Gender Health?

https://www.uclahealth.org/med-peds-care/gender-health-program

 

 

With deep respect for UCLA as an institution, and with deep respect for my training which has entirely occurred at UCLA, and with deep respect for the many departments within UCLA that I have been affiliated, I am quite curious and, dare I say, skeptical, about a “gender health program”. Reflecting back on my training in the 1980s (yea, I am getting old, I know), UCLA was doing transgender surgery, mostly in the department of urology. Mostly they were turning male genitalia into female genitalia. Other tertiary care medical centers were doing this too, and so this was a “standard of care” a phrase which has now been replaced by “evidenced-based medicine”. In the early 90s they stopped doing this surgery and so patients seeking a change in genitalia sought private practice doctors, both here in LA and around the world. Medical tourism was a popular notion among male-female transgender folks as they could pay out of pocket a fraction of the cost in another country, and that would include their airfare, a fancy hotel, and an American trained physician working in another country (usually their birth country). Somewhere around 2010, the “medicalization” of transgender patients took off, with the example being in LA, that children’s hospital started a clinic…

http://www.chla.org/the-center-transyouth-health-and-development and then pediatricians throughout LA, when faced with a patient who expressed discomfort with their gender, would be sent to Children’s Hospital. The assumption is that CHLA is a good hospital and so, therefore, they must appropriately deal with transgender issues, since most pediatricians have no training in this area. Somehow, UCLA seems to want to join the party, and so the Gender Health Program is born. I say this, with the complete disclosure that I am not aware of the politics, or the motivation behind opening this clinic, but I do enjoy speculating publicly (to my 50 or so readers), as to how transgender issues seem to come and go within the medical profession. Having Gender Dysphoria..as opposed to Gender Identity Disorder (GID)..see below

 

GID was reclassified to gender dysphoria by the DSM–5. … The American Psychiatric Association, publisher of the DSM–5, states that “gender nonconformity is not in itself a mental disorder. The critical element ofgender dysphoria is the presence of clinically significant distress associated with the condition.

 

…is a mental disorder. I am not sure that I agree that those who have distress over their gender are mentally ill. Sure, they need a prescription for hormones, and possibly surgery, to change their gender, so they do need medical care, but whether they need mental health care has more to do with individual preference. A patient, for example, might have extreme distress over the size of their nose, but they don’t need to see a psychiatrist if they opt for rhinoplasty to attempt to minimize their distress. I know this statement is very controversial when it comes to gender, but I think this argument is worth consideration. If the patient is curious as to why their nose distresses them so much, then mental health intervention makes sense, but if there is no curiosity, then mental health care is harder to execute. In the 70s being gay meant you had a mental illness. That quickly got fixed when psychiatrists realized the absurdity of that notion. Being bisexual, or uncertain of your sexuality, is also not a mental illness. So, I would say that being uncertain about your gender is not a diagnosis, but only a nodal point, which suggests thinking about how to proceed. As with all big decisions, we, as psychiatrists, can help people through them, but it is also true that people make big decisions without our help and do just fine.

Returning to the Gender Health Program, I can see the advantage of pooling patient populations in order to develop an expertise. I can also see the marketing advantage that the program makes people feel like they will have a place of understanding. My issue is that Gender Health is a made-up term. I wish they would call it a Gender Program. I am not sure what Health has to do with it, as the patient may not be sick to begin with.

 

 

Should Psychiatrists Give A Patient Permission To Change Gender?

Jane wants to become John. She wants “top surgery” meaning she wants a double mastectomy. The surgeon requires a letter from a psychiatrist stating the patient can give informed consent. Yet, the surgeon does other procedures in which he obtains informed consent without the assistance of a mental health professional. In the surgeon’s mind, I suspect, is a fear of regret, resulting in a malpractice lawsuit, in which the letter from the psychiatrist serves as some protection. Further, for the patient to get insurance reimbursement, she/he needs a diagnosis of gender dysphoria, but who is to say that gender dysphoria is a mental illness? Yes, it causes suffering, but so does having body parts that cause distress. All of us need to decide what we accept and what we change, and perhaps, just perhaps, gender is no different. Perhaps Jane is not mentally ill, but only sees a way in which he can live in the world and be happier with himself. Perhaps Jane is navigating his world in a way that makes sense to him, and perhaps that is all that matters, given that Jane is an adult. The “Janes” of this world are a growing population; a population that gives some of us pause as to what the rules of the road really are. Jane reminds us that we are not restricted to our biological body parts and that change can happen, sometimes with happy outcomes and sometimes with sad outcomes, but this is what comes with decisions of adult life. If Jane wants help from a professional, that is an avenue that is open to him. To mandate that is simply absurd.

And Thinking About The Sexes….

A woman on our board has made us rise above the fray.

Do Girls Have A Harder Time?

“Womens’ lives involve deep and primary relationships, with their children, and importantly, with other women.” Nancy Chodorow PhD

“Sex-role development of girls in modern society is complex. On the one hand, they go to school to prepare for life in technologically and socially complex society. On the other, there is a sense in which this schooling is a pseudo-training. It is not meant to interfere with the much more important training to be feminine and a wife and mother which is embedded in the girl’s unconscious development and which her mother teaches her in a family context where she is clearly the salient parent.” Nancy Chodorow PhD

We might expect that a woman’s identification with a girl child might be stronger; that a mother, who is, after all, a person who is a woman and not simply the performer of a formally defined role, would tend to treat infants of different sexes in different ways.” Nancy Chodorow PhD

Brothers and sisters, close in age, give us an opportunity to postulate how families can mean different things to different genders, giving meaning to my frequent comment  that “although you are siblings, you did not have the same parents.” Parental expectations of boys and girls are different, even in our more progressive society, and even after the two waves of feminism. Specifically, boys are expected to have financial independence, get married, have a family, but with, generally speaking, a looser psychological tie to his mother, as time progresses. Girls, by contrast, are also expected to have financial independence, get married, have a family, but also maintain a tightness with her mother. This critical difference in both conscious and unconscious expectation often makes it more difficult for the emerging female adult to find their own path, while at the same time, taking emotional care of her mother, by maintaining a close bond.

Diedre and Ezra, boy and girl twins illustrate the point. Ezra grows up, goes to college, graduate school, gets married, buys a house and is hoping to have children in his early thirties. He married a girl, quite similar to his mom, a remark that almost everyone said at their wedding, according to Diedre. Ezra calls his mom every Sunday and they chat for about twenty minutes. There is little tension, and, again, according to Diedre, Ezra has “checked every box.” Diedre, my fictional patient, has had a more “windy” path, by her description. She went to college, then traveled, then cobbled together some “jobettes” then figured out she wanted to be a speech pathologist, so landed back in graduate school. Meanwhile, her relationships with men have been satisfying to her, but distressing to her mother. She has found men along her journey who had “alternative” lifestyles. Mark, for example, lived out of his car, not because he could not afford an apartment, but because he thought it was a great way to save money. Diedre comes to me worried about her relationship with her mother. She feels torn between “checking the boxes” and doing her “own thing.” Diedre looks at Ezra with contempt and boredom. “He is living a life that looks like a script. I am not sure he even knows what makes him happy,” Diedre says, with a tinge of jealousy. “On the other hand, I can see that he has stability,” she explains her envy. “Still, my biggest problem is that I know my mom worries about me because although now I am on a career path, I am not married, and she never likes the men I am with.” I wonder aloud, “maybe you pick men that you know your mom won’t like, in order to demonstrate to yourself that you are your own person and that you are not your mom.” I say, thinking about how hard, for certain young women, it is to separate emotionally from their moms, and so with this difficulty they go to extremes. “I am certainly afraid of turning into my mom. You are right about that part.” Diedre says, not sure if that explains how she is choosing her boyfriends.

Dr. Chodorow reminds us that girls both want and do not want to be close with their mothers, and this duality creates an unsteady feeling that boys, generally speaking, do not have to wrestle with. Boys are not their moms because they are a different gender, and because their mom does not expect the same intimacy from them. Girls, by contrast, are imbued with a deeper narcissistic investment from their mom and this burdens them into pushing back in ways that create anxiety and uncertainty. Going forward, girls then have babies, which sandwiches them between maintaining the tie to their mom, while at the same time as nurturing their infant. They are thrown into the challenge of parenting, forcing them to “remember” sometimes, by re-experiencing, their own early childhood. Boys, typically, are not on the front lines of infant care, and as such, do not re-live their early childhood so intensely. The complexity of this emotional interior, Dr. Chodorow argues, makes women have harder psychic lives. I agree.

 

See also…https://shirahvollmermd.wordpress.com/2013/10/07/struggle-of-the-sexes/

Struggle of The Sexes

“Chodorow sees gender differences as compromise formations of the Oedipal complex. She begins with Freud’s assertion that the individual is born bisexual and that the child’s mother is its first sexual object. Chodorow, drawing on the work of Karen Horney and Melanie Klein, notes that the child forms its ego in reaction to the dominating figure of the mother. The male child forms this sense of independent agency easily, identifying with the agency and freedom of the father and emulating his possessive interest in the mother/wife. This task is not as simple for the female child. The mother identifies with her more strongly, and the daughter attempts to make the father her new love object, but is stymied in her ego formation by the intense bond with the mother. Where male children typically experience love as a dyadic relationship, daughters are caught in a libidinal triangle where the ego is pulled between love for the father, the love of the mother, and concern and worry over the relationship of the father to the mother. For Chodorow, the contrast between the dyadic and triadic first love experiences explains the social construction of gender roles, the universal degradation of women in culture, cross-cultural patterns in male behavior, and marital strain in the West after Second Wave feminism. In marriage, the woman takes less of an interest in sex and more in the children. Her ambivalence towards sex eventually drives the male away. She devotes her energies to the children once she does reach sexual maturity.”http://en.wikipedia.org/wiki/Nancy_Chodorow

This will be our discussion in class  on Friday. Do women have harder lives? According to Dr. Chodorow, yes, indeed, beginning with the Oedipal challenge of falling in love with her father, still intensely in love with her mother, and feeling perpetually torn, leading to the future torn feeling between her husband and her own children. The girl, unlike the boy, can never experience the bliss of a dyadic relationship, as it is challenged by a third-party. The boy, by contrast, can love his mother, admire his father, find a wife, and seamlessly go from one dyadic relationship to another. This Oedipal challenge leaves a girl to experience intense guilt for having a firmer alliance in one direction and not another. So many marriages teeter with the challenge of raising children because the husband, often gets demoted. Second marriages are often about husbands yearning and seeking for the time in his first marriage where he felt like he really mattered, instead of feeling like he was a wallet. How does a woman, expend energy on raising children, while still ensuring that her husband is narcissistically gratified. One could say that husbands should not need this narcissistic gratification from his wife and that he should embrace his new role as a father, but if the dynamics of a marriage are such that the wife makes her husband feel that he is the center of her universe, it would be quite ambitious to think that the husband can gently leave that perch?

Clarene, twenty-seven, is quite tight with her mother, loves her father, and lives with her boyfriend, Stan, much to the dismay of her father, but not her mother. Clarene’s mom likes Stan because he is caring and kind to Clarene. By contrast, Clarene’s dad feels that Stan is not “good enough” but then again, when pressed, Clarene says no one would be “good enough.” “He does not want me to separate from him,” Clarene says, wanting me to know that Clarene’s point of view is that she is “daddy’s little girl” and Stan interferes with that dynamic. Knowing this, however, Clarene is still torn between pleasing Stan and pleasing her father, in a way that might remind her of her childhood when she could not please both parents at the same time. When she did well in school, her mother was proud, but her father said she could do better. Clarene painfully recalls the multitude of times when she wanted to make her dad happy, but she never felt she did. Clarene’s brother, Eliot, never seemed to care if he made his dad happy. Eliot only cared what his mother thought of him, and yet he admired his dad a great deal, according to Clarene. This difference between Clarene needing to please all, whereas Eliot was more narrow in his “love-objects” gives Clarene, and hence all women, in general, according to Dr. Chodorow, the burden of needing consensus among her loved ones. Dr. Chodorow would say that as long as women take care of their children, girls’ lives will always be more complicated by this ever-pressing guilt involved in pleasing one, but not the other. This explains how girls, from a young age, form groups, where the dynamics are critical, whereas boys, focus on activities where slights tend to be less felt or noticed. This long history of emotional complexity may explain why girls migrate towards helping professions, understanding the push and pull of relationships.

 

See also…http://www.latimes.com/nation/nationnow/la-na-nn-pew-moms-exhausted-dads-20131007,0,2841039.story

Women And Opiates: My Rant

Pills of hydrocodone, also known as Vicodin, are shown. Drug overdose is one of the few causes of death in the United States that is worsening, eclipsing fatal traffic accidents in 2009. (Toby Talbot / Associated Press / February 19, 2013)

“About 15,300 women died from overdoses of all kinds in 2010, more than from car accidents or cervical cancer, according to the CDC.

Overdose deaths rose most rapidly among middle-aged women who, previous research has shown, are more likely to suffer from chronic pain and to be prescribed painkillers.

“Mothers, wives, sisters and daughters are dying at rates that we have never seen before,” Frieden said. ‘These are really troubling numbers.’ ”

http://www.latimes.com/news/local/la-me-rx-painkillers-20130703,0,916397.story

 

I highly suspect that many of these “middle-aged women” taking opiates, overdosing from opiates, complaining of chronic pain, are suffering from disappointments, psychic pain, and frustration with their lives, particularly their relationships. This “middle-age” for women, as we all know, is associated with launching children, coping with elderly and disabled parents, menopausal body changes, along with mid-life relationships which range from long-term marriages to being new to the dating scene to perpetuating a single life, which may or may not feel satisfying. Where do these women turn? The psychiatrist? Nope. For both social and financial reasons, these women, generally speaking,  turn to their trusted primary care physician. However,  complaining about their husbands, children or their parents, seems like a “waste of time,” so they focus on the very real pain of aging. Joints do not work as well. Injuries are more common. The fluidity of the body is slowly declining and so they complain. Exercise, of course, should be the first line of defense, but primary care physicians are usually coached to get rid of pain quickly, rather than telling patients to exercise, as primary care doctors often feel that the exercise  recommendation is unlikely to be understood as helpful, but rather the patient responds with  “yea, I know, but I won’t.” The culture of doctors wanting to please their patients, encourages physicians to give them opiates for pain that is not clearly understood, but complained about. “What is going on with your life, right now?” is the question that I wish happened in that eight minute office visit. Primary care doctors could venture an educated guess, that the pain of aging is exacerbated by disappointments in relationships. Middle-age is a hard time for women. The culture seems to understand the “mid-life crisis” of men, but women, too, examine their choices, sometimes with feelings of deep regret and despair. Maybe opiates numb that despair, and over time, as the feelings mount, so does the opiate use, leading to tragic and preventable death. My solution: Exercise and psychotherapy for these women who come complaining of body pain, while working them up to make sure that they do not have an underlying disease process which requires medical intervention. Opiates are wonderful drugs for those facing the end of their lives due to a debilitating disease. By contrast, opiates ruin the lives of those who could have a lot to look forward to, but who need to get over a major hurdle in their lives.  Physicians need to understand that. Women deserve it.

Boy or Girl: Introducing a Continuum

This blog will continue my series on gender.

But let me tell you, this gender thing is history. You’re looking at a guy who sat down with Margaret Thatcher across the table and talked about serious issues.
George H. W. Bush

The term ‘gender identity’ was used in a press release, November 21, 1966 to announce the new clinic for transsexuals at The Johns Hopkins Hospital. This was originally a medical term used to explain sex reassignment surgery to the public.

The formation of a gender identity is a complex process which starts at conception, but then involves learning experiences after birth. Language and tradition in many socieities insist that every individual be categorized as either a man or a woman, although there are societies, such as Native Americans, where they acknowledge two-spirit, and this includes multiple gender categories.

Some people refuse to be categorized. RuPaul Andre Charles (b. 11/17/60) is an American actor, drag queen, model, and singer-songwriter who first gained fame in the 1990s. RuPaul is famous for saying “You can call me he. You can call me she. You can call me Regis and Kathie Lee; I don’t care! Just as long as you call me.”

During the 1950s and 60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homsexuality which was viewed as a mental disorder at the time. In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersexuals and transsexuals. Psychoanalyst, and my supervisor, Robert Stoller MD documented the findings from this projet in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden in 1963. At the same time, behavioral psychologist John Money was working at Johns Hopkins Medical School’s Gender Identity Clinic (established in 1965). Dr. Money popularized an interactionist theory of gender identity, suggesting that up to a certain age, gender identity is relatively fluid. Money remains a controversial figure because of his assertion about the fluidity of gender identity.

From 1990 to 1992, I worked at the Los Angeles Gender Center. The Los Angeles Gender Center is a group of clinicians who evaluate adults who are searching for a medical intervention to change their appearance so that the world will respond to them in the way that matches how they feel. To the extent that self concept may be informed by how a person understands how others perceive them, then when there is a disconnect between how one feels and how one is perceived, mental distress ensues. When faced with this dilemma, there are options. One could seek psychotherapy to help them deal with this discrepancy. One could seek hormones and surgery to change their appearance so that others respond differently to them. One could try to change society such that there is a continuum between male and female. Perhaps the combination of these three options is the answer.

Psychiatrists have the opportunity to support a continuum for gender. Our new diagnostic manual is scheduled to be released in 2012. We could eliminate the diagnosis of gender identity disorder. We could return to the pre-Hopkins Transgender Clinic days when gender was a field of study and not part of a diagnostic label. Analyzing the phenomena of gender should be left to scholars.

In looking back over fifty years, the creation of the diagnosis of gender identity disorder is evidence that we lost our way. Mental health practitioners need to focus on well-being. When we collude with gender stereotypes then we violate our fundamental principle of “do no harm”. If we broaden the notion of gender, we then develop a more expansive view of our world. This parallels the goal of psychotherapy which is to broaden one’s thinking in order to tolerate the difficulties both in ourselves and in others.  Embracing complexity is our mission. Putting gender on a continuum is a first step.

Gender Identity Disorders in Girls: A Plea For A Label Change

As it stands now, the diagnosis of Gender Identity Disorder in Girls is for girls who have intense negative reactions to attempts to have them wear feminine attire. Some may refuse to attend social events where such clothes may be required. Their fantasy heroes are often powerful male figures such as Ninja Turtles or Spiderman. These girls prefer boys as playmates, with whom they share interests in sports, rough-and-tumble play and traditional boyhood games. They show little interest in dolls or any form of feminine dress up or role-play activity.

Cross-gender behaviors are sometimes a sign that the child believes she would be better off as the opposite sex. According to Bradley and Zucker (Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, 1995) “this fantasy solution provides relief, but at a cost”.

Many times these are unhappy children who are using these behaviors to deal with their distress. They believe that being a boy would make their lives better. Forcing the girl to act “feminine” when the child feels inadequate or fearful is not the solution. These children need psychotherapy in order to uncover the root cause of the emotional conflict, so that the problem can be addressed and resolved.

I argue that gender dissatisfaction is a symptom of a larger problem, and hence calling it gender identity disorder is misleading. It would be as if one is calling anorexia nervosa the starving disease. Yes, starvation is present, but it is part of a larger picture of body image distortion and preoccupation with food. Similarly, cross-gender behaviors is a clue to a general sense of dissatisfaction with their lives, with their relationships and with their sense of security in their worlds. One needs to see the big picture in order to intervene.

Labels shape how we view disorders. Labels shape how the individual views herself. As such, if we broadened the label to state that these girls could be happier with themselves (ie put it in the category of low self-esteem), then we could intervene by trying to understand the obstacles to this girl having greater pride in her potential. Then, we could help her help herself to a fuller, and less conflicted life.