Earlier this week, we made good mention of some troublesome news regarding the American Psychiatric Association (APA), the Diagnostic and Statistical Manual (DSM), and one Kenneth J. Zucker.

Be forewarned: I’m about to get wordy. Please also have faith that this is well worth the time spent reading.

Some backtracking may first be in order. The DSM is easily considered the “bible” or “ultimate guide” for any mental health professional making diagnoses, treating patients, and/or looking for 3rd party payers (e.g., insurance providers). Published by the APA, the DSM is currently in its 4th edition (DSM-IV), with a 5th revised edition (DSM-V) slated for completion in 2012. Past revisions of the DSM have included the addition of Post-Traumatic Stress Disorder (PTSD) to the DSM-IV and the removal of homosexuality (which had appeared prior as a sociopathic, then sexual deviate personality disorder) in the DSM-III. As historically evidenced, the DSM and APA are capable of doing both great good and great harm; it is the latter that I am most concerned about.

While homosexuality was finally removed from the DSM in 1982, Gender Identity Disorder (GID) remains. Currently, the DSM-IV groups GID, sexual dysfunction, and paraphilias under the umbrella of “sexual and gender identity disorders.” With DSM-V currently in the works, this grouping is also up for revision. Enter: Kenneth J. Zucker.

APA STATEMENT ON GID AND THE DSM

May 9, 2008

The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns raised about the Sexual and Gender Identity Disorders Work Group.

The APA has a long-standing mission to provide guidelines for the diagnosis and treatment of mental disorders, based on the most current clinical and scientific knowledge. Through advocacy and education of the public and policymakers, the APA also affirms it commitment to reducing stigma and discrimination.

The DSM addresses criteria for the diagnosis of mental disorders. The DSM does not provide treatment recommendations or guidelines. The APA is aware of the need for greater scientific and clinical consensus on the best treatments for individuals with Gender Identity Disorder (GID). Toward that end, the APA Board of Trustees voted to create a special APA Task Force to review the scientific and clinical literature on the treatment of GID. It is expected that members of the Task Force will be appointed shortly.

There are 13 DSM-V work groups. Collectively, the work group members will review all existing diagnostic categories in the current DSM. Each work group will be able to make proposals to revise existing diagnostic criteria, to consider new diagnostic categories, and to suggest deleting existing diagnostic categories.

All DSM-V work group proposals will be based on a careful, balanced review and analysis of the best clinical and scientific data. Evidence accumulated from work group members and hundreds of additional advisors to the DSM-V effort will be considered before final recommendations are made.

The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., will have 13 members who will form three subcommittees:

* Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.
* Paraphilias, chaired by Ray Blanchard, Ph.D.
* Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.

Each subcommittee will pursue its own charge, provide ongoing peer review, and consult with outside experts. The DSM-V is expected to be published in 2012.

This may sound well and good, until one begins researching Dr. Zucker. Currently serving as the Head/Psychologist-in-Chief of the Gender Identity Service, Child, Youth, and Family Program at the Centre for Addiction and Mental Health in Toronto, Dr. Zucker’s history of treating gender identity disorder in children and youth is vast. Further research of his career digs up another nugget of gold: Zucker has many ties with the Ex-Gay movement, which uses reparative/conversion therapy for treating homosexuality (e.g., turning homosexuals into heterosexuals). You see where this is heading, right? Zucker uses reparative/conversion therapy to “cure” GID in trans* children and youth; and he cautions, “…clinicians have an ethical obligation to inform parents of the relationship between GID and homosexuality.” (Quote culled from narth.com)

The APA has a position statement against reparative therapy (not to mention a GLBT committee, staffed by GLBT psychiatrists who oppose reparative/conversion therapy). Considering this stance, it makes little to no sense that they would see it fit to place Zucker, an active practitioner of reparative/conversion therapy, as head of the GID Workgroup; but, alas, they have.

While a select few have accused me of being alarmist, I think that is far from the case: the threat that I see is quite real. Zucker’s appointment both saddens and frightens me on multiple levels. While I agree that including GID in the DSM can be helpful in procuring insurance coverage for expensive hormone replacement therapy (HRT) and sex reassignment surgery (SRS), I’ve found little evidence that Zucker supports either; instead, the reworking of the DSM’s GID entry will be chaired by someone who is an active practitioner of rehabilitating trans* children and youth via nigh-stone age methods. And while the APA has been careful to state that Zucker’s influence will not extend to clinical treatment of transpersons, I find it difficult to believe that his methods will go entirely ignored. It is a slippery slope that the APA is traversing, especially in a sociopolitical climate that still stigmatizes both homosexuality and transsexualism/genderism.

Online writing about Zucker (his past, present, and future; along with reactions from GLBT, heterosexual, and/or cisgendered folks) is plentiful. Below is a sampling links that I highly recommend perusing.

There is a wealth of information (along with informative links) to be found at the Transgroup Blog.
Read what Ex-Gay Watch has to say about Zucker and Bradley.
Delve into Zucker on Transsexualism at TS Roadmap.
Listen to a heart-rending piece on two transsexual/gendered children (one of whom is being treated by Zucker) at NPR.

I cannot stress enough that we need to be informed, and then let the APA know what we think. This is an issue that matters to all of us: homosexual, bisexual, queer, and heterosexual; transsexual/gender and cissexual.

Desire: How sleep deprivation, hormones, and stress can affect your desire. How to cultivate desire, how to negotiate your needs w/ partners

This is a topic that is near and dear to me. As a student in psychobiology, I feel that there is so much knowledge about the female body that is never even discussed, and then we are left to figure out changes in our bodies through the negative stereotypes that our society breeds. Every month a cycling woman that is not on hormonal birth control goes through so many hormone changes and levels, but then a pregnancy occurs and those levels go up to points that should be life threatening. Not to mention the plethora of other hormones that kick into gear throughout pregnancy. Then post pregnancy, most of the hormone levels begin to drop. If breastfeeding, oxytocin stays very high. Oxytocin is the bonding hormone, it makes you feel love and devotion but not lust and desire. So you have high levels of a hormone that makes you feel bonded, you are sleep deprived from feedings every 2 hours and then you have the stress of triple the laundry, cleaning house cooking meals, driving other kids to their activities and the memory of a relationship that once was loaded with hot and heavy sex.

What now? Cultivating desire is possibly the most difficult part because you are fighting internal and external forces. There is a book called the orgasmic diet http://store.babeland.com/books-sex-information/the-orgasmic-diet that has lots of great eating tips and information, however, there are limitations if your body is still sustaining another life. Remember those times when your partner would sneak up behind you and nibble your ear, or rub up on you just right…hold that feeling. Remind yourself of those little moments that would just titillate you enough to make you want it, then just keep remembering those moments. Do your kegel exercises while remembering these times. You can get exercise and a small dose of desire while going about the rest of your day. That may not always be enough. Tell your partner that they are responsible for courting you all over again. You are not the same woman you were and you need different things to get you going. This will add a level of excitement for both of you. Doing something new can stimulate your hormones that make you want sex too.

Now that you are trying to get the desire back on a personal level, you need to talk to your partner. This can be an ordeal all in its own. There is an opportunity that they are going through all of the external stresses that you are and are on edge themselves. So sitting down and having time without distractions (this might require a late night) and discussing where you are at and what you feel you need is a good first step. Be sure to use positive language and not place blame on one of you. Plan a block of time that is just for the two of you. Get a babysitter that will take the kids to the park or museum. Get the kids out so that you don’t have to feel put out and can enjoy each other in your own home. Then you can find little ways to stimulate each other and get each other really excited for your private time together. Get the sex night planner http://store.babeland.com/sexy-games/sex-night-planner and hide it in their bag as they leave the house, or send them dirty little text messages. Find a way to get yourself excited about the possibility of that time. I know that finding time is hard, but we make time for everything else in our days, and there is a good opportunity that an hour of great sex will leave you feeling better than an hour of going to the gym or the book club meeting.

What is stigma and why should we care about it? In the world of providing sex education no matter your age, gender, race, ethnicity, sexuality, etc, stigma affects the questions we ask, the questions we know to ask, the questions we feel like we can ask and even the answers we get sometimes. Here’s a little primer on stigma – the history of thought on the subject is very interesting.

Any history of the development of stigma as a concept must start with the work of Erving Goffman (1963). Goffman was the first to use the term stigma as he applied it to “an attribute that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted, discounted one.” Goffman saw stigma as something that marked an individual and reduced their status in society.

Goffman went on to develop three categories of sigma: ‘tribal’, ‘abominations of the body’ and blemishes of the individual. Tribal stigmas are those that are passed down or are familiar or hereditary. These include race and ethnicity as well as some religions. Abominations of body Goffman described as “un-inherited physical characteristics that convey a devalued social identity” (Crocker er al 1998) such as a physical handicap or obesity. These are nearly always very visible. Blemishes of individual character are stigmas given to social identities that are related to one’s personality or behavior such as being a substance abuser, juvenile delinquent or a homosexual.

Jones et al (1984) developed on Goffman’s work by illustrating six categories in which these different types of stigma would become more or less salient or damaging to individuals: concealability, course, disruptiveness, aesthetic qualities, origin and peril. Concealability is the degree to which a stigma is obvious or visible and to what degree it is controllable. Course refers to the pattern of change over time that is usually shown for the condition and what is the ultimate outcome? For this concept, the beliefs held by the “marked” person and the beliefs of the person doing the “marking” about the future course of the condition may be of great importance. For instance, “if the marker is of the general opinion that obese people typically remain fat, he will probably treat a fat person more negatively than someone who thinks that losing great amounts of excess weight is common” (Jones). Disruptiveness is the degree to which the condition blocks or hampers interaction and communication as might a mental disability. Aesthetic qualities refer to the extent to which the “mark” makes the possessor repellant, ugly or upsetting. Origin is simply the circumstances under which the condition originated and who might have been responsible for it. In this instance, when an individual is believed to be responsible for his deviance, some form of punishment is likely to be involved in the way that others respond to it. Lastly, Peril describes the amount of danger posed by the “mark” and how imminent and serious the threat might be. These frameworks were very important in helping researchers think about various types of stigma, especially when differentiating one stigma from another. This will be especially useful when thinking about LGB stigma.

Goffman’s work has inspired more than forty years of research and writing stemming from his original theory, much of this work focused on types and effects of stigma but neglected to discuss how stigma is created and maintained. In a seminal work in 2001, Link and Phelan followed by Parker and Aggleton in 2003 critiqued some of the fundamental aspects of Goffman’s work and cast stigma in a whole new, much more socially connected light.

Link & Phelan (2001) put forth the argument that stigma only happens when certain interrelated components converge. First, people must distinguish and label human differences. Then, dominant cultural beliefs must link labeled persons to undesirable characteristics. Labeled persons must then be placed in distinct categories so as to accomplish some degree of separation between “us” and “them”. These labeled persons then experience status loss and discrimination. As Link & Phelan state “thus, people are stigmatized when the fact that they are labeled, set apart, and linked to undesirable characteristics leads them to experience status loss and discrimination”.

These requirements make an important distinction between previous work on stigma that treated it as if it were a fixed thing or attribute instead of a subjective construct dependent on others to create and maintain it. Looking more closely at the concept of discrimination, Link & Phelan (2001) offer of a critique of this approach by illustrating that previous models asked, “what makes person A discriminate against person B”? This, they argue, is inadequate to explain stigma and argue that in fact, stigma has a group, or structural dimension. Institutional racism is a perfect example of this: “employers (more often white) rely on the personal recommendations of colleagues or acquaintances (more often white and more likely to know and recommend white job candidates) for hiring decisions.” Thus stigma affects the social structure around a person, creating a “disabling environment” (Hahn 1983) that is more than just one person not hiring another but is a system which works to deprive some of benefits based on certain characteristics, consciously or not.

Building on this, Link & Phelan (2001) and Parker and Aggleton (2003) define stigma in relation, not just to individual interactions, but society as a whole and in particular those people in society who have power. Stigma here is seen as something that can be created by everyone but is only available to those who have the power to wield it. Link & Phelan give an example of a group of mental health patients who develop stereotypes and stigmas about their caretakers in a psychiatric ward.

“Although the patients might engage in every component of stigma we identified, the staff would not end up being a stigmatized group. The patients simply do not possess the social, cultural, economic, and political power to imbue their cognitions about staff with serious discriminatory consequences”

Thus, stigma can be conceptualized as a social process that can only be understood in relation to broader notions of power and domination. Stereotypes might always exist and in fact, literature from psychology indicates that stereotypes help our brains to function and save cognitive space. Stigma occurs when this stereotyping is mixed with the power to make those stereotypes into social norms.

Another way to look at this is to say that stigma functions at the point of intersection between culture, power and difference. It takes a culture that defines a difference and has the power to make that difference meaningful in order for stigma to occur.

What does this mean for sex education? For me, it’s about remembering that people who walk in the door to Babeland and are possibly members of stigmatized groups aren’t just suffering from individual acts, they are part of a process and Babeland can be one of the few places that is not part of a stigmatizing system. Babeland can be a place that works to be stigma-free, to provide refuge and love for traditionally stigmatized groups. It’s not just that the sex educators at Babeland try to not act in a way that stigmatizes people, it’s that the whole philosophy of Babeland means that we don’t see people as worthy of being stigmatized and we work to create environments where they can feel the opposite of stigmatized.