LGNY: October 28, 1997
An Attack On Our Most Vulnerable
The Use and Abuse of Gender Identity Disorder
By Duncan Osborne, Associate Editor
At 15, Daphne Scholinski found herself locked up in Chicago's Michael Reese Hospital. Her failure in school, shoplifting, drug use,
But Scholinski was also more comfortable in pants and a t-shirt than a skirt with a blouse. She disliked make-up. She was skilled at baseball and was not above giving boys who harassed her a good beating. She was diagnosed with gender identity disorder.
For three years living in three separate institutions, she was urged, cajoled, and bribed by psychiatrists, nurses, and counsellors to appear "more feminine," according to The Last Time I Wore a Dress, a book she wrote with Jane Meredith Adams that is due out in November. Her relationships with other female patients were scrutinized for any sign of homosexual desire. When the staff at one facility concluded she was too close with another girl, they were separated.
"It wasn't my parents' intent to have me treated for my sexuality," says Scholinski, now a 31-year-old artist living in San Francisco. "The word lesbian was not ever used. I was just not appropriately feminine."
Those who diagnose and treat gender identity disorder,
Clarke Institute of Psychiatry and Bradley is a consulting psychiatrist there. The vignettes describe children who hate their bodies. They have sleep difficulties or are clinically depressed. Some are socially withdrawn. Others exhibit anti-social behavior that is out of control.
"A lot of the kids are preoccupied with gender," says Zucker in a phone interview. It consumes their fantasy life... A lot of the boys present as being anxious, timid... Ten percent of our sample have so many general difficulties that they require a day treatment centre."
Now, there is a growing chorus among some gay, transgender, and youth groups to either reform the GID diagnosis or eliminate it altogether from the Diagnostic and Statistical Manual of Mental Disorders, or the DSM, the official list of disorders published by the 38,000-member American Psychiatric Association.
Two thirds to three quarters of the children and teens diagnosed with GID will grow up to be gay or lesbian and advocates charge it is an underhanded method of diagnosing homosexuality, a category that was removed from the DSM in 1973. It is used by frightened parents and homophobic professionals to institutionalize queer adolescents. Critics of the GID diagnosis hold that gender non-conforming kids have the right to express themselves and the treatment is an assault on the most basic aspect of their lives - who they are.
All the professionals treating GID say they are presented with children who are suffering and that they are helping these children and their families manage being different in a hostile world. But others make no secret of their animosity towards homosexuals and they say quite openly that they are seeking to prevent these kids from growing up to be gay or lesbian.
The GID diagnosis first appeared in the DSM in 1980. All patients must have a "strong and persistent cross gender identification." Children must also show four of five behaviors. These can include cross-dressing; expressing a desire to be, or insisting that he or she is, the other sex; rejecting same-sex playmates and embracing toys or games stereotypically associated with the other sex. Adolescents and adults to be diagnosed with GID, must express a desire to alter their sex through surgery or hormones or state the belief that they are the wrong sex. In all cases, the patient must show significant distress or discomfort. However, intersex characteristics - ambiguous genitalia - automatically preclude a GID diagnosis.
"Most of the kids we are seeing are saying they want to be the opposite sex," Zucker says "To me, that's saying they are unhappy with a basic part of themselves... If the sine qua non of a disorder is distress, I think it is a disorder in the sense of being unhappy about who they are."
These kids are clearly suffering. In one Zucker study, 161 boys with GID, ages four to eleven, "had significantly higher levels of behavioral disturbance" compared to 91 of their male siblings. They were struggling with depression, social withdrawal, anxiety, aggressive behavior, and hyperactivity among other conditions. A sample of 24 girls with GID had similar problems compared to 76 female siblings.
We are talking about a population of unhappy kids. Views differ on the cause. Some evidence points to a biological connection, other evidence points to a disruption in the parent-child relationship. Zucker and Bradley conclude that "we view gender identity disorder as a relatively rare disorder that requires the presence of factors within the child, the parents, and the family system."
For activists, the cause is in the minds of those who diagnose GID. Certainly, these kids are troubled, but the "disorder" label is attached to them because their behavior defies social convention.
"I would assert that there is no such thing as gender identity so there is nothing to be disordered about," says Riki Anne Wilchins,
In social constructionist theory, identities are an invention that allow a dominant culture to assert one identity as superior. For instance the identity of "homosexual," as opposed to simply being a person who engages in sex with same-sex partners, has its roots in medical diagnoses beginning in the mid-1800s. The stigma of illness was attached to the homosexual label. Homosexuals could then be treated and required to behave in accordance with dominant cultural norms.
"I don't think I want to say that gender identity is a fiction, but I think it is something society constructs around certain kinds of acts," Wilchins says. "In that sense it is real, it has real political consequences, and people certainly come to identify with certain kinds of gender expression and not others. whether that forms a gender identity which can be said to be disordered is a political question not a medical or psychiatric one. It's about who has power to decide and who has power to enforce norms."
In the case of GID, these kids are expressing themselves, advocates say, in a gender-atypical manner. The treatment enforces conformity with cultural norms. Some psychiatrists express a variation of the views held by Wilchins.
"I think it's a very problematic diagnosis," says Dr. Ken Corbett, a clinical psychologist in private practise who has limited experience working with children who could be diagnosed with gender identity disorder.
"I think pain can collect around gender. but I think we haven't been careful enough to distinguish the pain from the gender," Corbett says. In a later written communication, he adds, "We also have not been careful enough to distinguish the politics and the history that inform our ideas about gender - in the case, specifically about effeminacy."
Even the extreme examples of gender-atypical behavior do not necessarily support a GID diagnosis in the view of some professionals. Those individuals appear to be very happy and enjoying it," says Ritch Savin-Williams,
Savin-Williams, who has published extensively on developmental aspects of gay, lesbian and bisexual youth, argues that the associated problems - the depression, social withdrawal or aggressive behavior - could be the appropriate diagnosis. "Use those as diagnoses," he says. "Why use gender identity disorder?"
Then there is the queer part. Two thirds to three quarters of GID children and adolescents will grow up to be homosexual. The usual concern of parents arriving at the doorstep of Dr Heino F. L. Meyer-Bahlburg is that their child is gay.
"Their basic fear in this homophobic country is usually homosexuality," says Meyer-Bahlberg, who is affiliated with the New York State Psychiatric Institute and the Department of Psychiatry of Columbia University. He has studied GID, primarily in four to seven-year-old children, but has devoted only part of his 20-year career to it. He typically sees fewer than ten GID cases each year.
The GID-homosexual correlation is not one-to-one, but might it be that the behaviors that constitute GID are part of the normative development of lesbian and gay kids?
"Nobody has data to say so," Meyer-Bahlburg says. Studies that ask gay men and lesbians to recall early behavior find one third report a typical childhood.
But Corbett has developed a pioneering theory of "proto-gay childhoods," arguing that adult homosexuals may have exhibited childhood behaviors that are distinct from heterosexual or bisexual childhoods. Noting this, Corbett writes, "The diagnostic category of GID is sufficiently problematic that it certainly seems possible that at least some proto-gay childhoods are mistaken for GID."
Zucker, Meyer-Bahlburg, and most other practitioners contacted by LGNY are not in the business of preventing homosexuality. The goal of treating GID is to ease the child's suffering. The intent, Meyer-Bahlburg says, is to "make the child more comfortable with their own gender."
In a later e-mail communication, he writes, "My impression is that we not only cut the emotional cost and reduce harassment, but improve same-sex peer relationships and related skills."
These practitioners are very careful with their patients. Most do not treat the child directly, working instead through the parents. In Meyer- Bahlburg's case, the child is never told that he or she is the subject. Speaking of Zucker, Dr Steve James, a professor at Goddard College in Vermont, says, "I very much value his caution and respect for the kids."
These folks, however, are keeping company with others whose efforts are driven by an unambiguous dislike for homosexuals. For instance, Dr. George A. Rekers, a professor at the University of South Carolina School of Medicine,
In 1990, Rekers join the Reverend Louis Sheldon, founder of the right-wing Traditional Values Coalition (TVC), in lobbying Dr. Louis Sullivan, then the secretary of the U.S. Department of Health and Human Services for federal funds to study reparative therapy, a purported "cure" for homosexuality, according to a 1990 TVC newsletter. Rekers wanted funds to create a nation-wide network of centres for the study of such therapy. It appears his anti-gay views have existed since the start of his career.
In a letter in a 1978 issue of American Psychologist, Rekers called the 1973 decision by the psychiatric association to remove homosexuality from the DSM a mistake that he attributed to the "rush to jump on the band-wagon of the advancement of gay civil liberties."
He further stated his dislike for homosexuals. "Personally, I believe homosexual behavior is morally sinful," Rekers wrote. "But even if research demonstrated that same-sex object choice results in happiness, mental stability and contentment, I would not change my moral evaluation of homosexual behavior."
This could be seen as a heartfelt moral position. It could also be construed as the very definition of prejudice. As evidenced by his later writings, his position remains unchanged today. Rekers' "home page" on the Internet is housed in a site maintained by the Campus Crusade for Christ. The site, dubbed "Leadership U," is meant to "accelerate the world-wide spread of the gospel of the Lord Jesus Christ."
At a June 19 conference "Homosexuality and American Public Life" sponsored by the right wing American Public Philosophy Institute at Georgetown University, Rekers gave this as one possible explanation for homosexuality: "Finally, the oldest explanation for the development of sexual orientation is found in religious thought... In theological terms, there is the fall... Humanity along with our biology as well as our environment and everything now are fallen. Also these views, historically, have pointed out that homosexuality is morally wrong and to be avoided."
Zucker went to some pains to distance himself from Rekers. LGNY first contacted Zucker by phone in Canada and described an interview in which Rekers expressed sincere concern for the children he has treated. Zucker promptly faxed an unfavorable review he wrote of two decidedly anti-gay books - Growing Up Straight: What Every Family Should Know About Homosexuality and Shaping Your Child's Sexual Identity - Rekers authored in 1982.
"What I would say about those two books is that if he was speaking under the authority of being a psychologist then his remarks are unprofessional and not helpful." Zucker says in a later phone interview. He calls Rekers' claims that he had prevented adult homosexuality by treating GID "unprofessional." In a later e-mail communication, he adds "Rekers' fusion of religious ideology and scientific/clinical matters is troubling for more secular- minded clinicians like myself."
But if Zucker rejects Rekers' politics, he has embraced Rekers' science. In his book's 75 pages of references, Zucker leads the list with 34 of his own books, papers or studies cited. John Money, a noted researcher, has 31 references and Rekers ranks third with 29. Rekers is in the book, in part, so Zucker can shoot him down - but only in part. Rekers is a prolific author claiming roughly 110 published studies, books or articles. Rekers is a major contributor to the study of GID. Isn't his science the fruit of a poisoned tree?
"I think his science is reasonable," Zucker says. His case reports of treatment using behavior therapy were standard for the 1970s."
Rekers' treatment methods were based in behavior modification theories, using rewards and punishments to alter the child's behavior. Meyer-Bahlburg says, "For that time, it was a reasonable thing to do... If I go by what [he has] written, I found it a bit too narrow... He was the first to demonstrate that gender identity can be changed."
But Rekers did not stop work in the 70s. He continues to be influential, as evidenced by Zucker's book. He received funding from the federal National Institutes of Mental Health though 1985. Rekers was the editor of and a major contributor to the 1995 book Handbook of Child and Adolescent Sexual Problems.
And activists do not make distinctions between Zucker and Rekers.
"Zucker is presenting himself as much more reasonable and as an advocate, but he is not about to say that there is nothing wrong with a little boy who plays with girls and dolls," says Shannon Minter, staff attorney and director
In her interview, Wilchins become agitated as the talk turns to Zucker. Pointing to his book, she says, "For me, this is hate speech. It is socially-sanctioned, medically-sanctioned hate speech."
Gender activists do not like any of the GID experts, but Rekers scares them as much as he makes them angry. His views conjure up dark visions. It is easy to imagine a queer child or adolescent locked up in some institution being drugged by an anti-gay bigot with a medical degree. The treatment looks more like torture to them.
That may be happening. NCLR receives four to five calls each month from youth as eleven and into their twenties who are contending with GID-related issues. The calls fall into three broad categories: "People who have been threatened with institutionalization, people who are in some kind of treatment center, and then people who have been in some kind of treatment and are dealing with the aftermath," Minter says.
"Young people are coming out at an earlier age," Minter continues. "A young person who comes out in his or her teens has four, five, six more years of living at home. They are minors, which means they basically have no meaningful legal rights. The parents are often freaked out and anxious to believe their child can be "cured."
In order to get an accurate picture of the use of this diagnosis, LGNY queried the Medicaid programs in the ten most populous states. Medicaid is the taxpayer-funded health insurer. In New York, 66 children were diagnosed in the 1995 fiscal year and 76 adults or adolescents were diagnosed. l996 saw 55 children diagnosed and 73 adults or adolescents. Some of these may be the same patients.
In Florida, two children and one adult or adolescent were diagnosed in the 1995 fiscal year. In 1996, six children and two adults or adolescents were diagnosed.
In other states the picture is murkier. Georgia had one case in the past two fiscal years, according to a spokeswoman, but diagnoses are not necessarily reported to the state. Michigan has enrolled 40 percent of its Medicaid recipients in HMOs. Among the remaining 60 percent, six children and twelve adults or adolescents were diagnosed with GID during the 1996 calendar year. Those numbers are an undercount, a spokeswoman told LGNY.
In Illinois and Texas, the costs of obtaining data were prohibitive. Illinois searched only one of the 20 to 30 separate databases of its Medicaid records, an inpatient database. In the 1995 fiscal year, one child was diagnosed with GID as were three adolescents or adults. In l996, two children were diagnosed as were four adults or adolescents. These results are an undercount. Texas also searched an in-patient records database and unearthed three adults or adolescents diagnosed in the 1995 fiscal year and no children. 1996 saw two children diagnosed and two adults or adolescents.
California claimed its records system was so large that it could only sample its tens of millions of records. A ten percent sample of its 1994 records revealed 30 claims filed for childhood GID and $936.10 paid out. There were no claims for adult or adolescent GID.
New Jersey had 18 adults or adolescents diagnosed in its most recent fiscal year and no children. New Jersey has enrolled most of its Medicaid recipients in HMOs. Ohio and Pennsylvania did not respond by press time.
The data is disturbing. In Texas, GID patients received a lot of therapy, according to the Medicaid procedure codes, but they were also drugged. There is nothing in the literature that supports treating GID with drugs. But GID was not the primary diagnosis of these patients so the drugs may have been for some other condition.
But at a 1995 conference sponsored by the Center for Lesbian and Gay Studies at the City University of New York, one GID expert, Dr. Susan Coates, was asked if she prescribed drugs for GID. "No" was the answer, but she added "I know that there are people who have done that." Coates, an associate professor in the Department of Psychiatry at Columbia University's School of Physicians and Surgeons, did not respond to interview requests
The data investigated excludes claims paid by private insurance companies and most Americans have private insurance. The Medicaid data raises more questions than it answers. Who are these practitioners? How do they diagnose and treat GID? And suppose the diagnosis is being abused. That does not necessarily make the diagnosis the villain.
"The issue is whether one acknowledges that kids have a problem when they may have gender identity disorder," Meyer-Bahlburg says. "The major issue is whether one sees it as a problem that needs some help."
The psychiatric association will soon take up the issue. In early September,
That work may begin as soon as early 1998. It is not soon enough for the activists. In their view, the children and adolescents facing this treatment are just being themselves. They are owed the protection of wider society.
"It's a civil rights issue," Minter says. "Every child has the right to safety and to be treated with respect. Gender non-conforming children are not doing anything wrong."
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