OK, so we'll get started by way of introduction. I'm Jack Drescher. I'm a psychiatrist, psychoanalyst, and private practice in Manhattan. I'm also a voluntary faculty member at Columbia University, also on the adjunct faculty at NYU, New York University. Topic for today is ethical issues in treating LGBTQ patients. I'm trying to find my button. Here we go. This is the table of contents, what I'm going to talk about. I'm just going to present a couple of principles of medical ethics that are useful in thinking about this subject. I'm going to define some terms. Some of you may know. Some of you may not know these terms. I'm going to give you a little bit of the history of psychiatric treatments and thinking and diagnosing about these patient populations. I would add that I worked on the DSM-5 work group on gender and sexuality and the ICD-11 working group on sexual and gender identity disorders. And I just finished editing the chapter on gender dysphoria in the DSM-5 text revision. So I have an interest in the history of diagnosing these categories. And then conclude with some questions that come up in the clinical setting. So as many of you know, the AMA publishes principles of medical ethics. What the APA does is they add annotations to give examples of how the principles of medical ethics might apply to psychiatry and psychiatrists. So section one of the AMA principle reads, a physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights. And the annotation. The second one is that a psychiatrist should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation. These annotations are from 2013. I'm presuming when they are updated, whenever that will be, it will probably include also gender identity and gender expression. And the other principle to keep in mind, actually a principle that has brought all of you here today, is that a physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. And the annotation is that psychiatrists are responsible for their own continuing education and should be mindful of the fact that theirs must be a lifetime of learning. So we'll start by defining some terms. We'll start with gender. Gender, as everybody knows, people are sending me links to Bill Maher's comments about gender. I don't know. I haven't seen it yet. But apparently, he's now weighed in on these culture wars. But for many people, gender is a binary concept. These are supposedly the universal symbols of male and female. If you're traveling anywhere around the world and you need to use the restroom, you would look for the one that carried the symbol with which you would identify. But if you went to Scotland and you were a man, you might have a problem knowing which restroom to use. Because binaries are sometimes inadequate, because gender is actually a cultural construct. So depending on the culture, you may get different concepts of what constitutes the two genders, two genders in quotation marks. So starting with my work in DSM-5, I'd been working for many years around issues having to do with sexual orientation and homosexuality. But as I started to familiarize myself with the issues around gender, I felt all the time that there was a big picture that I couldn't see. And this is the closest approximation I could get to the big picture that I can't see, which is six blindfolded scientists trying to describe an elephant, that there are a lot of moving parts. And as we'll hear today, you're going to be introduced to some of the moving parts. And this often happens when I give this talk. The question and answer will also introduce some other moving parts, which are not, perhaps, formally in the talk. So LGBTQ, lesbian, gay, bisexual, transgender, and queer slash questioning. Sometimes as LGBTQQIA, including queer, questioning, intersex, asexual. Some people call this alphabet soup. Or LGBTQ+, LGBT or LGBT+, sexual minorities covers everybody without having to go into alphabet soup. And sexual and gender minorities as well. So these are ways in which people are talking about these subjects today. Sexual orientation, this is a person's erotic response tendency or sexual attractions, whether they're attracted to someone of the same sex, which is called homosexual, the other sex is called heterosexual, or both sexes, which is called bisexual. When working with people in the transgender population, these are kind of clunky terms, because it's not clear whether you're talking about somebody's sexual attractions before or after a transition. So if you use the terms which are in the literature, androphilic, meaning attracted to men, or gynephilic, attracted to women, it eliminates the problems of talking about the gender identity of the person that you're talking about. Now sexual identities are the subjective experiences of one's sexual desires or attractions. And homosexual, lesbian, gay, or bisexual identities involve some measure of self-acceptance of one's homosexual desires, and perhaps an identification with a community of similar others by virtue of having same sex attractions. And the acquisition of a sexual identity is often conceptualized as a developmental process that occurs over time. And not all persons who experience homoerotic desire or participate in homosexual behavior develop a lesbian, gay, or bisexual identity. So to rephrase that, a sexual identity, how I think and feel about my sexual attractions, is not synonymous with my sexual orientation to whom I am attracted. And this is a very important distinction. So the terms gay men, lesbian, gay, bisexual, they emerge in popular usage as a way to refer to men and women whose sexual identity, to some degree, openly recognize their homosexual or bisexual attractions. And gay is also sometimes used as a politically inclusive term for both men and women, whether homosexual or bisexual. A lot of these, if you, my colleague William Byne and I have done the last four editions of the chapters on homosexuality and gender in Kaplan and Sadock's textbooks of psychiatry. And this is a kind of a drawing of a way to think about sexual identities in broad categories. There are more than four different kinds of sexual identities. But these are a broad way to think about the way most people in our culture here talk about their sexual identities. And so starting on the left, you have what I call a closeted identity, which is a person will report this identity, usually in retrospect, because this identity involves some degree of dissociation or detachment from awareness or knowledge about it. And after a person has moved along the spectrum to a certain degree, they will report, I always knew I had this feeling, but I didn't want to think about it. I didn't want to talk about it. It really involves dissociative processes. And there's an arrow going back and forth as you go to the next identity, homosexually self-aware, because for some people, it's like a switch going off. For many people, it is not. It's kind of a back and forth between two identities. And a homosexually self-aware identity simply means that they're no longer dissociated from these feelings. They recognize that they have these feelings. They haven't decided what they're going to do about it, but they're no longer saying, this is not me. This is something about me. And what they do from there can move in a couple of directions. If you go to the upper right, you see, again, a back and forth between being homosexually self-aware and accepting. If a person is accepting of that identity, they might call themselves gay or lesbian or bisexual. If they don't accept that identity on the lower right, they might adopt what is called a non-gay identity. And there is also the phenomenon, because I was a person who was writing a lot about the so-called ex-gay movement, a certain number of people who they did adopt a gay, lesbian, or bisexual identity, but then rejected it. And they moved into a non-gay or an ex-gay identity. So this is just a broad way of thinking about people's identities. And so just to give an example of why not everybody who has sex with someone of the same sex has an identity, the CDC classifies, in following the HIV epidemic, doesn't talk about gay men. They talk about men who have sex with men, because not every man who has sex with men identifies in a positive way with a gay or bisexual identity. So there are some other terms. MSM is men who have sex with men. Some other sexual orientations, some people refer to themselves as pansexual. We're going to talk a little bit about the subjectivity identities. So I'm on a committee for the Group for Advancement of Psychiatry. We put out a special issue that I edited of Focus magazine, which is an APA publication on treating LGBT patients. And the group, I thought it would be a great idea to have a glossary of terms for people who are reading it. We could not get the committee members to agree on definitions in the glossary of terms. So it's really important to keep in mind, because identities are so subjective. Whenever you meet somebody who presents with an identity that you don't recognize, don't be afraid to say, I'm not familiar with the term. Why don't you tell me what you mean? Or you can say, I've heard people use that term in different ways. How do you mean it? That's really important. Pansexual, I think, means people who are capable of having sex with anyone. But I'm not sure. Gynandromorphophilic are usually heterosexual cisgender men who are attracted to transgender women. And some people think of asexuality as a sexual identity. Now, one thing that happens in LGBTQ communities, as some things that are useful to know, is the concept of families of choice. As many of you know, some people are rejected by their families if they come out as being a member of a sexual minority. And if they do come out rejected, they may wind up having to find their support systems elsewhere. And in the sociological literature, this is referred to as families of choice, families of origin versus families of choice. Polyamory refers to a kind of relationships where people, and there may be a minimum of three people involved, in which people are sexually and romantically and intimately involved with each other. And these are often stable relationships. Not always, but often they are. And some people refer to themselves as non-monogamous, which is that they don't think that monogamy should be part of their relationship. Anthropos refers to people who have stable three-person relationships. Now, sex, as opposed to gender, refers to the status of biological variables that can be described as either male-typical or female-typical in normatively developed individuals, such as genes, chromosomes, gonads, internal and external genital structures. Whereas gender, a gender identity, is a persistent inner sense of belonging to either the male or female gender category or some other category. The DSM-5 introduced the concept of some other category when talking about gender identities. And gender expression, which is a term which is increasingly used in legal documents, refers to how the person publicly presents their gender. So I'm doing male gender expression for you today. Actually, all the time. And that's because this is how I choose to express myself. And some people, regardless of their sexual orientation or their gender identity, might choose a different form of gender expression. Gender assignment is historically what was referred to as being biological female or biological male. But we don't know where the biology of gender lies. Traditionally, most cultures assume that your genitals will determine your gender. But we know from the experience of both transgender people and from intersex patients that that isn't always the case. So the language that we use today in this literature is birth assigned male or female, or individual assigned male, female at birth. Back when we were doing DSM-5, the term natal male or female was acceptable. Now it is not. Gender dysphoria is a longstanding term that exists in the literature that talked about the distress that can accompany the incongruence between one's experienced or expressed gender and one's assigned gender. But more specifically, it was the term we decided to adopt when we revised the DSM-5 for what used to be called gender identity disorder, or GID. Gender incongruence, on the other hand, is the term we used when we revised the International Classification of Diseases, which came out in 2019 and which is being adopted this year in many countries around the world, which refers to a marked and persistent incongruence between an individual's experienced gender and their assigned gender, which replaced the diagnosis of transsexualism and gender identity disorder of childhood in the ICD-10. I'll further add, and I have a table to show later on, that in addition, the ICD-11 has removed the diagnosis from the mental disorder section. So it's now in a chapter called Conditions Related to Sexual Health. So if you're living in a country, not this one, that's using the ICD-11 and your doctors give you a diagnosis of gender incongruence, it's a medical diagnosis, not a psychiatric diagnosis. Transgender is a term originally coined in the 1970s to refer to people who live full time in one gender, but the one not associated with the one that usually went with their genitals. And it's broadly used today to define individuals who are not conventionally gendered. There are other terms. And again, people mean different things. I won't tell you what I think it means, but these are terms that people will use. The closest I can come to something that I think, non-binary means I don't identify as either a man or a woman. But again, it's really important. This is all about subjectivity. And these are the terms that are roiling. And there may be more as time goes on. Cisgender, this is a term used by the transgender community to describe individuals whose gender identities align with their assigned sex at birth. Meaning if you're not transgender, the trans community refers to you as cisgender. This is gaining a lot of popularity in the media. You can now read cis. The word appears in the New York Times all the time now. And there's a parallel between the coinage of terms like homosexuality, which entered popular usage before the term heterosexuality. So homosexuals were a group, and then people define themselves later on as heterosexual. But 100 years ago, nobody thought of themselves as heterosexual. They just thought of themselves as normal. And the same thing is going on now. People now identify themselves as cisgender. But I know there are age differences about which segments of our population are using the term cisgender. Usually, it's the younger generation. And this has its origin in the Latin prefix cis, meaning on the same side, as in the cis trans isomer distinction in organic chemistry. Remember organic chemistry? So the cis isomer is on the left. So the two green have an imaginary plane drawn through the gray molecules. The cis isomers are on the same side of the plane. And the trans isomers are on opposite sides of the plane. There are a lot of scientists writing in the transgender community. Transsexual is a historic term, a medical term, for an individual who received hormone or surgical treatment to modify their body so it conforms to their gender identity. That transition could be partial versus complete. This is the way the literature used to talk about it. Complete meant the person had had hormones and surgery. Partial could mean a social transition, or hormones and no surgery, or surgery and no hormones. And some people don't want a complete transition. Some people's dysphoria is satisfied by the partial transition. Some people cannot afford a full transition. In the literature, people who transition from male to female were called MTF. The community refers to them as trans women, female to male, or FTM is a trans man in the community. And keep in mind that gender identity and sexual orientation may be independent variables. Whether I think of myself as a man or a woman tells you nothing about whether I'm attracted to men or women. This is a very important distinction between these two concepts. In the middle of the 20th century, the standards of care that if you were assigned birth that male wished to transition to live as a female, you couldn't tell the doctor if you were attracted to women. Because they were not going to create a lesbian after all that medical intervention. The idea is that you would fit into the regular population after the transition. This is not a standard of care anymore. But this is our history. And psychiatry was very involved in this history. This is a very famous trans woman, Caitlyn Jenner, who publicly transitioned and who publicly is gynephilic. She was married to women before she transitioned. And she still has told people she's interested in women. And Chaz Bono, the child of Sonny and Cher, publicly transitioned again from female to male. He's a trans man. And again, publicly gynephilic, identified as a lesbian before his transition and is still interested in women. Transphobia is a word patent on the term homophobia. Includes a wide range of negative attitudes, feelings, or actions toward transgender people. It's seen as underlying much of the social stigma confronted by transgender individuals. And it often can lead to violence because fatal violence disproportionately affects transgender women of color. There are some other terms. These are terms from within the trans community. So misgendering refers to using the wrong name or the wrong pronoun for a person. And that could be accidental or deliberate. And sometimes, if it's accidental, that happens. One of the things I work with when I work with transgender patients is trying to help people get used to the idea that some people will inadvertently misgender them and you know and everybody needs to in treatment to develop a thicker skin but for those of us who are treating these patients it's helpful to know how sensitive people are to these kinds of phenomenon and dead naming refers to again from the community refers to using the pre-transition name for a person who's no longer using that name because they've changed genders pronouns Facebook's offers more than 50 gender options for pronouns and I have no intention of memorizing them so neither should you so ask what are your pronouns of course I've been on so many zoom calls where people announce their pronouns I'm not yet of doing that I'm an older person not your preferred pronouns what are your pronouns now gender policing refers to the imposition or enforcement of normative gender expressions on others we all we are all involved in gender policing pretty much all of us are constantly scanning other people making some type of assumption about who they are what their gender is and what their gender presentation is if you're walking out of the restroom for example in a public space like this and you see someone of the other gender walking in you might actually tell them you're going into the wrong restroom that's one way in which you know simply we all do a little bit of gender policing a more severe form of gender policing is what the transgender community calls gatekeeping and gatekeeping was the requirement that trans people have to prove to a mental health professional that they are worthy of receiving transition services from the perspective of the professions this was called evaluation but from the perspective of a trans person it's a blockade it's a way of keeping people from getting services they feel they need and there and there's controversies around that which we may talk about and then finally gender policing is part of our countertransference okay because all of us are raised with with so-called gender norms we learn about gender at a very early age young children learn about gender the way learned about everything early on in life in binary terms and so it takes a while for people to sort of get out of the notion particularly therapists that it you know what exactly is your job when you're working with a person whose gender identity is is not cisgender because it's really about you know if you are a stable cisgender identity it sometimes can be very difficult to understand what's going on in the mind of someone who is not feeling the same thing you are transvestitism is sometimes associated with the phenomenon if it's done for entertainment purposes we refer to it as drag I don't have to tell you what the slides the some of these slides were from before RuPaul's drag races so but but literally it's Latin for cross dressing there is a dsm-5 paraphilic disorder also the dsm-5 TR called transvestite disorder previously you know in dsm-4 you could only have this disorder if you were a heterosexual man so if you're a gay man who liked to cross-dress it wasn't a mental disorder but the dsm-5 changed that so it can apply to men and women but it does involve recurrent intense sexually arousing fantasy sexual urges or behaviors that involve cross-dressing and this is important because the dsm-5 did something a little bit different than the previous iterations which is it distinguishes between a paraphilia and a paraphilic disorder so you can have an atypical sexual or gender interest but it doesn't necessarily rise to the level of disorder unless it creates distress and dysfunction so that's that wasn't true in dsm-4 yeah there's my slide okay now intersex refers to a long-standing term as hermaphrodites because of act activism from intersex activists the term was changed to disorders of sexual development some intersex activists don't like the medicalization and they prefer differences of sexual development in dsm-5 text revision we use both terms it really refers to anatomic anomalies of the reproductive and sexual system encompasses a wide variety of conditions but most intersex people identify as men or women that is they are there's some transgender people who call themselves intersex but that's not how the term is usually used in the medical community and that there are some people who are intersex who but who just identify as male or female and we can talk about intersexuality which is a lecture in itself so we'll start with a history of historical attitudes to LGBTQ patients while they could be construed as patronizing at best and at worst overtly hostile mental health prejudices against LGBT patients still persist albeit in subtler forms such as sparse research on the health and mental health needs of these populations the Institute of Medicine has issued a report about these needs in 2011 it's available for free downloads online I actually reached out to before this meeting to someone who was who was on this committee that put this report together to find out if there's an update plan because this is now 12 11 years later and apparently something's going on I don't know why but this is still worth reading about these the needs of these populations so I'll talk start as homosexuality is a psychiatric diagnosis so in the 19th century we saw psychiatrists begin to classify homosexuality as a mental disorder the term homosexuality actually doesn't get coined until 1869 and not by a psychiatrist but by a journalist in Hungary who was writing about laws that criminalize same-sex behaviors but it was Richard von kraft ebbing a German psychiatrist who first popularized the term in psychiatry in a very interesting book called psychopathia sexualis okay just checking you can get English translations of it now when the book came out it was published in Latin so that only priests and doctors could read it but you can read it in English now and he used to put out various iterations of the psychopathia which were basically case reports of people living as an atypical sexual or gender interest so this was really the main part aspect of medicalization of the phenomenon psychoanalysis started to move away from the illness model but eventually moves back because Freud for example did not think that homosexuality was an illness he thought of it as a developmental arrest that is not quite an illness but still not quite normal so I like to say you know calling someone childish might not be as offenses as calling them sick but neither is particularly respectful and and and seriously until the 1991-92 the American Psychoanalytic Association would not accept openly gay candidates into their institutes because how could a developmentally arrested homosexual person treat a heterosexual who was higher on the developmental schema that was the thinking just till 30 years ago and this was this was came a lot because psychoanalysts after Freud moved away from the notion of homosexuality as a developmental rest and reclassified as a perversion a phobia and a condition in need of treatment now the theories of homosexuality of psychoanalysts were based on studies of individual patients who were seeking treatment because they were unhappy about their sexual orientation that is case histories and prison populations on the other hand the alternative theory which comes from modern sex research that they did field studies of non-patient populations and so this started to move in the 20th century toward a view of homosexuality as a normal variant of human sexuality akin to left-handedness I don't know young people may not remember but there was a time when kids who were left-handed were raised to not be left-handed they had to be converted out of their left-handedness and so that we don't I don't think that happens here anymore but I can't be sure so I'm going to talk briefly about some of the research that changed minds that has to do with the Kinsey reports in the work of Evelyn Hooker so Alfred Kinsey if you haven't seen the movie I highly recommend it it's a very interesting story about a man who was studying insect taxonomy and and decided because of the University we worked at there were a lot of undergrads who had lots of questions about sexuality that nobody knew the answer to actually go out and interview people who were not psychiatric patients about their sexual practices and they and the Kinsey group interviewed thousands of people who were not patients it was of course a skewed sample because you had they were only able to talk to people who were willing to talk to sex researchers in the middle of the 20th century and they found high rates of homosexuality anywhere between 10 to 37 percent in adult life which argued in the favor of a normal variation today the studies that have been done it's very hard to do these studies because it depends on how you ask the question studies give numbers like anywhere between one and four percent so it's not clear what the numbers actually are but I know the gay rights activists around the time of Stonewall they adopted the 10% figure so they got the price to say that 10% of the US population is gay how dare you discriminate against us and this is the Kinsey scale a Kinsey zero refers to exclusive heterosexuality Kinsey six refers to exclusive homosexuality with five grades of bisexuality Kinsey one to five in between and you know the Kinsey scale has found its way you know there if you google google images Kinsey scale you'll find lots of personal ways of thinking about that you know and here there is of course a sort of a conflation between gender presentations and and sexual orientation so the Grinch is exclusively heterosexual and frosty the snowman is exclusively homosexual Evelyn hooker has an interesting so Evelyn hooker was a psychologist in California who was approached by some of her grad students at the time homosexuality was not just considered a mental disorder it was considered a global disorder of psychological psychiatric functioning so akin to what we would take called borderline psychotic states the term borderline was not really being used in those days so she decided to do a study in which she interviewed 30 gay men and 30 heterosexual controls she gave them each the same three projective tests and then she showed the judges that she is three blind judges three experts in the three tests that she administered each of them saw the 60 test results and asked to tell the difference between who was psychopathological and who was not these were standard tests being used at the time not so much anymore and they could not tell the difference between the gay men and the straight men in terms of psychopathology and in addition this was a reproducible experiment as opposed to psychoanalytic treatments so this result was at odds with the prevailing dominant psychoanalytic theory of the time which supported a normal variant point of view so of course Kinsey was denounced by many people in the psychiatric community for his work and hooker published her work in the Journal of Projective Techniques which I don't anybody read the Journal of Projective Techniques so doesn't really find its way into our literature but in 1969 as you know there was a riot in my hometown New York City the police raided a gay bar which was a common practice at the time the patrons of the bar fought back and there was three days of rioting in New York City following that which galvanized a pre-existing gay rights movement that had been around since the 1950s prior to the Stonewall you know gay rights demonstrators would get dressed up in very conservative suits and conservative women's clothing wearing very nicely printed signs saying homosexuals are people too please give us our rights but by 1969 we had an anti-war movement we had an african-american civil rights movement we had a women's movement where people were getting really mad and so they decided that you know that that psychiatry was really the enemy of gay people that our diagnosis of homosexuality was a major cause of stigma for gay people and so they came to our meeting in San Francisco and they disrupted the meeting came in they told the doctor we're going to come in and disrupt your meeting and they took the microphone away and this got APA's attention APA heard them so in 1971 they gave the gay activists a scientific symposium panel for gay men when women spoke to an audience of psychiatrists saying this is gonna stop it you're making me sick was the name of one of the titles by a guy named Ron Gold and apparently this was a very successful meeting so what happened was they were invited back for the 1972 APA in Dallas and one of the actors said well wouldn't it be great if we had a gay psychiatrist on the panel to talk about what's going on but where are you going to find an openly gay psychiatrist in 1972 when homosexuality is illegal in almost every state you could lose your medical license you could lose your job you certainly won't get a position in a residency or an analytic training they found a psychiatrist who was willing to appear on stage if he could be in disguise and this is what an openly gay psychiatrist looks like in 1972 and that and he was and dr. Fryer who only came out about 20 years after that excuse me he's sitting next to Barbara Giddings and Frank Kameny to gay activists who passed away in recent years who were the first recipients of what APA now gives us the John Fryer award the John Fryer award is being given tomorrow at 430 to my colleague and friend Ken Ashley here at the Convention Center and this is dr. Fryer and picture taken shortly before he passed away in 2003 and dr. Fryer said you know I'm disguised because I can't tell you who I really am if you knew who I was I'm I have to pass you know using the language of African Americans I have to pass and so so this this had an enormous effect but a lot of other things were happening then while all this theater and drama is going on because gay people like theater and drama the scientific committees are reviewing the literature and they decided that the sex research literature is more scientific than the psychoanalytic literature so in 1973 the APA Board of Trustees voted to remove homosexuality from its diagnostic manual which at the time was the DSM 2 but this happened in December of 73 while the American Psychoanalytic was meeting at the Waldorf Astoria which was a big tradition and so they they circulated a petition got 200 signatures to force the APA to have a referendum on the board's decision that bylaw has been changed you can't do that in that way and the and the and bylaw was intended for administrative decisions not scientific decisions and so there was a vote 10,000 half of the APA members voted and 58% of the voting members voted to support the board's decision and this was this was front page of the New York Times psychiatrists although it's below the fold rather than above the fold but still it was on the front page and so it's really important to you know to look at this because some people have distorted the meaning of this event because what was the vote actually about well most of the psychiatrists of that time were trained in an illness model so if you ask them the question do you think homosexuality is an illness or disorder they probably would have said yes but that wasn't the question they were being asked they were asked were you willing to support the Board of Trustees and the scientific process that went on within the APA that came to this conclusion and that of course is what they were voting on now opponents of removal would later argue that science cannot be decided by a vote when I was a resident back in the early 80s the chapter and homosexuality that I now write in the same textbook Kaplan and Sadaq was apparently written by an opponent of the removal and so he wrote the science cannot be decided vote but he neglected to mention that his side was the ones who asked for the vote in the first place so if you didn't believe that could be decided by a vote why ask for it but actually it begs the scientific question if you can decide the begs the question if you can decide scientific issues by a vote and the answer is absolutely because in 2006 the International Astronomical Union voted that Pluto is not a planet so in science and medicines objective facts are often filtered through human subjectivity until consensus is reached which is why I always tell people our DSM is not the Bible of psychiatry it's the user's manual and it changes depending on how we rethink our theories and our clinical work with time and the support Pluto being excluded by the other planets so this is just a listing of homosexualities of various iterations and the various DSM's it was for in DSM one it was a sociopathic personality disturbance in DSM two a sexual deviation DSM before DSM three the DSM process was very different so with DSM two APA would print up a couple of thousand copies when they sold out they would print out another couple of thousand copies there wasn't as much interest in DSM as we have today and so the the diagnosis was changed in the seventh printing it went from homosexuality but it was changed it wasn't completely removed it was replaced by something called sexual orientation disturbance this meant that you if you were if you were homosexual feelings or even heterosexual feelings and you were unhappy about your sexual orientation you could see a psychiatrist who could code you with a sexual orientation disturbance now of course there aren't a lot of heterosexual seeing psychiatrists to become homosexual that doesn't happen a lot so in 1980s DSM 3 that was changed the ego dystonic homosexuality but that diagnosis became very controversial because you know it was a medical realization of a state of mind which we do all the time in psychiatry but could you say for example if someone thought they wanted to be taller do they have ego just height disorder you know or if somebody was unhappy about their eye color or their even their race could you do can you say so the so this diagnosis was a compromise between the forces so the diagnosis was really compromise of battles that had been fought in the early seventies so by 1987 the DSM 3 R came out ego dystonic homosexuality was removed it kind of resurfaced a little bit in the DSM for in the sexual disorder and the West category you had persistent and marked distress about sexual disorientation is an example of how to use that diagnostic wastebasket category and so the DSM 5 DSM 5 text revision that diagnosis is gone and a similar pathway you see in the ICD. ICD-6 was the first version of the ICD that carried diagnoses. Prior to that it was simply a mortality manual. And so you have sexual deviance, homosexual and in 1990 the ICD-10 followed the DSM example. They removed homosexuality, but they replaced it with things like ego dystonic sexual orientation or sexual maturation disorder. When we revised the ICD-11 back in 2019, these diagnoses were removed. Nobody uses them. Now a parallel path is how gender variance became a psychiatric diagnosis. So we return to Krafft Ebbing in the 19th century. He also referred to transgenderism as psychopathology in the Psychopathiae Sexualis, but he called it homosexuality. It's not really until the 20th century that the distinctions between what we now think about gender identity and sexual orientation were made. One of the first people to make that distinction was another German psychiatrist, Magnus Hirschfeld, who did distinguish the desires of homosexuality from the desires of transsexualism. But the phenomenon of transition really hit the popular imagination in the 1950s when Christine Jorgensen returned from Denmark as a woman. And here you see the headlines, New York Daily News, XGI becomes blonde beauty. And this is when the concept of transition entered the popular imagination. And in fact, this was a medical procedure. The Danish doctors who performed the surgery had been doing this for decades, and they published this case report in the Journal of the American Medical Association. You can look that up online if you're interested. But these diagnoses actually do not appear in either DSM-I or DSM-II, because at the time many physicians, psychiatrists, and particularly psychoanalysts were critical of using surgery and hormones to irreversibly, and in their view incorrectly, to treat people who suffered from what they thought was either a severe neurotic or psychotic delusional condition in need of psychotherapy and reality testing. Now these are people, for time's sake I'm not going to go into it, these are names you should know if you're interested in this history. John Money, who was a psychologist at Hopkins, who did a lot of work with intersex kids. Harry Benjamin, who was a private practitioner in Manhattan, used to give people hormones out of his private office. Bob Stoller was a psychoanalyst who worked with transgender and intersex patients in California, and actually coined the term gender identity in a 1962 issue of the International Journal of Psychoanalysis. And Richard Green, who passed away lately, who worked with children with what we today call gender dysphoria. I will talk a little bit about Money, because I think this is important. You know, he was studying intersex children. He came up with the theory that a gender identity is acquired, and the acquisition of a gender identity requires that the parents accept that the child is of the gender to which it has been assigned, and that if the parents don't accept the gender assignment, the child will not develop a stable gender identity. This meant that if an intersex child was born, it was considered a psychiatric emergency. But they didn't call in a psychiatrist. They would call in a surgeon to fix the child so that they could tell the parents what gender this child was. And as some of the intersex activists have pointed out, because it's easier to make a hole than a pole, usually the child was assigned to a female gender. And then there would be all these reports over the years about how great these kids were doing, and how wonderful this treatment is, until the modern Internet age in the 1990s, and you have all these adults who are now in touch with each other, and it turns out they weren't so happy with what the doctors did to them, many of them having had their organs which provided any sexual excitement taken away from them as children, just to make them conform to ideas of what children should look like. I mentioned Harry Benjamin, Bob Stahler, Richard Green. So this is just a listing, again, of the various iterations of our gender diagnosis. And again, DSM is not a Bible. It's a user's manual. It's not only that the names change with time, the parent categories change with time. And so you can see that the parent categories, we go from sexual deviations to psychosexual disorders. There was once a time, the DSM-3R, where they talked about disorders usually first evidenced in infancy, childhood, or adolescence. Then they were all lumped together in sexual and gender identity disorders in DSM-4, and then in DSM-5 and TR, gender dysphoria has a chapter all its own. And again, similar patterns in the ICD, where the diagnosis only really appears in 1975 for the first time, with a hyphen for some reason. And in ICD-11, as I mentioned, it was moved out of the mental disorder section and to a new chapter called Conditions Related to Sexual Health. So I'll have a sip, and then we'll talk about our final subject. So there's a dearth, as I mentioned earlier, there's a dearth of empirical research on the health and mental health needs of LGBTQ patient populations, that most psychiatrists, as well as physicians and other specialties and other mental health professionals, receive little formal training in human sexuality. I'm so happy to be doing this in front of a live audience after three years. How many people here in the audience feel that you've gotten good training in gender and sexuality in whatever part of your education has been? Sprinkling. Okay. So the general public is unaware of how little attention is given to human sexuality in clinical education. They think you actually have been trained in this subject. So the patients may ask you questions about sex and gender that you don't know how to answer. And sometimes, and this is not uncommon, rather than admitting a lack of knowledge or seeking out reputable sources of information, clinicians might offer no theory that they learned in university or grad school, or express their personal beliefs or other incorrect information, or express their countertransferences in reaction to a person who presents with a different sexual or gender identity than your own. So here are some of the questions that patients ask. A lot of people come in to treatment wanting to know why they're gay. Maybe not so much today as years ago, but many people would come for this reason. Why am I gay or transgender? And the answer is, we don't know. Speaking as an expert on many issues related to gender and sexuality, people don't like it when an expert says, I don't know, or we don't know. They expect you to know. So it's good for you to get comfortable saying, I don't know, when you don't know. It's not unusual for patients to ask the question. It's simply not a typical question for heterosexual and cisgender patients. You know, straight patients don't come in saying, doctor, why am I attracted to women, a man saying that? Clinicians are unlikely to raise the question with heterosexual and cisgender patients. It was advised in the middle of the 20th century, if a gay patient came in, but they weren't complaining about their homosexuality, the first time they had a crisis during the treatment would be the time to raise the subject. Did you ever think that your homosexuality might be the cause of your problems? This was, no, this was written in textbooks of the time. But LGBTQ patients, being members of sexual minority, often have an outsider's feelings that their identities require explanation. So, it's important to keep in mind, I don't care what you've learned, from whom, the causes of anybody's sexual orientation, homosexual, heterosexual, or gender identity are unknown. Keep in mind that the theory of John Money about how gender identities develop led to unnecessary surgery on all those kids in the middle of the 20th century. I'll add a coda to that, which is that when the intersex activists really got themselves organized, they began having meetings with the doctors about the standards of care. And they were able, in the United States at least, to change the standards of care, which is that there's no reason to do surgery on a child just to create a gender appearance. That is insufficient reason to do so. Sometimes some of these kids did need surgery because the urinary system is mixed up with the genitals, and sometimes they needed surgery. But if the surgery's not needed, make a tentative assignment. Nobody's going to look under the diapers except the parents. And you don't need parental acceptance, as Money argued, to have the gender identity. We don't know how a gender identity develops. And if the child changes their mind from the assigned gender at a certain age, then they can socially transition. So you want to let the child get as old as they can be so that they can be involved in any surgical decisions that they might need in their future. This is also very important. Two people talking to each other in a therapist's office can only discover what sexual orientation and gender identity means to the two of them. All these papers, psychoanalytic papers, about why this person is homosexual because of his mother, because of his father, this is nonsense. This is not what we call epistemological confusion. The method does not give you the answer. It's about finding meaning, not causes. And conducting a psychotherapy under the false assumption that one can find out why a patient is LGBTQ is ethically questionable and a waste of time and money. And I invite you to ask your heterosexual cisgender patients, would you like to learn more about why you're a heterosexual and see what kind of responses you get from them? As I said before, some people come in wanting to change their sexual orientation. And the answer here, again, is no one knows how to do that. Mainstream mental health organizations do not endorse sexual orientation change efforts. I don't know how to, even though I was on the committee that made this term, I don't know how to pronounce SOCH. The techniques are not offered in reputable mental health training programs anymore. That was not the case in the middle of the 20th century. As I tell journalists, you know, you can't learn it in a formal training program. You can only learn it on the street. And the majority of these practices are conducted by unlicensed non-clinicians and so-called ex-gay ministries. Our APA issued a position statement called Ethical Practitioners Refrain from Attempts to Change Individuals' Sexual Orientation, Keeping in Mind the Medical Dictum to First Do No Harm. And the American Psychological Association chimed in a decade later that efforts to change sexual orientation are unlikely to be successful and involve some risk of harm contrary to claims of SOCH practitioners and advocates. Currently California passed the first law banning conversion therapy for minors in 2012. It was appealed. It was challenged in the courts and held, and the law still exists, as in New Jersey. And now there's about over 20 states that have banned conversion therapies for minors. Then another issue that comes up clinically is, Doctor, what did you call me? And the answer is, how do you prefer to be addressed? So how do we address patients? Well, we try to use respectful language rather than medical terminology. Doctor, I'm gay. Well, how long have you been a homosexual? Don't do that. There it is. Transgender rather than transsexual. Although there are members of, there are people of transition who actually prefer transsexual to transgender. So this is really important about individual subjectivities. Again, what name should we use? I often get the question, I work in the hospital, the patient has a legal name which is male, but they're using a female name. What are we supposed to do? I say, you write the first page of the chart. The patient's legal name is male, but they prefer a female name, and we're going to use the female name in the chart from now on. What's the big deal? But this is about gender policing. People are very afraid to cross these barriers. Pronouns I talked about. So ask people what their pronouns are. And always ask, because there are always exceptions, and don't make assumptions about the other person. You know, we all are making assumptions about each other all the time. But when you're working one on one with a patient, it's always best not to make too many assumptions, particularly in this area. Sometimes people want to know about the doctor. Doctor, are you gay? Well, these patients often seek out therapists who are also LGBTQ, and some therapists are willing to come out to their patients, because in a heterosexual society, everybody's considered heterosexual, and I would add cisgender, until declared or labeled otherwise. And so disclosing one's sexual identity, however, is not an issue that stirs many heterosexuals. I can't tell you how many analysts I've met who said, oh, my patients don't know whether I'm gay or straight. Right. And some think self-disclosure is wrong. Now, there are arguments against therapist self-disclosure, and some of them are reasonable. One is to keep the primary focus of therapeutic conversation on the patient's inner world, rather than that of the therapist. You know, you've all learned the question is, well, why do you ask me that question, as a way to deflect the question back to the patient. And some patients may feel burdened by having knowledge about their therapist, and so maybe it's not a good idea to talk about yourself. And it is a way to teach fledgling therapists how to keep boundaries with patients, to think about the difference between talking about yourself and talking about the patient, because psychotherapy, although it is a conversation, it's not a typical conversation. It's a special kind of conversation. And it is a way to elicit information from patients. As I said, if the patient asks you a question, doctor, what are you thinking? Well, what do you think I'm thinking? You can get some idea of what's going on in the patient. But there are arguments for therapist self-disclosure, because coming out is an important developmental step in the lives of LGBTQ people. Richard Isay was an analyst who said that LGBTQ therapists should always come out to patients, lest they counter-transferentially perpetuate a patient's feelings of secrecy and shame. This is sort of the other extreme of not telling, is telling everybody. But there's little empirical evidence supporting non-disclosure as superior therapeutic technique compared to self-disclosure. There are no studies that show head-to-head comparisons in the two approaches. And in the internet age, I hate to tell you this, patients already know a lot about your therapist. You make political contributions. Your patients will know that. And then there's gaydar, which is, for those of you who don't know gaydar, gaydar is a pun on radar, which is the ability, not 100% accurate, of gay people being able to tell who is not gay. One of my transgender patients says the gaydar the equivalent is transceiver. And the original argument against self-disclosure comes from Freud, who believed that in order to develop a transference with a patient, you had to be a blank screen to allow libido to be transferred to the blank screen to reproduce earlier relationships and create transferences. But if you don't believe in libido theory, if you don't believe that is the way in which transferences develop, you discover that transferences will develop whether or not a patient knows anything about a therapist. And this is a more contemporary psychoanalytic perspective in the relational and interpersonal traditions. So an ethical approach to self-disclosure should depend upon whether the activity is of therapeutic value to the patient. And ascertaining the merits of self-disclosure requires ethical professionals to familiarize themselves with the long history behind this therapeutic approach, which, by the way, goes back to the 1920s with the work of Shonda Ferency, rather than simply dismissing self-disclosures out of hand for ideological reasons. So what needs to be done going forward? Well, there needs to be more focus of research and clinical interventions in which we increasingly shift the question from why are people LGBTQ to how should LGBTQ people live their lives? This is a major shift. You know, I'm not coming in here to find out why I'm gay. How can I live my life as a gay person? And freed from historical demands for ideological explanations, the ethical imperative going forward is for clinicians to develop and participate in research projects that better delineate the mental health problems and needs of LGBTQ patients and their families. And hopefully much-needed empirical research can aid in further developing best clinical practice guidelines for these patients. So I'll give you my email address here. Some of this talk comes out of a paper I did for the Oxford Handbook of Psychiatric Ethics. And as I mentioned earlier, the group for Advancement of Psychiatry, I edited a special issue of Focus magazine about some of these issues, and that's a paper I'm happy to share. For those of you who are interested, I run a mental health listserv, LGBT Mental Health, but I'm the only one who posts to it, so there's no chatter. I'm interested in chatter, but it's informational. So if you want to be on it, tell me who you are and, you know, your professional position, and I'm happy to add you to my listserv. And that's it. Thank you. And if there are any questions or comments, please step up to any of the microphones. One quick question. Go ahead. Nobody can hear you until you go over there. I saw the American Psychoanalytic Association apologize for its instrumentalization of sexual orientation. Has the American Psychiatric, I don't remember now, apologized for that? That's a good question. So the American Psychiatric Association did not actually issue an apology, but when they did remove homosexuality from that, they issued the first position statement by any professional organization decrying discrimination against gay people. So they were the pioneer, a very avant-garde statement. The American Psychoanalytic Association thing is actually very, I can tell you about that, because in 2019, I was the co-chair of the Committee on Public Information of the American Psychoanalytic Association, and we edited a blog, which is still up, Psychoanalysis Unplugged, that's a plug for a blog that I'm no longer editing, but, and Psychoanalysis Unplugged. So my co-editors said, you know, it was the 50th anniversary of Stonewall, they said, you know, Jack, you should write a blog about homosexuality for the 50th anniversary. I said, my job is to make our organization look good. This history is not good. So this conversation took place, I think, the day after the New York City police commissioner apologized to the gay community for the raid on Stonewall. So we asked Lee Jaffe, who passed away sadly recently, who was then president of APSA, if he wouldn't mind issuing an apology. So he wrote an apology. And so I could write my blog with the apology at the end of it. There was a happy ending. And that became an international story, leading to some other countries, their psychoanalytic groups issued apologies as well. So I was in London in November, for example. I was speaking to a group called the British Psychoanalytic Council, which certifies psychoanalysts and psychodynamic therapists. And they had invited me, before the pandemic, to go in 2022. They were going to have an apology issued to the community, like the Americans did. It got delayed a year. And by the time it got delayed, the British psychoanalytic society itself got itself into something. And they didn't want to issue an apology. So instead, they only issued a statement of regrets, per English. And not only a statement of regrets, but it was only addressed to the gay, lesbian, and bisexual community, and not to the transgender community. So that's the state of England. Yes? Hello, I'm a child fellow. I was just wondering if you could speak briefly on when parents are gender policing, and how to document in those situations, and how to bring parents who maybe aren't as accepting in the kids together, so that we can work together towards a common goal. That's a whole lecture. That's a whole lecture. Oh my god. Well, I often get consultations from parents who have a child who has come out, one form of gender variance. I'm actually giving that talk on Wednesday, on the panel on Wednesday, talking to parents. And depending on the age, and if it's a young child, I usually refer them to a child or adolescent therapist, psychologist, or psychiatrist that I know who work with kids. And so I usually wind up mostly seeing the parents who have older adolescents, or young adult children. So I've always done family work, because early in my career, I was interested in working with very psychotic patients. And you can't work with them unless you work with the family. So it really involves being sympathetic to the parent's belief system. I mean, you cannot get parents to change their minds by saying you're transphobic for feeling how they feel. Because the problem is the child is usually introduced a subject into the family that the family never wanted to know anything about. And often, even when they have a child, they still may not want to know anything about it. And as I like to say, it's not a good thing that your 15-year-old knows more about this than you do. So it's complex, but it really involves working in a systemic way with the family to find out what their concerns are. Sometimes you get parents who want to be accepting, but they're frightened about what's going to happen to the child. Sometimes you get parents in two different places, one more accepting than the other. And so if there's differences already in the marriage, one of the talks I do on these controversies starts with the case in Dallas. There were seven-year-old birth-assigned boys. One of them declared themselves a girl. The parents were divorced. The mother wanted to transition the child socially. The father was opposed. They went to court. A jury in Dallas granted custody to the mom, caused big political pushback that we're hearing about in Texas. That was the trigger for what's going on now in Texas. And the judge vacated the jury decision, feeling the heat. So complicated. Sorry. Hi. I was wondering about, because you explained the kind of transition from the approach to homosexuality as a dysphoric, I don't know the exact name in the DSM. And then you referred to the analogy with height dysphoria. Egotistonic height disorder? Yeah. Yes. But why don't we just apply the same thinking to gender? And why do we still carry a gender dysphoria in the DSM? Because of insurance companies. Can you get any treatment without a diagnosis? In Canada, I guess you can. Ah. Well, not in the, no. In Canada, you can't get treatment without a diagnosis either. National health care systems in Canada, because Ken Zucker, who is the chair of our work group in the DSM-5, is forced from practicing in Toronto. National health care systems and insurance companies will not reimburse, which is why when we switched, when we, so the DSM, and I have a paper on this subject, too. But the DSM, in a certain way, has the option of in, out, or V code. Although we're no longer using V codes. We're using Z codes, as is in the ICD-11. And V codes in the earlier versions of DSM referred to conditions that came to the attention of a medical professional or mental health professional, but were not diagnoses in and of themselves. The problem with V codes and Z codes is nobody reimburses them. So our work group had the problem of how to distinguish between, you know, how to balance the issue of stigma versus access to care. And we chose what we thought was the lesser of two evils, and said we need to keep it in. And one of the reasons, and the way we did it, we changed the name from gender identity to gender dysphoria. We had a whole list of things that we made to try and make it less stigmatizing, which was very well accepted. There are, for example, transgender advocacy groups that were pleading with us behind the scenes, please do not take it out, because if a transgender woman is incarcerated, usually in a men's prison, she's often denied her hormones in the prison. And when the advocacy groups take the prisons to court to argue, they argue this is a medical condition, there's a diagnosis, a code, and in the United States, it's considered cruel and unusual punishment to deny a person needed medical care. So people wanted it. With the ICD-11, we had a different way of working it, because ICD-11 includes all diagnoses. So we could move it out of mental disorder section and put it into a new chapter called conditions related to sexual health. You have a diagnosis. What does it mean? It doesn't say whether it's pathology or not. Menopause has an ICD diagnosis code. That's not a medical illness. Normal spontaneous delivery of a baby has an ICD code. So you could say it's that. We didn't want to get into that question whatsoever. Does that answer your question? Yeah, I guess it's, well, not as scientific, but it's justified in the sense that it allows for care, but why keep dysphoria, then, if it could be, it's not, especially now, it's not forced to be a dysphoric experience to live with, like, trans identity. That's true, but as I said, you know, I don't live in a perfect world. If I do, then I will, I would do things differently. You're welcome. So there's been an unprecedented number of anti-LGBTQ bills in state legislatures over the past year, especially targeting kids, especially targeting trans kids, including in Louisiana not too long ago. Was wondering if you could comment on how that affects our patients, and also what we all can be doing in this room as psychiatrists from across the country. I'm sure a lot of psychiatrists in here work in states where there are anti-LGBTQ bills in state legislatures, what we can do to better advocate for our patients. That's also another whole symposium. Well, what we can do is, you know, the APA has been asked to sign on to, all of these laws are being challenged in the courts, and APA is weighing in. We've been signing other people's briefs and the Committee on Judicial Action. After my last meeting with them, we realized we should have our own position briefs that we can submit in these laws. Yes, laws like this do probably affect the mental health of our patients. There was a study done about a decade ago having to do with laws banning, constitutional amendments banning gay marriage showed that in those states that banned, you know, that passed constitutional bans, there was a high report of mental health issues among LGBT populations as a result of those kinds of laws. So yeah, this is in the air. I mean, frankly, you know, after the Roe v. Wade decision, I thought Obergefell is next. So I mean, how could you not be concerned about it? It's just, we just have to be able to talk about it, you know? With patients, you know, and in our professional organizations, you know, to be able to try and dispel. There are groups now that are, there used to be a group called NARF, the National Association for Research and Therapy of Homosexuality, which had a bunch of, you know, Socrates and people who broke away from the American Psychoanalytic when they changed their policies, who present themselves as experts in courts and legislative hearings against gay rights. Well, there's now something called the Society for Evidence-Based Gender Medicine, which is doing the same thing, that they're saying that the scientific basis for providing any kind of transition services for young people is experimental and low quality of evidence, and therefore should not be done. I've written a couple of papers already in response to some of those people. So I'm doing what I can, sorry. Yes, sir. Yes, my name is Rex Tabor, and I'm a psychiatrist who's been very focused and interested in working with this population my whole career, but I was briefly just gonna inquire as to your level of optimism about ENDA, and whether at a federal policy level, ENDA would put a lot of these other... I'm sorry, my level of optimism? I can't hear you. Could you speak closer to the mic? Yeah, so with ENDA... ENDA, employment, non-discrimination... And how close would, in your estimation... At a federal level? At a federal level, I'm not optimistic at all because at a federal level, we have a minority representation of red states in our Congress and Senate, so not optimistic, sorry. Yes, and then Marshall. Hi. You're one of the heads that was shaking like this during my talk. I like you. Great talk, I really appreciate it. One thing I've noticed in a clinical setting for gender-affirming healthcare is that it is still very common, at least where I'm from, that a psychiatrist has to be involved for that person to be able to receive that care. And it puts, you know, we're four months out on a wait list. It puts people way behind getting their... Where is this? Kentucky. Oh, Kentucky. So I just wondered kind of what the APA's position on having a psychiatrist being involved. No position. Okay. APA doesn't have... APA actually did not have any position on anything other than the diagnosis in 2012 when I helped them draft a position statement in support of non-discrimination and access to care. And as I pointed out, you know, like we had this diagnosis, but we're not... And when I was chair of what was then called the Committee on Gay, Lesbian, and Bisexual Issues, we would get calls from journalists. What is APA's position on... We have an inmate at a Boston prison who's asking for the state of Massachusetts to pay for her surgery. What is the APA's position on that? I go, well, our only position is we have a diagnosis, but we never came forth. So I tried to get APA to take a position, which they did after the DSM brouhaha began, DSM-5. And as I pointed out, I said, you know, like we have this diagnosis and we take no responsibility. It's like that old Tom Lehrer song. I just shoot them up. I don't know where they come down. That's not my department, said Leonard von Braun. So. Thank you. Okay, Marshall. Just a couple of quick comments. One is that as I recall the final reading of the DSM, new DSM diagnosis with dysphoria, gender-based dysphoria, was that when the problem is resolved, it comes off the list. And any of you remember, you can take stuff off of patients' problem list if the patient and you agree that they're not in treatment anymore and the problem has been resolved. It depends on your medical record and the rules of your hospital, but we've been able to do that where I am and that seems to satisfy the needs of the patient. Before you next point, the recommendation that we came up with actually is we included a post-transition specifier, which meant that because we decided to keep the diagnosis to maintain access to care. What if somebody had gender dysphoria, met all the criteria, got treatment, was no longer dysphoric? If they don't have a diagnosis, how can they access care from a DSM perspective? So that was how we'd solve it, but I guess you used some other- That's what I was trying to say, thank you. Okay. Because in reading that final document, it was very clear that this was a much better approach than what we've had in the past. Just a couple of brief comments about the questions of disclosure and talking with patients, with parents of patients. First of all, I've been seeing GLBTQ people for 40 years and I think in Boston at least, if a patient comes to me and they don't know I'm gay, they are aggressively trying to not know that because you are Googled all the time. And for those of you who are active in any sort of, and if you don't show up on something, then they may ask you questions. But I've been asked questions and dealt with my being so out as a gay person for many, many years. I will tell you that in those 40 years, I've had patients come to me knowing I was gay and in the course of a deep dynamic treatment, repress that deeply and still had transferences to me as a heterosexual man, transferences of their mother, their grandmother, their father. So we have to accept that things happen in the treatment that we don't actually control and we have to be prepared for all things. I have never felt that a patient knowing I was gay has stopped that kind of deep investigation about who they are and the question, as Jack was saying, why we're gay, is an easy one to ask more about why is that question so important to you? What is it that you're trying to fend off without having an answer to that? And it often has to do with a sense of shame or uncertainty about how to position themselves in the world. In working with kids, what I have found, and I don't see the kids themselves, but I have seen the parents of kids who are conflicted about their young kids coming in and wanting to talk about gender. I use this technique of, as I do with parents about any issue, is I know that the primary concern you have is for the care and love of your daughter, son, whatever, and that everything we will do here will be to give you an option to make sure that you don't lose sight how much you love your child. And in that, we together can figure out a way to walk through the different concerns you have, leaving your child's concerns a little bit to the side for now so that your excitement and anxiety about this doesn't make it more difficult for them because they're struggling with trying to understand themselves as well, but at a very different level of development. And I think what you do is you kind of bond with the parents even if your countertransference is intense. One of the things we have to learn in therapy, and especially in the residency we have to teach, that you have to understand your countertransference so that you can monitor it and modulate it in the course of the treatment with people who you don't understand. Learn what your limits are. There are patients I cannot sit with. I know that. And there are patients who I don't want to sit with, but I can sit with. So you have to kind of figure out what you can and can't do, but we should be willing to kind of investigate that in ourselves and in supervision with other friends and colleagues, which is really a way to get to the heart of understanding what that's all about. And I think that's a really important point. Residents may not know that when you grow up, you actually can fire patients, which you can't do in your residency. But in your residency, you can. Ideally, if you're in treatment and in supervision, you can learn to expand your tolerance level for certain things that you might not have been able to tolerate, but I certainly have had that experience. But I actually, last week, fired a couple of gay women I was seeing for couples treatment for a few months, and I said, you know, when I come back, we're no longer, I'm gonna, I'm happy to report, and I didn't say I was happy to report, I said, when I come back, I won't be your therapist anymore and I'll help you find a new one if you need one. So you have to, you know, one option is, I know what I can tolerate, but when you're still in training, you're gonna learn more about what you can and what you cannot tolerate. But at a certain point in your professional development, you will figure out what you can and cannot tolerate, just keeping in mind that what you can do is abandon patients. So if you're not the person who's the right fit for this particular patient, you do have an ethical obligation to help them find somebody else who is. Some people do that in a very cursory way. Here's the name of three clinics in your neighborhood. Some people do that in a more substantial way, trying to find a better fit for the patient than you yourself. Are there any other questions or comments? Yes, I see somebody getting up. Yeah, hi, I'm Doug Woodruff. My question is, what are the current standards for deciding when hormone therapy is appropriate? When should you get hormone therapy? Hormone therapy for change of... Well, the World Professional Association for Transgender Health, or WPATH, is now currently working on their eighth version of their standards of care. The seventh version was issued in 2011 and is online, downloadable, long document, and you can read it there, okay? Well, if that's it, I would like to thank you all for coming and... Thank you.

history of psychiatric treatment

LGBTQ patients

homosexuality as a mental disorder

normal variation of human sexuality

subjective identities

biases in mental health care

ethical considerations

supporting LGBTQ patients

challenges in personal disclosure

political and legislative challenges

advocacy and support