This is another in a series of posts examining statements made by top gender specialists at the inaugural USPATH conference in Los Angeles in February 2017. (See here, here, and here for more.)

Note: The audio recordings linked in this post, as well as the presentation slides, were provided by an attendee at Dr. Karasic’s USPATH presentation.

Dan Karasic, MD, plays an important role in the area of transgender health care. He is clinical Professor of Psychiatry at University of California, San Francisco, and a practicing psychiatrist for the Transgender Life Care Program at Castro Mission Health Center, as well as at his faculty practice at UCSF. He is also the co-chair of the recently formed USPATH, on the Board of Directors of WPATH, and, as such, has been instrumental in the ongoing development of WPATH policies and standards.

With so much experience, as both a clinician and trans advocate, Karasic’s statements and clinical judgment carry a lot of weight. So it’s of particular interest that his presentation at a mini-symposium entitled DEVELOPMENT OF GENDER VARIATIONS: FEATURES AND FACTORS at the inaugural USPATH conference last February should focus on a topic as controversial as this: medical transition for one or more “alters” of people with multiple personalities (MPD)—also known as dissociative identity disorder (DID).

MPD/DID had its diagnostic heyday in the late 20th century, peaking in the 1990s. The public was fascinated by the idea that one human being could comprise more than one identity or personality, and novels, films, and breathless media coverage proliferated. The disorder was thought to be the result of trauma or abuse, but has since that time been subjected to the same skeptical reassessment as the now widely debunked recovered memories and satanic abuse diagnoses (MPD/DID was, in fact, often associated with/comorbid with both).

There is something eerily familiar in this excerpt from a 1999 book by Joanne Acocella about the rise and fall of the MPD diagnosis .

Another important circumstance in Carlson’s case, as in other MPD histories, was the media. During the period of Carlson’s therapy, magazines and newspapers were retailing utterly unskeptical stories about MPD. So was the evening news. MPD experts went on TV with their patients in tow. Bennett Braun, of the nine-hour abreactions, appeared on the Chicago evening news with his star patient. At his bidding she “switched” on camera—now she was “Sarah,” now “Pete”—thus providing early training for prospective MPs in the television audience. More important than the news were the talk shows. Phil Donahue was apparently the first talk-show host to present a program on MPD; he was followed by Sally Jessy Raphael, Larry King, Leeza Gibbons, and Oprah Winfrey. Meanwhile, celebrities were coming forward with their tales of childhood sexual abuse: Roseanne Barr, La Toya Jackson, Oprah herself. Some of them claimed to be multiples as well. Roseanne, who had unearthed twenty-one personalities within herself—Piggy, Bambi, and Fucker, among others—made the rounds. Again and again on the talk shows it was stressed that MPD was not rare; it was common, and becoming more so. “This could be someone you know,” said Sally Jessy Raphael. Oprah’s program was called “MPD: The Syndrome of the ’90s.” Today, as people are sifting through the wreckage created by the MPD movement, many therapists are blaming the media for spreading the epidemic. They are passing the buck, but still they have a point.

In the late ’90s and into the present day, a number of critical papers appeared in the clinical literature, and the verdict from many clinicians and researchers was that often cases were at least partly iatrogenic:

Although the relative paucity of data on the role of iatrogenic factors in DID renders a definitive verdict premature, several lines of evidence converge upon the conclusion that iatrogenesis plays an important, although not exclusive, role in the etiology of DID: (a) The number of patients with diagnosed DID has increased dramatically over the past several decades (Elzinga et al., 1998); (b) the number of alters per DID case has increased over the same time period (North et al., 1993), although the number of alters at the time of initial diagnosis appears to have remained constant (Ross, Norton, & Wozney, 1989); (c) both of these increases coincide with dramatically increased therapist awareness of the diagnostic features of DID (Fahy, 1988); (d) a large proportion or majority of DID patients show few or no clear-cut signs of this condition, including multiple identity enactments, prior to therapy (Kluft, 1984); (e) mainstream treatment practices for DID patients appear to verbally reinforce patients’ displays of multiplicity and often encourage patients to establish further contact with alters (Ross, 1997); (f) the number of alters per DID case tends to increase over the course of DID-oriented therapy (Piper, 1997); (g) therapists who use hypnosis appear to have more DID patients in their caseloads than do therapists who do not use hypnosis (Powell & Gee, in press); (h) the majority of DID diagnoses derive from a relatively small number of therapists (Mai, 1995); and (i) laboratory studies demonstrate that nonclinical participants provided with appropriate cues can successfully reproduce many of the overt features of DID (Spanos et al., 1985). Given the high rates of preexisting mental conditions among DID patients (Spanos, 1996), however, it seems likely that iatrogenic factors do not typically create DID in vacua but instead operate in many cases on a preexisting substrate of psychopathology, such as BPD.

As the authors of this article attest, some patients diagnosed with MPD got worse instead of better as they underwent treatment, and not a few came to realize that their deepening troubles were at least partly the result of the misguided efforts of their psychotherapists. Some high-profile cases ended up in court, like this suit brought by Pat Burgus, who settled for $10.6 million against her psychiatrist, Bennett Braun. Burgus had once believed she had 300 different “alters,” and she “recovered” memories under hypnosis that she had eaten human flesh and–among many other horrors–sexually abused her two sons. She blamed her therapist for convincing her these memories and personalities were real.

Before her ordeal was over, Pat would develop 300 personalities, attempt suicide twice, cut ties with her family in Iowa, and go to court to regain custody of her children. She would spend more than two years in the hospital; her children would spend three. And her insurance company would pay $3 million for a treatment regi­men that today seems utterly fantastic…. … Since 1993, more than 100 patients nationwide have sued therapists over treatment for MPD, which was diagnosed in explosive numbers throughout the eighties. “In many of these cases, we see a situation in which the poor training and instability of the therapist, coupled with the vulnerability of the patient, creates a situation fraught with the potential for a folie à deux”—that is, a delusion shared by therapist and patient, says R. Christopher Barden, a lawyer and psychologist who served on the Burgus legal team.

MPD/DID remains today a controversial diagnosis. In a 2004 review paper, “The Persistence of Folly: Critical Examination of DID. Part II. The Defence and Decline of Multiple Personality or DID,” authors Piper and Mersky, make the crucial points bluntly.

Concerns about the validity of MPD/DID raised by skeptics in the psych literature seem to coalesce around the following: only a small group of therapists have been involved in diagnosing it; the condition often worsens and more identities/personalities arise after treatment has commenced; and its close association with the widely debunked notion of “recovered memories” of childhood abuse further undermines its validity.

Given the precarious legitimacy of the MPD/DID diagnosis, it seems clear that–if it’s going to be made at all–it should be done with extreme caution and, above all, with an awareness of the potential for iatrogenic conditions that might exacerbate it—most importantly, the influence of the treating clinician.

Yet MPD/DID is apparently very much alive in WPATH circles. Returning to Dr. Karasic’s presentation about “trans plurals” at USPATH, he offered several case studies, all of which involved medical transition of all or some of the “alters”:

In the case of this 20-year-old “AMAB,” as seems to be typical with gender affirmative practitioners, medical transition is reported as curative (or at least palliative) for a host of other problems apart from gender dysphoria; in this instance, the patient’s Bipolar Disorder 2 and Alcohol Use Disorder were “treated simultaneously” with the T-blocker spironolactone and cross-sex estrogen. The patient “did well,” and the 7 alters (including 3 in “co-conciousness,” 2 agender, 1 female) seem to have reached consensus about gender surgery later on–presumably the requested “genital nullification” .

Then there is the 27-year-old who identifies as a genderqueer “system.” Diagnosed with autism in childhood, this “AMAB” with a primary “front” female alter, has undergone hormone therapy and presently has 85 “headmates” that include alters, tulpas, and fictives.

Headmates, tulpas, “fronting,” co-consciousness: Dr. Karasic seems well versed in the insider jargon used by the trans plural community.

“So I’ve had several patients who identify as trans and plural …and I guess I had a reputation as a psychiatrist who was not plural phobic.”

After discussing several cases of successful medical transition of alter identities, Karasic reported on an online survey of 250 self-identified “trans and plural” subjects conducted by three self-described members of the trans plural community, over a one-month period. From the data gathered, there seems to have been a plethora of different alter types reported by survey respondents.

Did these alters include “furries,” an audience member wanted to know?

Q: “…What are “damiens?” [sic] The other thing is, were all the alters human, or were there some alters that took on another form? Karasic: …I think there are people who have alters that take different forms. And I have had somebody with a wolf, you know, and sometimes fictional characters who might not be human, who can become a headmate, basically. Q: Separate from furries? We’re not talking about furries.. Karasic: No, no no, this doesn’t have anything to do with that. This is just different people’s identities, but there are people who may have within this a system with headmates. There can be kind of a variety of …headmates.

Last August, 6 months after the USPATH symposium, Dr. Karasic discussed his experiences with transitioning multiple personalities in a thread on the public WPATH Facebook page.

Dr. Karasic does acknowledge here the importance of mental health care for people with multiple issues, but per the informed consent model that Dr. Karasic subscribes to (evidenced by his many public statements, as well as the fact that his trans health clinics operate on the informed consent model), comorbid mental health problems are not seen as a barrier to medical transition instituted before treating other comorbid issues.

In the era before informed consent became the preferred approach , particularly in the United States, clinicians were often reluctant to initiate hormonal or surgical intervention in patients with comorbid, severe mental health issues. But in the age of gender affirmation, withholding medical transition is seen as restrictive—even immoral– “gatekeeping”—even if one runs the risk of one alter ego disagreeing with medical treatment and suing the provider in court for “violating the rights of one or more personalities“, as a commenter on the same thread hypothesized.

Taking this a step further, might one trans-plural headmate sue not only the surgeon or gender therapist, but one of the other headmates for forcing medical transition (or not) on the others?

Time will tell if the spectacular court cases brought by aggrieved clients who were diagnosed with DID/MPD in the 1990s will play out in a similar fashion within the labyrinthine world of trans plurals.

Meanwhile, the reader may find the concluding paragraphs of the previously cited Piper and Mersky paper relevant when weighing the plight of “trans plurals” and the clinical approach taken by at least one prominent WPATH clinician:

Wherever we look—whether at the posttraumatic model; at theories of repression; at the epidemiologic uncertainties and aggrandizements of the disorder; at the persistent proliferation of personalities; at the elusive data that attempt to sustain the claims of exceptional abuse; at the bland presentation of breathtaking assumptions such as cross-sex, cross-species, or cross-ethnic alters; or at the impossibility of proving almost any of the basic claims of the disorder—we encounter propositions that appear to be founded on beliefs and not on facts or logic. That such beliefs could prosper in a society or a discipline represents an embarrassing weakness of the academic and professional establishment of psychiatry. Perhaps the closest example of another culture-bound movement that resembles the modern DID–MPD movement occurred in the late 19th and early 20th centuries, when mediums and spiritist practices were popular. Hacking notes that “multiple personality has long had close links with spiritism and reincarnation. Some alters, it has been thought, may be spirits who find a home in a multiple; mediums may be multiples who are hosts to spirits” (79, p 48). Much of the best turn-of-the-century English-language research on multiple personality was published by the London- or Boston-based societies for psychical research. However, After 30-odd years of high times around the turn of the century, mediumship, spiritism and psychical research went into radical decline. A zone of deviancy that was hospitable to multiple personality severely contracted (79, p 48). When it becomes suspect to recommend MPD as part of psychiatric evaluation or treatment, the condition is diagnosed less frequently. For example, Pope and colleagues (80,81) and others (82) have shown that North American psychiatrists and psychologists are abandoning the notion of MPD–DID as an acceptable diagnosis. In these circumstances, we expect that the condition will revive momentarily and die several times before it finally ceases to be a ripple on the surface of the psychiatric universe. In the end, it is likely to become about as credible as spirits are today. Having attempted to rationally analyze the claims of MPD–DID, we trust that we have shown sufficient evidence to predict a steep decline in the condition’s status over the next 10 years and a gradual fall into near oblivion thereafter.

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