Friday, October 17, 2008

Good Journalism Can Deal With Controversy

Via Zoe's blog, I found myself reading this article on transgender children, and some of the psychological and ethical debate surrounding the subject.

I've blogged about treatment of young transsexuals before, and I remain cautious about how such cases should be handled (I do believe that the current WPATH SOC approaches the subject with a degree of caution and humility that is appropriate). That said, The Atlantic has done quite a good job of actually researching the topic, and talking to various clinicians and researchers - and pointing out both the good and the bad.

“Maybe we really have to think … that we don’t come to this world neutral; that we come to this world with some degree of maleness and femaleness which will transcend whatever the society wants to put into [us].”

This comes to us from Dr. Milton Diamond (I'd never heard of him before reading this article, and I'm thinking I'd like to read more of his material - that quote is brilliant and encapsulates my own thinking about gender identity and social gender just about perfectly.

It did bring one thing out about Dr. Spack that bothers me a little:

Spack has treated young-adult transsexuals since the 1980s, and until recently he could never get past one problem: “They are never going to fail to draw attention to themselves.”

He's basically talking about appearances here. While he's correct to a point, I'm a little disappointed by a couple of aspects of his claims. Yes, the younger someone is when they transition, the easier it often is for them to achieve "passability" - the ability to be taken as their chosen gender without getting 'hairy eyeball' looks.

But, in making such a claim, Dr. Spack is also promoting a 'cult of beauty' that I find equally troubling. Men and women come in all sorts of shapes and sizes - some more 'classically beautiful' than others. Second of all, I see an inherent danger in his reasoning - it places a pressure on people to make a decision about their lives long before such a decision may be appropriate. Certainly, if by the age that puberty would be onset, a child is expressing - and still expressing - a strong cross gender identity, then yes, there is some merit to making puberty blocking drugs available, but some degree of caution is still appropriate.

The reason for my caution is actually mentioned in this article (which is a testament to the quality and depth of research the authors went to - some of this data is fairly obscure).

For 15 years, Dr. Richard Green followed 44 boys who exhibited extreme feminine behaviors, and a control group of boys who did not. The boys in the feminine group all played with dolls, preferred the company of girls to boys, and avoided “rough-and-tumble play.” ...

Green expected most of the boys in the study to end up as transsexuals, but nothing like that happened. Three-fourths of the 44 boys turned out to be gay or bisexual (Green says a few more have since contacted him and told him they too were gay). Only one became a transsexual. “We can’t tell a pre-gay from a pre-transsexual at 8,” says Green, who recently retired from running the adult gender-identity clinic in England.

Green's work predates the existence of the puberty blocking chemistry that Spack is using, but it does send up an important caution flag. There is a legitimate question here. For those who are truly transsexual, Spack's work will unquestionably be beneficial. The open question is for the 3/4 in Green's work that are Gay or Bisexual, what would the outcome be. Under Spack's treatment would gender transition be successful for them? Is their cross-gender behaviour a result of a core gender identity question, or is it sexual identity at play? Is the plasticity of the brain in pre-adolescent children adequate to allow a successful gender transition if the child is not actually transsexual? (or more correctly, would not feel a need to transition if they faced the same question in their 20s?)

I don't know what the answers to these questions will be. I hope that Dr. Spack is correct in his assumptions, and that the long term outcomes for this emerging wave of very youthful transitions will be either proof or refutation.

Then the article turns to Dr. Zucker:

In his case studies and descriptions of patients, Zucker usually explains gender dysphoria in terms of what he calls “family noise”: neglectful parents who caused a boy to over­identify with his domineering older sisters; a mother who expected a daughter and delayed naming her newborn son for eight weeks. Zucker’s belief is that with enough therapy, such children can be made to feel comfortable in their birth sex.

Where Spack's work is unsettling, Zucker leaves many in the transgender community as a whole feeling quite suspicious that he is actually propagating the patterns of self-denial and repression that many transsexuals who transition later in life describe. Personally I find his "family noise" hypothesis troublesome - it smacks of long ago discredited ideas about the causes for homosexuality (that the religious right just loves to revive at every opportunity).

The article itself chronicles two of Zucker's "success stories", and I find them troubling indeed:

When I visited the family, John was lazing around with his older brother, idly watching TV and playing video games, dressed in a polo shirt and Abercrombie & Fitch shorts. He said he was glad he’d been through the therapy, “because it made me feel happy,” but that’s about all he would say; for the most part, his mother spoke for him. Recently, John was in the basement watching the Grammys. When Caroline walked downstairs to say good night, she found him draped in a blanket, vamping. He looked up at her, mortified.

I'm sorry to say, but that sounds to me far too much like denial and 'closet activity' - a pattern that can be deeply destructive, and in some cases will lead the individual to behaviours that are overtly self-destructive.

I spoke to the mother of one Zucker patient in her late 20s, who said her daughter was repulsed by the thought of a sex change but was still suffering—she’d become an alcoholic, and was cutting herself. “I’d be surprised if she outlived me,” her mother said.

Ouch - I feel for both the patient and her parents. That's a pretty ugly situation that has evolved. For all that Zucker claims that none of his younger patients have ever transitioned, I wonder aloud just how well they have fared in later life.

Neither Zucker nor Spack have a lock on "what's right" here. Neither of them can. Green's studies tend to favour Zucker's approach in some respects, but then again, the techniques Spack is employing didn't exist in the 1980s. How well a young person will adapt to gender transition when they have done so voluntarily is an open question, and one that only time will tell.

Long term outcome study is difficult in these circumstances, but it is also necessary. Spack is taking huge risks, and I fear Zucker has fallen into the trap of assuming that cross-gender identity as a lie that can be "overcome" through therapy.

The article itself is well written, intelligent and balanced overall. Kudos to The Atlantic for tackling a difficult topic and still keeping their sanity about them.


Lisa Harney said...

I don't think Green's results really mean anything, unfortunately. They don't sound very conclusive - and they are consistent with how many trans people cope with being trans without transitioning. That is to say, what were they like 20, 25, 30 years later? How many ultimately transitioned? How many repressed?

Also, the Atlantic's reporting is insensitive to trans people - the author consistently misgenders people, referring to them by their sex assigned at birth rather than by the sex they identify with. The article is titled "A Boy's Life" but the titular boy actually identifies herself as a girl.

I'd also compare Zucker's theories to the "refrigerator mother" theories about autism.

It would probably be a much better article if the correct pronouns were used throughout. It's not bad, but it's troubling because of the way it misgenders trans people.

MgS said...

Green's results are not conclusive, I agree. However, they should be seen as something of a cautionary note with respect to the work that Spack is doing.

I agree with your criticism of the gender pronoun usage - I wasn't reading the article wit an eye to that, but rather found that I was more interested in the fact that the article made a fairly honest effort to examine the various perspectives that are in the research and clinical literature. (Which, sadly, is all too rare)

Anonymous said...


I had been a patient of Dr. Spack for a number of years.

I've also been quoted in numerous articles about gender identity issues. In most of those article, I have been misquoted, by journalists who just don't appreciate nuances (despite attempts to educate them) and/or shorten quotes in a way that uses inaccurate terms that I didn't (and never) use (e.g., "sexual identity").

While I don't know what words Dr. Spack used, I suspect the point he was making is that it would far easier for a person such as me to "pass" if I had the opportunity to affirm my gender years earlier. It isn't an issue a beauty; it's an issue of avoiding social ostracization.

The fact is that testosterone alters the structure of a person's body. For those of us who are affirmed women, those alterations generally are not favorable.

Dr. Spack, and a few other people, helped me when no one else would. Dr. Spack never once made me feel as if I wasn't a beautiful person; never once suggested that I should have FFS, despite the fact that others urged me to so that I could better match their definitions of what a woman should/needs to look like.

The reason why I have succeeded so well in my affirmation is because of the few people like Dr. Spack who I was so fortunate to encounter early in my journey. I learned early on that success in my affirmation was tied to my own acceptance of who I am, not the acceptance of others. Dr. Spack, not those in our own community who overly praise the virtues of FFS, helped provide the right milieu for understanding that at a difficult time in my life. (Lest I be misunderstood, FFS may well be the right option for some people, and I'm glad it is an option to those who desire it.)

Please do give him the benefit of the doubt.


Christine Benjamin

MgS said...

Hi Christine,

Personally, I am quite supportive of Spack's work.

I am a little sensitive to what I often see as "looksism" as applied to transsexuals - society already plays a nasty game with women in general over beauty, and I am cautious when I see statements from practitioners dealing with transsexuals that focus on appearances only. It is my sincere hope that Dr. Spack is far wiser than those statements suggest, but I think you can appreciate my cautiousness.

The second aspect of the discussion is really an expression of a fairly obvious unknown - namely long term outcomes for Spack's patients. I believe he is on the right path in many respects, but at the same time I must recognize that we do not fully understand how psychological gender and social identity develop in children, and how Spack's approach will influence that development remains to be seen.

Do not take my commentary as hostile to Dr. Spack - for it is far from it. (and if you look through my archives, I think you'll see a pattern with respect to transsexualism in general that is not hostile in the least)