Update on Zucker, Blanchard and the Revision of the DSM

[Shana A]

Update on Zucker, Blanchard and the Revision of the DSM

http://transgroupblog.blogspot.com/2008/05/update-on-zucker-blanchard-and-revision.html

For those who are concerned about the establishment of an adherent to reparative therapy (Dr. Kenneth Zucker) and another seeking to entrench " ->-bleeped-<-" (a pathologization of treatment of non- "homosexual transgender" transfolk) in the DSM-V, there have been some new happenings.

One letter writer reports receiving an email from the APA which states that:

[joannatsf]

Since were getting excited about this I thought it would be helpful to know just what the DSM is.

The primary purpose of the DSM is to facilitate communication among mental health professionals.  The diagnostic terms in the manual provide a convenient shorthand when communicating about patients.  For example, when a clinician making a referral uses the term "Major Depressive Disorder" to indicate the patient's diagnosis, he or she is communicating in three words a great deal of clinical information.   One can expect that the patient's primary complaint is a sustained period of depressed mood or loss of interest in activities and that a number of other symptoms may occur as part of the depression, including sleep disturbances, changes in appetite or weight, low energy, difficulty concentrating, and very low self-esteem.   The clinician should also be on the alert to look for suicidal ideas or plans because this feature is often present in patients with this diagnosis.   Furthermore, use of the diagnostic term "Major Depressive Disorder" also indicates what NOT to expect.  For example, using this term indicates the absence of significant manic periods now or in the past; otherwise, the clinician would have used the term Bipolar Disorder.

Another important aspect of the DSM diagnostic system is that the diagnoses are described strictly in terms of patterns of symptoms that tend to cluster together; the symptoms can be observed by the clinician or reported by the patient or family members.  Since the cause of most mental disorders is currently unknown and subject to much speculation, the DSM avoids incorporating unproven theories in its diagnostic definitions.  This feature has been an important element in the widespread acceptance of the DSM.   Clinicians from widely differing theoretical orientations can still use the DSM because it focuses on manifest symptoms.

This is also an important limitation of the DSM system.   Patients sharing the same diagnostic label do not necessarily have disturbances that share the same etiology nor would they necessarily respond to the same treatment.   It is therefore critical to understand that the diagnostic terms and categories in the DSM represent only our current knowledge about how symptoms cluster together.

Usually where there are distinctions between types of illness in DSM (for example, homosexual or non-homosexual) there is also a non-differentiated option.  The thoughts of Chaiman Zucker may have little use in practical usage.  The manual does not discuss treatments.  Those are solely at the discretion of the patient and clinician.

[NicholeW.]

Some of us who are "getting excited about this" know exactly what the DSM-IV-TR is and how to use it. We have used it for years.

Some of us also understand that diagnosis, regardless what the DSM says, can be used strictlty, and often are used strictly, even by clinicians, maybe mostly by clinicians, to 'label' people into various groups based on pathology.

For instance, Borderline Personality Disorder and Anti-social Personality Disorder. We are also aware that there are particular socio-political agendas that are/have been used within the contexts of various incarnations of the DSM since its inception that cause and bolster those agendas.

You are right, Claire, that the DSM doesn't discuss treatment protocols; however, certain methods of making the entries for the various mental illnesses can cause widespread public reactions to people labeled with the particular disorder. There are good reasons, for instance, to NOT make an anti-social diagnosis for an African-American child of thirteen who was acting-out in school and uncontrollable by his caretakers.

There ARE very large ramifications for lives involved in mental health diagnoses. Using that same APD diagnosis as another example, it might interest you to know that female children are almost exclusively NOT diagnosed with it. Instead they tend to get BPS diagnoses (Borderline.) That is a 'tried and true' fact that changed very little in the past ten years. Although there are many studies that show the symptomatologies of persons diagnosed with one or the other are usually quite similar.

The differences are almost completely gender-related. The implications of APD are much more detrimental to young African-American children due to an already well-entrenched social prejudice. The DSM requires subtly and nuance, heart and understanding to use well and many practitioners don't bother.

I would suggest to you that the chairman of any revision committee of anything has a rather large power in what is included and what is not, especially when there are particular political and philosophical biases he brings to the committee, biases he is supported in by another influential colleague/member.

Nichole   

[Lisbeth]

Additional information has come in about other participants in the Sexual and Gender Identity Disorders Work Group (which, of course, oversees the entry for GID and several other conditions). Of these, Dr. Cohen-Kettenis appears to have a trans-positive reputation, and has reportedly pushed for liberalizing the WPATH standards of care. She has studied neuroanatomy and looked particularily at differences between male and female brain patterns.

While it is encouraging to know that we have a possible advocate on this panel, we continue to be concerned. Zucker is still directing the work, and Blanchard still retains the ability to entrench " ->-bleeped-<-" as a paraphilia in the DSM-V via his position.

Other members of the Work Group have mixed backgrounds and usually some kind of tie to the Clarke-Northwestern group (as the cadre including Zucker, Blanchard, Alice Dreger, J. Michael Bailey at. al. is often called, drawn from the clinics where some of them practice). Dr. Niklas Langstrom has treated mostly sex offenders and co-authored work with Zucker about transvestitic fetishism. Dr. Jack Drescher is the editor of the Journal of Gay and Lesbian Psychotherapy (where Anne Lawrence publishes) and involved with the Intersex Society of North America (ISNA), which in turn supports the Clarke-Northwestern clique via Dreger) -- although he differs with Zucker in that he opposes reparative therapy (or at least with regards to gay and lesbian persons). Others have unrelated fields, or, like Dr. Heino Meyer-Bahlburg, are completely ambivalent to whether transgender people should even receive treatment.

[joannatsf]

Some of us are mental health professionals and in their professional lives have found the diagnosis on the opening as a starting point for discussion rather than the final word.  Diagnosies change during the course of treatment as symptoms and causes present themselves.

I also fail to see the close similarities between APD and BPD but I'll see your red herring anyway.

To summarize diagnostic criteria for APD:

A pattern of a disregard for other people's rights, often crossing the line and violating those rights. This pattern of behavior has occurred since age 15 and consists by the presence of the majority of these symptoms:

    * failure to conform to social norms; repeatedly performing acts that are grounds for arrest
    * deceitfulness, repeated lying, use of aliases, or conning others for profit or pleasure
    * impulsivity or failure to plan ahead
    * irritability and aggressiveness; repeated physical fights or assaults
    * reckless disregard for safety of self or others
    * consistent irresponsibility
    * lack of remorse

How is anyone but a 13 year old's (which disqualifies him from the diagnosis anyway) doctors going to know about the diagnosis.  It would be a clear HIPPA violation and people would lose their jobs over it.

BPD:

The main feature of borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. People with borderline personality disorder are also usually very impulsive.  A person with this disorder will also often exhibit impulsive behaviors and have a majority of the following symptoms:

    * Frantic efforts to avoid real or imagined abandonment
    * A pattern of unstable and intense interpersonal relationships
    * Identity disturbance: markedly and persistently unstable self-image or sense of self
    * Impulsivity in at least two areas that are potentially self-damaging
    * Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
    * Affective instability due to a marked reactivity of mood usually lasting a few hours or days
    * Chronic feelings of emptiness
    * Inappropriate, intense anger or difficulty controlling anger
    * Transient, stress-related paranoid ideation or severe dissociative symptoms

Common to BPD clients is childhood sexual abuse or trauma.  Do these really sound like the same thing to you?

This has nothing to do with the issue at hand of course.

You might consider also the waning influence of psychiatry in society.  40 years ago a psychiatrist could have a person put away for a long time based on his/her word alone.  Today if a person can express a plan for finding food and shelter they are not conserveable.  The most they can be held is 72 hours IF the evaluators at PES agree with the application writer's opinion. 

The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers.

[NicholeW.]

  Diagnosies change during the course of treatment as symptoms and causes present themselves.

You've done that how many times in your career, changed a diagnosis, that is? How many times have you seen others change a diagnosis that was given 1, 5, 10, 20 years before? And how often have you seen clinicians maintain a diagnosis basically forever?

I also fail to see the close similarities between APD and BPD but I'll see your red herring anyway.

Cute use of color. How often have you worked with children and young adults who are diagnosed with either? 

Do these really sound like the same thing to you?

When you read the diagnostic criteria, no, they don't. When you actually work with the patients, they might very well. Does it strike you that APD may be a rundown of symptomatology for boys that, due to social conditioning, has a different look but the same basic etiology as that given to girls with BPD? Sexual, phusical, emotional abuse when their power is considerably less than that of an adult male, or female? That their rage and anger at their victimization may well enact as all or any of the criteria for APD? Perhaps you should work with a different set of clientele. Or in a facility that has patients who aren't simply medicated all day with thorazine.

It happens, a lot. Regardless the book diagnosis and how they are differentiated there.   

This has nothing to do with the issue at hand of course.

It has nothing to do with the designation of disorders based on outdated concepts of psychoanalytic, sexist, and racist theories of human being that are hallowed by those who make the definitions, collate, and weigh and interpret the reportage of clinicians? Or of the clinicians making those reports and how they view their patients through the lens of DSM? How do you figure that, Claire? Over cappucino and croissants?

I am under the impression that the people on that panel will do exactly that: collate, weigh and then make determinations based on their views and the majority and most forceful views of those on the committee. Do you suppose Zucker and Cohen-Kittinis will weigh and theorize the same things about childhood GID given their treatment protocols, world-views and general understanding and biases about their patients?

You might consider also the waning influence of psychiatry in society.  40 years ago a psychiatrist could have a person put away for a long time based on his/her word alone.  Today if a person can express a plan for finding food and shelter they are not conserveable.  The most they can be held is 72 hours IF the evaluators at PES agree with the application writer's opinion. 

The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers.

Except for the fact that the APA is the American Psychiatric Association. That gives them, medications pushers though many be, a very large influence, does it not?

Nichole

[joannatsf]

  Diagnosies change during the course of treatment as symptoms and causes present themselves.

You've done that how many times in your career, changed a diagnosis, that is? How many times have you seen others change a diagnosis that was given 1, 5, 10, 20 years before? And how often have you seen clinicians maintain a diagnosis basically forever?

I see it in the majority of charts I see, especially in long term clients.  Mis-diagnosis is common.

I also fail to see the close similarities between APD and BPD but I'll see your red herring anyway.

Cute use of color. How often have you worked with children and young adults who are diagnosed with either?

I work entirely with an adult population of varying ages.  All suffer from severe mental illness.  Many females with BPD often accompanied with an Axis I diagnosis.  APD is less common but I do see it. 

Do these really sound like the same thing to you?

When you read the diagnostic criteria, no, they don't.

That answers the question, thank you. 

I care deeply about my clients who are all outpatients struggling to rebuild lives for themselves despite overwhelming barriers to success.  No one takes Thorazine.  Even Haldol is a last resort used only if the client can't tolerate or find relief in atypical antipsychotics.   

This has nothing to do with the issue at hand of course.

It has nothing to do with the designation of disorders based on outdated concepts of psychoanalytic, sexist, and racist theories of human being that are hallowed by those who make the definitions, collate, and weigh and interpret the reportage of clinicians? Or of the clinicians making those reports and how they view their patients through the lens of DSM? How do you figure that, Claire? Over cappucino and croissants?

I am under the impression that the people on that panel will do exactly that: collate, weigh and then make determinations based on their views and the majority and most forceful views of those on the committee. Do you suppose Zucker and Cohen-Kittinis will weigh and theorize the same things about childhood GID given their treatment protocols, world-views and general understanding and biases about their patients?

My cappuccino is getting cold.

You might consider also the waning influence of psychiatry in society.  40 years ago a psychiatrist could have a person put away for a long time based on his/her word alone.  Today if a person can express a plan for finding food and shelter they are not conserveable.  The most they can be held is 72 hours IF the evaluators at PES agree with the application writer's opinion. 

The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers.

Except for the fact that the APA is the American Psychiatric Association. That gives them, medications pushers though many be, a very large influence, does it not?

Nichole

i think my original statement addressed that issue. "The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers."  What more do want me to say?

[NicholeW.]

  Mis-diagnosis is common.

Indeed, all the more reason not to place GID in Older Adult Males (which will be the wording you'll see or something close) in the manual at all under Paraphilias. Exactly where, I'm fairly sure, Zucker and Blanchard want it to go. Again, you only see what's written. The sub-text appears to escape you. Which is why, most often, there is so much mis-diagnosis. And should it go there what are the implications of that? What would "paraphilia" do for the religious right and other conservative pundits who already find all transsexuality invalid because it is assigned as a "mental illness," meaning, for them that we are all crazy anyway. Can you imagine how much crazier we'll be seen then? Crazy enough to halt the operations everywhere but Thailand and Iran?

No doubt it will not affect surgeries or public perception prior to 2012, but if the committee decides to go the paraphilia route do you really think that it won't 'leak' to the Anne Lawrences, the Trans-Kids and Michael Baileys who will surely release the decisions prior to the publication and do whatever's necessary to press that they "have been declared right?'

Do these really sound like the same thing to you?

When you read the diagnostic criteria, no, they don't.

That answers the question, thank you.

This has nothing to do with the issue at hand of course.

That does not answer the question. The question is a debate question, not one that contains the realization that some implications have a much wider importance than simply whether you or I can make debate points. You can win the debate, I truly do not care about that. I do care very much about the wider implications, not that I 'win' something.

It does have a lot to do with the issue at hand. The above point about APD is also the point with GID and what the Clarke-Northwestern-Seattle clique are attempting. It's also the point with other diagnoses made with an eye to pathologizing, getting paid by insurance and with no idea of nuance and understanding, issues other than those of the therapy room, beyond the therapy room. Just because something is "in the book" doesn't mean that it is in the best interest of your client to have that diagnosis. There are waves that move outward from the center in diagnosis as in everything else.

Therapy, psychiatry and psychology do not perform in some sanitary vacuum that affects nothing else. And I imagine you are well-aware of that. Supposed etiologies and diagnoses do matter in the real world. Clinicians who ignore that: implications of what they do, often violate the very first principle of all medicine and therapy: "Do no harm."

Abused men act out their anger and rage against whatever's available when they become adult. Bar fights, street fights, burglary, consistent criminal behavior result, very often, particularly among those less socially fortunate than yourself. All of those criteria you quoted up there from DSM apply to a 'criminal element.' They also apply to the reactions of many males who were subjected to sexual abuse as children -- same as the BPD girls. Yet, to give the APD diagnosis is to give a therapeutic imprimature to someone that they are dangerous (which they may well be) and unable to be employed, given housing and that, basically, they require locking away.

But, as you did, it is much easier to say "see, these don't match so they cannot be the same or similar." Without using some nuance and insight, some study, some ambivalence in diagnosis, relations between things get lost. Opening a book and reading a passage and applying it without understanding of implication, nuance, social attitudes, etc of the pathology is what many practioners do today. And in so doing they stigmatize people unjustly and contribute to the very real prejudices many 'regular' people have.

My cappuccino is getting cold.

So allow it to get cold and realize that pathology is not some game played with a book. It's the lives of people.

You might consider also the waning influence of psychiatry in society.  40 years ago a psychiatrist could have a person put away for a long time based on his/her word alone.  Today if a person can express a plan for finding food and shelter they are not conserveable.  The most they can be held is 72 hours IF the evaluators at PES agree with the application writer's opinion. 

The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers.

i think my original statement addressed that issue. "The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers."  What more do want me to say?

I suppose I want you to say IS that the matter is not as simple as you originally seemed to state that it was. That waves move from the book to lives and that what those men wish to do, apparently, given the direction of their writings, is to negatively pathologize older transitioners, regardless how much we might say we have felt this way for decades, and who don't need to be 'mutilated' to 'play into' their paraphilic fantasies. They then declare younger transitioners homosexual males who should get surgeries because that appears the only way to help them, but they must have certain looks, ages, and sexual orientations to receive such treatments.

Then I would like for you to realize that if and when the paraphilic diagnosis is set into the book that many practitioners will stop dealing with GID in the fashion they do. And, that when they retire and no longer practice, then younger people who 'follow the book' will take their places with the book saying what Zucker and Blanchard and allies want it to say.

I'd like you to admit to the realization that the issue isn't just psychiatrists and their diagnoses. They have control of the diagnostic manual used by all those practitioners you do name. What other group has a Diagnostic and Statistical Manual? Where do you go for the diagnosis except in the medical Diagnoses in the ICD-10? And when the surgeon requests a waiver showing that the patient has a 'true' etiology of transsexuality, but the DSM says they have a paraphilia what does one do then? 

BTW, your surgeon may not require sign-offs by a psychiatrist and a therapist. In fact, if you go to Thailand Suporn and others have their own in-house people who will do that.

But, all the doctors in the US and Canada do have that stipulation: one psychiatrist and one therapist.

This will all matter more than some are willing to concede. If these men control "The Book," as the Catholic Church proved 1700 years ago, they control the procedures as well and then the gatekeeping will go back to 'the good ole days.'

It may be moot to those of us who plan to have surgery prior to the new edition. We may say: it doesn't affect me. But, what about those who will come after. Do we say:we got ours, tough about yours?

Nichole

[joannatsf]

Perhaps we can agree that we're both intelligent women that have the best of intentions in our beliefs.  I don't see that psychiatrists have all that much power as gate keepers, at least not in my experience.

I don't have a GID diagnosis, yet I have access to hormones by prescriptions from doctors to facilitate my transition.  They are not 'scrip docs but practice at at one of the finest medical centers in the world.  I know a number of therapist and psychiatrist who treat TG clients that don't believe GID is a disorder at all.  I concur with that opinion.  The focus of therapy is self acceptance.  Unfortunately a great many of us also suffer from other mental disorders like depression, anxiety, bipolar and PTSD. 

When I go for surgery, I'll present the surgeon with an affidavit that says I've lived full time for over 2 years and have no psychiatric or cognitive conditions that would impair my ability to give informed consent or impair my judgement.  That meets WPATH SOC  requirements.  In fact RLE is likely a better predictor of success that a doctors opinion. 

I believe in empowering trans people to take control of their lives.  Treatment for all illnesses should be and can be a collaborative effort between doctor and patient.  If that's not happening, fire the doctor!  We're human beings, not 302.85s.  If you don't like the diagnosis given by one MD, fire them and find another!  You can doc shop for the desired diagnosis in the same way you can for an Oxycontin prescription.  And we'll always have Thailand.

[Lisbeth]

Dispite how you may think that the DSM is irrelevant, and perhaps it is for your life, it is of vital consequence for our children.  There are now people on the committee would change the DSM so that gender dysphoric kids can be committed to institutions so they can receive Repairative Therapy.  If you think that is acceptable, then do nothing.

[NicholeW.]

Perhaps we can agree that we're both intelligent women that have the best of intentions in our beliefs.  I don't see that psychiatrists have all that much power as gate keepers, at least not in my experience.

I don't have a GID diagnosis, yet I have access to hormones by prescriptions from doctors to facilitate my transition.  They are not 'scrip docs but practice at at one of the finest medical centers in the world.  I know a number of therapist and psychiatrist who treat TG clients that don't believe GID is a disorder at all.  I concur with that opinion.  The focus of therapy is self acceptance.  Unfortunately a great many of us also suffer from other mental disorders like depression, anxiety, bipolar and PTSD. 

When I go for surgery, I'll present the surgeon with an affidavit that says I've lived full time for over 2 years and have no psychiatric or cognitive conditions that would impair my ability to give informed consent or impair my judgement.  That meets WPATH SOC  requirements.  In fact RLE is likely a better predictor of success that a doctors opinion. 

I believe in empowering trans people to take control of their lives.  Treatment for all illnesses should be and can be a collaborative effort between doctor and patient.  If that's not happening, fire the doctor!  We're human beings, not 302.85s.  If you don't like the diagnosis given by one MD, fire them and find another!  You can doc shop for the desired diagnosis in the same way you can for an Oxycontin prescription.  And we'll always have Thailand.

You are most certainly intelligent, Claire. That's what puzzles me about what I perceive as your disregard of the importance of 'what the book says.'

You also live in SF which gives you a rather 'ivory tower' existence when it comes to gender presentation and diversity and the fashion in which it's treated.

I completely agree with client-centered therapy and practice it that way. I don't do the work, the client does. I don't make the decisions about proceeding or not, the client does. I am there to help them 'clarify' in their own hearts and minds if I can. But, I am also aware that client-centered approaches are often talked about, but much less practiced within the profession.

Clinicians come to the process with various 'schools of thought and practice' behind them, pushing them to 'handling' clients in all sorts of various ways. And we also come with our own prejudices and experiences firmly ensconced. And those DO act in the process. I am also aware that the DSM is used by all practitioners who wish to receive insurance payments for their services.

That becomes a huge problem for the people you don't know as well, in all liklihood. The 'street-->-bleeped-<-s' and those whose working class incomes allow them only the luxury of finding practioners who 'accept insurance.' They've not the resources to spend two years, once or twice a month, 'paying as they go.' But, given the resources required to simply reside in SF, perhaps those 'street-->-bleeped-<-s' I meet in Philly, Trenton, Camden, Newark, Pittsburgh and Baltimore do not live there much anymore anyhow.

Again, is it just 'tough luck' for them or does one believe that they are in as much need of transitioning as are white, educated, middle-to-upper class transsexuals? I have a problem with your arguments on a number of levels. 

Perhaps the most important being that you believe, according to what you write, that 'no one but psychiatrists' uses the DSM. ALL clincians use the DSM, and what goes into it is normally taught as 'catechism' by schools that train therapists and many of the people in those schools have very little to no experience working with clients in a caseload and often enter with no idea about a 'school' of practice that they can make their own.

So, when faced with gender-dissonance where do you think they are going to go to read-up? Not to transsexuals telling our own stories in print and on-line. They go to the DSM. And what they read there and how it is presented is very important, very important. That is the crux of what I see the difficulties are with the committee and its possible conclusions and revisions.

That's why the 'battles' fought by TSes over Bailey's book, Blanchard's and Zucker's essays, Alice Dreger's actions, views and articles as well as those of Anne Lawrence have basically meant little to those people in terms of prestige and importance. They can afford to dismiss Lynn Conway, Andrea James and Calpurnia Adams and Becky Allison because they absolutely know that none of those women are 'in-the-profession.'

It becomes obvious that they have, all-along, had a bigger fish in mind for their frying-pan: the DSM. You may pooh-pooh its importance like Lisbeth says, but that hardly makes it unimportant to the lives of everso many people, trans and otherwise.

Best,

Nichole

BTW, no one I have ever met HAS a 'transsexual diagnosis,' not one that is submitted for payment, because those diagnoses are verboten for any but those practicing in the area of gender and gender-surgery to speak to one another. The diagnosis is almost never put down on forms or clinical notes, simply due to the danger to a client should those papers be somehow released. To submit such a diagnosis to the insurance companies would be to 'do harm' to the client. They would not have their visit reimbursed and they would be labelled by the insurance company as transsexual so that any prescriptions or other treatment they rceived would be dismissed as being 'not covered' in the majority of states of the Union. 

[joannatsf]

Dispite how you may think that the DSM is irrelevant, and perhaps it is for your life, it is of vital consequence for our children.  There are now people on the committee would change the DSM so that gender dysphoric kids can be committed to institutions so they can receive Reparative Therapy.  If you think that is acceptable, then do nothing.

That's really a problem of the juvenile justice system, not the DSM.  Parent's can and do "put their children away" for a wide variety reasons.  Their is a cottage industry that forces reparative therapy on homosexual  children and that's not even in the DSM.  No note from a doctor or court proceedings is necessary.  Parents have the right to do it.  They just call the nice men to come and do an intervention.

There is a trade off between children not being treated as adults, in criminal justice for example, and negation of rights to parental control.  That will continue to be the case regardless of DSM.

I'm not saying that we shouldn't protest the appointments of Zucker and Blanchard.  It's an insult to the community.  It's just not the disaster of biblical proportion that some believe it to be.

[NicholeW.]

  It's an insult to the community.  It's just not the disaster of biblical proportion that some believe it to be.

It's more than an insult, it's a possible 're-definition' of 'the community.' And when one argues and fights about what goes into and what's left out or stricken from 'the Bible' the argument IS one of biblical proportions.

Your unwillingness to see beyond your own intelligence and life-status doesn't change that.

N~

[Lisbeth]

That's really a problem of the juvenile justice system, not the DSM.  Parent's can and do "put their children away" for a wide variety reasons.  Their is a cottage industry that forces reparative therapy on homosexual  children and that's not even in the DSM.  No note from a doctor or court proceedings is necessary.  Parents have the right to do it.  They just call the nice men to come and do an intervention.

There is a trade off between children not being treated as adults, in criminal justice for example, and negation of rights to parental control.  That will continue to be the case regardless of DSM.

I'm not saying that we shouldn't protest the appointments of Zucker and Blanchard.  It's an insult to the community.  It's just not the disaster of biblical proportion that some believe it to be.

Since you interpret this as a juvenile justice issue rather than a mental health issue I suggest you read The Last Time I Wore A Dress by Daphne Scholinski (1998, Riverhead Trade, ISBN: 1573226963).  This is the world where Zucker and company wants to take us.

This terrifying memoir recounts author Daphne Scholinski's three years spent in mental institutions for, among other things, Gender Identity Disorder. Daphne came from a busted home: Mom left to go to college and become a feminist and an artist; Dad stayed home with two daughters, the elder of whom, Daphne, he often beat. When Daphne started acting up at school, her shrinks decided to put her away. Her family, not knowing how to handle her, agreed. Because she was a tomboy who wore jeans and T-shirts and didn't act enough like a girl, her treatment, in addition to talk therapy, isolation, and drugs, required her to wear makeup, walk with a swing in her hips, and pretend to be obsessed with boys. This sounds awful enough, but when you realize that the confinement and treatment took place from 1981 to 1984, it's absolutely chilling. This book is both a powerful indictment of Gender Identity Disorder treatment and an inspiring testament of one person's survival. (amazon.com)

At fifteen years old, Daphne Scholinski was committed to a mental institution and awarded the dubious diagnosis of "Gender Identity Disorder." She spent three years--and over a million dollars of insurance--"treating" the problem...with makeup lessons and instructions in how to walk like a girl. Daphne's story--which is, sadly, not that unusual--has already received attention from such shows as "20/20," "Dateline," "Today," and "Leeza." But her memoir, bound to become a classic, tells the story in a funny, ironic, unforgettable voice that "isn't all grim; Scholinski tells her story in beautifully evocative prose and mines her experiences for every last drop of ironic humor, determined to have the last laugh." (Time Out New York)

[joannatsf]

School psychologists recommended the confinement.  It was the parents' consent that made it possible.  Without there assent it wouldn't have happened that way.  You realize this case happened 25 years ago, yes?  The rights of people with mental illness have advanced a lot in 25 years.  If an adult can express a plan for gaining food, shelter and cannot be shown to be a danger to themselves or others they must be released.  If they can can meet those 3 qualification they walk, even from a 5150 hold.  They can be hallucinating and psychotic as hell but they can't be held.  Not in California anyway.

It's ->-bleeped-<-ed up that kids are treated that way but it's not because of DSM.

Posted on: 13 May 2008, 17:00:11

Perhaps we can agree that we're both intelligent women that have the best of intentions in our beliefs.  I don't see that psychiatrists have all that much power as gate keepers, at least not in my experience.

I don't have a GID diagnosis, yet I have access to hormones by prescriptions from doctors to facilitate my transition.  They are not 'scrip docs but practice at at one of the finest medical centers in the world.  I know a number of therapist and psychiatrist who treat TG clients that don't believe GID is a disorder at all.  I concur with that opinion.  The focus of therapy is self acceptance.  Unfortunately a great many of us also suffer from other mental disorders like depression, anxiety, bipolar and PTSD. 

When I go for surgery, I'll present the surgeon with an affidavit that says I've lived full time for over 2 years and have no psychiatric or cognitive conditions that would impair my ability to give informed consent or impair my judgement.  That meets WPATH SOC  requirements.  In fact RLE is likely a better predictor of success that a doctors opinion. 

I believe in empowering trans people to take control of their lives.  Treatment for all illnesses should be and can be a collaborative effort between doctor and patient.  If that's not happening, fire the doctor!  We're human beings, not 302.85s.  If you don't like the diagnosis given by one MD, fire them and find another!  You can doc shop for the desired diagnosis in the same way you can for an Oxycontin prescription.  And we'll always have Thailand.

You are most certainly intelligent, Claire. That's what puzzles me about what I perceive as your disregard of the importance of 'what the book says.'

You also live in SF which gives you a rather 'ivory tower' existence when it comes to gender presentation and diversity and the fashion in which it's treated.

I completely agree with client-centered therapy and practice it that way. I don't do the work, the client does. I don't make the decisions about proceeding or not, the client does. I am there to help them 'clarify' in their own hearts and minds if I can. But, I am also aware that client-centered approaches are often talked about, but much less practiced within the profession.

I do live in San Francisco.  It is acceptable to be trans or any other form of queer.  While this may put me on an ivory tower there is the benefit that one may see a great distance from that height.

I don't know who the men were that appointed Zucker, et al, to their positions but there are a few things I'm sure of.  They were aware of the controversial nature of their ideas and that they are generally loathed by the TG community.  Why then did they appoint them?

My belief is that much of human activity is motivated by some desire for gain whether it be in the form of money or power.  Call me a cynic but history bears me out on this.  The APA poo-bahs clearly did not take this action because they thought it would be beneficial to transfolk.  Can you think of any other condition in the DSM where the preferred treatment is major surgery?  Recommending surgery opens up members of the profession to malpractice liability.  Could it be the goal of GID in DSM V is to offer a fiq leaf to clinicians that deny treatment.  With complicated rules and paraphillias it becomes easy to defend a decision not to treat.  I think the Dr. Richard Reid case in Britain (2006) struck fear in the hearts of the "compassionate professionals".

That's not an accusation against all mental heath professionals or even psychiatrists in general.  Just that the those that run APA have a Sauron like eye on risk management and the bottom line. 
Assuming that they will get their way on this we in the community had better come up with a plan B.

Clinicians come to the process with various 'schools of thought and practice' behind them, pushing them to 'handling' clients in all sorts of various ways. And we also come with our own prejudices and experiences firmly ensconced. And those DO act in the process. I am also aware that the DSM is used by all practitioners who wish to receive insurance payments for their services.

That becomes a huge problem for the people you don't know as well, in all liklihood. The 'street-->-bleeped-<-s' and those whose working class incomes allow them only the luxury of finding practioners who 'accept insurance.' They've not the resources to spend two years, once or twice a month, 'paying as they go.' But, given the resources required to simply reside in SF, perhaps those 'street-->-bleeped-<-s' I meet in Philly, Trenton, Camden, Newark, Pittsburgh and Baltimore do not live there much anymore anyhow.

Again, is it just 'tough luck' for them or does one believe that they are in as much need of transitioning as are white, educated, middle-to-upper class transsexuals? I have a problem with your arguments on a number of levels. 

You're talking about me in that last paragraph?  I submit that you know little about my experience in life.  I guess I'm one of the few middle-class white persons that qualified for the Earned Income Tax credit. 

That you believe, according to what you write, that 'no one but psychiatrists' uses the DSM. ALL clincians use the DSM, and what goes into it is normally taught as 'catechism' by schools that train therapists and many of the people in those schools have very little to no experience working with clients in a caseload and often enter with no idea about a 'school' of practice that they can make their own.

I don't recall saying that and I can't find it in this thread despite using a Firefox document search for "no one but".  You'll have to give more if I'm to learn the context of the statement.

For a clinician, MFT or MSW, to be licensed in California they must complete 1500 hours of supervised clinical experience.  While perhaps not seasoned they are not novices.  I have no idea what goes into a psychiatric residency but I'm sure it's a lot.

So, when faced with gender-dissonance where do you think they are going to go to read-up? Not to transsexuals telling our own stories in print and on-line. They go to the DSM. And what they read there and how it is presented is very important, very important. That is the crux of what I see the difficulties are with the committee and its possible conclusions and revisions.

That's why the 'battles' fought by TSes over Bailey's book, Blanchard's and Zucker's essays, Alice Dreger's actions, views and articles as well as those of Anne Lawrence have basically meant little to those people in terms of prestige and importance. They can afford to dismiss Lynn Conway, Andrea James and Calpurnia Adams and Becky Allison because they absolutely know that none of those women are 'in-the-profession.'

It becomes obvious that they have, all-along, had a bigger fish in mind for their frying-pan: the DSM. You may pooh-pooh its importance like Lisbeth says, but that hardly makes it unimportant to the lives of everso many people, trans and otherwise.

Best,

Nichole

As an experienced researcher I can tell you that I would consider the DSM a starting point for research but little beyond that.  If one wants to understand a complex subject they will need to read some published research and understand it's purpose and methodology.  The information contained in DSM is cursory at best.

[NicholeW.]

That you believe, according to what you write, that 'no one but psychiatrists' uses the DSM. ALL clincians use the DSM, and what goes into it is normally taught as 'catechism' by schools that train therapists and many of the people in those schools have very little to no experience working with clients in a caseload and often enter with no idea about a 'school' of practice that they can make their own.

I don't recall saying that and I can't find it in this thread despite using a Firefox document search for "no one but".  You'll have to give more if I'm to learn the context of the statement.

For a clinician, MFT or MSW, to be licensed in California they must complete 1500 hours of supervised clinical experience.  While perhaps not seasoned they are not novices.  I have no idea what goes into a psychiatric residency but I'm sure it's a lot.

So, when faced with gender-dissonance where do you think they are going to go to read-up? Not to transsexuals telling our own stories in print and on-line. They go to the DSM. And what they read there and how it is presented is very important, very important. That is the crux of what I see the difficulties are with the committee and its possible conclusions and revisions.

That's why the 'battles' fought by TSes over Bailey's book, Blanchard's and Zucker's essays, Alice Dreger's actions, views and articles as well as those of Anne Lawrence have basically meant little to those people in terms of prestige and importance. They can afford to dismiss Lynn Conway, Andrea James and Calpurnia Adams and Becky Allison because they absolutely know that none of those women are 'in-the-profession.'

It becomes obvious that they have, all-along, had a bigger fish in mind for their frying-pan: the DSM. You may pooh-pooh its importance like Lisbeth says, but that hardly makes it unimportant to the lives of everso many people, trans and otherwise.

Best,

Nichole

As an experienced researcher I can tell you that I would consider the DSM a starting point for research but little beyond that.  If one wants to understand a complex subject they will need to read some published research and understand it's purpose and methodology.  The information contained in DSM is cursory at best.

There is research and then there is Research, Claire. When clinicians who are ignorant or not well-versed in treating someone with, say, GID, begin researching their client and symptomatology they go to the DSM first. Besides being 'first and foremost a way to communicate between professionals' the DSM is primarily used as a diagnostic tool and is used 'primarily' for pathologizing and labelling people. No, they don't go there to found themselves on the sort of research you do. But they do research etiologies and symptomatology and 'how a condition is seen by others.'

If an etiology is somewhat like this:

302.2-- ->-bleeped-<-TS -- A man who is older than 25 at the onset of his desire to become a woman, he is accorded the diagnosis of ->-bleeped-<-TS, (autogynephilic transsexual.) This person has a deep-seated desire to fetishize his own body and to morph it surgically into an approximation of the female for the purpose of sexual excitement and sexual gratification. 

->-bleeped-<-TSes are very manly in appearance and desire, they are attrcated to women for the most part and may well have histories of cross-dressing. Their presentation is invariably different from and aesthetically less-pleasing to other men than that of HSTSes (see 302.1). ->-bleeped-<-TS is a paraphilia under the influence of which a man will desire the feminization of his own body as an implement for the gratification of his own sexual desire.

I cannot imagine a clinician recommending surgery for someone with that description or one very like it, one covering exactly those points. To do so, would, indeed, incline toward the client's paraphilia rather then to incline toward 'treating' the paraphilia so that the client would no longer have it, would in that fashion, become 'normal.'

To say, as you have more than once, that

You might consider also the waning influence of psychiatry in society.  40 years ago a psychiatrist could have a person put away for a long time based on his/her word alone.  Today if a person can express a plan for finding food and shelter they are not conserveable.  The most they can be held is 72 hours IF the evaluators at PES agree with the application writer's opinion. 

The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers.

And:

I don't see that psychiatrists have all that much power as gate keepers, at least not in my experience.

And:

i think my original statement addressed that issue. "The opinions of psychiatrists is becoming less and less relevant to the treatment of GID.  HRT, surgery - those are available without the approval of mental health providers."  What more do want me to say?

You did not say "no one but." However, until this last post you managed to ignore the fact that anyone but a psychiatrist might use the DSM for diagnostic purposes, which, as I am sure you know, was my point all along.

A researcher is likely to work with case records and numbers and lab tests, etc. Not very likely to work with people. Your impressions of those people might well be formed from what is usually a rather cursory note in the case record about treatment, statements, and almost no record of affect, unless that affect is perceived by the clinician as 'impacting on treatment' or 'threatening to the clinician' in some way or another. Actually sitting for 15-60 minutes with a patient can give one an entirely different view of their humanity and the importance of their individual life that may well be missing from a case record.

Thus, I would suggest that the view from the 'ivory tower' enclosed in another 'ivory tower' is rather different than being able to scan the distant landscape for items we on the ground do not see coming.

As I told you by PM I appreciate and laud the way you have overcome your own personal obstacles to health, career and your scheduled surgery and physical condition. Those are huge and worthy accomplishments.

I simply find your take on the importance of what that committee may well do as being short-sighted and narrow.

Your points about the sub-texts possibly at work in the appointment of this panel are very good ones. Many of the panels will be using patients' advocates and even patients as members of the panels. This panel will not. Why?

Probably because transsexuals and transgendered people have been unable to commit ourselves to any meaningful "patients' organizations" that can present a united front to lobby for our povs and lives. Instead we go our separate ways and argue about whether or not anything the APA does is 'meaningful.' Then we wonder why we always get the crap-end of the stick.

The reason why appears from this groundling's vision to be that we pride ourselves on how intelligent and remarkably 'real' we are and forget that other people do not perceive us that way. We spend a lot of effort and energy fighting to be 'better than her/him' amongst ourselves rather than realizing that our senses of privilege and importance are mostly delusional and that the effort, regardless of how one 'presents' and what others 'see us as,' is one that will require we work in concert rather than as 70,000 screaming voices raised in 70,000 different songs at once.

I don't have to like you, agree with you or be like you. Nor must you like, agree with or be like me. But, the success of you will, in some unfathomable way, affect whether or not I am successful as well and vice versa. And that is what you, I and the vast array of other gender-deviants truly need to see.

That one or another of us rises to be 'Queen of the May' is hardly an important issue at all. That Spartacus was able to be 'first among the gladiators' was hardly an issue when the gladiators and Spartacus were lying dead along the slopes and in the cauldron of Vesuvius.

We absolutely must find ways to relate ourselves with other people similar to us and find ways to form meaningful political and social action groups in order to have voices in the melees that revolve around our existences. Otherwise we give the power to the Dregers, Baileys, Blanchards and Zuckers of this world and they will, very much, use it to slit our throats. (Now that was overkill, but a good rallying cry is not a bad idea.)     

Thanks for the discussion.

Nichole