THE DSM AND NIMH: WHY INSEL GOT IT RIGHT AND WHAT IT MEANS FOR SEXOLOGY
05/21/13 by Margie Nichols
'Reserving Judgements Is A Matter Of Infinite Hope'-- Cool But That's Probably Bad
05/15/13 by Courtney Zehnder
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Queer Mind: LGBTQ and Beyond
by Margie Nichols
In a move that is causing consternation among psychiatrists, Thomas Insel, Director of the National Institutes of Mental Health, announced that NIMH will be ‘re-orienting its research away from DSM categories.’ Insel called the Diagnostic and Statistical Manual, the Bible of psychiatry, nothing more than a dictionary at best. He made it clear that it is founded on symptom-based categories, and that this method of classifying disease has become outmoded in every other area of medicine. He says NIMH will replace the DSM with what he is calling RDoC, or ‘Research Domain Criteria.’ In this new system, mental illnesses will be categorized not by symptoms but by genetic, neural, and cognitive data. Only problem – the system doesn’t exist yet – because the data doesn’t exist.
In other words, Insel is saying having no category system at all for mental disorders is better than the current DSM. He did acknowledge that the DSM will still be useful for mental health treatment (although that is questionable) and will certainly be in place for insurance purposes for quite some time. But he was emphatic in stating that it would be a disaster to base scientific research on the DSM categories. There just isn’t any evidence tying DSM categories to underlying brain/biological based entities. As Insel said, “Biology didn’t read the book.”
Validity has been a chronic problem with the DSM. The first DSM begun in the 1950’s constructed mental illness categories based on psychoanalytic theory. But the tenets of psychoanalysis have never been proven scientifically and few professionals use that model in their work today. In 1980 the psychoanalytic system was replaced with a model based on symptoms; DSM III was a major departure from the past.
In other words, the DSM was first based on a theory never backed up with scientific evidence, and then by a system that assumed that things that looked alike were the same. This is like assuming that all illnesses with the symptom of ‘high fever’ were caused by the same pathogen. As Insel points out, the rest of medicine progressed beyond symptom-based models sometime in the mid-20th century. Today, most medical diagnosis is based on physical and structural evidence and some on etiology: we know that the HIV virus causes certain changes in the immune system which result in a dizzying array of mostly dissimilar symptoms, we realize that Kaposi’s Sarcoma and PCP pneumoni, despite their dissimilarities, are both the end result of the HIV infection, and we know how the infection is transmitted. By contrast we merely hypothesize that, for example, Major Depressive Disorder is different from Generalized Anxiety Disorder, because the symptoms are different, and we then presume that the brain mechanisms underlying the two are different as well.
But we are beginning to accumulate evidence that turns the DSM categories upside down. For example, the same genetic anomalies found in schizophrenics are also found in some people diagnosed with autism and others with bipolar disorder. The same drugs that treat depression also work for panic attacks and obsessive-compulsive disorder, and medications developed for psychosis also help those with anxiety. In other words – categories based on symptoms may be very misleading. And research based on these categories will be both wrong and often irrelevant. Based on psychopharmacology , it is a reasonable working hypothesis that some underlying structure and etiology are similar in conditions that respond to the same medication. We should be looking at these similarities, but we won’t do that if our category system, our theory, considers them different and unrelated.
Insel is proposing a system he calls RDoC – Research Domain Criteria – which would be based on genetic, neural, and cognitive data. Data we are only just beginning to gather.
Basically, Insel is saying until we have the data it is better to have no theory and no categories than to use the DSM. And he is completely right. The designers of the DSM actually realized that their categories were basically stabs in the dark, a tentative work-in-progress model. But the DSM quickly became reified, and now we act like there actually is a distinct disease of ‘Major Depressive Disorder’ that has a precise location in the brain. And once we do that – we stop looking at the issue with what the Buddhists call ‘Beginner’s Mind,’ or ‘Don’t Know Mind.’
The truth is, we should have ‘Don’t Know Mind’ about psychology and psychiatry because – we really don’t know. And it’s not just categories of ‘mental illness’ we don’t know about. Our psychological theories are as flawed as the DSM, but that’s the subject of Part II of this blog.
The implications of the RDoC approach, when applied to sexology ,are profound, particularly the sexology of GSD (Gender and Sexually Diverse) people. First, RDoC, if it is truly atheoretical, must start with a neutral view, not a disease model. Without concepts like ‘Gender Identity Disorder,’ and ‘Paraphilias’ we are free to simply investigate the broad diversity of human gender and sexual behavior. This research has already begun. There are neuroscientists and biologists examining the role of genetic and epigenetic factors in influencing all aspects of sexuality, especially gender variation and same/opposite sex attraction. Second, the continuum concept will replace the categorical system we have now, making judgments about ‘normal’ vs. ‘variant’ a matter of judgment and debate. A new paradigm , being neutral, would have to assume that sex and gender diversity is innocent until proven guilty – i.e., variation, not disease. And that would have immense social implications: unusual gender presentations and expression, uncommon sexual desires, would not be assumed to be problematic unless evidence is discovered to suggest that they are.
Insel’s system would radically affect the science of sexology as well. Few people realize how much the category system we use to look at GSD has been influenced by modern psychiatry. We label some people ‘homosexual’ because psychiatry classified same-sex attraction as a ‘perversion:’ historically, the category came into being via psychiatrists. We label others trans* because psychiatry has categories based on the concept that atypical gender expression is an illness. Other cultures, and other time periods, have sliced up the GSD pie differently. Both the DSM and the culture at large draw a bright line between sexual orientation (narrowly defined as same vs. opposite sex attraction) and gender identity. But most cultures have not, and earlier, non-disease sexology models blended the two, as in the concepts of ‘inverts,’ or a ‘third sex.’
As Maria Konnikova explains in the New Yorker, the RDoC system is a dynamic one: as data continues to be accumulated from different sources, inter-relationships between variables will continuously evolve. Eventually, dimensions and processes that underly the behavior we observe will become clear, and they may have nothing to do with the categories we use now. Consider the above example, the bright-lining the distinction between same-sex attraction and gender. The fact is, we don’t actually know if there is a genetic/neural/cognitive difference between gender variation and sexual orientation, we don’t even know what ‘orientation’ is and whether other sexual drives (kink, nonmonogamy) should be considered ‘orientation.’ We have some reason to believe all these things are related: there is a good deal of overlap among people who are LG or B with those who are T, kinky, and nonmonogamous. Moreover, research on neuroanatomy, genetics, and prenatal hormonal influences is turning up similar results for transgender people and same-sex oriented people, suggesting some similar developmental pathways for both.
I ran across an obvious example of how the DSM categories hinder sexology very recently. The April 2013 issue of the Journal of Gay and Lesbian Health contains two excellent reviews of the current biological science regarding male to female transgender people and gays and lesbians, respectively. A number of findings turned up in both reviews: fraternal birth order, for example, and digit ratios. But neither author seemed aware of the other area of research – because the research parameters were set by the DSM categories of homosexuality and transsexualism, and these two ‘conditions’ are presumed distinct.
If we get rid of our current categories based on the DSM, as Insel suggests, and replace it with a dynamic, atheoretical, data-based paradigm, we can truly investigate the similarities between gender identity, expression, and behavior and different sexual ‘orientations’, or desires and preferences. In short, if RDoC is implemented in the study of GSD, we might actually learn something.
by Margie Nichols
A couple of weeks ago, the Pink Therapy group in the UK made news by proclaiming ‘GSD’ – Gender and Sexual Diversities – as the new umbrella term for a community that seems to add letters by the season. Seriously, I’ve seen: LGBTQQIAA- lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, allies. And lots of groups - nonmonogamous people, kinky people, those who identify as pansexual, for example- aren’t included in that mouthful of letters.
At first I thought it was just the brilliant Brits. And then I did a little research and discovered that the term is already in use in some academic and educational circles here in the U.S. Pink Therapy is publicizing a growing cultural shift. I'm jumping for joy! I feel like I’ve waited a lifetime for this trend.
Because this isn’t just a new alphabet soup. This is a different paradigm, a reversal of the pattern of making finer and finer distinctions of sex and gender that prevails in all areas from identity politics to scientific discourse.
They say in scientific thinking there are ‘splitters’ and ‘lumpers; ’different issues at different times require both approaches. LGBT activism started in the 1970's with organizations that just used 'gay' in their titles, e.g. the National Gay Task Force. Then lesbians argued that 'lumping' them with gay men made them invisible, and that started the trend of adding letters to distinguish the different groups who wanted to be included under the 'big tent.' Politically, this made sense. But science followed politics, and over time researchers as well as the culture at large have behaved as though each letter in the acronym represents a distinctly different group. And this has led to some problems- identity politics have become conflated with reality. This is a time for us to be ‘lumping’ together people who are outliers, minorities, nonconformers in their gender expression/ identity and/or their sexual expression/identity. This group of people includes those with same sex attractions, or both/pan gender attractions; it includes the whole spectrum of TGNC (transgender and gender nonconforming) people; but it also includes kinky, nonmonogamous, asexual, queer, refuse-to-label-myself people as well.
Here’s why we should all switch to GSD immediately:
- It’s easy. Say it a few times – it trips off the tongue.
- It’s inclusive. We like inclusivity, right? Well, actually some of us don’t, but I’m going to assume here that it’s a good thing.
- It’s politically advantageous. Strength in numbers. (And yes, I know the arguments against including people who are stigmatized even more than you. It's the reason why drag queens and other gender benders were excluded from gay politics for a long time. I disagree with the 'Virtually Normal' argument.)
- It encourages us to find our commonalities. And believe me, as a queer shrink for 30+ years – we have SO much in common.
- It encourages us to work together. Good karma, good communities – good politics, too.
- THERE IS A LOT OF OVERLAP AMONG THESE COMMUNITIES ANYWAY. Especially among gay men/nonmonogamy/bisexual/kinky folk.
- Which leads me to my last and not insignificant reason: IT IS VERY LIKELY SCIENTIFICALLY MORE CORRECT. Or at least it is a BETTER paradigm for scientific research than the one we are using now.
The paradigm that currently dominates the field of sex therapy and research is one that first and foremost is a pathology model, a medical/psychiatric model that tends to see all ‘outliers’ as indicators of disease. And it is a ‘splitting’ model: every time the psychiatric Bible, the DSM, is amended the fights are about adding new categories of sexual anomaly/pathology. This time around, in the preparation of DSM5, there was a group proposing that ‘hebephilia’ be added as a ‘paraphilia’ i.e., sexual perversion. (Hebephilia, by the way, means sexual attraction to teenagers. Perhaps a majority of men would qualify as hebephiles.)
And what I keep coming back to is – maybe our categories are just plain wrong. Different cultures at different historical periods have ‘sliced up’ the GSD pie in different ways. For example, although we draw a bright line between gender and sexual orientation, throughout history more commonly the two have been conflated: ‘Invert’ was the nineteenth century term for homosexual.
We ‘see’ gender and the gender to which one is attracted as the two most important dimensions of sexuality. What if there are others we are missing completely? What if there are reasons – perhaps including even biological reasons – why the kink, nonmonogamy, and LGBT communities overlap so much? More intriguing examples: young people are replacing 'bisexual' with 'pansexual,' and it is true that there is a huge overlap between the bisexual, kink, transgender, and open relationship communities. What if we are missing an important dimension of human sexuality like general openess to a multitude of sex and gender expressions? Or this - there is a growing phenomenon of previously lesbian identified transmen who become attracted to gay men after transition. What if 'same-sex' orientation is exactly that - attraction to others of the same gender as you.
What if we don’t have a clue? What if we are our understanding of sex/gender variation is in its infancy, as I believe? If there is a chance that is true – then the lens we need to use must be broad and inclusive. For now, GSD – Gender and Sexual Diversities – is the best paradigm we can use.
by Margie Nichols
Recently I saw a special report put out by the Gallup organization on the results of polling done last year. Gallup asked 120,000 people the following questions: ‘Do you, personally, identify as lesbian, gay, bisexual or transgender?’ This is the largest number of Americans who have EVER been polled about their sexual orientation in history (by comparison, the highly regarded NORC survey done by University of Chicago asked 2,000 people).
The results are fascinating, and upend some of the more common stereotypes about queer people. 3.4% answered ‘yes,’ 92.2% answered ‘no,’ and 4.4% said they didn’t know, or refused to answer. It’s important to understand that the 3.4% represent people who are willing to publicly declare their queerness to a pollster, and that this number is far smaller than:
- The number of people who identify this way but won’t disclose this, which in turn is smaller than
- The number of people who live an LGBT life but don’t self-identify, which is smaller than
- The number of people who experience LGBT attractions and inclinations but don’t act on them
Anyway, you get the idea – a very significant minority of people are at least a little bit ‘queer,’ and 3.4% probably under-represents LGBTQ people a bit.
But the breakdown of the Gallup stats shows a dramatic difference by AGE – and to some extent, gender. 6.4% of 18 to 29 year olds identified as LGBT, compared to 1.9% of those 65 or older. And a whopping 8.3% of 18-29 year old women identified as queer.
Something is happening here. Either people stop being queer as they get older – or there are striking generational differences. Not surprisingly, as LGBT people are increasingly accepted and integrated into mainstream society, more people feel comfortable identifying themselves openly.
We’re recruiting the young. Well, not exactly. To be more precise, the culture is allowing people who might have lived in the shadows or never expressed themselves at all to live full, free and open existences. If the number of LGBTQ-identified people increases, as it seems sure to continue to do, it will not be the result of indoctrination. Rather, it is a testimony to how many people are still hiding- in some way – now.
Other results of the poll fly against statistics in almost all previous but smaller and older surveys. Gallup found the rates of LGBT identification to be higher in less educated, lower income, and minority respondents – past studies have shown the opposite. It’s intriguing to speculate on why this is so, and I’ll probably write another article when I’ve pondered it more. The rates of motherhood among lesbian and heterosexual women are now identical, another statistic probably attributable to increasing social acceptance.
But those generational numbers excite me. I have a vague feeling of a revolution coming, a cultural revolution of gender and sexuality that is starting as a wave of queer young people, led by women, and will eventually transform the way we look at these dimensions now.
by Margie Nichols
Two things recently have made me think about that important piece of LGBT history, the 'de-classification' of homosexuality as a mental illness in 1973. The first is the news, released this week, that the fifth edition of the 'Bible' of psychiatric illness, the Diagnostic and Statistical Manual, will be published in Spring of 2013. The second was the election, and the two are related.
In the Novenber election, LGBT people made up 5% of voters - enough to make the difference. And it showed. The election results were almost unimaginable for someone like me who came out in the mid-70’s. The gay Congresspeople, the lesbian Senator, the four Marriage Equality ballot initiatives that won – I still have to pinch myself. So it made me reflect on the progress of the 'gay agenda' since the '70's.
Many LGBT people don’t fully understand the critical role that the political action against the mental health community played a in advancing lesbian and gay rights. Soon after the Stonewall Rebellion of 1969, the new gay activist movement took on the task of getting homosexuality removed from the psychiatric ‘Bible,’ the Diagnostic and Statistical Manual of mental disorders (DSM). Before 1973, if you were gay, you were automatically ‘mentally ill,’ and that implied you were emotionally stunted, prone to other mental disorders- mentally disabled. Homosexuality was considered a ‘treatable’ disorder, something caused by bad parenting. ‘Sick’ gay people were encouraged to devote themselves to treatment in the hopes of a cure. (Sound familiar? The Christian Right still believes this.)
The diagnosis enabled horribly cruel psychotherapy ‘treatments.’ People were committed to mental institutions against their will, subject to aversion therapy – electrical shocks- or years of treatment where they were considered sick and in need of controlling their ‘perverted’ impulses to love. And it justified discrimination of every form. The diagnosis, along with the sodomy laws that still existed in most states, insured that gay people would have to live in the shadows of normal life.
And so just like Marriage Equality is one of the key LGBT rights issues of the 21st Century, gay activists made removal of homosexuality from the DSM a major target of political action right after Stonewall. They succeeded in 1973 through a combination of direct action and persuasion of the more liberal members of psychiatry. One of the problems activists had was that gay psychiatrists and therapists were for the most part themselves afraid of ‘coming out’ for fear of being drummed out of their profession. One psychiatrist testified at hearings held by the APA wearing a wig and mask, John Fryer, known then only as “Dr. H. Anonymous.”
Most queer historians agree that the psychiatric de-classification of homosexuality was a pivotal moment for gay rights. Although psychiatrists didn’t mean it this way, the public generally interpreted the action to mean that doctors were saying that homosexuality was ‘normal.’ While it has taken decades for this to become a true majority mainstream belief, it lay the ground work for anti-discrimination legislation.
It did lots of other things, too, one of which was to transform my field. As the attitude towards homosexuality changed slowly, some mental health practicioners felt emboldened to ‘come out’ themselves and to dedicate their practices to working with other lesbians and gays. We worked with our clients to help restore the self-esteem that had been battered down by decades of being marginalized – we developed ‘gay affirmative psychotherapy.’ We addressed issues special to the LGBT community, we educated non-gay clinicians, and we advocated the idea that the higher rates of depression, suicidality, and drug and alcohol abuse in the LGBT community were caused by discrimination, not anything intrinsic to being gay. Some of us went into research and developed studies showing that gay people are not harmful to children and in fact are just as good at parenting as non-gays.
So reforming the mental health field has been very important to gay politics – and in turn, gay political successes improve mental health among LGBT people, as they gradually reduce the amount of ‘minority stress’ we experience, stress that can trigger emotional disturbance.
And because of the actions of our gay activist forebears, I can write this blog as an openly queer psychologist and sex therapist – and write about the special mental health and sexuality issues of the LGBTQ community. The fight rears its ugly head from time to time, most notably in the fights about so-called 'reparative' therapy. The proponents of this therapy claim - surprise! - that homosexuality is a mental illness caused by bad parenting.
And today, the same wars against psychiatry are being waged by transgender people and other sexual minorities. Just as it did for gay people, being considered 'mentally ill' has held back rights for other people with non-heteronormative sex and gender expression. And just as gay people did, trans people and others have fought with psychiatry, sometimes vocally with demonstrations, placards, and loud voices. As a result, the DSM 5 incorporates some changes in the right direction. Transgender people are not 'auitomatically' considered mentally ill - only if they are 'dysphoric' about their gender. And people in the BDSM community are not 'ill' unless they are unhappy with their sexuality.
There is still more to be done. But we have the model- the actions that preceded, and the change that followed, the DSM decision of 1973.
by Margie Nichols
Last week this was all over the Internet: a London transman named Maxwell Zachs began a petition to the World Health Organization to remove ‘transsexualism’ from its list of ‘mental disorders’ in the ICD, the international disease classification system. Zachs says: “There is nothing wrong with me. I am perfectly healthy. I just happen to be transgender.” But his move has generated a lot of controversy even among trans rights activists.
If you don’t know a lot about transgender issues, you might not understand the significance of Zachs’ petition. You might not know why the issue is a big deal in the first place.
If you don’t know – you need a refresher in LGB history. Before 1973, homosexuality was classified as a ‘mental disease,’ and this reinforced social views that ‘those people’ were deviant, unstable, and deficient. It legitimized all kinds of discrimination, not to mention providing the basis for unvoluntary psychiatric commitments and other ‘treatments,’ being discharged from the Armed Forces or teaching – well, you get the point. In fact, most queer historians consider the removal of this diagnosis one of the pivotal ‘gay rights’ events of the last forty to fifty years.
At this point, if you have made the translation you are probably asking why Maxwell Zachs is controversial. Why would a trans activist have problems with his petition?
And that brings us to the complicated stuff that the blogosphere got only half right.
Many, if not most, transgender people need body modifying medical treatments to feel at peace with themselves, and they want those treatments to be covered by health insurance. At the present time, this is done for some but not all procedures. So it is true that removing ‘Gender Identity Disorder’ as a psychiatric diagnosis might leave some transgender people without a ‘medical diagnosis,’ as those opposing Zachs’ petition point out.
What has NOT been reported is that the premier world-wide organization for the medical care of transgender people has already proposed an alternative that avoids this problem. The World Professional Association for Transgender Health – WPATH – is asking the World Health Organization to remove ‘gender identity disorder’ as a psychiatric diagnosis, re-name it, and find a medical diagnosis that will allow the coding necessary to satisfy insurance companies.
So Maxwell’s petition is a no brainer, and tens of thousands already agree - do you?
Jordan Hunt, L.C.S.W., our guest blogger, is a psychotherapist who worked at IPG for many years until he moved to Connecticut this summer.
A friend of mine recently asked me to comment on his blog where he was posing the questioning of why gay men have such a difficult time finding people to "date". Below is my response.
So, you have asked me to respond to your blog about the difficulties that men (gay men, in particular) have when it comes to dating. Where do I begin? I mean, this topic is truly worthy of a dissertation. However, I did see that someone else responded saying, “I can’t even find a man worthy of a date. ” To me, his statement is the crux of the problem that gay men encounter when trying to date or “make a real connection”. We prematurely JUDGE as a way of avoiding risk and vulnerability.
To be fair, perhaps gay men are not really entirely to blame for the difficulties we encounter. Regardless of whether we realized we were gay since birth, we are socialized based upon our anatomy. Society as a whole does not “socialize” people to be in romantic relationships…it socializes us to be in romantic heterosexual relationships; and since it is impossible to “opt out” of society, we are subliminally conditioned to view relationships (and the world) through a “masculine” lens. Herein lies the problem, as I see it.
The “masculine” lens teaches us (in an unconscious and insidious way) to be competitive. Regardless of whether as gay men we were ever “athletically inclined” has nothing to do with it. We are taught to be “strong” (don’t even get me STARTED on that one), competitive, ego-centric and entitled-all qualities that make a good “warrior”; and that all works really well (sometimes), as it helps us to be good protectors and providers to our families. But inherent in being a competitor is the fact that someone must LOSE. Now, women know how to lose. Our sexist society (though ever changing) has conditioned them to be OK with losing. They are OK with “acquiescing” or rationalizing or sacrificing because they think RELATIONALLY. We, as men do not. First of all, we are not wired that way, NOR are we taught to think that way. It’s a double whammy. Given the relationship template we’ve been given, SOMEONE needs to be OK with being vulnerable, sacrificing, and not somehow feeling inadequate as a person because of it.
So…here were are, 2 (gay) men, neither one wanting to be vulnerable (which is required in order to make a connection), sizing up a potential partner (making judgments about our competitor) and feeling “entitled” to entering into a relationship with someone as equally masculine as ourselves. Because we are wired visually, we see a well-muscled Adonis and think, “Oh, he’s masculine, like me. I want HIM!” And if we’re lucky, he finds us physically attractive, so we go to bed together (because let’s face it, as men we are not taught to initially access levels of attraction based on what our HEART tells is, we look to our penis as the barometer). Ok, let’s say that all goes well in the bedroom and we decide that we want to do it again, and again, and again…which we assume means that we ought to have an exclusive relationship. But remember, because we view life as a competitive sport, someone eventually has to lose if I’m to retain my identity as a “real” man. The irony here is that if we both are fierce competitors the relationship will be filled with drama and hardship; yet if one of us acquiesces…we’re no longer the “masculine” guy we were thought to be…and therefore we are no longer attractive...because we essentially have become “feminized”.
So, in a nutshell, it is the power struggle that trips us up. No one ever really wins. I think that as soon as we are able to embrace the “feminine” sides of ourselves…the part of us that can sacrifice our ego for the sake of a relationship, the better off we will be. We can learn a lot from women, if we allow ourselves to do so and not be threatened by what it might mean about our identity as “real men”.
by Margie Nichols
Last night I watched ‘How to Survive a Plague’ home alone on my TV. A little context: HTSAP is a history of ACT-UP – The AIDS Coalition To Unleash Power- an activist organization that transformed the way the government responded to AIDS and forever changed drug treatment, drug trials, the FDA, the CDC, and NIH. As Larry Kramer says in the film, what gay people did from 1987 to 1996, in particular, may go down in history as our greatest humanitarian legacy.
And I am a queer psychologist, sex therapist, and activist who was the first Director of New Jersey’s AIDS service organization, Hyacinth Foundation, back in the mid 80’s.
More personally, many of my closest friends died of AIDS, for three years I co-led a group of men with AIDS, and saw dozens of them die, and by the early 90’s I was burned out.
So when I watched ‘How To Survive A Plague’ I was stunned – instant PTSD – and still can’t get some of the images of dying men out of my brain tonight. It’s impossible to describe the way a grown man who weighs 80 pounds looks, the way a 30 year old can look like a 90 year old after months of opportunistic infections and wasting syndrome. I recognized many of the people in the film – one was my own doctor for many years. I racked my brain trying to figure out which of the demonstrations on the film was the one (and only) ACT UP action I had personally attended. I can’t gauge the impact of this film for someone who did not live through this epidemic. I’m guessing the down stuff might not be so heavy.
But for me, twenty-four hours later I am left with a profound feeling of heaviness – the weight of the enormous loss, the loss of a generation of young gay men, and the gravity of the senselessness of it all.
And yet there is another feeling.
We were grand back then. For many of us, these were our shining moments. We will go down in history for something besides the loss, and it is this: when the chips were down, with yes, some bickering and infighting, we mostly pulled together, men and women, straight and gay, and took care of our own.
And we did it in a way that benefited many others besides the gay men stricken with HIV. We felt an intensity and bonding that was a type of spirituality. We felt authentically alive because we were acutely aware of the fragility of life and because we felt sure our cause was just and good. The HIV epidemic brought out the best in us, and our best was damn good. HTSAP shows this vividly – and inspirationally. It’s worth watching just to see how a despised group of people can band together not only to help themselves but to transform medical practice for everyone with life-threatening illnesses.
I’m not the kind of person that believes that everything happens for a reason. Or rather, I would say: it happens for a reason, but not necessarily a reason that is good, important, or rational. But I do believe in making the best of what you are given to work with. The way to do this, beautifully portayed in ‘How to Survive An Epidemic’ is:
by pulling together, being brave, loving, smart, and leaving a legacy to benefit others.
California just passed a law, SB 21172, making it illegal to practice ‘conversion therapy’ – the attempt to convert a homosexual to a heterosexual orientation – on minors. Few people understand the importance of this law, not only for gay teens, but also for all trans and gender nonconforming children, some of whom are as young as four when brought for treatment.
And last week State Assemblyman Tim Eustace, openly gay representative from Bergen County, said he would introduce a similar bill in New Jersey. If he does and it is passed, New Jersey will be the second state, after California, to ban this dangerous therapy. He’s framing the bill as protecting children from abuse, and he’s right.
Before I explain why, let me explain a little of the history of psychiatry’s relationship to sexual minorities. Since the late 1800’s, psychiatrists considered all forms of unusual sexual behavior and gender expression automatically ‘sick,’ in need of ‘treatment.’ The perception of gay people as mentally ill stood in the way of many other rights, so much so that after Stonewall in 1969 psychiatrists were one of the first groups targeted for political action. And in 1973 the activists succeeded: by a 51-49% vote, psychiatrists removed homosexuality from the Diagnostic and Statistical Manual – DSM- the ‘Bible’ of mental disorders. Although even the ‘liberal’ psychiatrists didn’t actually think being gay was normal, they did agree – barely- that it wasn’t a ‘mental illness,’ and therefore not in need of treatment. The impact of the DSM change was enormous. Almost immediately, the forced hospitalizations, drugging, and electroshock aversive therapies commonly used to ‘treat’ homosexuality were discontinued. The behaviorist John Bancroft even expressed his regrets publicly and admitted his treatments had failed.
And that, the gays thought, was that- diagnostic removal, treatment over. But attempts to cure same-sex sexual orientation never totally died, and they were revived with gusto by the Christian Right during the anti-sex backlash of the 80’s and 90’s. Still, reparative therapy may have become an oddity in the millennium but for psychiatrist Robert Spitzer, ironically an early supporter of the 1973 DSM removal. In 2003 his paper claiming that reparative therapy could change sexual orientation was published without peer review in the prestigious journal, Archives of Sexual Behavior. Spitzer’s study gave credibility to the Christian fundamentalist ‘ex-gay’ movement, and it grew exponentially.
For the last nine years the issue of the effectiveness, and the ethics, of conversion therapy has been hotly debated. In 2009 the American Psychological Association undertook a review of all research on so-called ‘ex-gay,’ ‘conversion,’ or ‘reparative therapy. They concluded that there was no evidence that such therapy is effective, and some research suggesting that it was harmful.
The evidence that conversion therapies harm is accumulating. There are higher than normal rates of depression and suicidality among those who undergo it, for example. This makes sense: the ‘reparative therapy’ model contends that sexual orientation is not inborn. Clients are told that their orientation is the result of bad parenting , that is it not ‘natural’ to them, and that it is under their control. They are convinced that ‘giving in’ to urges is sinful – and willful. What better way to inculcate self-hatred and despair than to tell someone they can change when they can’t, and then tell them they’ll burn in Hell if they don’t change?
And now we have evidence, research that has come out in the last year,that damns this treatment from another angle (read more here). We know, for example, that the LGBTQ people with the highest rates of depression and other mental problems are the ones who are gender-nonconforming, especially gender-nonconforming young males. We know these kids are more likely to be abused and abandoned by parents and bullied outside the family, and that the bullying, harassment, and abuse from school and peers explains their mental unbalance. We know that the more they are expected to live up to gender stereotypes – ‘act like a boy’ or ‘act feminine’ – the more depressed they get. And we know that parents who support and validate their LGBTQ children, who affirm their uniqueness instead of urging them to change, can shield their children from the insults of the outside world.
In the past few years, the American Psychological Association, along with virtually all professional associations in mental health, have condemned conversion therapy as unethical.
In 2012 Gabriel Arana published an online memoir of his experienced with ‘ex-gay’ treatment – and in the process got Robert Spitzer to recant and apologize for his 2003 paper. He now believes sexual orientation can’t be changed. (Read about this here and here)
And Saturday California became the first state to make conversion therapy with minors illegal.
Why is this so important? Because children, as our research shows, are particularly at risk from any therapy that tells them that ‘who they are’ is wrong. Kids need to be visible, and to feel secure that they are loved for who they are. Being attracted to people of the same sex is not a voluntary behavior, and it cannot be voluntarily eliminated, and that is why attempts to cure young people of their orientation is cruel.
And there is another lesser known form of ‘conversion therapy’ going on with kids even younger than the ones treated for their expressed gayness, kids so young they often don’t know who they are attracted to. These children who, as young as toddlers, behave in ways society doesn’t consider appropriate for their assigned gender. Sometimes they express a wish or a belief that they are the ‘other’ gender. Sometimes they just violate our expectations of how little boys and little girls ‘should’ act- the girl who wants short hair and rebels against dresses, the boy who loves dolls and make-up. And they are being preventatively treated with therapy aimed at making them gender conforming. For many years, the standard protocol for these children was behavioral therapy aimed at pressuring the young person into gender conformity. The rationale was that this was the way to prevent the child from growing up to be gay or transgender. The man who developed this type of treatment is a psychologist named Kenneth Zucker – ‘throw away the Barbies’ Zucker he is sometimes called. And coincidentally, Zucker is the guy who published Spitzers 2003 study defending conversion therapy – without peer review.
More and more, this type of treatment of gender nonconforming children- preventative conversion therapy - is widely condemned as unethical by progressive mental health groups. But it is still practiced. Uninformed parents are convinced that the treatment can be successful and that it carries no risk. And But, like the treatment aimed at slightly older children who have ‘come out’ as gay, it inculcates deep shame, self-hatred, and despair in the kids who are subjected to it. Imagine being told that all your likes and dislikes, desires, even the way you physically move, is bad. And imagine being told that by your parents, your therapist, and every other adult around you that this is true, that you can control your behavior – and that you should hide a big part of your authentic self.
If that’s not abuse, I don’t know what is. The practicioners of gay conversion therapy are mainly Christian fundamentalists. The therapists who practice preventative conversion treatment are not – they are Zucker and his colleagues, the old guard dinosaurs of the field. But these guy still wield tremendous power, and the only thing that will make them desist is the threat of loss of professional status – and loss of income.
So I’m sad to say that I believe that the only thing that will eradicate conversion therapy of minors is legislation. We need the California legislation in New Jersey. We need it everywhere. We need it to protect our kids from abuse- and from a lifetime of struggle to heal their psychic wounds.
The Journal of Sex Research is one of my favorite professional journals, and a recent issue included a study on sexual identity and sexual behavior in older lesbians, those 51 or older at the time of the survey – Baby Boomer lesbians, born before 1960.
Some of the results are really interesting. Here’s one to shoot down the “lesbian bed death” theory: about 11% of the women with partners, average age 63, reported no sex in the past year. The comparable figure for heterosexual partnered women over the age of 50, according to Kinsey Institute statistics? Twenty-five to thirty percent, depending on whether they are married or not. Most older lesbians in relationships had sex a few times a year to weekly – but 3% were still having sex daily! And most of the women who were having little or no sex with their partners were satisfied with this frequency, noting that their relationships had changed over the years, with emotional intimacy increasingly more important than sexual intimacy.
Lesbian sexuality is underappreciated. Yes, there are women for whom 'lesbian bed death' is a reality and they hate it. Whether lesbians in sexless relationships outnumber heterosexual women in similar circumstances is questionable. And more to the point- IPG statistics from an Internet study we did a few years ago show that sexless lesbian relationships are still full of affection; that when women do make love they spend more time, incorporate lots of nongenital as well as genital touching, are less likely to report they have sex just because their partner wants it, and more likely to report that both they and their partner orgasm. In fact, reflecting on lesbian sexuality makes you wonder about our own tendency to focus on frequency as the all-important measure of sexual relationship quality. Maybe we should be looking at time spent or mutuality of experience.
Other results from the older lesbian study seemed tied to history: Over half of this sample had been married to men before ‘coming out’ as gay, even though the average age when they realized their attractions to women was 18. Let’s hope this was the last generation to have such a struggle to claim their lesbianism, the last to feel the necessity to ‘try’ heterosexual marriage.
And one other result that I hope, as a self-identified bi woman, is also tied to history. Although only 4% of these women identified themselves as bisexual, the vast majority not only had sex with men at some point in their past, many had not been sexual with women until their 40’s ---and 38% currently reported heterosexual fantasies.Now it may be that the women don't self-label as bi because their primary attractions are to women, or possible that they are defining their identity based on the gender of their current partner. But it's also true that bisexuality is still vilified within and without the gay community. Lesbians have the usual objections - it doesn't exist, it's women who can't face being gay - as well as an uncommon one. Lesbians blame bisexual women for bringing STI's - sexually transmitted infections - into their world.
Why am I always surprised at the stigma against bisexuality? It’s so widespread –it was only this week that Google took ‘bisexual’ off their list of ‘banned’ search terms. But there’s hope in younger people who more readily identify as bisexual, pansexual, or just plain queer. Here’s to a day when women who love women – and the entire culture- doesn’t put ‘bisexuality’ in the realm of the invisible, the feared, and the despised.
Many people are puzzled and confused by what seems to an explosion of people who identify as transgender, genderqueer, gender fluid, or something else that is not ‘male’ or ‘female.’ Even to LGB folk, the changes seem to have occurred almost overnight. So let’s start our exploration of trans issues by explaining what happened.
In the 1970’s and 1980’s, the common wisdom was that sexual orientation and gender identity were totally separate things, unrelated to each other. The gender binary – the idea that there are two distinct sexes, male and female, biologically determined- was unquestioned. ‘Transsexuals’ were nature’s mistakes, a female brain trapped in a male body, and female to male transsexuals were thought to be rare. ‘MtF’ transsexuals- natal males with a female identity- yearned to be perceived as women and to fit into mainstream heterosexual society by ‘going stealth’ – keeping their history as males hidden. They rejected -and were rejected by -the newly emerging gay community. At the same time, the gay male community embraced the male macho ideal, and drag queens and ‘sissy’ men were marginalized even in the gay ghetto. Lesbians were more accepting of ‘dykes’ or ‘butches,’ but suspicious of anyone who was ‘too’ male. ‘Transsexualism’ and same sex sexual orientation seemed world apart.
But that began to change in the 1990’s. Over the last twenty years, more and more ‘butch’ lesbians gradually started to identify as female to male transsexuals. Even today, most ‘FtM’s’ go through a period of identifying as gay women before settling on a transgender identity. Many of these FtM’s choose to live within the lesbian community post-transition, and eventually most gay women have accepted their presence. Cross-dressers - natal males, attracted to women, who live part time as women – began to go to another level. Increasingly, some move to a full-time female identification and ‘transition’ - ie., take feminizing hormones, undergo gender reassignment surgery, and live entirely as women. Post-transition, many retain their attraction to women and enter into same-sex relationships. Increasingly they are accepted by and integrated into the lesbian world. Even gay men are changing their attitudes: some transmen are discovering post-transition that they are attracted to other men, and they are claiming a place in the gay male community.
The addition of the ‘T’ to the LGB has produced an interesting change in the LGBTQ community, something some social scientists call ‘intersectionality.’ Within this world, there is a widespread questioning of the gender binary, and a recognition that sexual orientation and gender identity can’t be neatly separated. This new outlook is especially prevalent among younger ‘queers,’ many of whom refuse to self-label, or who choose idiosyncratic labels. Beemyn and Rankin, whose book ‘The Lives of Transgender People’ appeared in 2011, found that their subjects choose no fewer than 103 separate, distinct ways to describe themselves. The concept of ‘gender blending’ or ‘gender fluidity’ is more widespread: I may feel ‘mostly’ female, but some days I’m more ‘butch,’ and my gender expression and behavior is different at different times. Or – I may throw out the concept of gender entirely, as the person in the picture heading this blog entry has done.
Changes have been taking place in the mainstream culture as well. Transgender people, aided by the Internet in the 1990’s, formed coalitions and lobbied for recognition, acceptance, and legal change. The transactivist movement has had a good deal of success, changing laws on local, state, and Federal levels. Trans people have become increasingly visible – think ‘Chaz Bono’- and this visibility encourages young people to ‘come out.’ At the same time, the children of the Baby Boomers, raised on feminism and ‘Free To Be You and Me,’ have supported a wider range of gender expression in their own children. Parents who twenty years ago might have taken a little boy who played with dolls to a shrink now just simply buy him the Barbie he desires. And the kids who might have suppressed their gender nonconforming identities until middle age have begun to express them by adolescence.
Are there more transgender people now than thirty years ago? Perhaps – or perhaps they are just ‘coming out’ younger and feeling freer to live their inner experiences. The next time I blog about this, I’ll address the issue of gender fluid, gender non-conforming, and transgender kids.