Meeting Notes

[JesusA]

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]

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]

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

[JesusA]

Now, after the teasers on paraphilias and on the proposed change of terminology from Gender Identity Disorder to Gender Dysphoria, the important part.

Richard Wassersug and I were in Norway and Sweden to propose that Male-to-Eunuch be added to the DSM as a category that needs and deserves proper consideration from professionals - including surgery by a properly licensed surgeon, where indicated. The response at both meetings was quite positive and our proposed DSM wording was accepted by the chair of the appropriate sub-committee for transmission on up the line to the final editor. (This is not a guarantee that it will be in the final edit, but it bodes well for it.)

This would not, of course, mean castration-on-demand from a surgeon such as Murray Kimmel, but it would mean that there would be many more surgeons willing to perform castrations and/or penectomies with proper letters from professional counselors. And, it means that counselors would be more willing to provide such letters.

What we proposed is mostly parallel to what is required for Male-to-Female or Female-to-Male Gender Dysphoria. The major difference would be that there would be no requirement for a year of "real-life experience" of living in the target gender. (How does one dress and present publicly as a eunuch?) Instead, there would be a requirement for a year of chemical castration. Ultimate diagnosis and treatment would depend on the person's response to chemical castration:

1) If the person was pleased with the results and still wanted surgical castration, he should, as soon as he demonstrated that he fully understood that it was irreversible and fully understood the long-term side-effects, be given a letter and helped to obtain surgery.

2) If the person was pleased with the results and did NOT still want surgery, he probably was most interested in libido control and should be provided with chemical castration on a long-term basis.

3) If the person was NOT pleased with the results of chemical castration and still wanted surgery, he probably has a Body Integrity Identity Disorder or a Body Dysmorphic Disorder. He should continue counseling and may, at some point, be referred for surgery. Research on BIID is in its infancy, though there doesn't seem to be any "cure" other than amputation at this point. Since BIID will probably be in the next DSM, surgery may become the treatment of choice, after proper counseling.

4) If the person was not pleased with the results of chemical castration and no longer sought surgery, he may still need some further counseling, but he will have certainly been saved from an irreversibly mistake.

It will, of course, take time for all of this to happen, but I think that important progress has been made. There are now many more professionals out there who are ready to take all the varieties of eunuch-wannabes much more seriously and who are ready to help.

In talking with several of them, it was fun to see their shock of recognition as they realized that some of their "Male-to-Female" clients who had disappeared after getting an orchiectomy were really Male-to-Eunuch. I even recognized some of the clients whom they spoke about and could add information to help them understand that MtE is real and deserving of appropriate care.

Two more articles on the subject have been provisionally accepted for publication (pending rather minor revisions). One should go back to the journal next week and be in print by the end of the year. The other is for a special journal issue scheduled for next spring and will be revised in light of the other articles accepted for that issue. We don't expect to begin our revision until the fall. There are more articles targeted for a variety of professional journals at various stages of construction. I will post abstracts and a way to get copies as each finally sees publication. Remember that the four articles based on the first Eunuch Archive survey are available in PDF format for anyone who sends me a <Private Message> requesting them and gives me a return email address that will accept attachments.

Those with whom I have spoken on the telephone in the past week know that there's also an exciting extension of the survey data that may help prostate cancer patients. We're working with a young neuroanatomist on the findings. I will keep you all informed as his research begins to jell.

I want to again thank all of you who took part in the Eunuch Archive surveys. The data you provided should provide long-term benefit for a great many people.

[Losethem (imported)]

Jesus--

I like you, but this particular path for people with BIID, of which I consider myself one, is a rather terrifying prospect. If I still had my balls, chemically castrating me for a year before going, "yup, unhappy with this, so he must be BIID" would be hugely counterproductive and likely set me on the path to sucking on a gun.

I hated my balls, they were a foreign growth on my body, and I wanted them gone. I knew this for 20-years or more, and the solution that made me absolutely happy with my body was to get my testicles amputated.

Is the medical establishment going to chemically castrate all BIID sufferers, regardless of the type of limb/tissue removal they seek? (IE people who want to lose limbs) Yes, I know that is a ridiculous question, but that's essentially what you're doing. Giving a type of treatment to a person that is counter to what they are ultimately seeking. Why not just euthanize BIID eunuchs at that point, it would be more humane.

Chemical castration will work if you're testing a person that is interested in lowering their libido decide if physical castration is right for them (and it sounds like you would insist they remain chemically castrated but not physically castrated indefinitely), but doing this to a person with BIID in my opinion would do more harm than good.

This said, I'm glad someone is at least taking up this project and presenting it to people, but I'm afraid as presented, if I still had balls I'd do the same thing I did before - go to a cutter. And isn't that what you're wanting to prevent?

Just my $.02 worth.

--LT

[kristoff]

Jesus--

I like you, but this particular path for people with BIID, of which I consider myself one, is a rather terrifying prospect. If I still had my balls, chemically castrating me for a year before going, "yup, unhappy with this, so he must be BIID" would be hugely counterproductive and likely set me on the path to sucking on a gun.

I hated my balls, they were a foreign growth on my body, and I wanted them gone. I knew this for 20-years or more, and the solution that made me absolutely happy with my body was to get my testicles amputated.

Is the medical establishment going to chemically castrate all BIID sufferers, regardless of the type of limb/tissue removal they seek? (IE people who want to lose limbs) Yes, I know that is a ridiculous question, but that's essentially what you're doing. Giving a type of treatment to a person that is counter to what they are ultimately seeking. Why not just euthanize BIID eunuchs at that point, it would be more humane.

Chemical castration will work if you're testing a person that is interested in lowering their libido decide if physical castration is right for them (and it sounds like you would insist they remain chemically castrated but not physically castrated indefinitely), but doing this to a person with BIID in my opinion would do more harm than good.

This said, I'm glad someone is at least taking up this project and presenting it to people, but I'm afraid as presented, if I still had balls I'd do the same thing I did before - go to a cutter. And isn't that what you're wanting to prevent?

Just my $.02 worth.

--LT

I have raised the same objection. I concur that there needs to be some form of "testing" protocol for diagnostic purposes for BIID, but a year of chemical castration is definitely not the answer, in my opinion. A much shorter period may be facilitative in conjunction with other approaches to diagnosis and treatment.

[Uncle Flo (imported)]

I, also, see this as a flaw in the process for most of the reasons expressed in the foregoing two posts; however I sense this may be a necessary provision in order to gain acceptance from therapists who may not be willing to go along with anything less. It may be useful to emphasize the inherent shortcomings of this approach to the relevant therapists and surgeons who will actually be dealing with real people in this situation. --FLO--

[JesusA]

While I understand the objections here to a bout of chemical castration for those who are certain that they have BIID, I would still argue its importance. Not only do we have the data (still being analyzed and yet to be published) from the second Eunuch Archive survey, but there is also an important RAT project that is currently underway. Both point to the necessity of the "test run" of chemical.

The rat study is looking at the impact of castration, followed by HRT, on adolescent male rats. They have achieved full sexual maturity and functioning and have all of the rat mounting behaviors and observable sexual behaviors before they are castrated. Some are left with no testosterone. Others are given full rat-level HRT. Those on rat-level HRT have an AVERAGE return to full sexual functioning of about three-quarters. Some higher; some much lower.

The data from the Archive survey is that those who go back on full replacement level testosterone after castration have an average reported return to prior sexual functioning at about that same three-quarters level. (The data is fuzzier and the sample size much smaller. There's certainly no ethical way to directly observe human sexual behavior before and after castration!) Some eunuchs on HRT return to the same self-reported level of sexual functioning as they had before. Some achieve only a MUCH lower level.

The testicles provide more than just testosterone. HRT doesn't replace everything.

Chemical castration provides a worst case scenario. Are you willing to risk the lowered sexuality in order to have those parts removed? No ethical surgeon would operate unless he was certain that the patient understood the risks involved.

A competent counselor would not push someone through an entire year of chemical castration once it was clear that it was BIID, and not something else. BUT, a competent counselor would certainly want to ensure that the person fully understood the risks involved, no matter how small the risk, before providing a letter recommending surgery.

[devi (imported)]

How about a term like "dermaphilia"? The man that who had once assaulted me and had tried to force me into the cellar and was threatening to rape me (I scream very very LOUD) cited that I had very soft SKIN and a beautiful voice and that if I didn't have all the right holes for him he would use something to make another hole blah blah blah.

[tugon (imported)]

I have never thought of myself as BIID but as one who desired reduction of libido. Maybe I had situational BIID and the only time they bothered me was when someone wanted to do something with them. I was fine with them as long as they were ignored by others. After castration my desires to have a penectomy has faded.

If I had access to chemical castration I may never have had surgery. At the time it was easier to find a cutter than a great resource like the EA to learn of chemical castration. I may have still needed surgical castration because several members who have done chemical still need surgical castration. I do support the one year of chemical castration for those wanting libido control. Hearing of one's regrets over being castrated has convinced me a waiting time with chemicals and a letter from a therapist is a good idea and a change in my thought.

As several have posted it took them years to achieve their goals. I began to think about castration when I was about 23 and several years to realize this is what I needed. Before I knew of eunuchs I thought I might be happier as a woman. During those early years the guidelines and years to live as a woman would have kept me from making a mistake. I am glad that a delay might be put into place for MtE. Again this is for men who want to be eunuchs and not men who dislike their testicles and want to be male.

I am happy for these surveys and presentaions not for myself but for all the young folks and future generations that this may help. When BIID and MtE are widely known and appropriately treated many of us will not live with our torture for 18-20 years. I have achieved my goals but I would like to think some young male would not have to wait so long for diaganosis and treatment. I wonder how I would have lived my life if I had been a eunuch since 19 or 20 which I feel would be an ideal age for me. On the other hand I wonder how those for whom castration is not right might live their lives.

For myself doctor's who are more educated and aware of our needs might give better medical care after the fact. I am changing to a doctor who is comfortable with transgender patients. I may finally get some of my issues addressed. I think that this next step even though not perfect for all is a great beginning.

[chilliwilli (imported)]

Jesus's work is the basis for real change not only in the medical community, but society at large. While there is greater understanding of gender variant, doctors need science to form a basis for treatment.

I think three to six months of androcur is plenty of time. The true personality surfaces quite quickly once testosterone is blocked. The hard part becomes gaining acceptance and self awarness once testosterone is no longer a driving force. If someone does not enjoy living without a strong libido, that person would quickly stop the meds.

I did a stint for six weeks a few years back and it was awesome. The trick is getting comfortable in your job/community/family.

chilli-

[devi (imported)]

These meetings were a great step forward. You do great work, Jesus.