment offered at the Centre for Addiction and Mental Health in Toronto.
According to this article, gender identity clinic director Ken Zucker is not allowed to speak to the media. However, clinic founder Susan Bradley gave her views along with parents of children treated by the clinic. Quite appropriately, the clinic evaluates each situation and creates an individualized treatment plan. Some kids later transition and some don’t.
The writer, Margaret Wente, provides several illustrative cases. Here’s one:

“They never tried to force my son into something he wasn’t,” one mother told me. Her son had been a hyper-anxious child since birth. In kindergarten he became obsessed with dressing like a girl. The CAMH therapists determined that anxiety, not gender, was the key issue, and advised the parents to discourage their son’s obsession with girls’ clothing. Today, he is a well-adjusted young adult with a girlfriend and no interest in women’s clothes. The mother, who describes herself as “quite liberal” says she would have supported gender change if that had been the right thing to do.

This fits my experience working with such children. In some cases, it is very clear that gender is not the primary issue. Clinical response should not be “one size fits all.”
I hope the legislative effort to stop the work of the clinic is not successful.
For prior posts on Zucker and gender issues in children, see:
Gender identity disorder research: Q & A with Kenneth Zucker
Two families, two approaches to gender identity
60 Minutes Science of Sexual Orientation: An Update from a Mother of Twins
60 Minutes Science of Sexual Orientation: An Update from a Mother of Twins, Part 2