July 6, 2012
Excerpts From the APA Task Force on GID report issued this week:
Edgardo J. Menvielle, M.D., M.S.H.S. and Richard R. Pleak, M.D.
The optimal approach to treating pre-pubertal children with GV, including DSM-defined GID, is much more controversial than treating these phenomena in adolescents and adults for several reasons. Intervention, or the lack thereof, in childhood as opposed to later may have a greater impact on long range outcome (Crouch, Liao, Woodhouse, Conway, & Creighton, 2008); however, consensus is lacking regarding the definition of desirable outcomes. Further, children have limited capacity to participate in decision making regarding their own treatment and must rely on caregivers to make treatment decisions on their behalf. An additional obstacle to consensus is the lack of randomized controlled treatment outcome studies of children with GID or with any degree of GV (Zucker, 2008b). In the absence of such studies, the highest level of evidence currently available for treatment recommendations for these children can best be characterized as expert opinion. Such opinions do not occur in a complete vacuum of relevant data, but are enlightened by a body of literature (mostly APA level C and lower), including systematic experimental single-case trials as well as both uncontrolled and inadequately controlled treatment studies, longitudinal studies without intervention, and clinical case reports.
Opinions vary widely among experts depending on a host of factors, including their theoretical orientation as well as their assumptions and beliefs (including religious) relating to the origins, meanings, and fixity/malleability of gender identity. For example, do gender variations represent natural variations, not assimilated into the social matrix, or pathological mental processes? Even among secular practitioners there is a lack of consensus regarding some of the most fundamental issues: What are indications for treatment? What outcomes with respect to gender identity, gender role behaviors, and sexual orientation are desirable? Is the likelihood of a particular outcome altered by intervention? What constitutes ethical treatment aimed at bringing about the desired changes/outcomes? Adding to this complexity, service seekers as well as providers differ in their religious and cultural beliefs as well as in their world-views regarding gender identity, appropriate gender role behaviors, and sexual orientation. Primary caregivers may, therefore, seek out providers for their children who mirror their own world views, believing that goals consistent with their views are in the best interest of their children.
We begin by examining the natural history of GID as defined by outcome without treatment. We then discuss the goals of interventions in treating these children and the factors that influence clinicians in goal selection. Next, we describe various interventions that have been proposed. The empirical data available to inform the selection of goals and interventions are then reviewed and an opinion is offered regarding the status of current credible evidence upon which treatment recommendations could be based.