Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 1, by Kelley Winters

July 5, 2013

Kelley Winters, Ph.D.

GID Reform Advocates

The Sunday Dialogue feature of the June 30 edition of the New York Times responded to the recent Colorado Human Rights Division ruling in favor of Coy Mathis, a six year old transgender girl who sought the same equal treatment and facilities access as other girls at her public school. The Times editors turned to Dr. Jack Drescher, a New York psychiatrist who served on the Work Group on Sexual and Gender Identity Disorders for the DSM-5, the diagnostic manual of mental disorders published by the American Psychiatric Association. Dr. Drescher could have taken this opportunity to acknowledge young Ms. Mathis’ remarkable courage and tenacity. He could have taken this teachable moment to note the barriers of intolerance and injustice that transgender people face as children, both in and out of the closet. But, instead, Dr. Drescher said this:

Actually, no one knows whether Coy will continue to feel that she is a girl when her body develops further, since most children like her grow up to be gay, not transgender.

Although Coy has identified as a girl, lived happily as a girl and attended school as a girl since kindergarten, Drescher’s statement impugns her legitimacy as a girl and suggests that her strong sense of gender identity is a likely just a passing phase. The statement not so subtly passes judgement on the Mathis family for allowing Coy to be herself as she sees herself. Although the “passing phase” mantra is heard frequently among psychiatric policy makers and institutional researchers in recent years, serious questions remain. Is this prediction based on scientific evidence? And, what exactly is meant by, “children like her”?

Conflating Gender Expression with Gender Identity

Young children, like Coy, who strongly, consistently and persistently identify as other than their birth-assigned sex, and who have fully lived in their affirmed gender roles, have been criticized while left unstudied by researcher/policymakers who publish literature on gender variant youth. Since the early 90s, most study populations have instead been selected by much broader diagnostic criteria for Gender Identity Disorder in Children (GIDC) from the DSM-IV and IV-TR, published in 1994 and 2000. Under these controversial criteria, children could be diagnosed with GIDC strictly on the basis of gender nonconforming behavior, with no evidence that they identified as other than their birth-assigned gender. Therefore, children who were intensely distressed by their birth-sex or assigned gender roles (gender dysphoria) were not distinguished from larger numbers of effeminate male-identified boys or masculine female-identified girls. Under these criteria, gender expression that differed from birth-assigned roles was deemed psychopathological, no matter how happy, functional and well adjusted the child. Moreover, children who conformed to birth-assigned stereotypes were exempt from GIDC diagnosis, no matter how gravely distressed with those roles and even if conformity was compelled under duress or physical punishment.

In 2000, Bartlett, et al., noted shortcomings in the GIDC criteria:

…it appears that a minority of children diagnosed with GID have a sense of discomfort with their biological sex.

Concerns about broad false-positive diagnosis of children who were never actually transgender and potential therapeutic abuse of youth suspected of being “pre-gay” led to revision of the Gender Dysphoria in Children category in the DSM-5 in 2013. Its criteria were tightened to resemble the prior DSM-III and DSM-III-R GIDC categories, requiring evidence of desire or insistence of other than the birth-assigned gender. In other words, the childhood diagnosis was restricted in the DSM-5 to gender dysphoric children in conflict with their birth-sex or assigned role, not merely gender nonconforming. However, sample bias resulting from old diagnostic flaws in the DSM-IV and IV-TR was not subsequently acknowledged by researchers who based their studies on GIDC diagnosis. Dr. Drescher’s remark about Coy Mathis was informed by dated research and old attitudes that conflated gender nonconformity with gender dysphoria, not controlled studies of children who actually resembled Coy.

The Doctrine of Desistence

Medical and public policy have long been influenced by research, suggesting that gender variance from birth-assigned roles in young children will most likely “desist” by adolescence and adulthood, when they will identify with their birth-assigned sex. Dr. Kenneth Zucker, of the Toronto Centre for Addiction and Mental Health (CAMH) and chairman of the DSM-5 Work Group on Sexual and Gender Identity Disorders, is the most prolific proponent of the 80%-desistence assumption. In 2006, he remarked to the New York Times:

80 percent [of preadolescent gender variant children] grow out of the behavior, but 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex.

This “it’s just a phase” stereotype, has been repeated for many years and has underpinned policies that keep gender dysphoric children in the closets of their birth-assigned gender. It is based primarily on studies at Dr. Zucker’s own practice at CAMH and at VU University Medical Center in Amsterdam. Since 1994, sample selection for these studies has relied on diagnostic criteria for Gender Identity Disorder in Children (GIDC) in the DSM-IV and IV-TR. In fact, Zucker and his colleagues at CAMH were instrumental in defining these criteria. As discussed earlier, these criteria required only gender nonconforming behavior for diagnosis, and not necessarily evidence of gender dysphoria (persistent distress or incongruence with birth-sex or birth-assigned gender role). Gender dysphoric subjects in the resulting study samples were diluted by gender nonconforming children who were not gender dysphoric.

Therefore, much of this research actually suggests that the majority of children who are merely gender nonconforming, and meet the overinclusive GIDC criteria in the DSM-IV and IV-TR, will not be gender dysphoric later in life and will identify with their birth-assigned gender. However, some researcher/policymakers have inexplicably interpolated the 80%-desistance assumption to a smaller subset of children who are gender dysphoric. They have arbitrarily substituted “gender dysphoria” for “gender identity disorder” or “gender variance” in their literature, even though these terms have widely disparate definitions. As a consequence, there are concerns that these studies have scooped up large proportions of gender nonconconforming kids who were never actually gender dysphoric, found them still not gender dysphoric at puberty, and then declared them “desistent” in the literature.

In his NY Times commentary, Dr. Drescher went further still, applying the desistence doctrine to an even smaller subset of extremely gender dysphoric children like Coy Mathis, who have surmounted formidable barriers to live a real life experience in their affirmed gender roles at school. However, the Toronto and Amsterdam studies discouraged real life experience social transition before puberty and therefore lacked validity for “children like her.”

While mental health researchers and policymakers may not know Coy’s inner gender identity, there is a real chance that she does. Unlike those of past generations, Coy has been given a chance at a childhood, a life, without closets, without shame and without punishment for behaviors and expression that would be ordinary or even exemplary for other children. The real questions are, whether this chance should be taken away from her, and on what scientific basis?

In his response comment in the Times, Dr. Drescher called for “less polemics and fewer opinions presented as hard facts.” We might start with closer scrutiny of the 80%-desistence doctrine. In the meantime, Coy Mathis is busy defying false stereotypes, political attacks and media sensationalism by being herself in her Colorado first grade classroom. American psychiatry could learn a lot from this brave little girl.

© 2013 Kelley Winters, GID Reform Advocates