Meeting Notes

[JesusA (imported)]

As promised, I will begin posting notes about the two professional meetings that I attended in June. Professor Richard Wassersug (my colleague and co-author on research into voluntary eunuchs) and I attended and presented two papers each at the biennial meetings of the World Professional Association for Transgender Health (June 17 – 20 in Oslo, Norway) and the World Association for Sexual Health (June 21 – 25 in Göteborg, Sweden). At both meetings our presentations were about the need for proper professional care for those desiring actual castration. A major topic at both of the meetings was the current revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-V is scheduled for publication in 2011 and Richard and I wanted to make certain that there was recognition of Male-to-Eunuch as a valid category. I think that we made significant progress, as I will describe below.

I plan to make a series of posts, rather than cramming everything into one very long one. This should allow time for Archive readers to digest things and to begin a conversation about some of the points raised at the meetings. Rather than beginning with the presentations that Richard and I made, I will start with a description of a plenary presentation by Dr. Ray Blanchard that ties neatly to the article which I posted yesterday that was written by Michael Bailey, Was Michael Jackson A Pedophile? (http://www.eunuch.org/vbulletin/showthread.php?t=16048)

Blanchard is the chair of the group that is writing the section of the DSM-V having to do with paraphilias and he addressed the entire group in attendance at the WAS conference in the large auditorium of the Göteborg Convention Center. What follows is a general sense of the current thoughts of his committee about paraphilias in general and a couple of paraphilias specifically.

Remember these are proposals for the 2011 edition of the DSM and are not the current definitions. They may also be changed before the DSM-V is completed.

The proposal is that a paraphilia will be defined as any erotic desire which does not involve genital interaction with a consenting adult or preparation/foreplay leading to such interaction. This covers a great deal of territory and paraphilias are very common among males, though less common among females. Their causes are poorly understood, though testosterone does seem to play a role. As such, there is nothing wrong with having one or more paraphilias.

A paraphilic disorder, however requires intervention. It will be defined as any paraphilia that either (1) causes distress or impairment to the person holding it or (2) results in harm to others. A paraphilia is NOT a mental disorder; a paraphilic disorder is. If it involves others, it may also be a crime, depending on the jurisdiction, though that is beyond the scope of the DSM.

For example, a castration paraphilia (not mentioned by Blanchard, but appropriate for this audience) could involve erotic interest in reading or writing stories for the Eunuch Archive or fantasizing privately about self-castration or the castration of others. It could involve castration play by oneself or with one or more consenting adult others – so long as the play did not cause permanent or nonconsensual harm or harm resulting in a need for medical care. It is not a disorder unless you are disturbed by your erotic thoughts involving castration and want to change them, or unless you involve someone else who is not a consenting adult, or unless you cause permanent harm or harm beyond that which was consented to. Too many of those who responded to the Eunuch Archive survey who had been castrated or penectomized were so because of play gone awry or play that was carried too far.

A castration paraphilia may be perceived as incredibly strange by outsiders, but under the proposed definition for DSM-V, it would not be classified as a mental disorder unless it crossed the line into a paraphilic disorder.

A desire for actual castration is not a paraphilia and will be discussed in a later post on this thread.

Blanchard then spent the second half of his talk on the proposals concerning pedophilia and hebephilia for the DSM-V.

The proposed definition for pedophilia will be erotic attraction to children younger than eleven (before the beginning of puberty). Hebephilia will be defined as erotic attraction to children ages eleven through 14 (while they are going through puberty, and before they are sexually mature). Erotic attraction to sexually mature individuals ages fifteen and up would not be considered a paraphilia, though it could certainly be considered a crime if any actions were taken involving a child who is still legally a minor in the jurisdiction involved. (Blanchard noted that the age of consent for sexual activity in Sweden, where he was speaking, is 15, though it is older in most of the world.)

Most of the Catholic priests, for example, who have been accused of pedophilic crimes actually suffered from a hebephilic disorder. They were sexually attracted to boys who were ages 12 to 15 and still going through puberty. They took actions on their erotic desires, making it both a disorder and a crime because it involved someone other than a consenting adult. If they had simply sat in the parish office and daydreamed about sex with an altar boy and had taken no action, it would not even have been defined as a disorder under the DSM-V proposal unless they were disturbed by those thoughts (and, as priests, I hope they would have been).

I’ll leave time for a bit of discussion before I write about the next point – the desire for actual castration, which was the subject of the papers that Richard and I presented and about which we had a great deal of discussion with others in attendance at the meetings.

[bobbie (imported)]

As always looking forward to reading the notes and hearing about the studies. Great having a wise and helpful friend around.

[calmeilles (imported)]

The proposed definition for pedophilia will be erotic attraction to children younger than eleven (before the beginning of puberty). Hebephilia will be defined as erotic attraction to children ages eleven through 14 (while they are going through puberty, and before they are sexually mature).

Was there any discussion about these definitions and the reasoning behind them?

For example why a given age of eleven years rather than a physiological indicator such as the onset of puberty.

It's rather more obvious why legislators might favour the simpler age related definitions if only for ease of application. But why in this context?

[markle (imported)]

Thank You, Jesus, for the ongoing posts. Excellent insight to levels most seldom pondered. Looking forward to the next.

markle

[gareth19 (imported)]

The proposed definition for pedophilia will be erotic attraction to children younger than eleven (before the beginning of puberty). Hebephilia will be defined as erotic attraction to children ages eleven through 14 (while they are going through puberty, and before they are sexually mature).

Pedophilia (from Greek παιδ- stem of παῖc 'child' and φιλόc 'beloved') has already been defined and can be found in most reputable dictionaries; if there were such a coinage as hebephilia it would actually mean "an attraction to or love of youthfulness" (from Greek ἥβη 'youth, vigor'). The sexual attraction to young jocks is called ephebophilia (from Greek ἔφηβοc 'young man before the age of citizenship').

[Beau Geste (imported)]

I'm curious as to whether the cultural context in which paraphilias occur, is considered to be a determining factor in whether the person's thoughts and behaviors constitute a paraphilic disorder. There have been--and presumably are--cultures in which some of the things which are described as paraphilias, were simply considered to be part of daily life, and acting on them seems also to have been perceived to be more or less normal. I think this was true in ancient Greece, and perhaps in some South Pacific cultures.

[JesusA (imported)]

There have been some issues raised here that deserve an answer before we move on with the next set of notes from the two meetings. I will make my next post in a couple of days on the central issue of the WPATH meeting and a major issue at the WAS meeting – the question of “Gender Identity Disorder.” Once we’ve had a chance to discuss that, I’ll post on the issue of Male-to-Eunuch that Richard and I worked on. There is a logic to the sequence.

Gareth19 raises the issue of terminology. He’s correct that logic and linguistics should require the term ephebophilia. However, the psychiatrists who control the DSM have decided on hebephilia for describing the paraphilia and that is what they will use for coding it. As an anthropologist, I can assure you all that logic has nothing to do with human behavior anywhere in the world. Psychiatrists are no more or less logical than others.

Calmeilles and I had the same immediate thought about definition. I was the second person in line at the microphone to ask a question of Blanchard after his talk. The person ahead of me asked exactly what I had planned to ask, “Why are you proposing age, rather than Tanner Stage, in the definitions?”

Blanchard’s answer essentially said that the current “moral panic” over anything related to children meant that those individuals with pedophilia or hebephilia were highly unlikely to seek out a psychiatrist on their own for fear of stigmatization or prosecution – even if they had never touched a child. Those who come to the attention of psychiatrists do so because they have paraphilic disorders and have acted on their paraphilias. Police reports give the age of the victim and the offenders may or may not actually be seen by a psychiatrist who could determine the Tanner Stage in which they were interested.

Blanchard was, at one point, hired by the Catholic Church to investigate and interview a number of the priests who had been accused of and/or arrested for “pedophilia.” He used line drawings of children at various Tanner Stages to determine their actual erotic interests. They were nearly all interested in Tanner Stages 3 and 4 and would be classified as having a hebephilic disorder.

Finally, Beau Geste asks about the cultural context of paraphilias. This is, of course, a major factor, though one that we can do little about. Those paraphilias that involve erotic attraction to consenting adults or to inanimate objects don’t become paraphilic disorders, even if they are acted upon, so long as the individual holding them is not disturbed by the thought of having the paraphilia.

For example, both sadism and masochism are considered paraphilias. Played out with consenting adults, where no one is permanently injured or hurt beyond mutually agreed limits, is NOT a paraphilic disorder. Someone who has “podophilia” – an erotic attraction to feet – does not have a disorder, so long as he finds a willing adult partner who enjoys long, erotic foot massages.

Since, in the modern world, children and adolescents cannot be defined as “consenting adults,” acting on pedophilic or hebephilic desires is always a crime, though there have been times and places in human history where they were considered to be within the range of normal human sexual desires. As an anthropologist who has conducted research and written on late childhood and early adolescence (upper elementary through junior high), I know that they are not capable of acting as consenting adults, no matter what any culture might decide. They need to be protected from adult paraphilias. Two 13 year-olds engaging in mutual sexual exploration is one thing; an adult and a 13 year-old is something else entirely.

[JesusA (imported)]

Central to the entire meeting of WPATH (

the World Professional Association for Transgender Health

) was discussion of the next edit

ion of the Diagnostic and Statistical Manual of Mental Disorders (

the DSM). While the editing and publishing of the DSM is controlled by the American Psychiatric Association, the APA farms out pieces of it to relevant other organizations. WPATH has primary responsibility for all sections relating to transgender issues. The group will provide a consensus draft which will then go to the editors of the DSM, where it may or may not be modified before final publication. DSM-V is due to be published just about the time of the next WPATH meeting in 2011 and plans are for it to, again, be the central focus of the meeting. This time on the practical interpretation and use of the final wording.

The first major discussion was whether or not transgender issues ought to be included in the DSM at all. There has been a very strong push to drop it entirely and hope that transgender issues will be part of the next edition (scheduled for 2015) of the International Statistical Classification of Diseases and Related Health Problems (the ICD). This would move transgender from a mental disorder to a physical disorder. It would more clearly require hormones and/or surgery as the appropriate treatment. Efforts are already underway to have it included in the ICD-11, when it is finally published, but the ICD is controlled by the World Health Organization and has strong representation from countries where transgender is not simply unrecognized as needing attention, but it is actually ILLEGAL to be transgender. (How you can consider a health issue as illegal is completely beyond my comprehension!)

There is also the issue of obtaining health insurance coverage for treatment if it is not included in the current edition of one of the two volumes. No one seemed to want a four year gap where it was part of neither system.

The main issue about having transgender issues included in the DSM is stigmatization. “It’s a mental disease.” “It’s only in their heads.” Not all health insurance covers it, using the “mental disorder” terminology to deny coverage. In most jurisdictions, “trans-bashing” is not a hate crime because “it’s only a mental issue,” and individuals supposedly have a choice. [My answer would be that being Jewish, for example, is much more of a choice than being Male-to-Female. Should bashing someone because he’s Jewish not be a hate crime?]

Keeping the above discussions in mind, terminology, if transgender is to be kept in the DSM, was the next issue. It was generally agreed that both the term Gender Identity Disorder and a description that, once it was diagnosed, could never be left behind, were major issues. The GID name will, if approved by the APA, be changed to GENDER DYSPHORIA in the DSM-V. The verbal narrative will emphasize that “dysphoria” means ‘discomfort’ and that it is not a mental disorder. The incompatibility between brain and body will be central to the discussion and treatment by hormones and/or surgery emphasized. The wording will also be such that, once a person is “comfortable” in his or her body, the gender dysphoria will be considered to be “cured.” Continuing hormone treatment may be required (with appropriate insurance coverage), but it will be maintenance doses in the same way that allergies require continuing maintenance doses of antihistamine.

Other than this major issue, which ran through all four days of the meeting, there were many other topics covered and a number of social gatherings for members to discuss the topics informally.

The welcoming reception for the meeting was held in a large ballroom at the Oslo city hall. The opening symposium was attended by His Royal Highness Crown Prince Haakon of Norway. The major welcoming address was delivered by Dagfinn Høybråten, the leader of the Christian Democratic Party (the conservatives) in parliament and a former Minister of Health of Norway. Transgender issues are considered worthy of public notice in Norway, and the conference was well covered in the news media.

Topics covered in the various sessions included work with the intersexed, legal issues, health issues, ethics, surgery, cross-cultural comparisons, speech and voice therapy, and psychological adjustment. Transgender issues across the age range were covered in many sessions. My favorite presentation title was “It’s never too late to live a happy life: late life transitions.”

It was announced at one of the early sessions that the Endocrine Society had, only a few days before our meeting, issued new guidelines recommending puberty-delaying treatment for transgender children and adolescents. This is already the norm in the Netherlands and has been done in several other countries as well. GnRH agonists are used to stop the production of testosterone or estrogen (as the case may be), but treatment using the appropriate target hormones is delayed until closer to the age of legal majority.

A presentation in one of the surgery sessions was a case study of a young MtF in the Netherlands. She was put on GnRH agonists at age 12 – essentially chemical castration. At 16, she was eligible for both estrogen and sexual reassignment surgery. The presentation was on the development of a technique to provide a neo-vagina where the penis is too small to use for the tissue. Instead, a four-hour surgery (with two surgical teams) removed a section of her colon to use in constructing a neo-vagina. Skin from the thigh was used to supplement the tiny bit of scrotum for constructing labia. Since she was not forced to go through male puberty, she should be much happier as a female than a transwoman who has masculinized before transition.

The next WPATH meeting will be held at Emory University in Atlanta from September 24th though the 27th of 2011. The annual Southern Comfort conference on transgender issues will begin on the 27th, and it is hoped that there will be shared events and participation between the two groups.

Next up: Male-to-Eunuch as a transgender category.

[Danya (imported)]

My favorite presentation title was “It’s never too late to live a happy life: late life transitions.”

Amen to that, Jesus! Although I don't consider myself, at the age of 57, to be in late life I have a hunch the presenters would have a different opinion.

[sag111 (imported)]

I always enjoy your notes sag111