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APA Statements on DSM Workgroups

Jim Burroway

June 3rd, 2008

Last week, we posted a statement from four transgender advocacy organizations on the American Psychiatric Association’s ongoing efforts to update the Diagnostics and Statistical Manual for its fifth edition (DSM-V). This week, we have two statements from the APA. The first one is about the DSM revision process, and the second one is about Kenneth Zucker’s participation on the DSM workgroup.


APA STATEMENT ON GID AND THE DSM-V
May 23, 2008

The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns about the Sexual and Gender Identity Disorders Work Group. The APA recognizes that this work group and others will address difficult and sometimes controversial issues. The APA’s goal is to develop a diagnostic manual that is based on sound scientific data, but also sensitive to the needs of clinicians and their patients. To this end, the APA has created a process that involves opportunities for review and input from persons with varied backgrounds and opinions.

Thirteen DSM-V work groups have been established to review all existing diagnostic categories in the current DSM. Individual work groups may propose revisions to existing disorder criteria, inclusion of new disorders, removal of existing disorders, or no changes to a disorder or its criteria. They may also propose revisions to the text that accompanies the criteria for each disorder. The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., has three subworkgroups:

  • Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.
  • Paraphilias, chaired by Ray Blanchard, Ph.D.
  • Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.

Each subworkgroup meets regularly, in person or on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are developed and then investigated through literature reviews and analyses of existing data. They also may further test research questions in field trials involving direct data collection. Because the work groups are limited in size, they may request outside advisors to assist them in these tasks, and to provide reviews and comments from other perspectives. Finally, in order to invite comments from even wider communities of researchers, clinicians, and consumers, the APA launched a web site in 2004, on which these groups can submit questions, comments and research findings, which are then distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses and clinical expertise, the subworkgroups will develop draft DSM-V diagnostic criteria. After a period of comment, the subworkgroups will review submitted questions, comments and concerns. The final draft of DSM-V will be submitted to APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. The final, approved DSM-V is expected to be released in May, 2012.

In summary, the DSM-V development process was constructed to achieve a thorough, balanced review of scientific data, with multiple levels of approval required, and opportunities for input from stakeholders. It is important to recognize that the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines. The APA is aware of a need for more scientific and clinical knowledge about the best medical and psychiatric care for individuals with Gender Identity Disorder. To address this need, the APA Board of Trustees voted to create a Task Force to review the scientific and clinical literature on GID treatment. The members of this Task Force will be appointed shortly.


Statement on Dr. Kenneth Zucker and Gender Identity Disorder (5/23/2008)

Kenneth J. Zucker, Ph.D., C.Psych., the Chair of the DSM-V Sexual and Gender Identity Disorders work group, is a widely respected and pre-eminent scholar in the world of academic sexology research. As Chair of the work group for Sexual and Gender Identity Disorders, Dr. Zucker’s role is to coordinate and facilitate the work of the three sub-work groups addressing Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders. Further information on the DSM-V development process can be found at [this web site].

Dr. Zucker has published 97 peer-reviewed journal articles, 48 book chapters, and a landmark textbook. His published work addresses psychosexual differentiation and its disorders, based on a wide range of empirical research studies on children and adolescents with gender identity disorder, with a focus on diagnosis and assessment, and their associated behavioral and psychological distress. As the current Editor of Archives of Sexual Behavior, the premier human sexuality research journal, he also has a wide familiarity with the disparate areas of sexual dysfunctions and paraphilias. Since 2001, he has been the Psychologist-in-Chief at the Centre for Addiction and Mental Health (CAMH), is a Professor in the Departments of Psychiatry and Psychology at the University of Toronto, and is on the Scientific Staff (Division of Child Psychiatry) at the Hospital for Sick Children. He was the President of the International Academy of Sex Research in 2005-2006.

Dr. Zucker and his service team at CAMH in Toronto have the longest standing research-clinical service for children and youth with gender identity problems in North America. Since the mid-1970s, Dr. Zucker and his team have evaluated over 900 children and youth with gender identity issues. Dr. Zucker is one of the few researchers who is doing long-term follow-up of the patients he has treated.

The philosophy of Dr. Zucker’s team is to provide client-centered care that maximizes benefit and minimizes harm to each child or youth. The goal of treatment is a well-adjusted youth, regardless of ultimate gender identity or sexual orientation, who feels she or he has been genuinely helped by her or his healthcare providers. Dr. Zucker has offered a variety of treatment options, understanding that options may vary greatly with the age of the client. For younger clients, therapy options include helping the child to overcome discomfort with his or her body, i.e., helping clients learn to live comfortably in their natal sex. Diagnosis and treatment of other problems that may be present, such as anxiety, depression, or substance abuse are also available, as are services for family members.

For adolescent patients (including those who first came to the clinic as young children), Dr. Zucker follows the Standards of Care Guidelines of the World Professional Association for Transgender Health. The treatment options include helping patients make a satisfactory transition to the opposite sex, including the institution of hormonal treatment to facilitate transition. In some cases, treatment may include helping an interested adolescent obtain sex-reassignment surgery.

For all patients, regardless of age, the focus of therapy is the patient’s gender identity, not the patient’s sexual orientation. Dr. Zucker’s therapeutic approach has no relationship to so-called reparative or sexual conversion therapies that attempt to change homosexual orientations to heterosexual ones. The goal of his therapy is the opposite of conversion therapy in that he considers well-adjusted transsexual, gay, lesbian or bisexual youth to be therapy successes, not failures.

Comments

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Ephilei
June 3rd, 2008 | LINK

I respect the APA very much, but I don’t see how they can not call Zucker’s methodology “conversion therapy.” If gay converstion converts from gay to straight, then isn’t a therapy that converts from trans to cis also conversion therapy? Isn’t it that simple?

Some similarities:

Zucker and ex-gay groups have a base assumption that gender and orientation are very fluid whereas the bulk of research suggests barely fluid.

Both focus on changing gender roles and gender expressions to change the root identity.

Neither has a peer reviewed model for gender identity/orientation or how they can change.

Both are overly concerned with how others, especially parents, peers, and partners react. Namely, both believe parents may choose the gender identity/orientation of their child.

Both outcomes have a huge failure rate and even “successes” have significant same-sex attractions.

Both don’t want to call a duck a duck. Ex-gays groups call their clients “same sex attracted” instead of gay and Zucker refuses to call any child transgender unless they fail therapy.

Both blame depressed mothers and distant fathers.

Both seem pre-occupied with born males over born females.

Both ignore the many healthy, productive queer people in favor of the depressed, rejected queers.

Ex-gays love Zucker and while Zucker has said little vice versa, it’s all been positive or neutral.

Boo
June 4th, 2008 | LINK

So basically, the trans community is going to have to repeat the gay community’s storming of the APA to get any real reform. Which will happen about the time that hell freezes over. In the meantime, they’ll just ignore all concerns and lie their asses off. Zucker has a very long paper trail of statements to the effect that transsexuality is a bad outcome, and that transsexual youth are failures.

Zucker thinks that an important goal of treatment is to help the children accept their birth sex and to avoid becoming transsexual. His experience has convinced him that if a boy with GID becomes an adolescent with GID, the chances that he will become an adult with GID and seek a sex change are much higher. And he thinks that the kind of therapy he practices helps reduce this risk.

Failure to intervene increases the chances of transsexualism in adulthood, which Zucker considers a bad outcome.

So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder.

quo III
June 4th, 2008 | LINK

Boo,

Regarding the idea that transsexuality is a bad outcome, why do you disagree?

Ephilei
June 4th, 2008 | LINK

Not speaking for Boo, I disagree because it de-legitimizes transexuals (or any kind of trans person) as worse than anyone else. I am trans and glad to be so. I’m glad my childhood therapist didn’t change my gender. Being trans has challenges, but they’ve made me stronger, more creative, and just more interesting. You hear a lot of sob stories about how awful it is to be trans (remember those analgous people struggling with homosexuality?) but they’re anecdotal at best and transphobic at worst. Like all LGBT people, we have pride in our queerness.

Besides, this is assuming that these children aren’t just brainwashed into thinking their gender identity isn’t trans. So far the jury’s out. If your identity is trans, it’s far better to know and accept it than repressing it. And if it can be chosen, I think kids should have the right to choose.

Boo
June 5th, 2008 | LINK

Regarding the idea that transsexuality is a bad outcome, why do you disagree?

Interesting that you would state it that way, because I didn’t actually give an opinion. I was just pointing out that the APA is lying about Zucker’s opinion.

As for my opinion, I don’t think it’s been proven that one should necessarily think of transsexuality as an “outcome” in the first place. There is no empirical research whatsoever demonstrating that Zucker’s brand of reparative therapy, or anyone else’s performed on transkids, actually changes any outcomes. The only results we know for sure of Zucker’s methods is that he makes children cry and have anxiety attacks.

Denise
June 10th, 2008 | LINK

Congratulations APA: Gender identity and sexual orientation are two distinct phenomena, and your board members are using an absurd level of literalism to dismiss an analogy to similar harmful practices in an attempt to justify your decision to put one K. Zucker in charge of a gender identity work group.

I would certainly not have entrusted my former partner to his care. The idea of this guy determining the standards that will guide diagnosis and treatment of transgender & genderqueer patients turns my stomach.

I talked with a clinician who usually uses the diagnosis code for PTSD for her gender-variant patients — because usually their work consists of unpacking all the damage from a lifetime of being mocked and abused for being gender-variant and moving forward into the fullness of self-expression. I wonder if the APA would consider such a reclassification for DSM-V.

Jonathan
June 10th, 2008 | LINK

I am disturbed by this paragraph:

“APA believes that no psychological disorder should be stigmatized or used as the basis for discrimination. People who are concerned about issues having to do with their gender identity should have access to appropriate and non-discriminatory treatment. Mental health providers need to educate themselves about how to provide such care.”

In other words, we may find your sexuality or gender identity to be disordered (which carries social and legal consequences), but we won’t discriminate on that basis?

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