Friday, April 25, 2008

DSD Guidelines: A bridge to mental disorders

Deconstructing the Feminine Essence Narrative
Ongoing investigation by OII
Part 3
by Curtis E. Hinkle
Posted April 22, 2008

DSD Guidelines: A bridge to mental disorders

It is urgent that people who are currently diagnosed as having what is now unfortunately known as a DSD (Disorder of Sex Development) be prepared for what is one of the cruelest hoaxes that people with intersex variations have ever been subjected to.

Consider the following hypothetical case which is sure to happen:

A child subjected to surgery without consent grows up and rejects the sex assigned only to find that they are diagnosed as having a paraphilia known as autogynephilia. This is one of the cruelest forms of medical abuse because the very person who has been surgically altered without consent is diagnosed as having a sexual fetish for rejecting and denouncing the very medical procedures which caused the suffering to begin with – surgery and other non-consensual normalization procedures used to assign a gender to the child.

Currently, people with intersex variations who reject their gender assignment fall under the diagnosis of GIDNOS. In reading the following from the DSM-IV, please note that intersex will be replaced by DSD (which is a much larger group of “disorders”). This will be important in understanding why the term” intersex” was changed to DSD in the first place despite an overwhelming rejection from the intersex community and the sinister motivations behind this change will become more apparent later in this analysis.

The DSM-IV provides a code for gender disorders that did not fall into these criteria. This diagnosis of Gender Identity Disorder Not Otherwise Specified (GIDNOS, 302.6) is similar to other "NOS" diagnoses, and can be given for, for example:[3]

  • 1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
  • 2. Transient, stress-related cross-dressing behavior
  • 3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex, which is known as skoptic syndrome

Intersex (which will be replaced by DSD, a much larger group of “disorders”) is the only non-paraphilia currently listed under the diagnosis for GIDNOS. Several years ago, ISNA and Dreger called for mental health professionals to be involved in the evaluation and care for intersexed folks and shortly thereafter the NICHD committee was started.

The objectives of the DSD research that is being conducted by the NICHD committee, the Network on Psychosexual Differentiation at Penn State which resurrected the Disorder terminology in a psychosexual context include:

“Develop or refine animal paradigms that model and help to explain the genetic, neuroendocrine, and social processes underlying both normal sex-typed behaviors and pathological behaviors observed in individuals with intersex conditions or gender-atypical behavior.

Let’s consider the implications of this NICHD research at Penn State and in so doing, let’s analyze how the use of the new term “DSD” which is a larger class of “disorders” instead of the term “intersex” will broaden the scope of the GIDNOS diagnosis listed above.

The main objective is to link intersex with autogynephilia (often described as a fetish or paraphilia in which the person is sexually excited by the feminization process itself. In other words, some autogynephiles are sexually excited by the same procedures currently used to feminize intersex children because it is the process of becoming a “woman” that sexually excites some of them – sometimes called “forced feminization”).

Just recently the Johns Hopkins publication, Perspectives in Biology and Medicine, which was edited by Alice Dreger, included an article by J. Michael Bailey and Kiira Triea which deconstructed the feminine essence narrative with inaccurate information about Dr. Swaab’s research and he was not permitted to point out the flaws in their article. In that same publication, Anne Lawrence wrote an article which compared autogynephilia to romantic love. Was this more of a response to the upcoming assault on DSD which the NICHD is studying as a group of “psychopathologies”? That is, is there an attempt to soften the impact that autogynephilia could have on people with a DSD who reject their assigned gender, by changing the focus away from the feminization surgical process itself (the idea of sexual arousal to the surgical feminization process itself is very disturbing to many intersexed people) so as to invite less criticism about the motivations often given previously in Anne Lawrence’s writings about autogynephilia? In a previous publication, she had compared autogynephilia to an amputation fetish, a very jarring idea to many in the intersexed community, which made many of us wonder why she was so interested in intersex issues.

Presently, people with transsexualism are often said to self diagnose themselves. Many will state that they are transsexual and are gender dysphoric, that they are trapped in the wrong body and have a feminine essence. Clinicians are seen as gatekeepers and clinicians and health providers may disagree on the legitimacy of their condition. Intersexed people, in many cases, will tell the gatekeepers that they got the gender assignment wrong, that they are the other gender, neither gender, or both genders (Two Spirits) or that they are intergender. Without official recognition of this self-defining process which empowers the intersexed person to articulate their own gender identity, they will be stifled and will not feel free to do so because the only “officially recognized” diagnosis will be a paraphilia – homosexual attraction as the motivation for rejecting one’s assignment or autogynephilia, the sexual arousal associated with viewing oneself as the target of one’s sexual attraction.

It is also important to point out that the request for surgery without hormones or other treatment is becoming popular in trans circles. Requesting surgery in a vacuum makes it seem like the GIDNOS disorder of requesting penectomy or “castration” only.

I am convinced that one of the main reasons for changing intersex to DSD is because DSD will create a much larger class of people to pathologize as paraphilic (or suffering from a fetish). The researchers and other medical specialists involved will probably try to start with conditions which previously would NOT have been considered as intersex at all but which are now DSD’s, such as cloacal exstrophy, penile ablations (such as the Reimer case) and penile agenesis, cases which include children which have been forcefully assigned as female. Some will be “satisfied” with their forced assignment but others will have serious objections. However, if the objections to forced gender assignments are diagnosed as a sexual fetish or paraphilia, intersex surgeons can never be held responsible for making a wrong assignment based on the argument that the gender did not match that of the child who insists that their "gender" assignment is wrong because there will be NO diagnosis for GENDER identity as the cause. Instead, the experts will say that the person later developed a paraphilia. More so, since they will point to others who didn't have a problem with their assignment.

Next, I would think that they would classify the syndromes which they have been studying and have been frustrated about the most lately, and those are the 3 in which patients are MOST likely (more than surgeons) to request a reassignment. These categories are 5 alpha reductase 2 deficiency, NC-CAH, and 17 Beta HSD 3. There have already been studies on 5 alpha in transsexuals which found that M to F's don't have 5 alpha. Thus, those who wish to reject a male assignment will be labeled as paraphilic, and those who want to live as males will make this appear more justifiable, plus this will fuel their desire against feminizing surgeries Those who virilize at puberty and insist on masculinizing surgeries will be those whom they will seek to find grant money for in order to investigate if autoandrophilia (the counterpart in “females” of autogynephilia) exists. Then, because they have found such a high incidence of NC-CAH in F to M transsexuals, they will likely claim that CAH is similar to F to M transsexualism. Those who wish to live as males will continue to pull in more grant money because they will be more than tomboys: they will be autoandrophilics. Homosexuals would be the only other category.

Here is the progression I see in how DSD is important in reframing intersex as a sexual fetish (or paraphilia).

A) M to F TRANSSEXUALS will be the first to be classified as paraphilic. Then-

B) "DSD persons" who would not have been called intersex under the LESS inclusive category of intersex, if they reject their gender assignment, will be labeled as paraphilic. Then-

C) the conditions which PATIENT initiated gender re-assignment is requested (most common in 5 alpha, CAH, and 17 Beta) will be classified as paraphilic. Then-

D) Autoandrophilia will be created for female to male transsexuals.

E) people who were always considered intersexed, who reject their assignment, will be labeled as paraphilic.

As a conclusion, consider the fact that Anne Lawrence is on the APA committee which is responsible for gender variance and intersex (DSD) issues. Anne Lawrence is known for her writings which compare transsexualism to an amputee fetish. I personally do not dispute Anne Lawrence’s theory of autogynephilia because there most likely are people who do have a fetish for surgical feminization.

Then consider the fact that Alice Dreger, one of the architects of the new DSD terminology, recommends Anne Lawrence as a speaker on transsexualism and that she is also supporting one of the main proponents of autogynephilia, J. Michael Bailey.

The problem is not autogynephilia per se. It is the conflation of intersex issues (or people with DSD’s) with something unrelated to why many people with intersex variations reject their gender assignment which is problematic.

We in the intersexed and trans community risk ending up in a situation where:

Surgeons who perform intersex normalization surgeries without the consent of the child will always be right.
Surgeons who offer sex reassignment surgeries to adults with informed consent will always be wrong.

Many stakeholders involved in intersex treatment benefit from this, especially the surgeons and pediatric endocrinologists. Unfortunately, the main victims are the intersexed children themselves.

A call for a person-centered approach

There is a recent surge of surveying reports to find out the probability with which a person with a PARTICULAR DSD will reject their assignment. If they find in their literature searches, for example, that 94% "accept" their assignment and 6% request re-assignment, the probability is used to create a majority/minority balance, where they (the DSD proponents) then create a UNIFORM standard, which discriminates against the minority. The assignment "rejecters" then have a mental disorder, and the majority "rule" actually "rules". It is an artificial paradigm. It reduces people to mathematical formulas

Probability always involves a gamble. It occurs in medicine all the time. If you are 1 of 20 who has a side effect (a pharmacologically INDUCED illness), then you don't matter. You can't sue, and you are accused of making these side effects up, because they are "insignificant" in the population. This is what can eventually happen to the "insignificant" numbers who reject their assignment. In an era, where there is mounting discussion of pharmacology being tailored to the individual, do we really need to REGRESS with intersex treatment, and play a check/balances, game of probability (Russian roulette)? Such a bullet killed Reimer. Have the medical specialists learned anything from this?. For all of the studies in the literature of outcomes in gender assignment according to specific conditions, they have tried to guess at hormonal exposure to the brain, Prader scales, family approval ratings, timing of surgeries, amount of information given to patient/family, cultural differences in outcomes, but they have failed.

We need to have a new paradigm. Treatment needs to be PERSON centered first, and CONDITION centered, second. At present the DSD paradigm is CONDITION focused – not PERSON focused. Information about conditions are helpful, but can never be made universal. People cannot be fit into cookie cutter categories, based upon probabilities. There are too many variables (people who are unhappy with their assignment don't participate in studies, professionals like "cooperative" patients), etc. and this makes all these surveys suspect.

To pathologize someone who rejects their gender assignment is no better than to claim that pharmaceuticals don’t cause other diseases or cause side effects. Even Dreger and other DSD proponents should take a lesson from pharmaceutically-induced thalidamide effects.

Commentary from Michelle O'Brien, OII-UK:

Thinking about this, and the new Handbook of Sexual and Gender Identity Disorders, whilst DSD is included as background to GID rather than being a 'Sexual Disorder' itself (of the sort concerned about in the book), having DSD stand alongside GID and Sexual Disorders themselves opens up a possibility for the future re-establishment of homosexuality (& bisexuality) as a disorder, maybe a 'Disorder of Sexual Identity' (DSI). So, you would get Sexual Disorders, Disorders of Sexual Development, Gender Identity Disorders, and Disorders of Sexual Identity.

Sexual Disorders would presumably become 'Disorders of Sexual Function' (such as impotence, pain on intercourse, asexual tendencies), or DSF, and Disorders of Sexual Paraphilia (presumably including transsexual autogynephilia as distinct from homosexual transsexualism), or DSP; so, MtF GID would disappear, because HSTS, as a form of homosexuality, would become a type of DSI, and AGP-TS a form of DSP; no doubt FtM GID would become incorporated into either DSI (as an FtM HSTS) or DSF (based on whether there was sexual attraction to women or men - in the latter case this would be a dysfunction rather than a problematic autoandrophilia to match autogynephilia). This then would make GID a redundant category, as all instances of transsexualism would be caught within one or other form of the sexual disorders. This then would leave a neat new taxonomy of all sexual disorders, incorporating intersex and transsexuality, including homosexuality, alongside paraphilia and sexual dysfunction:

DSD (Disorders of Sexual Development) - the conditions formerly known as intersex
DSI (Disorders of Sexual Identity) - the identities formerly known as homosexuality
DSF (Disorders of Sexual Function) - problems formerly known as sexual dysfunction
DSP (Disorders of Sexual Paraphilia) - perversions formerly known as paraphilias

Nobody wins in this game, apart from those who make the rules; this scenario is partially hypothetical, although between DSD and Bailey a substantial part of this has begun to be achieved. Maybe I am being a bit paranoid, but to the man-in-the-street, they will all mean one thing - sexual disorders. What such a taxonomy would be based upon is deviation from male-female sexual reproductive norms.

Her lawsuit is an anti-surgery case that was widely publicized in Europe with articles appearing in many languages throughout the world. There was almost nothing in English except what I translated.

The reason for the silence among English-speaking experts is very simple. This is about a "feminine essence narrative." Christiane Völling was assigned MALE and her female reproductive anatomy was removed without her consent. She has proof of this and presented it in court. She won, but the surgeon is now appealing and the letters from the court still address her as "Herr Völling".

Christiane knows that she is a woman despite her assignment as male. That is the reason there is NO support from Dreger and other DSD activists of this intersex woman who has been subjected to a life of suffering.