Gender Identity Disorder: Has Accepted Practice Caused Harm?

As transgender activists protested outside the American Psychiatric Association (APA) meeting, speakers at the meeting were presenting on the same topic: gender identity disorder (GID). Some of their words would add clinical weight to the political slogans.

Some of the speakers are activists themselves, including Rebecca Allison, MD, cardiologist who is transgender, widely published author Sarah Hoffman, whose son is gender variant, and Hewlett-Packard engineer Kelley Winters, PhD, founder of GID Reform Advocates. Winters¹ has called on the APA to use the DSM-V revision to affirm that “in the absence of dysphoria, gender identity and expression that vary from assigned birth sex are not, in themselves, grounds for diagnosing a mental disorder.”

Some mental health professionals made the same point in their own presentations. Sidney W. Ecker, MD, a former clinical professor of urology at the Georgetown University School of Medicine, Washington, DC, and chief of urology at the Washington DC VA Medical Center, was scheduled to review studies documenting that factors that influence gender identity are present before birth. While social and hormonal influences act later during childhood, he wrote, “gender identity is determined before and persists despite these effects.”²

Diane Ehrensaft, PhD, a professor at the Wright Institute in Berkeley, Calif, had a message more difficult for psychiatrists to hear. “The mental health profession has been consistently doing harm to children who are not ‘gender normal,’ and they need to retrain,” she told Psychiatric Times. Ehrensaft has specialized in therapy for foster children as well as for children with gender issues.

When she trained in the late 1960s, Ehrensaft said, the attitude of psychiatrists who taught her about such matters was that “children with gender identity issues other than normative are confused and are suffering from dysphoria” and need to be reoriented. That is “diametrically opposed” to what has been found since, she added.

To document the harm that has been done, she cited a January 2009 article in Pediatrics that found homosexual and bisexual young adults to have highly significant increases in a history of depression, illegal drug use, unprotected sex, and attempted suicide if their parents had rejected their sexual orientation.³ That study, in turn, cites numerous others over the prior decade with similar results, although none had previously examined parental rejection.

Ehrensaft said she would advise psychiatrists at her presentation that their role today is to help children understand their gender identity—which may not be what the birth certificate says—and to support rather than pathologize or malign their parents. “There’s more evidence of harm now than even 10 years ago,” she added, “and also a developing field of practice that clearly demonstrates means of helping these kids.”

Protestors are also focusing on the fact that the DSM-V Task Force on Sexual and Gender Identity Disorders is being led by Kenneth Zucker, PhD, psychologist-in-chief and head of the gender identity service in the child, youth, and family program at the Centre for Addiction and Mental Health as well as professor in the departments of psychiatry and psychology at the University of Toronto. Zucker has been on the record as saying that parents and clinicians should work to socialize very young children who behave in ways discordant with their physical gender so that they come to identify with it—but that teens who have not done so should be helped to adjust to their discordant gender identity.

A program at Children’s National Medical Center in Washington, DC, takes a different approach, offering in-person and online support groups to help families adjust to and help their children work through their own gender identity issues. Edgardo Menvielle, MD, MSHS, director of the program, was curious whether children seen in Washington have different mental health profiles than kids involved with the Toronto program. Based on Child Behavior Checklist ratings, he reported that the Washington youth showed “less pathological tendencies,” suggesting that peer support may “lessen manifestations of pathology in the child.”⁴

Speaking by telephone before the conference, Menvielle hastened to distance himself from that conclusion. “The implications are not very clear,” he said. “We’re dealing with a population that appears healthier overall, but it could be that we attract different families.”

Menvielle also said there is “a lot of anger about these issues,” and added, “I hope I don’t receive any tomatoes.”

Psychologist Ehrensaft said she’s eager to see studies that compare adults who received treatments intended to “normalize” their gender identities as children with those treated in more accepting environments. Meanwhile, she said, there is a move afoot to change the membership of the Task Force so that it is “more balanced.” She added that she hopes the protests do succeed in reorienting psychiatrists’ thinking about GID.

“We got homosexuality out of the DSM because of protests at the APA,” she pointed out. “Now it’s time to do the same with GID.”