Saturday, 11 July 2009

The Puzzle, The Science, The APA and the DSM-V

Clinical implications of the organizational and activational effects of hormones. Diamond M Horm Behav. 2009 May;55(5):621-32

Debate on the relative contributions of nature and nurture to an individual's gender patterns, sexual orientation and gender identity are reviewed as they appeared to this observer starting from the middle of the last century. Particular attention is given to the organization-activation theory in comparison to what might be called a theory of psychosexual neutrality at birth or rearing consistency theory. The organization-activation theory posits that the nervous system of a developing fetus responds to prenatal androgens so that, at a postnatal time, it will determine how sexual behavior is manifest. How organization-activation was or was not considered among different groups and under which circumstances it is considered is basically understood from the research and comments of different investigators and clinicians. The preponderance of evidence seems to indicate that the theory of organization-activation for the development of sexual behavior is certain for non-human mammals and almost certain for humans. This article also follows up on previous clinical critiques and recommendations and makes some new suggestions.
Professor Milton Diamond (who I hold in the very highest regard BTW) then goes on to say in the conclusions:
The evidence for androgen-induced organization-activation in nonhuman mammals is clear. The preponderance of evidence does point in that direction for humans as well but the evidence is less clear. Due to pre birth conditions the human appears to be biased towards sex appropriate patterns of behavior, sexual orientation and gender orientation. The reason for the lack of surety is simple. With animals experimentation is possible so one can modify parameters of study to get a better understanding of cause and effect relationships. This is not ethically proper for humans. For humans it takes so-called experiments of nature and different clinical situations to offer opportunities for analysis. And basically the human experiments of nature are in the areas of intersex and different trans conditions, principally transsexuality.
We must be careful about the standards of proof here. From a biological and scientific viewpoint, he's not only correct, but an adequate standard of proof is impossible. From a medical viewpoint though, the standards have to be set far lower. That's because most of medical practice suffers the same disadvantage - that vivisecting humans is unethical, pace Dr Mengele & Co. We have to take our best guess, where the proponderance of evidence is on one side, and then base our treatments on that. And most importantly, follow up on the results of that treatment, to make sure we're curing more than we kill.

Meanwhile, back at the American Psychiatric Association... the brouhaha over the whole DSM-V revision is getting worse - and not just in the area of "sexual disorders". Many are questioning just what the heck they're doing, and how much of Psychiatry has any evidential basis whatsoever.

From the Carlat Psychiatric Blog article, The DSM-V Armageddon Part 2 :
Dr. Jane Costello has had enough of DSM-V, and has quit the prestigious DSM-V Work Group on Disorders in Childhood and Adolescence. Her letter of resignation has been making the rounds (with her permission); I've reproduced it below, or you can access it directly here. Dr. Costello is a full Professor at the Duke Institute for Brain Sciences where she co-directs the Center for Developmental Epidemiology, and she is an international expert in understanding the course of mental illness across the life span.

Essentially, Dr. Costello resigned because she feels that the DSM-V process is being rushed to completion without an adequate scientific basis.
Much of psychiatry doesn't even meet the medical standard of proof - it's based on philosophical theory, anecdote and what can only be described as superstition. Just because it's difficult to gather the evidence, and that the evidence by its very nature can never be conclusive, doesn't mean to say that you can look at a Tabloid article, and from that formulate a completely new disorder, diagnose it for someone recently deceased who you've never actually met, and then pretend that it's science rather than speculation. Oh yes, disregarding any physiological disorders or biological evidence that doesn't fit your lede.

Not that anyone would do that of course. Well, except for Dr J.Michael Bailey in his article on Scientificblogging, Michael Jackson: Erotic Identity Disorder?:
Am I suggesting Michael Jackson was a homosexual autohebephile? I sure am.
"Erotic Identity Disorder" is a whole new diagnosis he's just made up for the occasion. Yes, well, and younger trans women are particularly suited to prostitution too, as he stated in his "scientific" book The Man Who Would Be Queen based on talking to less that a dozen Trans prostitutes at a gay bar. (Hint: go to a gay bar and don't be surprised if you find gays rather than women)
Bailey's perceptions might have been skewed by his lack of contact with the health professionals in this field (he is not a member of the Benjamin Association) and his reliance on very limited field work with a very small sample of transgender informants in Chicago gay bars.
In the book, Bailey explicitly states how much he respects his informants, yet information from transsexuals that contradicts his theory is dismissed as self-justification, identity politics, and lies: ". . . they are often silent about their true motivation and instead tell stories about themselves that are misleading and, in important respects, false" (p. 146).

by Walter O Bockting PhD. The Journal of Sex Research Volume 42, Number 3, August 2005: pp. 267—270
But enough about him. His publicity-seeking wild speculations have now started to alienate even those who used to take him seriously.

Some psychiatrists are looking at this professor of psychology, and seeing far too much of themselves in him. Which is unfair to them, as they're trying to do their best, with so little evidence to work with. What's really scary is that the puzzle of transsexuality and gender identity is now rather better researched than most areas.


Anonymous said...

The real scandal is not that the DSM is not particularly scientific--it's that clinicians DO NOT USE DSM criteria when making "DSM" diagnoses, and routinely concoct patient histories!

-- bonze

Boo said...

From my experience working in the mental health field, if you send a person to 5 different psychiatrists, you're likely to get five different diagnoses.

The damn thing is, a lot of clinicians working in this field will privately admit the GID diagnosis is pretty much complete BS, but no one wants to do anything about it. I exchanged a few emails with Bockting after his review came out. He was harsher off the record, but asked me not to forward his comments to Lynn Conway or Andrea James because he didn't want them printed publically.

I wonder if it might be possible, assuming DSM V turns out to the the travesty it looks like it will, to start a movement to get gender therapists to start diagnosing everyone as a "homosexual transsexual" or whatever equivalent they come up with, since it's arbitrary anyway and just to underline the ridiculousness of it?

MgS said...

I can't speak for the psychiatric profession as a whole, but I must point out that the clinicians and researchers who are part of WPATH are making an honest and sincere effort to quantify their findings with respect to transgender people.

Of particular interest from the WPATH Symposium in Oslo this year are Revision Suggestions for Gender Related Diagnosis in the DSM and ICD. (full text)

I won't say I agree with everything in that presentation, but I certainly think it is overall well thought out and reasoned.

If the working group for Gender diagnosis takes at least some of these recommendations, you may well find that the DSM goes in a much more constructive direction.

Zoe Brain said...

I don't question anyone's honesty and sincerity. OK, maybe Bailey's, but even then....

With Ken Zucker in charge of the panel though, whose relationship with WPATH is to say the least strained, I'm not sure how much influence they will have.

I have problems with some of the well-meaning people who are doing their very best to be the best medics they can be, "curing" trans kids in 5% of cases, and in the process, all too often leaving them with wrecked lives, depression, suicidal ideation... but "cured".

There are worse things one can be than trans. I don't think some of them see that.

The trouble is, I can't be certain of my own objectivity here either. We *all* need peer-review.

Anonymous T-Girl said...


Powerful gods struggle. Helpless people watch.

A shocking amount of DDT was used throughout the area that my mother lived and gave birth. So much so that research studies were conducted in the area to look into cancer rates after the fact.

No one i know of has taken notice, let alone interest, in transsexuality there. i am one of four hard-core transsexuals i know of born within one mile and one year of each other.

In a population of about three thousand people.

i have yet to find anyone i can make contact with, doing any form of research whatsoever.

By all means, please. When i die, poke and slice away.

MgS said...


While Zucker and Blanchard's involvement in the DSM V is troubling from the perspective of transgender people in general, I think that depends entirely on how much direct control they are able to exert over the final outcomes.

(Not being overly familiar with the workings of APA workgroups, I don't know if the Chair position grants its occupant "final say", or is more of a moderating role)

However, it is important to note that neither Zucker or Blanchard are directly involved with the GID part of that work group.

From what I can discern, the working committee actually involved in the gender identity discussions is composed of people who are much less controversial than Zucker or Blanchard.

So, the real question is in fact structural - does Zucker's position as Chair give him any kind of veto or final say?

(As an aside, Blanchard is spending his time in the paraphilias side of the discussion, and unless he can persuade the rest of the committee that Autogynephilia is a legitimate paraphilia, I'm not so sure he'll get too far.

The interesting question that would arise is if GID remains in the DSM in more-or-less its current form, and autogynephilia were added as a paraphilia, would one exclude the other or not? A recent conversation I had with a researcher/clinician type about that was that at most it might be a secondary diagnosis, but since the outcomes in general are consistent with transsexualism in general, there is little reason that autogynephilia would be used as an exclusive diagnosis to deny access to transition related treatment.

R S said...

To "Anonymour T-girl",

Apparently, DDT is/was not the only danger, and nowhere on Earth is safe from man-made chemicals; for example, things like pesticides, PCBs, dioxins, etc. are insidiously dangerous. These chemicals - which affect hormone levels in foetuses - are believed to cause certain types of cancers, fertitlity problems, attention deficit disorders, sexual abnormalities, IQ levels, and other problems. This is covered in a very scary book called "Our Stolen Future", by Theo Colborn, et al. I read it a few years ago, and it made me very angry.