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

Abstract
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).

Review 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.