Bias In Writings On Gender Identity Disorder

Acknowledgements

The author would like to thank Dr. Harold A. Roth for his research assistance and insights into academia, and Marah Rosenberg-Cavuto for her organizational suggestions.

Introduction

Most transgendered people have read at least some research on gender identity disorder. As Richard Green points out, transgendered people have become both professional and consumer within the field of gender research (1999). If a trans person manages to overcome the obstacles of gaining access to an online database or well-stocked library, finding scholarly articles on GID, and reading and comprehending them, there still remain the obstacles of interpreting the article as one speech within a conversation among overlapping conversations in fields of academia that include many of the medical and social sciences. What are the seminal works within gender identity research to which most other researchers refer? What institutional politics affect the research done by their faculty? Which outside political forces affect the internal politics of the academic communities? These are just a few of the forces that contribute to the inevitable biases in a researcher’s work: what they choose to study, which institutions fund them, and the results interpreted from analyzing the data.

This article is a broad overview of just a few researchers in the field of Gender Identity Disorder, and is meant to be only one in what will hopefully be several articles on the subject of bias within GID research. Not everyone with a voice or even published work on the subject is represented. I leave it for the reader to explore on his or her own the writings in the field, to form an awareness of those biases that exist in the research, and to read carefully and critically.

As a complement to this article, I have also created a timeline of important research in gender identity; use it to place not just works mentioned here, but any research you find, in a chronological context.

Pioneers of GID Research

The work of a few researchers are frequently cited by researchers who came onto the academic scene after them, regardless of their institutional affiliations and apparent biases: for example, conservative, moderate, and radical alike cite the 1987 book by Richard Green, The “Sissy Boy Syndrome” and the Development of Homosexuality. The works of John Money and Kenneth Zucker are also frequently cited.

Richard Green, MD, JD, a psychiatrist and attorney, is formerly a professor of psychiatry at UCLA and director of the Program in Psychiatry, Law, and Human Sexuality, and Senior Research Fellow and Member of Darwin College, Cambridge. He is a founding committee member and past president of the Harry Benjamin International Gender Dysphoria Association, previously directed the human sexuality program at the State University of New York at Stony Brook, is the founder and editor of Archives of Sexual Behavior, and was the founding president of the International Academy of Sex Research. He’s currently with the Gender Identity Clinic at Charing Cross Hospital. Green’s books and articles on gender identity are arguably among the most important in the field.

John Money is a medical psychologist, professor emeritus of Johns Hopkins University, and co-founder of the Johns Hopkins Gender Identity Clinic. He has authored over a hundred articles and more than thirty books on intersex conditions, gender identity disorder, transsexuality, and transvestism. He’s credited by Green with coining the term “real-life test” (Green 1999). He’s about 80 years old, but still alive and publishing. John Money and Richard Green co-edited Transsexualism and Sex Reassignment in 1969.

Contemporaries of Green and Money

Domenico Di Ceglie writes about the Green study in “Gender identity disorder in young people.” In the introduction to his article, Di Ceglie talks about the rape and murder of Brandon Teena:

Here I would like to suggest that a sense of unbearable identity confusion in the two young people is what leads to the violence. It is aimed at changing Brandon and eventually destroying him when their attempt to make him submit to their views of order on gender and sexual matters fails. For them, having a female body is inextricably connected with having a female identity. Any digression from this rule is a terrible threat to their flimsy sense of identity. (Di Ceglie, 2000)

Di Ceglie seems compassionate in his statement about Brandon Teena, and appropriately places the blame for his death on his murderers, while giving a compelling argument for the the reason the attack occurred. In the same article, he refers to the Green study from 1987. The Green study followed up on “feminine boys” and found that “three-quarters of them were found to be homosexual or bisexual. Only one boy in this study had a transsexual outcome.” (Di Ceglie, 2000) In the Aetiology section of this paper, Di Ceglie recounts the research that suggests causes of GID, but is emphatic that no single cause has been certainly identified.

On the same subject, Green was radical enough in 1999 to ask:

Of what relevance is it if biological or genetic bases of transsexualism can be demonstrated? Why should it matter? The same issue is raised in discussion of the origins of homosexuality. On the one hand the person with a variant in sexual orientation or in gender identity may be seen as more “legitimate” if the variation is biologically based, not the result of psychological trauma during formative years, or worse yet, sin. But from the perspective of John Stuart Mill, the original civil libertarian, it should be irrelevant whatever the basis of same-sex attraction or wish to be the other sex, providing this is not harmful to another.

The case studies presented in Di Ceglie’s paper include two boys and a teenage female to male transsexual (identified as female to male transsexual, yet referred to consistently with a female name and pronouns) who were counseled out of their trauma-induced GID. Following these cases, Di Ceglie outlines a proposed treatment of GID in youths, beginning with therapy. If GID persists, the next stages of treatment are hormone blockers, HRT, and SRS. The treatment is that recommended by the Royal College of Psychiatrists (a 1998 citation appears for these stages), not dissimilar to the Harry Benjamin Standards of Care.

Di Ceglie is a Consultant Child and Adolescent Psychiatrist at the Tavistock Clinic, and Director of the Gender Identity Development Service, Portman Clinic. He was the founder in 1989 of the Gender Identity Development Clinic (for children and adolescents) at St George’s Hospital, London, now at the Portman Clinic His therapeutic approach to GID, if conservative, does not appear to be “reparative,” although all of the examples he provides are cases where the patients were apparently cured of GID. His naming of the female to male transsexual is consistent with the outcome of therapy, in that she resumed living as a young woman afterward.

Dr. Kenneth Zucker is a frequently cited researcher of gender identity disorder, is on staff at The Clarke Institute in Toronto, and on the editorial board of The International Journal of Transgenderism. Zucker concludes that children with GID less often ultimately seek SRS than those who first present with GID at adolescence (Zucker & Bradley, 1995, p 289), supporting Di Ceglie and others who believe children should not be offered permanent options to live in the gender of their choice (The Royal College of Psychiatrists, 1998).

A Proposal to Remove GID From the DSM

In Remove Gender Identity Disorder From DSM, published in Psychiatric News, Dr. Richard A. Isay called for removal of GID from the DSM. His argument is that since most of the boys diagnosed with GID grow up to be gay, based on Green’s 1987 study of “feminine” boys, therapy may damage their self-esteem as gay men. He’s clear that parents should be supportive of their potentially gay children.

Isay’s books are listed on a number of gay-oriented sites, including sites directed at gay Christians. Dr. Isay chaired the American Psychological Association Committee on Lesbian, Gay, and Bisexual Concerns, and is also a member of the American Psychoanalytic Association and The Western New England Psychoanalytic Society. His membership in the American Psychoanalytic Association, according to an article in The Advocate, was based on Isay’s threat “to sue the American Psychoanalytic Association through the American Civil Liberties Union for not accepting gay and lesbian applicants in analytic programs. As a result of this action, they finally opened their doors.” (Eidenberg 1998) Despite his work for gay psychoanalysis clients, which hinges upon research on Gender Identity Disorder, I’ve been unable to find any work or quotations by Isay on transgendered adults.

NARTH, the National Association for Research and Therapy of Homosexuality, whose mission is to “defend the right to pursue change of sexual orientation,” accuses Isay of being “a vehement critic of the traditional psychodynamic approach to homosexuality” because Isay doesn’t believe homosexuality reflects a lack of psychosexual maturity, and because he doesn’t believe in reparative therapy to “cure” homosexuals. (Berger n.d.)

The month after Isay’s article, Children with Gender Identity Disorder Benefit From Early Psychiatric Intervention, uncredited, but based on the research of Lawrence Newman, M.D., and containing quotes from Dr. Newman, appeared in Psychiatric Times, proposing to cure Gender Identity Disorder in children through counseling them into having greater self-esteem. In the article, Newman cites a study from the 1980s, certainly the 1987 study by Green, in which it was discovered that most boys with childhood GID become gay men. The next month in the same journal, Dr. Friedman defended both the inclusion of GID in the DSM and “all children with GID, not just those who grow up to become gay men.” (Friedman 1998)

Dr. Newman wrote in the abstract of a 1976 article that “[b]ecause extreme boyhood femininity is often a precursor of adult transsexualism, transvestism, and homosexuality, the author recommends early intervention for boys who meet specific behavioral criteria of gender disturbance.” A search of PubMed found only a handful of articles on gender identity and transsexuality by Newman, most of them co-authored with Stoller. The Psychiatric News article, published in 1997, credited Dr. Newman with being “a child and adolescent psychiatrist in private practice in Los Angeles who treats numerous children and adults with gender identity disorder” and an assistant clinical professor at UCLA. A search of business listings in the Los Angeles area did not reveal a Dr. Newman practicing psychiatry, and a search of faculty and staff at UCLA also did not find Dr. Newman. Because he has a very common name, it is difficult to track down where Dr. Newman may have moved his practice or taken a new university position.

According to a website promoting his latest book, Richard C. Friedman, M.D., is a clinical professor of psychiatry at Cornell University Medical College, research professor of psychology at the Derner Institute of Advanced Psychological Studies at Adelphi University, and a lecturer at Columbia University´s College of Physicians and Surgeons. Friedman has written dozens of articles and several books on homosexuality, including research on the physical differences between gay and straight men, prejudices against gay people in clinical settings, internalized homophobia, and biases in traditional psychoanalytic understanding of homosexuality. His other work not dealing with sexuality is primarily about depression and suicide, particularly in adolescents.

There were several homophobic responses to the issue of GID in the DSM in subsequent issues of Psychiatric News. Dr. Voth’s letter to the editor denies both that sexual orientation is biological and innate, and declares heterosexuality the ideal and healthy result of treating not just the children with GID, but their parents. (Voth 1999) Dr. Socarides’ letter to the editor, written on behalf of himself and four other doctors from around the U.S. (including the aforementioned Dr. Voth, who apparently hadn’t had enough to say on the topic), equates homosexuality with “other deviations.” (Socarides 1999)

Of the doctors listed on Socarides’ letter, all but one are connected in some way with NARTH, ranging from an article of Tait’s being listed as a resource to Kaufman and Socarides, who are two of the founders of NARTH. Freedman, according to one source, is Honorary Clinical Professor of Psychiatry and Human Behavior at Jefferson Medical College of Thomas Jefferson University in Philadelphia, and on the faculty of the Institute of the Philadelphia Association for Psychoanalysis, although this information appears to be dated (Southwestern).

Dr. Voth, who was included on two different letters to Psychiatric News about the superiority of heterosexuality, has a bio online at the American Council for Drug Education, where he’s on the Scientific Advisory Board. He’s also an officer of NARTH. A search of PubMed found only one article relevant to the subject of childhood gender identity disorder by Voth, a case study of dream analysis performed on an “effeminate” boy (1978), and several articles unrelated to GID with such portentous titles as “The future of America” (1980) and “The family and the future of America” (1978).

One of the doctors who wrote to Psychiatric News opposing Isay’s call for removal of GID from the DSM, Dr. Charles Socarides, was clinical professor of psychiatry at Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center in New York from 1979-1997. He’s currently an officer of NARTH, and is a past president of NARTH. Socarides’ article, “How America Went Gay,” is published online at Leadership U, and was originally published, according to the Leadership U website, in America, “the national Catholic weekly,” available online at http://www.americamagazine.org. Leadership U is created and hosted by Christian Leadership Ministries, “The Faculty Ministry of Campus Crusade for Christ,” whose mission is “to reach and equip professors to change the world for Christ.” Richard Socarides, a former Wall Street lawyer, openly gay man, and former gay and lesbian liaison under the Clinton administration, is Dr. Charles Socarides’ son (Mills 1997).

Another writer associated with Leadership U and NARTH is George Rekers, Ph.D. of the Professor of Neuropsychiatry and Behavioral Science, Research Director for Child and Adolescent Psychiatry, and Chairman of Faculty in Psychology at the University of South Carolina School of Medicine. The NARTH Sigmund Freud Award was presented in absentia to Rekers in 2000. The Journal of Human Sexuality, edited by Rekers, is available online at the Christian Leadership Ministries website. A search of NARTH’s online articles includes several that quote him or cite Rekers’ work.

Rekers advocates for therapy to treat GID in children and adolescents. I emailed Rekers, asking to confirm the credentials I’d found on him and inviting him to provide his position statement on GID. In one of two articles Rekers sent in response he writes: “psychotherapeutic interventions for childhood gender identity disorder have been scientifically demonstrated to produce durable normalization of gender identity extending through adolescence” and “early detection and early intervention for gender identity disorder holds the greatest promise of normalizing gender identification.” (Rekers, personal communication, March 1, 2001). His reason for treating GID in children is, in part, to prevent homosexuality, a condition Rekers claims was removed from the DSM in a political rather than scientific decision. He writes, “If the psychopathology of ‘Gender Identity Disorder of Childhood’ is one of the major etiological precursors to adulthood homosexual orientation disturbance (as the research indicates at present), it would now appear logical that homosexuality per se be re-examined as a mental disorder.” (italics mine) In addition to his own technique, which he claims as a possible “preventive treatment for transvestism, transsexualism, and some forms of homosexuality,” Rekers mentions “positive therapeutic results” from “religious conversion” and church ministries. (1996)

Green mentions Rekers twice in The “Sissy Boy Syndrome,” both times to point out that, in disregard of Green’s strong suggestion, Rekers has used Green’s research to create and promote therapeutic methods to prevent not just atypical gender behavior, but homosexuality. (Green 1987)

Isay makes the argument in “Remove Gender Identity Disorder From DSM” that if one holds with the DSM-IV position that homosexuality is not an illness, then neither is its childhood manifestation as GID. This is a reversal of Rekers’ argument that, since childhood GID is an indicator of potential adulthood homosexuality, homosexuality itself is a psychiatric illness.

There are several unresolved issues in current research on GID. One is that it is difficult to reconcile the existence of gay, lesbian, and bisexual transgendered people (using the terms in relation to their gender of identity, not the one in which they were raised) with much of the theory that explains how people develop cross-gender identities. Early research interpreted transvestism and transsexuality as part of a continuum that includes homosexuality (Money and Tucker, 1975, p. 24; Green 1987, p. 6). Zucker and Bradley claim that adult females with GID “are invariably attracted sexually to biological females,” (1999, p. 372) a statement the several hundred “trannyfags,” or female-to-male, homosexual- and bisexual-identified transgendered people I am aware of may contest. Even Green’s “Sissy Boy Syndrome” describes the formation of a boy or man’s cross-gender identity as being a more extreme version of Freudian homosexual development: an overly close relationship with the boy’s mother and subsequent formation of an identity with the mother. Green quotes Socarides’ (whom he describes as an “inveterate treater of troubled homosexuals”) Freudian explanation of the homosexual boy’s identity with the mother (Green, 1987, p. 50). If transvestism and transsexuality are merely extremes on the same axis as homosexuality, what creates gay, lesbian, and bisexual trans people? Green explains very early in his book that there are three factors in sexual identity: “core-morphologic identity,” or one’s self-categorization as male or female; gender-role behavior, or sex-typed behavior; and sexual orientation (1987, Green, p. 6). Only relatively recently have transsexuals of every sexual orientation been acknowledged to exist: “Today the relation between components one and two versus three is being refined. We have considerable experience with lesbian women male transsexuals and limited experience with gay men female transsexuals.” (Green 1999).

Another issue which has not been adequately researched is the long-term outcome of the various therapies suggested to treat GID. Most researchers admit it is difficult to treat adolescents and adults, but many claim some success with children. Truly long-term follow up on these cases— not merely from childhood into a person’s late teens or early twenties— is absent from the literature.

References

Berger, Joseph, M.D. A Critique of the Writings of Richard Isay. NARTH 1996 Collected Papers. Retrieved February 27, 2002 from http://www.narth.com/docs/1996papers/berger.html.

Children with Gender Identity Disorder Benefit From Early Psychiatric Intervention. (1997, December 5). Psychiatric News. Retrieved February 27, 2002 from http://www.psych.org/pnews/97-12-05/gender.html.

Eidenberg, David. (1998, May 26). It’s all in your head. (psychoanalyst Richard Isay discusses homosexuality as pathology). The Advocate Retrieved March 1, 2002 from http://www.findarticles.com/cf_0/m1589/n760/20620439/p1/article.jhtml.

Di Ceglie, Domenico, M.D. (2000). Gender identity disorder in young people. Advances in Psychiatric Treatment 6: 458-466. Retrieved February 27, 2002 from http://apt.rcpsych.org/cgi/content/full/6/6/458.

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Green, Richard. (1987). The ‘Sissy Boy Syndrome’ and the development of homosexuality. New Haven, CT: Yale University Press.

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Mills, Kim I. (1997, Fall) Richard Socarides Acts as a Conduit Between the Gay Community and the White House. HRC Quarterly. Retrieved February 27, 2002 from http://www.hrc.org/publications/hrcq/hrcq97fa/pg16.asp.

Money, J. & Tucker, P. (1975). Sexual Signatures: On Being a Man or a Woman. Little, Brown, and Co.: Canada and U.S.

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Rekers, GA. (1996) Gender Identity Disorder. The Journal of Human Sexuality. 1(1), 11-20. Retrieved February 27, 2002 from http://www.clm.org/jhs/rekers.html.

The Royal College of Psychiatrists, Council Report CR63, January 1998 (1998), Gender Identity Disorders in Children and Adolescents. IJT II,2, http://www.symposion.com/ijt/ijtc0402.htm.

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Zucker, KJ & Bradley, SJ. (1999). Gender Identity Disorder and Transvestic Fetishism. In Child and Adolescent Psychological Disorders: A Comprehensive Textbook. Ed. Netherton, SD, Holmes, D, Walker, CE. Oxford University Press: New York.

Zucker, KJ & Bradley, SJ. (1995). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. The Guilford Press: New York.