The war is over. There will be, as is usually the case, post-truce skirmishes, guerrilla warfare, even major battles as occurred at New Orleans in 1815 because word of the Treaty of Ghent hadn't yet made it to the combatants. The losers may shift residence and find new employment, even continue to publish papers in a journal they founded and still completely control (so much for peer review), but the consensus on the treatment of gender-variant children has shifted to the gender-affirming crowd.
I will provide my personal take on this issue later, and I've covered the debate in the past few years. Nothing much has changed, except that more children are being supported and allowed to transition when appropriate. There is still no high quality clinical evidence to guide the treatment of these children on hand, though projects such as TransNet, co-led by medical doctors Joshua Safer and Jamie Feldman, and the Transyouth Project led by psychologist Dr. Kristina Olson of Seattle, the first large-scale, national, longitudinal study of development in gender nonconforming, transgender, and gender variant youth, are developing. What does exist, in the absence of medical studies, however, is the experience of treating children supportively, vs. the decades-long experience of rejecting them.
This conclusion was evident to me over the course of the recently completed 2016 World Professional Association for Transgender Health (WPATH) conference in Amsterdam. It was not only evident in the wealth of presentations by those who practice such care, such as Drs. Jo Olson, Maddie Deutsch and Carys Masarella, who run major trans health clinics, and psychiatrists such as Dr. George Brown, who keeps churning out research data, but in two presentations which highlighted the denouement of the conflict. The first was during the initial plenary session, opened by the Queen of the Netherlands (it's nice having a queen around who is available for such duty), when there was a "debate" over the inclusion of the diagnosis "Gender Incongruence of Childhood (GIC)" in the upcoming World Health Organization's ICD-11 manual of diseases due in 2018. The second was evident in what may very well be the last pitched battle of the war, a presentation on "Gender Laws" by the proponents of the traditional form of care, which many consider a form of reparative therapy. The audience in that much smaller room did not sit on their hands or remain quiet.
First, the plenary "debate." Unfortunately, it wasn't a debate, time was limited and there were no questions from the attendees. However, just the fact that this is the last major question regarding the treatment of trans persons left on the menu is remarkable. The debate about trans care for adults and adolescents is over, and the consensus is global. Barring any unforeseen effort by religious fundamentalist countries, the World Health Organization (WHO) will de-psychopathologize adolescent and adult trans persons, i.e., remove Gender Identity Disorder in Adolescence and Adulthood from the mental illness classification, and rename it the value-neutral "Gender Incongruence" coding in a new chapter in Sexual Health. The new term, "gender incongruence," begins and is used throughout the text of the North American DSM 5 (as written by Edgardo Menvielle, Michael Hendricks, Ellen Feder, and me, among several others, back in 2009). The question remaining is how to categorize the children, if at all.
One group, led by Drs. Morris Bersin and Nathaniel Sharon, believe maintaining the diagnosis will assist in allowing access to care and managing it properly, as well as encourage more research and adequate reimbursement so access can be improved. The opposition, led by Drs. Sam Winter and Simon Pickstone-Taylor, believe the diagnosis, in and of itself, is pathologizing, and all the desirable goals outlined by Bersin and Stone can be obtained through general mental health coding with the addition of Z-codes to clarify the gender issues. Think of z-codes as footnotes; they will be in the record but in small print either at the bottom of the page or as endnotes.
It should be noted that when the WPATH board voted in 2014 the vote was exactly even, and when the general membership weighed in, it was virtually the same. That was, however, prior to this conference and its plenary session, and the multitude of discussions and lobbying which occurred afterward. "Stop GIC" buttons were in evidence throughout the conference hallways. My hope is that the organization will perform another online poll in the near future of those who were present to see if there was any movement. My fear is that if we can't make up our mind then the WHO will make it up for us (which they may very well do, anyway).
A very interesting coda to this debate was presented by a young woman named Valentijn, who transitioned 21 years ago at age five. She noted that while she had no issues with her social transition or the quality of her care, she was always aware that she was a patient, and that knowledge had an impact on her childhood. Being a patient with a diagnosis implies there's something wrong with you.
Another very important bit of progress was evident near the end of the conference when the trans health issue of the British medical journal, The Lancet, was presented and the authors had the opportunity to speak. The issues in the journal were the same of those presented at the conference, but that they now have the imprimatur of the global medical giant is of incalculable worth. It sends a major signal to the WHO that we should be taken seriously.
The main event occurred during a group presentation on Monday in an SRO room with the heat on full blast. Moderated by Dr. Heino Mayer-Bahlburg, a well-respected expert on intersex conditions and a friend of the traditionalists, the topic was "Gender Laws," a discussion about reparative therapy bans.
The neutral presenter was Dr. Annelou de Vries, who was clearly uncomfortable as she presented the WPATH position already published in the Standards of Care version 7. She discussed the three approaches to the treatment of gender variant children:
therapeutic (reparative therapy)
She was sandwiched in between the two big draws - Drs. Richard Green and Ken Zucker. Most people don't know Dr. Green, but he was a past president of tWPATH and the author of The Sissy-Boy Syndrome and the Development of Homosexuality, published in 1987. Prolific since the late '60s, he studied at Hopkins with John Money and co-authored with him in 1969, founded and ran the Archives of Sexual Behavior which he turned over to Ken Zucker in 2001, and was also a founder of WPATH in 1979, but he had not appeared at a conference in 17 years. The reason was evident -- while physically well preserved at age 80, his ideology and theories have not stood the test of time. After his presentation I talked with him and thanked him for coming and making his presentation. I also said that his book had made my life hell for many years, and the conversation ended when we discussed the issue at hand - the treatment of gender variant kids - and he insisted there was no way to distinguish trans girls from gay boys and that, therefore, transitioning such children was wrong.
His presentation was a legal one (he received his JD from Yale in 1987, the year he published The Sissy Boy Syndrome), primarily focused on the vagueness of conversion therapy laws, their target of banning sexual orientation work with which he did not disagree, but the confusion that results when gender identity is conflated with sexual orientation. His arguments, if divorced from the purpose of the presentation, were not misplaced, and were worthy of presentation and discussion. As a trans ally extraordinaire said to me in the back of the room, it is only necessary for the government to become involved, however imperfectly, when the profession fails to police itself. Fortunately there was very effective pushback from Asaf Orr of the National Center for Lesbian Rights (NCLR).
The conclusion in Part Two.