Exodus Shuts Down ... And Is Replaced

While LGBT people in North America have been celebrating the shutdown of Exodus International, the moment of schadenfreude has perhaps resulted in overlooking something equally important that has been happening in parallel.

Alan Chambers has issued a heartfelt apology for the damage his organization did to the lives of so many over the decades of its existence.  I will applaud him for that - although it is much easier to applaud his recent change of understanding than it will ever be to forgive what his organization did to so many.

However, at the same time that Exodus was collapsing, another organization was being created to take its place - Restored Hope Network.  This is, to say the least, an evil little twist.  One look at their advisory board is pretty much an index of the most extreme hardline cases in the anti-gay world.  It contains Matt Barber, Dr. Michael Brown, Joseph Nicolosi and Mat Staver to name a few.

About the only crazy they don't have on their board are the discredited ones like Peter LaBarbera and Paul Cameron.

I expect that we will start seeing propaganda out of this group in the not too distant future.

The real question is whether this "ministry" (propaganda machine, more like) is actually able to draw in new membership, or is it simply going to be reflective of the increasing concentration of activity in a group that is increasingly isolated and dwindling in numbers?  I don't have an immediate answer to this, it is the question that will only be answered by time.

In Outer Wingnuttia ... The Howling Begins

I wrote about the APA's report on "change therapy" for sexual orientation yesterday.

Today, we have the loons in Outer Wingnuttia squawking about it - and they aren't happy at all.

I'll let Mr. Hooper over at the Good As You blog take apart the pathetic attempt at spin from Exodus.

NARTH, on the other hand delivered some whoppers in their press release.

Unfortunately, however, the report reflects a very strong confirmation bias; that is, the task force reflected virtually no ideological diversity. No APA member who offers reorientation therapy was allowed to join the task force.

Oh dear, apparently NARTH's all upset because nobody "from their team" was on the task force. I think this tells us a great deal about NARTH's approach to research. Good research is impartial. That is to say, it is evidence based, not rooted in political ideology.

The APA report doesn't make any statements without citing what research those statements are based on. There's a lot of a research that they reviewed from NARTH's Nicolosi, Byrd and others - in addition to all the other material they reviewed.

They selected and interpreted studies that fit within their innate and immutable view. For example, they omitted the Jones and Yarhouse study, the Karten study, and only gave cursory attention to the Spitzer study.

Ummm...bullfeathers. Spitzer's work is cited multiple times through the document, as is work by E. Karten. Similarly, the Jones & Yarhouse study from 2007 is in fact cited in the bibliography. NARTH can't even be bothered to read the documents they are criticizing!

In a fit of complete irony, Mark Yarhouse served as one of the scholarly reviewers of this study.

Further, the APA report actually takes the time to explain the problems with reports like Jones & Yarhouse, or Spitzer come to that:

65 A published study that appeared in the grey literature in 2007 (Jones & Yarhouse, 2007) has been described by SOCE advocates and its authors as having successfully addressed many of the methodological problems that affect other recent studies, specifically the lack of prospective research. The study is a convenience sample of self-referred populations from religious self-help groups. The authors claim to have found a positive effect for some study respondents in different goals such as decreasing same-sex sexual attractions, increasing other-sex attractions, and maintaining celibacy. However, upon close examination, the methodological problems described in Chapter 3 (our critique of recent studies) are characteristic of this work, most notably the absence of a control or comparison group and the threats to internal, external, construct, and statistical validity. Best-practice analytical techniques were not performed in the study, and there are significant deficiencies in the analysis of longitudinal data, use of statistical measures, and choice of assessment measures. The authors’ claim of finding change in sexual orientation is unpersuasive due to their study’s methodological problems.

Then NARTH goes on to try and spin the issue of Reparative Therapy causing serious harm to clients:

We believe the report indirectly supports the findings published in the current Journal of Human Sexuality that reveal no significant ill-effects of therapy. Further, if some clients are dissatisfied with the therapeutic outcome, as in therapy for other issues, the possibility for dissatisfaction appears to be outweighed by the potential gains.

The Journal of Human Sexuality? Oh NARTH's Journal of Human Sexuality - their in-house vanity journal. Somehow, I'm not thinking that this is exactly seen as a high value journal outside of NARTH's membership. As Ex Gay Watch points out, the study NARTH is referring to is flawed from the start - and its authors have admitted as much.

I find it deeply troubling that NARTH simply tries to dismiss the prospect of psychological harm experienced by clients of Reparative Therapy dismissively as "dissatisfaction".

The APA report is much more honest about the issue, and state the following:

We concluded that research on SOCE (psychotherapy, mutual self-help groups, religious techniques) has not answered basic questions of whether it is safe or effective and for whom. Any future research should conform to best-practice standards for the design of efficacy research. Additionally, research into harm and safety is essential.

In short, the APA is saying that the research done into various attempts to change one's sexual orientation is so limited, and flawed, that it neither refutes nor substantiates claims of harm.

The problem that groups like NARTH face is that their "research" is simply not credible when you hold it up to scrutiny.

So Much For Reparative Therapy

For the last ten years or more, the "Pray away the Gay" crowd in the religious right has been trying to prop up NARTH to provide the appearance of legitimacy for their position that "homosexuality can be changed/cured/prayed away".

As reported on CNN, the American Psychological Association chose to review the real research on such programs (not the spewage from Paul Cameron, or the various lobby groups, but actual peer reviewed research that has been published in reasonable journals), and released their report titled Appropriate Therapeutic Responses to Sexual Orientation.

The upshot of their findings:

The appropriate application of affirmative therapeutic interventions with adults is built on three key findings in the research: (a) an enduring change to an individual’s sexual orientation as a result of SOCE is unlikely, and some participants were harmed by the interventions; (b) sexual orientation identity, not sexual orientation, appears to change via psychotherapy, support groups, or life events; and (c) clients benefit from approaches that emphasize acceptance, support, and recognition of important values and concerns.

In short, reparative therapy is snake oil. Something which most critically thinking people would have long ago figured out.

Ironically, NARTH founder Joseph Nicolosi's work is heavily cited in this study:

Nicolosi, J. (1991). Reparative therapy of male homosexuality. Northvale, NJ: Jason Aronson.
Nicolosi, J. (1993). Healing homosexuality. Northvale, NJ:Jason Aronson.
Nicolosi, J. (2003). Finally, recognition of a long-neglected population. Archives of General psychiatry, 32, 445-447.
Nicolosi, J., Byrd, A. D., & Potts, R. W. (2000). Retrospective self-reports of changes in homosexual orientation: A consumer survey of conversion therapy clients. Psychological Reports, 86, 1071-1088.
Nicolosi, J., & Nicolosi, L. A. (2002). A parent’s guide to preventing homosexuality. Downers Grove, IL: InterVarsity Press.

Although, Nicolosi's work is cited primarily in the background chapters describing the discussion itself, and in particular advocacy from groups like NARTH.

Where Nicolosi's research is actually cited or discussed for its merits, it comes in for some fairly harsh criticism:

A meta-analytic review of 14 research articles (Byrd & Nicolosi, 2002) is not discussed in this report. The review suffers from significant methodological shortcomings and deviations from recommended meta-analytic practice (see, e.g., Durlak, Meerson, & Ewell-Foster, 2003; Lipsey & Wilson, 2001) that preclude reliable conclusions to be drawn from it.

For instance, to assess whether sexual orientation had changed, Nicolosi et al. (2000) performed a chi-square test of association on individuals’ prior and current self-rated sexual orientation. Several features of the analysis are problematic. Specifically, the nature of the data and research question are inappropriate to a chi-square test of association, and it does not appear that the tests were properly performed. Chi-square tests of association assume that data are
independent, yet these data are not independent because the row and column scores represent an individual’s rating of his or her past and present self.

Recent studies have investigated whether people who have participated in efforts to change their sexual orientation report decreased same-sex sexual attractions (Nicolosi et al., 2000; Schaeffer et al., 2000; Spitzer, 2003) or how people evaluate their overall experiences of SOCE (Beckstead & Morrow 2004; Pattison & Pattison, 1980; Ponticelli, 1999; Schroeder & Shidlo, 2001; Shidlo & Schroeder, 2002; Wolkomir, 2001). These studies all use designs that do not permit cause-and-effect attributions to be made. We conclude that although these studies may be useful in describing people who pursue SOCE and their experiences of SOCE, none of the recent studies can address the efficacy of SOCE or its promise as an intervention.

Childhood interventions to prevent homosexuality have been presented in non-peer-reviewed literature (see Nicolosi & Nicolosi, 2002; Rekers, 1982). ... Thus, we concluded that there is no existing research to support the hypothesis that psychotherapy in children alters adult sexual orientation.

Not exactly a promising assessment ... and arguably invalidates many of the shibboleths held by the advocates of "change therapy".

H/T: Commenter "SB" for bringing this to my attention

NARTH Demonstrates Their "Science"

I see that NARTH has decided to brag about their recent appearance on Dr. Phil.

Here's Nicolosi's statement.

I took the position that children should not, however, be encouraged to think of themselves--and live as--as the opposite sex. All of the other psychotherapists disagreed with me.

An opening position that sits in direct conflict with the WPATH Standards of Care for managing transgender clients.

Psychological and Social Interventions. The task of the child-specialist mental health professional is to provide assessment and treatment that broadly conforms to the following guidelines:
1. The professional should recognize and accept the gender identity problem. Acceptance and removal of secrecy can bring considerable relief.

2. The assessment should explore the nature and characteristics of the child’s or adolescent’s gender identity. A complete psychodiagnostic and psychiatric assessment should be performed. A complete assessment should include a family evaluation, because other emotional and behavioral problems are very common, and unresolved issues in the child’s environment are often present.

3. Therapy should focus on ameliorating any comorbid problems in the child’s life, and on reducing distress the child experiences from his or her gender identity problem and other difficulties. The child and family should be supported in making difficult decisions regarding the extent to which to allow the child to assume a gender role consistent with his or her gender identity. This includes issues of whether to inform others of the child’s situation, and how others in the child’s life should respond; for example, whether the child should attend school using a name and clothing opposite to his or her sex of assignment. They should also be supported in tolerating uncertainty and anxiety in relation to the child’s gender expression and how best to manage it. Professional network meetings can be very useful in finding appropriate solutions to these problems.

Then Nicolosi goes on to pronounce the following:

"Gender-identity disorder is primarily an attachment problem." These words, spoken by me during the TV interview, were edited out, but they are critical to the understanding of gender-disturbed children. No one on the show discussed this issue.

Where to start with that steaming turd of idiocy? Besides being a classic reframing of the standard right wing 'blame the parents' approach to GLBT people in general, it's just plain wrong. Transsexuals come from all backgrounds, and most are disappointingly ordinary.

Experts in the area of childhood gender-identity disorder (GID) have found certain patterns in the backgrounds of GID children. A common scenario is an over-involved mother with an intense, yet insecure attachment between mother and child. Mothers of GID children usually report high levels of stress during the child's earliest years.

Besides the fact that Nicolosi conveniently doesn't refer to any published papers to substantiate this claim, the claim itself doesn't make any sense when held up against the stories of so many who have transitioned. Raising children is difficult, stressful work to begin with, and raising a child who is transgender - and expresses such at an early age - is going to be all the more so because most parents have no idea what they are dealing with.

The infantile dynamic of "imitative attachment" is such that "keeping Mommy inside" becomes truly a life-or-death issue - "Either I become Mommy, or I cease to exist." This explains why gender-disturbed boys are willing to tolerate social rejection for their opposite-sex role-playing--it feels like death to abandon this perception of themselves as a female.

This is pure conjecture on Nicolosi's part. We do not know enough about how personality develops to make such claims - especially with respect to what is going on in an infant's mind. The one thing I will say is that parents (and other adults) routinely underestimate just how much babies understand of what is going on around them.

No one on the Dr. Phil Show mentioned the implications of taking the opposite approach--actively preparing a boy for future sex-change surgery. Surgery can never truly change a person's sex. Doctors can remove the male genitals and form an imitation of the sex female sex organs, but they cannot make the simulated organs reproductively functional--nor can they change the DNA which exists in every cell of the boy's body to indicate that he is, and always will be, biologically a male.

For starters, this is neither news, nor is it filled with unstated implications. Again, I refer to the WPATH Standards of Care for a clearer sense of guidance in the treatment of youthful transsexuals:

Physical interventions fall into three categories or stages:
1. Fully reversible interventions. These involve the use of LHRH agonists or
medroxyprogesterone to suppress estrogen or testosterone production, and consequently
to delay the physical changes of puberty.
2. Partially reversible interventions. These include hormonal interventions that masculinize
or feminize the body, such as administration of testosterone to biologic females and
estrogen to biologic males. Reversal may involve surgical intervention.
3. Irreversible interventions. These are surgical procedures.
...
Fully Reversible Interventions. Adolescents may be eligible for puberty-delaying hormones as soon as pubertal changes have begun. In order for the adolescent and his or her parents to make an informed decision about pubertal delay, it is recommended that the adolescent experience the onset of puberty in his or her biologic sex, at least to Tanner Stage Two.
...
Partially Reversible Interventions. Adolescents may be eligible to begin masculinizing or feminizing hormone therapy as early as age 16, preferably with parental consent. In many countries 16-year olds are legal adults for medical decision making, and do not require parental consent.

Mental health professional involvement is an eligibility requirement for triadic therapy during adolescence. For the implementation of the real-life experience or hormone therapy, the mental health professional should be involved with the patient and family for a minimum of six months.
...
Irreversible Interventions. Any surgical intervention should not be carried out prior to adulthood, or prior to a real-life experience of at least two years in the gender role of the sex with which the adolescent identifies. The threshold of 18 should be seen as an eligibility criterion andnot an indication in itself for active intervention.

The term 'informed consent' echoes throughout the WPATH SOC. Nobody is talking about surgically altering anybody until the person is old enough to make their own decision on the matter - when they are old enough to make those decisions in the full knowledge of the consequences.

Further, Gender Reassignment Surgery is often necessary to remove the potential for discrimination to take place - namely the legal requirement for surgery before key identification documents may be changed to reflect the individual's chosen gender. Nobody undergoes GRS with any illusions about the limitations of that procedure.

We believe that every effort should be made to help a gender-disturbed boy accept his biological maleness, and be comfortable in life with the intact (not surgically mutilated) body with which he was born.

Again, I refer Mr. Nicolosi back to the WPATH Standards of Care for more practical guidance. Attempting to 'make' a transgender child act different than they express so openly is merely asking for that individual to grow up at war with themselves - a painful state to condemn anyone to. As I have stated before on this blog, and elsewhere, the ethical considerations of managing youthful transition are being actively studied and considered. The reason that the SOC today addresses GID in youth in the cautious way it does is explicitly because practitioners have already learned that GID in youth causes very real distress that needs to be addressed constructively, not suppressed or denied.

With this latest episode, NARTH simply continues to demonstrate what so many in the GLBT world have claimed for so long - that they exist not to do real research, but rather to put a face of legitimacy on the suppositions that religious conservatives make about transsexuals and other sexual minorities in the first place.

Dr. Phil & Focus on the Family on "Feminine" Children

I don't know where to start with Dr. Phil's show today.

Viewers flooded the message board with letters and impassioned opinions after Dr. Phil’s first show on gender-confused kids. This hotly contested topic is back on the table. Should parents support a child's decision to live as the opposite sex, or is it the parent’s job to guide the child into his or her biological gender?

The first thing that makes me angry with this is the use of the exceedingly misleading term 'Gender Confusion'. For someone purporting to have a decent background in psychology, he should know that "gender confusion" is an invention of the religious right, intended to denigrate and diminish transgender people as a whole.

Special Thanks

* Dr. Joseph Nicolosi
Narth.com
* Glenn Stanton
Focus on the Family
* Dr. Dan Siegel
* Dr. Michelle Angello
* Dr. Jo Olson
* Dr. Eva Cwynar

Great - so far, of those players, we have two people from known anti-GLBT organizations, and only one of the rest appears to have any qualfications at all with respect to gender and sexuality - Dr. Michele Angello.

Did the idiots at "Dr. Phil" even contact WPATH to get someone who actually specializes in gender identity issues?

Granted, I'm not sure anyone from WPATH would touch a program involving Dr. Phil, much less the inclusion of NARTH and Focus on the Family.

Instead, they bring in people who think that gender identity issues are trivial and easily dismissed, or that gender roles should be strictly enforced:

The question:

I have written Focus before (over the years) about how to handle the feminine behavior that my 8 yo son exhibits. He LOVES long hair. As a toddler he would put hi s blanket on his head and declare that he was a girl for the day. We eventually took the blanket away, but there has always been something in its place. He would rather braid his sisters' doll's hair than just about anything.

The other day I (Mom) got after him for playing w/ his sister's American Girl Doll. I raised my voice and told him to put it away "now!" Then I got myself together and spoke w/ him about how this desire to fix girl's hair honors God. I asked him to pray about it and told him I would too, but I am not gleaning any fabulous wisdom, yet. Until today, when I'm convinced, God lead me to this site, just at this time so I could post this question.
...

The response from FOTF's Stanton:

Thank you so much for your note. It is important to understand the age, and you say this boy is 8. That is a pretty advanced age for this kind of behavior, but do not fear. It is VERY important that MOM be the one that does the "scolding" of more feminine boys and dad do the "redirecting" play...good cop/bad cop kind of thing. Dad MUST be the good cop for boys, to help welcome them into this curious world of men.

It sounds like you are doing that, which is good. It will be important to talk to the boy about his desires and have him explore what is behind them...redirecting him gently toward masculine understanding of that, such as "Hey, some men have long hair. Some men are hair dressers." Connect a seemingly feminine interest with masculine ideals. What this will do and help with is helping understand the world of men, by connecting it to something he can currently relate to. It is the idea of moving the chess piece of gender understanding and identity one small move at a time.

This is important. My son dealt with, around the age of 4, loving to dress up with his sisters in their dresses and stuff. We did the above and it worked great.

Oh goody - this one's ripe. Not only do we implicitly blame the parents for this, he then suggests nothing more than rigid enforcement of gender roles based on stereotypes.

I have a newsflash for this idiot - if this child is transsexual, he already is - all of the attempts at behaviour modification techniques you can try are doomed to fail. The most you will accomplish is alienating and shaming the child into hiding how they feel.

If they aren't transsexual, then chances are that as the child goes through puberty, things will settle down into something quite normal. Frankly, the parents making the kind of worried fuss that they are is the problem, not the child's behaviour.

Blaming the parents is just downright offensive. Parents can influence a child's behaviour, but there are some things that simply cannot be influenced. Besides, just what is wrong with a boy that has "stereotypically feminine" interests? We nudge and wink at 'masculine girls' and call them 'tomboys', but it is some kind of tragedy when it's a boy? Please, get over it.

Dr. Phil gets a giant brickbat for giving the wingnuts a platform to spew their misleading, deceitful nonsense.

NARTH - Bad Science Masquerading

When an article appeared on NARTH's website entitled "Transsexuality Explained", I braced myself for some pretty awful reasoning ... I wasn't disappointed.

Just as NARTH wants people to believe that homosexuality is "abnormal" and "curable", they would dearly like us all to believe that transsexualism is somehow invalid. (Go ask a transsexual sometime how they feel about someone else declaring their entire life experience "invalid")

The author of this boldly titled paper is Sander J. Breiner - a man who's involvement in sexuality appears to start and end with NARTH, most of his online CV is in domains well outside the domain, much less focused on the highly specialized field of gender identity. This gap in Breiner's background is significant because it influences his analysis of evidence that he cites.

I'll scroll to the end of Breiner's argument to start with because it contains an important gem that reveals his assumptions:

However, when an adult who is normal in appearance and functioning believes there is something ugly or defective in their appearance that needs to be changed, it is clear that there is a psychological problem of some significance.

The more pervasive and extensive is this misperception of himself, the more significant is the psychological problem. The more the patient is willing to do extensive surgical intervention (especially when it is destructive), the more serious is the psychological problem.

Superficially, Breiner is almost sounding reasonable here. However, in making this claim, he is confusing two distinct diagnostic categories. He is claiming (quite incorrectly) that Gender Identity Disorder as a variation of Body Dismorphic Disorder.

Let's consider the key criteria for both for a moment:

Body Dismorphic Disorder:

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Gender Identity Disorder:

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex
(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games and pastimes of the other sex
(5) strong preference for playmates of the other sex. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

What I'd like to draw your attention to is the fact that the emphasis NOT upon the physiology, but in fact upon the social role associated with a given gender:

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

Which is dramatically at odds with Body Dismorphic Disorder, where the focus is very much upon the physical manifestation of the body:

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

The point I'm trying to get to here is that when we are talking about transsexualism, we are talking more about the social role which an individual lives in far more than the physical changes that are associated with the condition, and that is such a key distinction that it calls into question a great deal of Dr. Breiner's analysis.

Individually, the topics that Breiner attempts to string together to arrive at his conclusion that in fact a transsexual is not a transsexual suffer from some basic logical errors, and inferences that simply do not hold up to scrutiny.

The transsexual male, who was not part of a university/medical school treatment program, will often take hormone treatment (self-prescribed and administered); and play a feminine role with unsuspecting heterosexual males (often as a prostitute). They will play the part as if they are a passive feminine object. Their approach has many masochistic behavioral qualities. However, their thinking about how they are tricking, fooling and using others has a clearly sadistic dynamic. Their histories almost invariably demonstrate a mother figure who is at least domineering, manipulative and controlling.

This is quite amusing, as it is filled with a series of completely invalid assumptions and associations.

1. Inference: Many transsexuals are prostitutes. Although there are sex-trade workers who are transsexual, they are often in that world out of economic necessity, rather than out of any real choice.

2. Claim: Transsexuals come from dysfunctional backgrounds. This is so blatantly false it isn't even funny. By far the majority come from perfectly normal family backgrounds. Although some percentage may well have bad family histories, such sweeping generalizations simply don't hold together when you explore the stories of these people more rationally.

3. In emphasizing a specific subgroup of the overall population of transsexuals, Breiner is creating the false association between gender identity and sexual identity - suggesting by inference that there is an enormous physical, sexual component to the psychological motivations involved. Again, as with Michael Bailey's thinking, Breiner has made the very fundamental error of inferring that this is very fundamental to the picture when it is not.

Breiner goes on to discuss "his experiences" with a gender identity program at Wayne State University, which I can find no trace of either the program nor of Breiner's participation in it. (If any readers out there are familiar with this program, please feel free to pass on what you know - if you have references to it, that would be great!)

My clinical experience in participating with the Wayne State University program has been corroborated by others at the University as well as at Johns Hopkins University, a medical school even larger and with a longer-lasting program.

Of course, what Breiner isn't telling us here is that most of the formalized "Gender Clinic" programs run by University and hospital organizations gradually closed down over the late 1980s and early 1990s. Why? In part because they had run their course as useful constructs for both transsexual patients and the legitimate need to have a more rigorous understanding of the condition itself. This doesn't mean that treatment doesn't exist, but that it has taken on a more flexible form with the individual patient an active participant in the progression.

However, let us move on to examining Breiner's observations about the outcomes of those formalized programs, shall we?

He is a well spoken and reasonable, dependable historian; well spoken and seemingly reasonable in all areas -- except how he feels about himself in terms of his gender and his body image. He describes himself as somehow feeling that something inside is trying to come out -- that somehow or other -- the real self is being restricted and limited.

This is actually a surprisingly reasonable statement in itself. It is hardly surprising given the social taboos that wrap around the often conjoined subjects of gender and sexuality that an adult will present a cautiously worded, almost hesitant sounding description of themselves and their emotional state. That there would be room for "doubts" to be examined is easily understood as a perfectly rational response to a lifetime spent avoiding themselves.

All tests by psychologists and psychiatrists in testing his judgment of reality (except in his body image) is within normal limits. There is no evidence of psychosis or any significant problems in any other area than his body image (related to gender only). He is cooperative and patient and helpful in his manner. His only area of insistence is concerning his belief about his body and the need to become a woman. He is not afraid of psychological and psychiatric evaluation. However, he is not interested in intensive psychoanalytic/psychotherapy for a period of months or years. He firmly believes that his problem is not psychological but that it is truly on an organic basis.

Around about this point, Breiner starts to go awry, and either has misunderstood or misrepresented his clients. I suspect that a lot of patients have never really considered the origins of their condition when they present for treatment. However, it is also quite understandable that many would assume that feelings that had followed them since early childhood would be seen as having some very fundamental cause. What Breiner should be taking away from this observation is the fact that transsexuals often present with feelings that they have struggled with ever since they were very young. Feelings which have caused them a great deal of anxiety and distress, and that no matter what the patient has tried have resurfaced some time later.

Further, by the time the patient is asking for clinical help, what the client believes to be the "origins" of their state is quite immaterial.

Initially, there is less tension and discomfort psychologically experienced by the patient. He begins to feel better about himself and hopeful about his future as a woman. Despite the physical, social and economic discomforts, he is positive and cooperative in every way in the program. ...Between six months to two years following the completion and healing of the surgery the surgeons begin to request more evaluations from the psychiatric division of this program. The surgeons do not understand what is transpiring because the patient is now asking for more surgery.

This is an interesting pattern that Breiner is putting forward. It feels a little too anecdotal to me. Although there are some number of patients who do pursue additional surgery to address various physical issues that they feel make them 'less than ideal' in their chosen gender, Breiner merely gives us the anecdote without really putting forth any concrete evidence that measures the frequency of such occurrances, nor does he address what the psychiatric evaluations he alludes to found.

I think Breiner would be wise to consider the intense pressure that society exerts upon women to be "beautiful" by often arbitrary standards. Given that a Male to Female transsexual comes to life in the world of women with a few "handicaps" by the common measures of beauty, it should come as little surprise that some will resort to drastic measures to conform. Looking more rationally, it's hardly as if genetic women don't engage in similar practices.

Having presented us with an anecdotal "pattern", Breiner brings us to his grand revelation about transsexuality:

At this point in the process, I, along with other psychoanalyst colleagues concluded that the disturbed body image was not an organic at all, but was strictly a psychological problem. It could not be solved by organic manipulation [surgery, hormones], no matter how well intentioned or brilliantly successful it was done.

Rationally speaking, current medical interventions intended to assist transsexuals are limited in scope and the outcomes are necessarily imperfect. Whether the root cause of transsexualism is organic (e.g. a genetic variation or a difference in brain structure) is almost irrelevant, in my view. If the cause is "purely psychological", that doesn't invalidate the basic path of treatment - especially in the absence of any reasonable alternatives in treatment.

But the significance of the psychological difficulty should not be minimized by a patient's seeming success socially and professionally in other areas. This principle of isolated significant psychopathology indicating serious psychological problems (despite their ability to function in all other areas of life) is well known psychiatrically, historically, and by the judiciary.

This conclusion became so well established at Wayne State University that the program was eventually discontinued. The much larger and more extensive program at Johns Hopkins University and medical school in Baltimore, Maryland was discontinued for the same reason.

In short, Breiner would like us not to provide relief to transsexuals because he believes that there is some "underlying, unknown" psychopathology that has not yet been identified. We know that that transsexuals aren't delusional in any clinical sense, nor by his own experience, has there been any significant evidence of other serious psychological problems - just the distress that results from a lifetime spent feeling as though one should be living in a different gender role.

While Breiner's hypothesis that there is some "deep underlying psychopathology" involved that is driving the patient, his claim is just that - a claim. Since Christine Jorgensen became a public figure in the 1950s, we have the work of a great many people that do not provide evidence of "hidden" psychological issues.

In fact, Breiner is violating the principles of Occam's Razor by supposing some unknown pathology. Most of what he is raising as points to suggest that transsexualism isn't real are readily explained in terms of the social and societal pressures that shape the lives of every person in this world, and are hardly surprising or necessarily unique to transsexuals.