Voices - Identity Crisis

While psychiatrists and psychologists debate gender identity disorder, Duncan Osborne finds support for this diagnosis from a surprising group - young transsexuals.

Beginning at age 5, Karl Bryant would make the one-hour drive with his parents to the University of California, Los Angeles, every other Saturday to see psychiatrist Richard Green. The trip always ended with a treat, Bryant recalls: He got to press the elevator button to take them to Green's office on the third floor.
     Bryant, now 40, was seeing the psychiatrist because he was insufficiently masculine. Green was studying 66 "feminine boys," as he later called them in his 1987 book, The "Sissy Boy Syndrome" and the Development of Homosexuality.
     Bryant was one of his subjects.
     "We had conversations that allowed him to bring up the subject of boys who want to be girls," Bryant says. "My general sense is that it was a way for him to push me on the fact that it was not normal or not the way things should be .... In part he was trying to understand what I was thinking."
     But that was not all. "There was some measure of cure involved in it," Bryant says."Getting me to be more masculine was the goal or, at least, to see that I should be more masculine. If that wasn't his message to me, it was what I heard."
     Bryant liked and wanted to please Green, whose message started to get through. "I remember one week in the process I brought a towel with me to show Dr. Green," Bryant says. "This was sort of my proof that I had been playing as Superman that week."
     Three years of visits were supplemented by follow-up sessions, which included psychological testing - until Bryant quit at 13. "I went for a few years, and then I said, I don't like this,"' Bryant recalls. "He would ask me about things, including my sexual fantasies and things that for a 13-year-old are a little threatening .... I think I was fantasizing about men. This was the 1970s. There were no gay-straight alliances. I didn't want to be conscious of that myself, and having him asking me about it kind of undermined that."

Any effort to reform GID threatens to collide with a growing trend among transsexuals: earlier transitions that rely on a GID diagnosis to set the process in motion. In fact, many transgendered people strongly support the current GID diagnosis

     In 1980, Green's work led to a new diagnosis - gender identity disorder - in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association's official list of mental illnesses. The disorder is characterized by a "strong and persistent cross-gender identification," and patients must express significant discomfort with their gender.
     GID could become a flash point in San Francisco at the APA's annual meeting in May, when a session will debate reforming the diagnosis. That session reflects a growing debate within the psychiatric association. While gay groups have called on the association to reform or eliminate the diagnosis, that demand has been complicated by an emerging population of transgendered youths who seek to transition earlier than their predecessors. Since the first step in that transition for these teens is often a GID diagnosis, transgender activists are divided about this issue.
     In children, behaviors leading to a diagnosis can include cross-dressing, wanting 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 must express a desire to alter their sex through surgery or hormones or say that they are the wrong sex.
     While many GLBT adults will recall that they engaged in gender-bending behavior as kids, the GID diagnosis is intended for only the most extreme cases. Think for a moment of the cross-dressing little boy in 1997's haunting film Ma Vie en Rose rather than the kid who occasionally tries on clothes of the opposite sex.
     Some psychologists and psychiatrists use the diagnosis on GLBT kids in an attempt to turn them into heterosexual adults. Other professionals reject the idea that adult homosexuality or transsexuality can be prevented but believe they can use the diagnosis to help kids and teenagers with GID who are deeply troubled.
     The diagnosis, which is rare, is clearly associated with adult homosexuality or, less often, transsexuality. Among the 44 "sissy boys" Green followed long-term, 75% were either gay or bisexual, and one wanted sex reassignment. Psychologist Kenneth J. Zucker, the head of Toronto's Child and Adolescent Gender Identity Service at the Centre for Addiction and Mental Health, is a leading GID expert who has seen roughly 625 children or adolescents since 1978.
     "The majority of kids will have resolved their gender dysphoria and identify themselves as gay" Zucker says. "We're also going to find that around 15% have significant gender dysphoria that has persisted into adolescence and young adulthood to the point where they are wanting sex reassignment .... If we add on to that a small minority of kids who report being heterosexual, we're seeing a real range of outcomes."
     Activists have criticized Zucker, but he counters that his efforts are intended to help the child be happy with his or her gender. Zucker works with parents to restrict behaviors such as cross-dressing or cross-gender role playing while encouraging the child to value his or her current gender. It is the child's discomfort that he is treating.
     "Just yesterday I spoke with a 5-year-old who reported that being a boy made him sad," Zucker says. "We know that kids with GID are subject to a whole range of social problems. If one can avoid those problems, that would be a basis for treatment."
     Zucker usually tells parents that their child is likely to grow up gay and that his efforts will not change that. "As a clinician, my ethical obligation is to tell parents about what treatment does or doesn't do," he says. "We will usually let parents know that the most common psychosocial outcome is that they usually grow up to be gay."
     Responding to questions faxed to him at Charing Cross Hospital in London, where he heads the Gender Identity Clinic, Green makes a similar argument. "The treatment program for the boys whom I saw with parents was to help them be happier being male, integrate more confidently into a mixed-gender peer group, and reduce alienation with a parent, usually [the] father," Green writes.
     Though both Green and Zucker have been attacked, they are not easy pigeonholed as antigay, some gay psychologists and psychiatrists have praised Zucker's work And Green was instrumental in removing homosexuality from the DSM in 1973; he has also been an expert witness in lawsuits opposing discrimination based on sexual orientation or gender identity. He is a past president and longtime member of the Harry Benjamin International Gender Dysphoria Association, the group that sets the standards of care for transsexuals.

Even those who support the GID diagnosis do not dispute that some who use it are driven by ideology. The best-known of these is psychologist Joseph Nicolosi, a founder of the National Association for Research and Therapy of Homosexuality.
     NARTH promotes therapies that claim to convert homosexuals to heterosexuality, and Nicolosi has long been associated with right-wing groups. He declined to speak with Out, but in his 2002 book, A Parent's Guide to Preventing Homosexuality, Nicolosi uses terms such as "pre-homosexual," "gender-confused," and "gender identity disorder" interchangeably. He is working with children with the goal of preventing them from growing up to be gay or lesbian.
     During an appearance on Fox's The O'Reilly Factor, Nicolosi said, "For parents who want their children to go in a heterosexual direction, I'm available." He has made similar claims in the past. In a 1998 speech, he said he was treating about 25 "pre-homosexual boys," including 5- and 6-year-olds as well as some as young as 3. "These boys want to be girls," he said in the speech. "They are denying their masculinity. They are preoccupied with feminine activities. They are infatuated with Barbie dolls ...."
     While Nicolosi cites the work of GID experts, Zucker and Green dismiss him, though they do not question the diagnosis. "There are people who claim they can 'cure' adult homosexuals too, but I don't accept either the need for a 'cure,' or their reported outcomes," Green writes in response to Out's questions. "I don't know of any evidence that treating children with gender identity disorder interrupts later homosexual orientation."
     Zucker asserts that Nicolosi's work is unsupported by any evidence, but he adds that some who object to the diagnosis are as prone to confuse politics with science as Nicolosi is.
     "Nicolosi is deeply embroiled in sexual politics, so it is not surprising that he takes this particular position with regard to GID, but there are people who have no sexual orientation ax to grind who would also see GID as a phenomenon that causes kids a lot of trouble," Zucker says. "He has very strong views about things, and the boundary between the clinical issues and the ideological issues seem a little blurry to me, just as with gay politicos on the Left."
     Efforts by those "gay politicos" to reform the diagnosis date back several years. The American Psychiatric Association formed a committee in 1998 to look into allegations that the diagnosis was being abused. It finished its work in 2000, but the report has not been made public. In 1999 a dozen leading GLBT and women's groups wrote to Alan Tasman, then the APA's president, seeking a dialogue on GID. That effort went nowhere, but a rancorous debate within the ranks of the association has begun.
     Richard Isay, clinical professor of psychiatry at Weill Medical College of Cornell University in Manhattan and the author of Becoming Gay: The Journey to Self-Acceptance, published an article in Psychiatric News in 1997 urging that GID be removed from the DSM. Isay argued that the diagnosis "implicitly labels homosexual boys as mentally disordered," noting that every adult gay male patient he had seen over 30 years reported some "'feminine' traits and interests."
     Perhaps as many as two thirds of lesbians and gay men recall that at some point they exhibited behaviors typical of the opposite sex, though rarely to the degree found in GID kids, according to some studies. What these children are expressing is the early development of a gay, lesbian, or transgendered adult. Sissies and tomboys are just young queers, and they are not mentally ill.
     "I would say each of the gay men that I have seen have had one or more gender-atypical traits during their childhood," Isay said. "I'm concerned by the treatment of GID, which is ... to help these boys conform to cultural stereotypes rather than supporting their differences."
     Zucker responded in a professional journal that Isay's piece was "a poorly reasoned, revisionist view that, almost effortlessly and with little reflection, attempts to undo 40 years of empirical research and theoretical work on the topic." One conclusion of his was a zinger: "Lastly, one must raise the thorny and difficult question of Isay's professional credentials to comment on the validity of the diagnosis of gender identity disorder," Zucker wrote. "As far as I can ascertain ... Isay has never published an empirical, data-based, peer-reviewed journal article on anything pertaining to gender identity disorder in children."
     The APA's Committee On Gay, Lesbian, and Bisexual Issues told a senior association officer that it "would like to ensure that someone familiar with some of the problematic features of and conceptual confusion in the GID is assigned to the appropriate work group" for the fifth edition of the DSM, according to the January 2002 edition of "Spectrum," an APA newsletter. Jack Drescher, MD, the committee chair, would not comment on the specifics of the committee's work.
     "I'm happy to say that we are talking about it," Drescher says. "We very much hope that when the final committees are formed to work on the next version of the DSM, there will be inclusion of various points of view."
     Any reform effort, however, threatens to collide with a growing trend among transsexuals: earlier transitions that rely on a GID diagnosis to set the process in motion. In fact, many transgendered people strongly support the the current GID diagnosis.
     Avery Porch, who started life as a biological female, for instance, felt from an early age that he was a boy. "I would destroy all Barbies that I received," says Porch. "I would cut their heads off or melt them in microwaves."
     At 18, he found a sympathetic counselor and started on hormones in 2001; chest reconstruction surgery came the next year. The process would not have begun so early without the GID diagnosis. "It's made my transition a lot easier," he says. "If the diagnosis did not exist, it would be even harder for people to transition."
     Similarly, "Jenny," a 19-year-old Englishwoman, was also helped by the GID diagnosis. At 16, England's "mature minors law" allowed her access to medical care, and she started on hormones as part of her transition [the magazine omits here that she also had sex reassignment surgery]. Now she has moved to a new city and started college, and she does not call herself a transsexual. That is her past - she is now simply a young woman. "My body feels pretty great to me," she says. "Every time I happen to see myself naked in the mirror I think, My God, that look so great. Transitioning - that relieved a large amount of pain."
     But not all transgender activists think that the diagnosis is needed. "Transgendered adults who get the diagnosis are split over whether it's a good or bad thing," says Riki Wilchins, executive director of the Gender Public Advocacy Coalition. Wilchins points out that only a small portion of people who transition can get insurance reimbursement for their medical procedures. While the diagnosis may help those individuals, "at the same time this means that everyone who applies for medic help ends up being diagnosed as having a mental illness," Wilchins says. Others argue that the diagnosis is not necessary, since some medical procedures for transsexuals are delivered without it.
     This complicated situation puts activists in a difficult position: How do they get help for transgendered teens and adults while protecting the children who are more vulnerable to abuse of the GID diagnosis?
     "I think that the single most important thing is that there be a consensus that trying to change a child's gender identity or gender expression is unethical or harmful," says Shannon Minter, the legal director at the San Francisco-based National Center for Lesbian Rights and a female-to-male transsexual.
     Whether such a consensus is even possible remains an unanswered question. Can psychiatrist and psychologists who have banked their careers on the diagnosis, queer activists who oppose it ideologically, and right-wingers who use it in their efforts to extinguish homosexuality agree on anything?
     Indeed, the debate is growing more heated - which may only guarantee that the youngest queers will continue to face a difficult road as they come to terms with gender identity and sexuality.