Input: Could not generate response.

Response:
"Id tease her and make her see what she was missing. Id bring her upstairs and make her beg for it. . . . " But when he contemplates following through on the fantasy, he thinks of Nancy. He was filled with trepidation at the possibility of endangering his marriage; the arousal was diminishing.

"Well, how about Nancy? How would it feel to have this kind of intense, driven, overwhelming sex with her?" I asked. "Can you even imagine what it might be like if you let yourself go wild with Nancy? I dont know . . . are you allowed to do that with a wife?"

"Yeah, I could lift her straight up onto the dining room table while I stand next to her and then really fuck her. And then we could shower together afterward—we havent done that since we were dating—and be really close. You know what else? We could go back to that bed and breakfast with the whirlpool. The last time we were there we just looked at it, and each other, and never said a word. But this time, I could get a bottle of champagne and we could make love with bubbles everywhere."

"Thats very sweet, but theres more, though, more that you and Nancy never do, never try, never talk about, wouldnt even dare think about together . . . not that you should, of course. But I can feel it coming up. . . . "

"You know what I really want? I want her to take control," he says.

"Now thats more like it. Say it to Nancy," I suggest. He turns to his wife, saying, "I want you to be rough with me and command me to go down on you. Thats what Id really like! I want you to entice me and spread your legs and tease me. I dont want to be responsible. I want to be a plasticene doll. I want to burn and have to have you to release me. I want you to be forceful but gentle. I want you to have balls." Mrs. Sinclair is now looking gleefully mischievous and nodding.

As he winds down, I ask, "Okay, thats a pretty good start. Is there more?" Mr.

Sinclair comes up with one scene after another, each involving overwhelmingly intense, outrageous sex and/or passionately close sex—with moments of easy closeness.

By the eighth session, Mr. and Mrs. Sinclair had followed up on all the possibilities hed imagined during the previous session. More important, he said that he had experienced the feelings that had permeated the previous session while with his wife. "I saw the creative side of Nancy." He was feeling much freer and no longer worried about her reactions. "It makes a big difference. . . . Id buried my sexuality but Im feeling what I felt at 16." She confirmed that they had each dared to share their fantasies together, uncertain of what to expect. Both were thrilled with the outcome. "Nancy was perfect . . .

I experienced some sensations while she was teasing me that Id never experienced before. It was the ultimate! Im more easily turned on, more present, and Im able to tell her if Im not entirely in the mood. It should be like this all the time."

He added that he felt no desire to reach for his binoculars nor to prowl the streets for open windows. "Even my need to gawk at every woman who walks by isnt there anymore."

At the 6-month, 18-month, and 5-year follow-up marks, Mr. Sinclair reports that his voyeurism has been eliminated. Mr. and Mrs. Sinclair report that although there have 200

been daunting moments, the erotic intimacy between them has continued to grow. In addition, his shyness, stuttering, and lifetime low-level depression and fears of losing control are gone.

**CONCLUSIONS**

This clinical illustration is quite different from what is ordinarily seen as the methods and goals in working with the paraphilias. Unfortunately, there is no empirical support for the treatments of voyeurism in the conventional literature (Mann et al., 2008). What accounts for the outcome in Experiential Psychotherapy? The alternative to behavioral/pharmacological management is to consider transforming the underlying experiencing. In the conventional treatment of the paraphilias, the individual is taught to keep the fantasies at bay and to stay away from whatever stimuli might trigger his or her behaviors. In parallel with the treatment of sexual dysfunctions in general, the predominant approach to the paraphilias targets the symptom while leaving the source of the problem unexplored (Kleinplatz, 2012.). The focus is on reducing the strength, frequency, or impetus to act on unacceptable urges, but there is no talk of changing the person who has the proclivities or his or her desires.

In the sex offender literature, the goals have traditionally been to eliminate dangerous behavior, to contain corresponding desires, and to promote public safety. From the Experiential perspective, these goals duplicate the problem already there for the patient/offender: He or she feels his or her deepest desires are unacceptable and wants to reduce or at least control them. In each instance, the treatment models and methods involve modulating and attenuating the disturbing symptoms, as if they were the problems themselves (Kleinplatz, 2007). By contrast, in Experiential Psychotherapy, it is in entering into whatever is front and center for the client, no matter how menacing or innocuous, that profound change can be effected. The goal is not to remove the symptoms, although, fortunately, those, too, tend to fade away. In this instance, that means not only change in behavior but also in the nature of ones desires (Kleinplatz, 2006, 2007, 2012; Mahrer, 2012).

Mr. Sinclair felt alienated, unlovable, and ashamed. Underlying that was a longing, a reaching out, a capacity for warmth and affection. Similarly, beyond his cool, safe, inhibited sexuality was a long-inaccessible capacity for passionate, intense, almost frenzied erotic intimacy. His capacity to integrate these potentials allowed him to be more authentically fulfilled in his marriage and to relinquish his voyeurism. Whatever might arise in moments of peak feeling can be used as an avenue toward substantive personality change. Similarly, there is discussion of the history of attachment problems in the genesis of the paraphilias in the sex offender literature (e.g., Marshall & Marshall, 2010). We can go further than social skills training by entering directly into the patients loneliness, if that is what arises, as it did here.

Are these the characteristics that lie deeper in each voyeur? There is no way of knowing what is to be found within any patient a priori except that it is unique. Dealing 201

with sexual fantasies may be a particularly crucial but often overlooked element required for substantive change to come about in dealing with paraphilias in therapy (Vanhoeck, Van Daele, & Gykiere, 2010).

There are myriad advantages that come with the use of Experiential Psychotherapy with paraphiliacs. In conventional treatment, the first step is often to stop sexual behavior; patients generally do not like giving up activities that are so rewarding. This approach is less intrusive. As illustrated here, there are often increases in "conventional"

sex, and thus this approach is less prone to problems of compliance. There is no judging or pathologizing of the patient; this frees the therapist from acting as an agent of social control. By merely controlling behavior, we may help to fuel the alienation from within and thereby make forbidden sexual desires, shrouded in secrecy, seem more compelling and menacing (Kleinplatz, 2012). It is only by entering into the heart of it that we may find hope for transformation.

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**CHAPTER 10**

"Gold-Star" Pedophiles in General Sex Therapy

Practice

James M. Cantor

**C** antor argues that the treatment of men who have a sexual interest in or preference for children is well within the skill set of sex therapists. He makes the important distinction between child molestation (a criminal offense) and pedophilia (a sexual interest). One of the major reasons for the reluctance of many sex therapists to treat clients with pedophilic interests is that their treatment raises ethical and legal questions that are not easily answered: Does the use of erotica increase or decrease the likelihood of sexual offending? Where does confidentiality end and duty to warn begin? Although this chapter does not provide easy answers to such questions, the author does guide us in thinking about these issues.

According to Cantor, most pedophiles commit sexual offenses when they have nothing in their lives worth protecting. And so he advises that "although the focus of ones sex drive cannot be meaningfully addressed by talk therapies, the feelings of hopelessness and isolation often can be." He notes that as sex therapists we have a unique opportunity to help someone before they commit an offense ("gold-star pedophiles"), both aiding the individual and addressing social safety concerns as well.

**James M. Cantor, PhD,** is Associate Professor of Psychiatry at the University of Toronto Faculty of Medicine.

Additionally, he is Senior Scientist of the Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Dr. Cantor is Editor-in-Chief of Sexual Abuse: A Journal of Research and Treatment.

Few aspects of human sexual desire remain taboo in the practice of sex therapy. When confronted with the possibility that a client might have a sexual interest in children, however, even very experienced sex therapists find themselves struggling with competing instincts: unconditional positive regard for the client versus sympathy for victims of child molestation; client confidentiality versus ethical and legal obligations to protect children; the recognition of the potential stakes in clinical decision making versus the current limitations of the fields empirical knowledge; and many other concerns. There is a large and growing forensic literature regarding the assessment, treatment, and recidivism risk of sex offenders—people who have already committed sexual offenses against children and are under legal supervision (e.g., Seto, 2007)—but there is scant discussion regarding persons who recognize or fear that they experience sexual fantasies or interests involving children and voluntarily consult a (nonforensic) sex therapist for help.

Jason was a 34-year-old male presenting to a general sex therapy practice, reporting 205

difficulties during intercourse with his wife of 6 years, Mai. The couple had enjoyable intercourse several times per week for the first 3–3½ years of their relationship, until Jason began experiencing increasingly frequent erectile dysfunction, an inability to achieve orgasm during intercourse, and increasing feelings of depression. Jason reported no erectile or orgasmic difficulties during masturbation, in which he continued to engage approximately weekly. The couples sexual contact together decreased to less often than monthly.

Jason told Mai he was seeking help for his depression rather than for any sexual concerns, and he attended therapy alone. A previous trial of PDE5 inhibitors had no effect on his sexual function, and he decided against a trial of antidepressants, due to their potential to exacerbate his anorgasmia.

Such initial presentations are well known to sex therapists: Male clients will often emphasize their physiological symptoms, especially at the beginning of therapy, and such symptoms can be an unclear combination of erectile dysfunction, delayed or rapid ejaculation, and decreases in or lack of sexual desire. Generalist clinicians (non-sex therapists) will sometimes focus first on what seems to be a diagnostic issue: Do the symptoms represent erectile dysfunction, anorgasmia, or both? Is one of these symptoms driving the others? To sex therapists, however, such symptoms are commonly conjoined and can reflect any of many etiologies. Marital conflict, lack of sufficient partner novelty, and cultural differences in expectations about sex all have the potential to interfere with sexual function, necessitating a broad assessment. With Jason, a particular question was why he was attending alone.

Jason grew up in a middle-class, suburban neighborhood of a North American city.

He was a talented student and athlete, receiving high grades throughout his schooling and graduating from a university with a degree in engineering. He reported no health difficulties. Although attractive and athletic, he was relatively reclusive socially and did not date until his university years. During his 20s, Jasons family of origin settled a wrongful-death lawsuit, which provided him with enough money to support him comfortably without other income. He began to travel widely, with Thailand being a favorite destination. It was there that he met and married Mai.

The couple lived there until a family illness required that Jason relocate with her to North America.

Jason professed great affection for Mai but described her as traditional, even subservient, and psychologically unsophisticated. He gave that as the reason for not including her in therapy. He noted that she was not reserved sexually but never complained about Jasons changes in sexual function; nor did she ever make demands of him (sexually or nonsexually).

Jasons description of Mais lack of psychological sophistication led to exploration of what he does find attractive about her (sexually and nonsexually), as well as his history of sexual and romantic attractions. He indicated that he had a preference for Asian women in general, which he attributed to their having more slight builds on average and a characteristic he hesitatingly referred to as androgyny. Although 206

identifying as heterosexual, he noted that he had wondered during adolescence whether he was gay. He never had any sexual contact with other males, either in adulthood or before, and he did not sexually fantasize about men outside of transient images while masturbating during adolescence. However, he indicated he never felt as sexually obsessed with women as his peers seemed to be.

The fact that it appears in this chapter at all will make the eventual revelation about Jasons sexual interests already obvious, and editing the case to fit this short space places the relevant clues closer together than they would typically appear during therapy. The most salient (and often the most diagnostic) of these include the breadth of the sexual dysfunctions (except during masturbation to covert fantasies), the history of sexual orientation confusion, and the atypical preferences for physical features in sexual partners. These features do not, in and of themselves, indicate a paraphilia, but they do seem to emerge in a substantial proportion of men who are paraphilic, homosexual, or transsexual and suggest that an assessor acquire much greater detail than usual about exactly what features such clients do find to be of greatest sexual interest.

Jasons recollection of thinking he might be gay suggested the possibility that he might still (or again) be struggling with such issues. Because his implied denial of being gay obviated very direct questioning, he was instead asked about his preferences for various physical features in fantasized sexual partners. In addition to being Asian, he preferred partners who had small breasts and trimmed (or, more preferably, shaved) pubic hair. As the description of Jasons optimal sexual contacts became clearer, and as the therapeutic rapport developed, Jason acknowledged first that he preferred younger women and later that he felt sexually aroused by girls as young as 12 or 13. Although Jasons explicit goal for therapy was the resumption of his prior sexual activities with Mai, his underlying goal was for therapy and his marriage to manage his sexual interest in children, which he had been doing so far by effortfully redirecting his attractions to approximations of his ideal.

**COMMENT**

Research on pedophiles outside a forensic context consists of only a small handful of studies, and these are based on self-reports of members of online or real-world social groups for self-acknowledged pedophiles and hebephiles (e.g., Bernard, 1975; DeYoung, 1989; Durkin & Bryant, 1999; Wilson & Cox, 1983). These are descriptive surveys of community samples; none pertains to providing treatment or support in a clinical context. Unlike treatment protocols tested for use with pedophilic offenders, there are no therapy manuals and no empirically based treatments endorsed as "best practices" by professional organizations of clinicians. Therapists, both forensic and otherwise, can rely only on general principles, doing the best we can with what we have. Indeed, working with clients on these and related situations is one of the remaining frontiers in the field of sex therapy.

Pedophilia and hebephila refer to the sexual preferences for prepubescent and early pubescent children (typically < 11 years and 11–14 years, respectively; Cantor, 2012, p.

59). There is often a belief among sex therapists that such interests, or any other 207

paraphilic interest whose expression might involve illegal or harmful activities, requires referral to a forensic specialist. It is an error to confuse pedophilia or hebephilia with actual child molestation, however. Whereas child molestation refers to overt sexual contact with children, pedophilia and hebephilia refer to the sexual interest or preference for children, regardless of whether the person acts upon it or spends his life actively and successfully resisting it. Sex columnist Dan Savage referred to these latter individuals as gold-star pedophiles (Savage, 2010), and helping them to live productive, offense-free lives is very often within the skill set both of sex therapists and of general mental health providers.

Although few data are available, it is my experience that the pedophilic and hebephilic men who go on to commit sexual offenses against children appear to do so when they feel the most desperate—when they have nothing to lose, nothing in their lives worth protecting. Although the focus of ones sex drive cannot be meaningfully addressed by talk therapies, the feelings of hopelessness and isolation often can be.

Cognitive-behavioral therapy (CBT) and other structured techniques have been particularly useful in that regard. In public health care systems (frequently serving individuals less wealthy than those in private clinics), clients can similarly benefit from addressing basic life needs, including regular employment, a stable living environment, and the pursuit of hobbies or other recreational interests.

In general sex therapy, the use of sexual fantasy, visual pornography, and written erotica are mainstays. When working with a person with pedophilia, however, those techniques pose certain ethical and legal questions. That is, with clients unable to express their sexual interests in the real world, one logical strategy is to help them develop enjoyable fantasy lives, and erotica is usually a substantial component of that life. Complicating that strategy, however, is that the content of erotica for pedophiles can constitute child pornography. A legitimate concern exists regarding whether any children were harmed in the production of stimuli that pedophiles would find erotic; however, stimuli involving no actual people (e.g., written-text-only and drawn or cartoon depictions of children) have also been subject to legal challenges. The legal definitions of child pornography continue to evolve; so, should such erotica be considered for therapeutic use, their current legal status should be checked first.

The foregoing embeds another complicated question: Can the use of (or the permission to use) erotica depicting even fictional children increase the probability that a self-acknowledged pedophile would go on to seek sexual contact with a real child? A widely used therapeutic model for actual sex offenders is "relapse prevention," which includes as a tenet that someone who committed a sexual offense must never use erotica (or masturbatory fantasies) involving children. Unfortunately, there are no strong data to reveal whether such erotica can either increase or decrease the probability of committing an offense. Rather, the recommendations to ban versus to employ such erotica are based on the theoretical stances of the therapists.

**ETIOLOGY**

208

During initial sessions, clients seek, often desperately, to understand themselves and their interests, and their greatest need is information: Why are they different from everyone else? Why were they born this way? The need for and benefits of psychoeducation are one of the ways in which these cases are no different from typical sex therapy situations. The sexual interest Jason was hoping to escape was the most stigmatized of all paraphilic sexual interests. His initial presentation and incremental revealing of his genuine concern, however, can occur with any paraphilic or stigmatized sexual interest or behavior. Unlike homosexuality, consensual BDSM, autogynephilic transsexuality, and other alternative sexualities, Jason cannot easily enact his sexual interests without risking harm to someone.

The nature–nurture debate over the causes of pedophilia dates back more then a century. Krafft-Ebing claimed in 1886 that pedophilia was a neurological disorder (Krafft-Ebing, 1886/1965). Most 20th-century authors, however, instead referred to

"nurture" arguments, typically citing reports that the majority of child molesters were themselves victims of molestation during their own childhoods. Contemporary findings, however, have revealed that men who sexually prefer children manifest multiple physical, neuropsychological, and neuroanatomical differences from nonpedophiles.

They perform significantly lower on IQ and other neuropsychological tests (Blanchard, Cantor, & Robichaud, 2006; Cantor et al., 2004; Cantor, Blanchard, Robichaud, & Christensen, 2005) and demonstrate significant differences in the grey and white matter of the brain, relative to nonpedophilic controls (Cantor, Kabani, Christensen, Zipursky, Barbaree, et al., 2008; Schiffer et al., 2007; Schlitz et al., 2007). They have more frequently suffered head injuries causing unconsciousness before but not after age 13

(Blanchard et al., 2002, 2003), and they have significantly greater probabilities of having failed a grade or having been assigned to special education classes during their school years (Cantor et al., 2006), suggesting that any neuroanatomical differences existed before the commission of any sexual offenses (and before any effects of incarceration or other sequelae). They are physically shorter in height than controls (Cantor et al., 2007), indicating suboptimal physical development overall—indeed, the magnitude of the height deficit (approximately 2.5 cm) is roughly double the effect found from a mother smoking cigarettes during pregnancy (cf. Fogelman & Manor, 1988). Pedophilic men are also up to three times as likely as nonpedophiles to be non-right-handed (Blanchard et al., 2007; Bogaert, 2001; Cantor et al., 2004; Cantor, Klassen, et al., 2005), indicating that the differences in brain development were likely present prenatally. (Fetuses demonstrate on sonograms a hand preference for thumb-sucking; Hepper, Wells, & Lynch, 2005.) Considered together, this body of findings suggests that pedophilia might be considered a sexual orientation, that is, an innate and likely immutable characteristic.

Indeed, some authors have referred to pedophilia as an age orientation (e.g., Seto, 2012).

Notwithstanding those findings, there remain claims that having been a victim of sexual abuse in childhood causes or predisposes one to develop pedophilia in adulthood.

This putative association appears intuitive to several schools of psychological thought, including conditioning, social learning, and psychoanalytic formulations (e.g., Araji & Finkelhor, 1985; Burton, Miller, & Tai Shill, 2002; Laws & Marshall, 1990). Despite the near ubiquity of the belief of a causal link between being a victim of sexual abuse and 209

developing pedophilia, it is not clear to what extent the association actually exists. The claim that pedophiles were themselves victimized comes from the pedophiles themselves, suggesting the possibility that they generate such claims to evoke sympathy.

In a very interesting report, sex offender clients were asked whether they were sexually abused in childhood; 67% reported that they were. After that clinic began informing its clients that they would be undergoing testing with a polygraph ("lie detector"), however, only 29% claimed to have been abused (Hindman, 1988). More recently, Jesperson, Lalumière, and Seto (2009) meta-analyzed reports of the proportions of sex offenders and sex offender subtypes who reported having been victims. On the one hand, sexual offenders against children reported being childhood victims significantly more frequently than did sexual offenders against adults; however, no significant difference was detected between pedophilic child molesters and nonpedophilic child molesters.

Their findings are consistent with the interpretation that suffering childhood sexual abuse (or other adverse developmental circumstances with which it is associated) facilitates inappropriate sexual behavior but does not cause pedophilia or hebephilia themselves. Because the data entered into the Jesperson et al. (2009) meta-analysis were, in turn, from self-reports, it remains unclear to what extent the child molesters might still be providing inflated rates of their own abuse.

Regardless of the magnitude of the association between sexual abuse in childhood and subsequent pedophilia, the aforementioned developmental theories also fail to account for multiple other observations. The majority of victims of child molestation are female (Snyder, 2000), whereas pedophilia appears to be a phenomenon nearly exclusive to males. Thus, if the aforementioned models account for the development of pedophilia, some other factor(s) must also be involved. The intuitiveness of the correlation comes from a "like makes like" perspective; however, the similarity between the stimuli is only superficial. From the point of view of the child victim, the putatively sexual stimulus (the abuser) is an adult, not another child. Were the mechanism one of simple learning, one would expect the sexual interaction to cause a sexual interest in older sexual partners, rather than in much younger ones. Similarly, sex play between peers in childhood is common. Were early sexual experiences central to the development of pedophilia, one would expect sexual interactions with other children, not adults, to be associated with a future sexual preference for children.

**LIFE IN THE DUNKELFELD**

It is unsurprising that convicted child molesters show elevated depression scores (e.g., Raymond, Coleman, Ohlerking, Christenson, & Miner, 1999), but the same has been reported among pedophile self-help group members (Wilson & Cox, 1983). The unparalleled stigma and lifelong inability to have sexual contact with the objects of ones attractions would challenge most men—depression in this group would seem unsurprising, too.

One of the hindrances to reliable data about pedophiles and hebephiles who 210

voluntarily seek out treatment are their perceptions (right or wrong) about the reportability of their cases. North American clinicians have noted the calamitous drop in the number of people seeking treatment or support after the enactment of mandatory reporting laws, leaving neither the opportunity to help them stay offense-free nor the scientific opportunity to develop and test new methods of intervention and improve public safety. There is an exception, however. In 2004–2005, Prevention Project Dunkelfeld was launched in Germany, with an extensive media campaign announcing (translated) "You are not guilty because of your sexual desire, but you are responsible for your sexual behavior. There is help! Dont become an offender!" (Beier, Neutze, et al., 2009). A prevention project such as the PPD is possible there, as Germany requires strict confidentiality on the part of therapists should the client disclose any offenses or plans to commit such offenses (unless the plan includes an intent to commit homicide; Beier, Ahlers, et al., 2009). With such a protection, research and prevention efforts can be aimed at situations otherwise unknown to legal authorities, existing only in the "dark field" (dunkelfeld). After its initiation, more than 450 men contacted the PPD, and nearly 300 provided data in screening procedures. Of these, 26.3% reported "strong" and 43.3% reported "very strong" distress, 30.0% reported "some/medium" and 20.9%

reported "strong/very strong" fear of offending, and 68.4% reported previously seeking psychiatric or psychotherapeutic treatment.

**INTERVENTIONS**

There are no compelling data to suggest that pedophiles might be converted into teleiophiles (persons with a primary sexual interest in adults). Multiple types of interventions have been attempted, including sex-drive-reducing medications and talk therapies informed by any of many theoretical orientations. Although there exist authors who have claimed that their interventions changed their clients fundamental sexual interests (e.g., Fedoroff, 1988, 1992), such reports do not include comparison groups, long-term follow-up, or any validated, objective measure to verify the claims of successful change. Typically, such reports describe sexual offenders who claim that they have ceased to be pedophilic, but those reports are unable to distinguish such claims from demand characteristics and noncritical evaluation by the treatment provider(s). In the absence of a technique that might alter ones fundamental sexual interests, therapy must instead be aimed at helping clients to manage or suppress those interests or to express them in way that would cause no harm to any other person.

The Internet—and its anonymity—has provided the opportunity for people with even the rarest of sexual interests to gather and form communities for mutual support, education, socializing, and political advocacy. In general, Internet-mediated contact with peers who share an atypical sexual interest can serve as an important component in combating isolation and in developing ones self-identity and sexual identity.

Individuals with pedophilia and their online communities are no exception.

I have not yet encountered a client who had contacted such a group before attending 211

therapy. (This is unlike persons attending therapy to help in their coming-out process as homo- or bisexual or as transsexual. In my experience, such individuals very often have already explored online social or support groups.) Clinicians need to apply caution in recommending such groups to individuals with pedophilia seeking peer support, however. Social media groups can be very prosocial in their cultures, with their sexual interests being only an infrequent topic of conversation (Malesky & Ennis, 2004). As is true with other sexuality interest groups, however, groups can and do discuss a range of political ideologies, and some advocate (or have vocal members who advocate) controversial agendas. That is, their views vary from emphasizing responsibility for ones behavior to opposing increases in the age of consent to the complete legalization of adult–child sexual contact (e.g., Durkin & Bryant, 1999). Unfortunately, a printed book chapter cannot easily include an evaluation of the existing online communities.

Although such a list would be a handy reference, Internet groups are not without their internal drama, splintering, and rapid revision of agendas as their leadership changes. It can be fruitful for the therapist to explore potential online venues together with the client. This should include discussion of the policy or philosophical statements that such groups typically include on their mainpages, but should also include exploration of their members actual discussions: It is my experience that mainpages contain only the least controversial and most prosocial philosophies, but that many or most of the members and their comments pursue less productive agendas.

PPD recently released an evaluation of the use of anti-androgenic medications in men seeking treatment, but outside a forensic context (Amelung, Kuhle, Konrad, Pauls,

& Beier, 2012). Although it was not possible to assign participants randomly to treatments, those researchers compared the treatment seekers who opted for pharmacological interventions (with cyproterone acetate or gonadatropin-releasing hormone [GnRH] analog) with those selecting nonpharmacological treatment only, both on their pretreatment and posttreatment characteristics. On pretreatment questionnaires, the men opting for medications perceived themselves as less able to control their sexual interests and more aware of potentially dangerous situations. After completion of the trial, they indicated greater ability to control their sexual interests, but, remarkably, lower self-esteem. Amelung et al. indicated this to be consistent with their clinical impression that the clients often view their need for medication as having lost the fight with themselves to resist their own impulses.

**CONFIDENTIALITY VERSUS DUTY TO WARN/REPORT**

Confidentiality has long been a backbone of sex therapy, but in the context of sexual interests in children, it becomes pitted against professionals duty to report cases or warn potential victims, leaving clinicians in less familiar situations. (In some jurisdictions, not only licensed professionals but even private citizens are legislated to report; "State-by-state look," 2011.) Further complicating the situation is that multiple levels of government and other regulatory bodies have overlapping jurisdiction, each 212


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Response:
with regulations in place: child protection laws, licensure laws, professional regulatory boards, and each of the (sometimes numerous) professional associations to which a clinician might belong. They contain analogous but differently worded versions of two opposing principles (confidentiality and duty to warn/report), giving little clear guidance to a clinician for navigating them without tripping either a false positive or false negative. More difficult still is the frequent use in such regulations of terms that have no objective referent, such as what might constitute a reasonably foreseeable or substantial risk. Although there now exist multiple, empirically validated instruments for use in quantifying the risk of reoffending posed by men who have already committed one or more sexual offenses—including the Rapid Risk Assessment of Sexual Offense Recidivism (Hanson, 1997), Sex Offender Risk Appraisal Guide (Quinsey, Harris, Rice,

& Cormier, 2006), and Static-99 (Hanson & Thornton, 2000)—there do not exist any such instruments validated for men without such a history. (The field also lacks validated instruments for predicting reoffenses among men convicted of child pornography but no "hands on" offenses.) Alleviating some of the pressure, perhaps, is that regulations that require therapists to break confidentiality often contain a clause such that no action can be taken against a clinician who makes such a report in good faith.

Notwithstanding the laws, in my experience many clinicians are guided (for better or for worse) by their awareness of potential civil litigation and of action by their professional licensure boards, to whom a future hypothetical victim might report them.

There is unfortunately little guidance from the civil courts. Although there exist such cases (e.g., Bruni, 1998a, 1998b), they typically arrive at financial settlements outside of court rather than a ruling that might set a precedent and guide clinicians in the future.

There is still less guidance regarding the attitudes of licensure boards. The opinions of such boards vary still more widely, according to the cultures of the local professional associations. Indeed, contacting the licensing board to ascertain its opinion (and documenting doing so) can often be an optimal approach to conflicting principles in practice.

Although Jason disclosed his sexual interests later in therapy, there also exist men who disclose their attractions to children to the therapist up front. Very often, such individuals are keenly aware of either the clinical reporting requirements or of client confidentiality and will ask about the limits of confidentiality at the outset. In most situations in general mental health practice, a general indication of limits is sufficient for the client to make an informed decision about whether and what to disclose. In the present context, however, the task can be more complicated, and most therapists will feel the need to check the current requirements in their jurisdictions. The limits of confidentiality can be the deciding factor in what a client decides to disclose, and such disclosures can sometimes result in triggering a mandatory report. Thus it can be useful, or even necessary, to halt conversations to allow the clinician time to verify the status or receive an outside opinion about reportability (such as by the licensing board). With clients in this situation, it can often be helpful to acknowledge the ambiguity of the situation at the outset, to conduct initial information gathering by telephone or e-mail (so that whole sessions do not become forestalled), and to interrupt as necessary.

213

**DIAGNOSTIC ISSUES**

A primary issue surrounding diagnostic criteria for pedophilia pertains to its cutoff point: Should the sexual preference for the average 11-year-old be diagnosable? The average 13-year-old? 15? That is, at what point do we cease to classify the "age orientation" as a mental illness? Few authors have argued that the sexual preference for persons with Tanner stage 4 characteristics (ages 15–16, on average; called ephebophilia) should be diagnosable, and few that the sexual preference for Tanner stage 1

characteristics (before age 11, on average) should not be diagnosed. Rather, the debates have centered on the status of hebephilia (preference for Tanner stages 2–3; ages 11–14, on average). There is a general consensus that hebephilia exists and is meaningfully distinct from the sexual preference for adults (Tanner Stage 5; teleiophilia), but there remains debate regarding whether it ought to be considered a mental illness, with opinions (often strong opinions) offered by expert witnesses paid to testify in court on behalf of accused or convicted child molesters, by victim advocates, and even by alternative sexuality advocates who philosophically reject the idea that any sexual interest (including pedophilia) should ever be deemed a mental illness. Unfortunately, many of the discussions surrounding the issue have been fraught with multiple factual inaccuracies (cf., Franklin, 2010; Cantor, 2012), hampering sober discussion. In the context of clients seeking assistance for their sexual interests in either age group, however, this distinction can be moot: The sexual interest in either age group presents the same issues for the client seeking to manage those interests.

Not all clients who self-refer for sexual interests in children are actually pedophilic—

a nontrivial portion of such clients instead suffer from obsessive–compulsive disorder (OCD), manifesting as an obsessive fear that they will molest a child (e.g., ONeil, Cather, Fishel, & Kafka, 2005). No data from samples of such cases have yet been published in either the forensic, sexological, or OCD literatures. In my own clinical experience, however, such cases differentiate themselves the most strongly from genuine pedophilia when the clients are asked to describe their sexual interests: Whereas individuals with pedophilia express (if hesitatingly) the physical (or, sometimes, emotional) features that arouse them, the "pseudo-pedophiles" instead express disgust.

That is, although both those with genuine pedophilia and with OCD pseudo-pedophilia fear that they might molest a child, only those with genuine pedophilia express sexual attraction to children. Whereas those with pedophilia experience a motivation to contact a child sexually, those with pseudo-pedophilia do not.

**WHEN TO REFER**

Despite the potential instinct to refer out to forensic specialists any case involving pedophilia or hebephilia, such issues can often be addressed by nonforensic sex therapists and by many general practitioners. There do exist situations, however, for 214

which at least consultation with forensic or other professionals can be necessary.

One of the most common potential referral issues is for clients considering sex-drive-reducing medications and their management. As noted by Amelung et al. (2012), this kind of therapy may have a beneficial effect on clients ability (or perception of their ability) to control their behavior, but a referral to an endocrinologist or other specialist should accompany psychotherapy to assess and address any sense of failure that may accompany the perceived need for pharmacotherapy. Depending on the local availability of a laboratory equipped to conduct it, therapy may also be aided by psychophysiological testing of a clients sexual responses to stimuli depicting males or females ranging in age from adult to prepubescent (e.g., Blanchard, Klassen, Dickey, Kuban, & Blak, 2001). Objective testing such as this (called phallometry or penile plethysmography) would generally provide little information in cases wherein the client admits to his sexual interests; however, it can be an important tool in differentiating clients who experience genuine pedophilia or hebephilia from those with (for example) an obsessive or irrational fear of having it. Finally are situations wherein a client does commit or reveal a sexual offense. Such situations are not an automatic end to therapy.

They can, however, evoke a complicated set of issues, for which consulting clinicians with specific forensic experience can be more than helpful.

It is outside the scope of the present chapter to outline those issues themselves. A resource for identifying colleagues from any of multiple disciplines, however, is the Association for the Treatment of Sexual Abusers (ATSA; www.atsa.com). In addition to ATSA, other resources that may aid over the course of treatment are Stop It Now!

(www.stopitnow.org)

and

publications

from

the

Safer

Society

Press

(www.safersociety.org/safer-society-press).

**CONCLUSIONS**

Over the course of therapy, Jason came to acknowledge the nature of his sexual interests. He realized that his interest in Mai (and their instances of successful sexual intercourse) were related to his desire to approximate the sexuality he could not actualize. The couple eventually divorced, and Jason found that being divorced rather than never married reduced the social pressure he experienced to be in a romantic relationship. He continued in therapy, however, indicating that it was the only venue in which he could unburden himself without risk.

Mai, interestingly, turned out to be less unsophisticated than Jason first described her. Upon disclosing his full story to her, she indicated both that she was already aware of Jasons status and that he was not the first person to be attracted to her due to her physical resemblance to underage girls. She continued to live in North America with her citizenship via marriage, started a house cleaning business, and helps support her family in Thailand.

The great majority of the treatment literature pertains to treating victims of abuse 215

and to preventing convicted offenders from repeating their crimes. Both of these efforts, however, apply only after an offense has already occurred: That is, the best a therapist could do is to help minimize consequences or prevent a second offense. But when meaningful attention is to paid to persons struggling with their sexual urges—on both the individual level and the social safety policy level—we have the opportunity to help prevent the first offense.

**REFERENCES**

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Beier, K. M., Ahlers, C. J., Goecker, D., Neutze, J., Mundt, I. A., Hupp, E., et al. (2009). Can pedophiles be reached for primary prevention of child sexual abuse? First results of the Berlin Prevention Project Dunkelfeld (PPD).

Journal of Forensic Psychiatry and Psychology, 20, 851–867.

Beier, K. M., Neutze, J., Mundt, I. A., Ahlers, C. J., Goecker, D., Konrad, A., et al. (2009). Encouraging self-identified pedophiles and hebephiles to seek professional help: First results of the Prevention Project Dunkelfeld (PPD). Child Abuse and Neglect, 33, 545–549.

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Blanchard, R., Cantor, J. M., & Robichaud, L. K. (2006). Biological factors in the development of sexual deviance and aggression in males. In H. E. Barbaree & W. L. Marshall (Eds.), The juvenile sex offender (2nd ed., pp. 77–

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Blanchard, R., Christensen, B. K., Strong, S. M., Cantor, J. M., Kuban, M. E., Klassen, P., et al. (2002). Retrospective self-reports of childhood accidents causing unconsciousness in phallometrically diagnosed pedophiles. Archives of Sexual Behavior, 31, 511–526.

Blanchard, R., Klassen, P., Dickey, R., Kuban, M. E., & Blak, T. (2001). Sensitivity and specificity of the phallometric test for pedophilia in nonadmitting sex offenders. Psychological Assessment, 13, 118–126.

Blanchard, R., Kolla, N. J., Cantor, J. M., Klassen, P. E., Dickey, R., Kuban, M. E., et al. (2007). IQ, handedness, and pedophilia in adult male patients stratified by referral source. Sexual Abuse: A Journal of Research and Treatment, 19, 285–309.

Blanchard, R., Kuban, M. E., Klassen, P., Dickey, R., Christensen, B. K., Cantor, J. M., et al. (2003). Self-reported injuries before and after age 13 in pedophilic and non-pedophilic men referred for clinical assessment. Archives of Sexual Behavior, 32, 573–581.

Bogaert, A. F. (2001). Handedness, criminality, and sexual offending. Neuropsychologia, 39, 465–469.

Bruni, F. (1998a, April 19). A child psychiatrist and pedophile; his therapist knew but didnt tell; a victim is suing.

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Bruni, F. (1998b, October 9). Jury finds psychiatrist was negligent in pedophile case. The New York Times. Retrieved from www.nytimes.com/1998/10/09/nyregion/jury-finds-psychiatrist-was-negligent-in-pedophile-case.html.

Burton, D. L., Miller, D. L., & Tai Shill, C. (2002). A social learning theory comparison of the sexual victimization of adolescent sexual offenders and nonsexual offending male delinquents. Child Abuse and Neglect, 26, 893–907.

Cantor, J. M. (2012). The errors of Karen Franklins Pretextuality [Commentary]. International Journal of Forensic Mental Health, 11, 59–62.

Cantor, J. M., Blanchard, R., Christensen, B. K., Dickey, R., Klassen, P. E., Beckstead, A. L., et al. (2004).

Intelligence, memory, and handedness in pedophilia. Neuropsychology, 18, 3–14.

Cantor, J. M., Blanchard, R., Robichaud, L. K., & Christensen, B. K. (2005). Quantitative reanalysis of aggregate data on IQ in sexual offenders. Psychological Bulletin, 131, 555–568.

Cantor, J. M., Kabani, N., Christensen, B. K., Zipursky, R. B., Barbaree, H. E., Dickey, R., et al. (2008). Cerebral white matter deficiencies in pedophilic men. Journal of Psychiatric Research, 42, 167–183.

Cantor, J. M., Klassen, P. E., Dickey, R., Christensen, B. K., Kuban, M. E., Blak, T., et al. (2005). Handedness in pedophilia and hebephilia. Archives of Sexual Behavior, 34, 447–459.

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Cantor, J. M., Kuban, M. E., Blak, T., Klassen, P. E., Dickey, R., & Blanchard, R. (2006). Grade failure and special education placement in sexual offenders educational histories. Archives of Sexual Behavior, 35, 743–751.

Cantor, J. M., Kuban, M. E., Blak, T., Klassen, P. E., Dickey, R., & Blanchard, R. (2007). Physical height in pedophilia and hebephilia. Sexual Abuse: A Journal of Research and Treatment, 19, 395–407.

DeYoung, M. (1989). The world according to NAMBLA: Accounting for deviance. Journal of Sociology and Social Welfare, 16(1), 111–126.

Durkin, K. F., & Bryant, C. D. (1999). Propagandizing pederasty: A thematic analysis of the on-line exculpatory accounts of unrepentant pedophiles. Deviant Behavior: An Interdisciplinary Journal, 20, 103–107.

Fedoroff, J. P. (1988). Buspirone hydrochloride in the treatment of transvestic fetishism. Journal of Clinical Psychiatry, 49, 408–409.

Fedoroff, J. P. (1992). Buspirone hydrochloride in the treatment of an atypical paraphilia. Archives of Sexual Behavior, 21, 401–406.

Fogelman, K. R., & Manor, O. (1988). Smoking in pregnancy and development in early adulthood. British Medical Journal, 297, 1233–1236.

Franklin, K. (2010). Hebephilia: Quintessence of diagnostic pretextuality. Behavioral Sciences and the Law, 28, 751–

768\.

Hanson, R. K. (1997). The development of a brief actuarial scale for sexual offense recidivism (Research Report No.

1997-04). Ottawa, Ontario, Canada: Public Safety Canada.

Hanson, R. K., & Thornton, D. (2000). Improving risk assessments for sex offenders: A comparison of three actuarial scales. Law and Human Behavior, 24, 119–136.

Hepper, P. G., Wells, D. L., & Lynch, C. (2005). Prenatal thumb sucking is related to postnatal handedness.

Neuropsychologia, 43, 313–315.

Hindman, J. (1988). Research disputes assumptions about child molesters. NDAA Bulletin, 7, 1–3.

Jespersen, A. F., Lalumière, M. L., & Seto, M. C. (2009). Sexual abuse history among adult sex offenders and nonsex offenders: A meta-analysis. Child Abuse and Neglect, 33, 179–192.

Krafft-Ebing, R. von (1965). Psychopathia sexualis: A medico–forensic study (H. E. Wedeck, Trans.). New York: Putnam. (Original work published 1886)

Laws, D. R., & Marshall, W. L. (1990). A conditioning theory of the etiology and maintenance of deviant sexual preference and behavior. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 209–230). New York: Plenum.

Malesky, L. A., & Ennis, L. (2004). Supportive distortions: An analysis of posts on a pedophile Internet message board. Journal of Addictions and Offender Counseling, 24, 92–100.

ONeil, S. E., Cather, C., Fishel, A. K., & Kafka, M. (2005). "Not knowing if I was a pedophile . . . ": Diagnostic questions and treatment strategies in a case of OCD. Harvard Review of Psychiatry, 13, 186–196.

Quinsey, V. L., Harris, G. T., Rice, M. E., & Cormier, C. A. (2006). Violent offenders: Appraising and managing risk (2nd ed.). Washington, DC: American Psychological Association.

Raymond, N. C., Coleman, E., Ohlerking, F., Christenson, G. A., & Miner, M. (1999). Psychiatric comorbidity in pedophilic sex offenders. American Journal of Psychiatry, 156, 786–788.

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217

**CHAPTER 11**

Gender Dysphoria

Kenneth J. Zucker and Nicola Brown

**A** profound disconnection between ones felt or experienced gender (most often the gender assigned at birth) and ones biological sex is the basis for the diagnosis of gender dysphoria (GD). Although there is some controversy about whether GD is a psychiatric disorder or nonpsychiatric medical condition, it is clear that GD is not a sexual dysfunction. However, Brown and Zucker note that an important therapeutic task is helping individuals suffering from GD to have clarity with regard to their sexuality and their gender identity. "The kind of sexual activity, the way it is enacted, and how one relates and is related to in the interaction, the sexual language used, and the degree to which sex can be embodied are all factors that contribute to our experience of the quality and enjoyment of sex, and also can powerfully affirm or undercut our sense of gender." Sex therapists may be uniquely suited to discuss these issues with transgender patients. Brown and Zucker provide a critical review of the relevant literature, including recent changes to the DSM-5 diagnosis of GD. They also adopt a lifespan developmental approach, discussing the important theoretical and clinical differences between GD in childhood, adolescence, and adulthood.

**Kenneth J. Zucker, PhD,** is a certified psychologist with the College of Psychologists of Ontario. He is the Psychologist-in-Chief at the Centre for Addiction and Mental Health (CAMH) and the Head of the Gender Identity Service for children and adolescents in the Child, Youth, and Family Program at CAMH. He is a Professor in the Department of Psychiatry, University of Toronto. Since 2002, he has been Editor of the Archives of Sexual Behavior.

Dr. Zucker was the chair of DSM-5 Sexual and Gender Identity Disorders Work Group.

**Nicola Brown, PhD,** is a certified psychologist with the College of Psychologists of Ontario. Dr. Brown completed a Postdoctoral Fellowship at Harvard University in the Victims of Violence Program. She is a staff psychologist in the Gender Identity Clinic for adults at the Centre for Addiction and Mental Health (CAMH) and also has a private practice.

In this chapter, we review therapeutic approaches and clinical management strategies for children, adolescents, and adults with gender dysphoria (GD). Although GD is not a sexual dysfunction, interpersonal sexual relationships (whether functional or dysfunctional) for adolescents and adults are an important part of the clinical picture, and thus the practicing sex therapist should be cognizant of this diagnostic class.

Moreover, as there is evidence that an increasing number of people identify along the transgender spectrum, it is likely that more clients with GD or its variants will be seen in the clinical practice of sex therapists who work with adults. It is also quite likely that sex therapists will encounter some couples who have a child or adolescent with GD, and thus they should have some familiarity with clinical management approaches for the pediatric population.

218

**PHENOMENOLOGY**

In DSM-IV-TR (American Psychiatric Association, 2000), the diagnosis of gender identity disorder (GID) can be given to children, adolescents, or adults. There are separate criteria sets for children versus adolescents/adults. "Gender dysphoria" was a term coined by Fisk (1973) that can be used to characterize individuals who, at one time or another, experience sufficient discomfort with their biological sex to form the wish for sex reassignment. GD refers to a sense of awkwardness or discomfort in the anatomically congruent gender role and the desire to possess the body of the opposite sex (or at least "parts" of that body), together with the negative affect associated with the marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced or expressed gender. This discrepancy is the core component of the diagnosis. There must also be evidence of distress or impairment about this incongruence. As we note in more detail later, DSM-5 (American Psychiatric Association, 2013) has renamed the diagnosis of GID as GD. Hence, we predominately use the GD diagnostic term in this chapter.

**EPIDEMIOLOGY**

There have been no formal epidemiological studies of GD in children, adolescents, or adults (Zucker & Lawrence, 2009). Accordingly, estimates of prevalence have relied on less sophisticated approaches.

**Children and Adolescents**

The Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983), a parent-report behavior problem questionnaire, and the Youth Self-Report Form (YSR; Achenbach & Edelbrock, 1986) are two widely used assessment measures that include items related to cross-gender identification.

On both the CBCL and the YSR, behaving like the opposite sex was reported to be more common than wishing to be of the opposite sex and was more common in girls than in boys. In the nonreferred standardization sample for children ages 4–11 years, only 1.0% of mothers of boys indicated that their sons wished to be of the opposite sex

"sometimes," and 0% indicated that this was "very true." The comparable percentages among nonreferred girls were 2.5% and 1.0%, respectively (Zucker, Bradley, & Sanikhani, 1997). On the YSR, for youth ages 11–18 years, the percentages of nonreferred boys who indicated a desire to be of the other gender were 2.5% and < 1%, respectively. For nonreferred girls, the corresponding percentages were 11% and 2%, respectively.

A limitation of such data is that they do not adequately identify patterns of cross-219

gender behavior that would determine "caseness," that is, the presence or absence of a disorder using DSM diagnostic criteria. Therefore, such data can be best viewed as screening information for more intensive evaluation.

**Sex Differences in Referral Rates**

For the clinician, a more practical matter concerns information about sex differences in referral rates of children and adolescents to specialized gender identity clinics (Wood et al., 2013). Three facts are noted here: First, among children (12 years of age and younger), the sex ratio favors boys. In our clinic for children and youth, for the years 1975–2011, the sex ratio among referred children was 4.49:1 of boys to girls (N = 577), which was significantly larger than the 2.02:1 sex ratio of boys to girls (N = 468) from the Amsterdam clinic in the Netherlands. Second, for our adolescent cases, the sex ratio was near parity, at 1:04:1 of boys to girls (N = 253), quite comparable to the Dutch sex ratio of 1.01:1 (N = 393). Third, the number of referred adolescent cases has increased dramatically over the past 8 years, with an almost fivefold increase in annual referrals from prior years.

**Adults**

Given the absence of epidemiological studies, estimates of GD have been attempted using other methods. This process has been aided by the fact that adults are eligible for treatments, such as hormone therapy and sex reassignment surgery (SRS), which theoretically equate with "caseness." These methods have included surveys of primary care or surgical care providers, analysis of case series from specialty hospitals and clinics that serve as principal gateways for sex reassignment, and examination of central medical and legal registries in countries in which these are available. Limitations in these methods likely result in underestimates of prevalence. In particular, the increase in community-based or alternative care settings for transgender people may lead to many adults with GD escaping notice, simply because care providers in these settings are less likely to publish information on the number of clients served.

Regarding prevalence rates inferred from the number of individuals who present at specialized gender identity clinics at university- or hospital-based centers, DSM-IV used data from several European studies to suggest a rate of 1 out of 30,000 for natal males and 1 out of 100,000 for natal females. In Zucker and Lawrences (2009) review of data from 25 adult clinics, it was concluded that there was evidence for an increase in prevalence rates from the earlier DSM-IV estimate—at least a threefold increase (and perhaps as high as an eightfold increase).

Asking about GD in population-based surveys has been advocated in order to more accurately estimate prevalence rates. Recent efforts using probability samples and using the term "transgender" yield much higher rates: 1 out of 300 (Gates, 2011) and 1 out of 215 (Conron, Scott, Stowell, & Landers, 2012). However, it is quite likely that these 220

numbers would include many individuals subthreshold for a clinical diagnosis of GD.

The range provided, however, suggests how complex a task it is to establish solid prevalence rates among hidden and stigmatized populations.

**DIAGNOSIS**

In early 2008, the American Psychiatric Association announced the formation of the DSM-5 Task Force that was responsible for recommending changes to the DSM-IV. The launching of the Task Force opened the door for a long-simmering debate on whether GID should remain in the DSM as a psychiatric diagnosis (Drescher, 2010; Meyer-Bahlburg, 2010; see also the special issue of the International Journal of Transgenderism, guest edited by Knudson, De Cuypere, & Bockting, 2010). Some argued for various kinds of improvements in the conceptualization of GID, along with modifications to the diagnostic criteria; others argued that it should be deleted and reconceptualized as some kind of nongeneral medical condition or even as a central nervous system (CNS) limited form of a physical intersex condition (see Meyer-Bahlburg, 2011). However, in the absence of data to support a reclassification as a nonpsychiatric medical condition, others argued that it should remain in the DSM so that people could access medical treatment through public health care systems or private insurers (Drescher, 2010).

It was the decision of the Board of Trustees of the American Psychiatric Association to retain the GID diagnosis in DSM-5 (American Psychiatric Association, 2013). There are 9 substantive changes from DSM-IV: (1) change in name of the diagnosis from gender identity disorder to gender dysphoria; (2) decoupling of the GD diagnosis from the sexual dysfunctions and paraphilias and placement in a separate chapter; (3) change in the introductory descriptor to the Point A criterion, including the specification of a 6-month duration criterion; (4) merging of what were the Point A and Point B criteria in DSM-IV-TR; (5) for children, the desire to be of the other gender as a necessary indicator for the GD diagnosis; (6) for adolescents and adults, much more detailed diagnostic criteria than in DSM-IV-TR and, like the criteria for children, polythetic in form; (7) elimination of the sexual attraction specifier for adolescents/adults; (8) inclusion of a subtype pertaining to the presence (or absence) of a disorder of sex development; and (9) inclusion of a "posttransition" specifier (for adolescents/adults).

**From GID to GD**

The diagnostic name change was based on several considerations. First, it represented a conceptual shift in focus to the incongruence between a persons experienced/expressed gender and his or her natal (biological) sex, not a persons gender identity per se (De Cuypere et al., 2010). Second, it captures the essence ("dysphoria") of the distress/impairment criterion. Third, it was a term that has a long history in clinical sexology, as noted before. Fourth, removal of the "disorder" label was considered to be 221

helpful in destigmatizing the diagnosis (Vance et al., 2010). The diagnostic name change is already reflected in the seventh version of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (SOC) issued by the World Professional Association for Transgender Health (WPATH; Coleman et al., 2011).

**Elimination of the Sexual Attraction Specifier**

In DSM-IV-TR, for sexually mature individuals, there is a sexual attraction (sexual orientation) specifier to measure whether an individual is sexually attracted to males, sexually attracted to females, sexually attracted to both, or sexually attracted to neither.

There is considerable evidence that the sexual attraction specifier (perhaps better characterized as a subtype) is associated with meaningful differences among adolescent and adult patients with GD (for a review, see Lawrence, 2010), such as age-of-onset of symptoms, degree of expression of cross-gender behavior in childhood, age at presentation for clinical evaluation, marital status, co-occurrence with transvestic disorder, and so forth. These findings likely reflect underlying differences in causal mechanisms among subgroups of patients with GD. This has been particularly so for natal males with GD, who show much more variability in their sexual attraction patterns than do natal females with GD.

In the early years of sex reassignment surgeries, it was posited that male-to-female transsexuals with late-onset histories (typically attracted sexually to women or bisexual) had poorer outcomes. Nonetheless, the absolute percentage of regrets of carefully assessed clients is rather low (Gijs & Brewaeys, 2007). Moreover, more recent research has shown that the levels of presurgery distress, as well as improvement on numerous postsurgery outcome measures among male-to-female (MTF) transsexuals with early and late-onset GD, are comparable, regardless of sexual orientation (Lawrence, 2003).

There is also a growing body of literature among large community-based samples suggesting that sexual attractions and practices are quite diverse. In contemporary clinical practice, therefore, it has been argued that sexual attraction (sexual orientation) per se plays only a minor role in treatment protocols or decisions. Because sexual attraction (sexual orientation) subtyping is of interest to researchers, this associated feature of GD is discussed in the DSM-5 text. Clinicians also need to be mindful of the variation in sexual attraction among patients with GD, as it will help understand relational issues that are important for the therapeutic context.

**Posttransition Specifier**

For adolescents and adults, the GD diagnosis contains a "posttransition" specifier colloquially referred to as the "out" clause. The addition of this specifier was prompted by the observation that many individuals, after transition, no longer meet the criteria for GD but that they require ongoing hormone treatment, further gender-confirming 222

surgery, or intermittent psychotherapy or counseling to facilitate the adaptation to life in the desired gender and the social consequences of the transition. Although the concept of "posttransition" is modeled on the concept "in [partial or full] remission" as used for mood disorders, "remission" has implications in terms of symptom reduction that do not apply directly to GD. Cross-sex hormone treatment of gonadectomized individuals could, of course, be coded as treatment of hypogonadism, but this would not apply to individuals who have not undergone gonadectomy but receive hormone treatments. In the DSM-5 text, there is mention that the course specifier of "full remission" in its original meaning does apply to many children with the diagnosis of GD

and perhaps to a small number of adolescents and adults.

**ASSESSMENT**

Apart from a clinical interview to ascertain the presence of the GD diagnosis, the practicing clinician can also utilize a variety of quantitative assessment measures that are available in the published literature. For children, a summary of measures can be found elsewhere (Zucker, 2005; Zucker & Bradley, 1995; Zucker & Wood, 2011). For adolescents and adults, options include the gender-related scales of the Minnesota Multiphasic Personality Inventory–2 (Mf, GM, and GF; Martin & Finn, 2010), which provide objective measures of clients gender-typical or atypical attitudes and interests.

The Utrecht Gender Dysphoria Scale is now available in English (Steensma et al., in press). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (Deogracias et al., 2007) is a recently developed, published instrument with good sensitivity and specificity and has been cross-validated (Singh et al., 2010). Some advantages of this last measure are that the items were developed, in part, based on DSM

indicators; it is relatively brief (27 items); and it appears well suited to identifying caseness.

**ETIOLOGICAL MODELS**

The causal mechanisms that might account for the development of GD include a range of conceptual models: an emphasis on biological mechanisms, an emphasis on psychosocial mechanisms, or an emphasis on some type of biopsychosocial framework that attempts to integrate both biological and psychosocial factors. For the contemporary clinician who studies this literature, it will become apparent that there is much that we still do not know and that one has to tolerate this ambiguity.

**Biological Factors**

Several lines of evidence provide some support for biological mechanisms in the genesis 223

of GD. These include genetic factors, as judged by a higher rate of concordance for GD

in identical twins than in nonidentical same-sex twins (Heylens et al., 2012). Candidate gene studies, however, have yielded mixed results in adult males and females with GD, including high rates of "false positives" in control groups and failures to replicate (Ngun, Ghahramani, Sánchez, Bocklandt, & Vilain, 2011).

It has long been noted that classic prenatal hormone theory does not easily account for GD, as the vast majority have a grossly normal somatic phenotype. Thus, there is little reason to believe that the prenatal hormonal milieu was grossly atypical. However, it is conceivable that more subtle variations in patterns of prenatal sex hormone secretion play a predisposing role. A relevant rhesus monkey animal model demonstrates the dissociation between sex-dimorphic behavioral differentiation and genital differentiation that is related to prenatal hormonal exposure and has the most direct relevance for explaining the marked cross-gender behavior of individuals with GD (Goy, Bercovitch, & McBrair, 1988). Another example potentially related to prenatal hormone exposure is 2D:4D digit ratios that demonstrate normative sex differences (Grimbos, Dawood, Burris, Zucker, & Puts, 2010). Whether these differences are related to GD is not clear (Wallien, Zucker, Steensma, & Cohen-Kettenis, 2008).

More recently, several studies have assessed, via structural magnetic resonance imaging, whether or not there are neuroanatomical regions in the brain that are altered in adults with GD when compared with unaffected males and females (Luders et al., 2009; Zubiaurre-Elorza et al., 2012).These studies suggest that the brains of individuals with GD are shifted, although not completely, in the direction of the opposite sex. This conclusion is somewhat qualified by sexual orientation differences. Homosexual MTF

transsexual brains are shifted toward a more female-typical structural pattern (Zubiaurre-Elorza et al., 2012). Conversely, nonhomosexual transsexual brains are similar to those of control males, not control females, and instead differ from controls for aspects of brain morphology that are not sexually dimorphic among controls (Savic

& Arver, 2011).

**Psychosocial Factors**

To merit truly causal status, psychosocial factors should be able to account for the emergence of GD in the first few years of life, when its behavioral expressions are first manifested (at least for those patients who have the early-onset form of GD). Otherwise, psychosocial factors would be better conceptualized as having a perpetuating role.

Parental tolerance or encouragement of the early cross-gender behavior of children with GD has been reported on by clinicians of diverse theoretical persuasions and has also marshaled some degree of empirical support (Green, 1987; Zucker & Bradley, 1995).

The reasons that parents might tolerate, if not encourage, early cross-gender behaviors appear to be quite diverse, suggesting that the antecedents to this "end state"

are multiple in origin. For example, if one listens to the reports by contemporary parents of children who have made an early gender social transition (later discussion), a 224

common narrative is that the parents are simply "supporting" what they view as their childs essential "nature." Such parents would argue that the direction of effect is from child to parent, not the other way around, or even some kind of interactive, iterative transactional process. In an earlier generation, parents of children with GD have reported being influenced by ideas regarding nonsexist child rearing and thus were as likely to encourage cross-gender behavior as same-gender behavior. In other parents, the antecedents seem to be rooted in pervasive conflict that revolves around gender issues (Zucker & Bradley, 1995, pp. 213–215).

In the normative-development literature, the role of parental reinforcement efforts in inducing sex-typed behavioral sex differences was studied extensively between the 1970s and the early 1990s. Lytton and Romneys (1991) meta-analysis concluded that, with one exception, there was "little differential socialization for social behavior or abilities"

(p. 267). The exception was in the domain of "encouragement of sex-typed activities and perceptions of sex-stereotyped characteristics" (p. 283), for which the mean effect sizes for mothers, fathers, and parents combined were 0.34, 0.49, and 0.43, respectively.

Although Lytton and Romneys overall conclusion minimized the influence of parental socialization on sex-dimorphic behavior, the domain for which clear parental gender socialization effects were found is precisely the domain that encompasses many of the initial behavioral features of GD (see also Zucker & Bradley, 1995, pp. 222–226).

Over the past couple of decades, cognitive-developmental models have come to play a much more central role in the normative-development literature regarding gender development (Martin, Ruble, & Szkrybalo, 2002), building on the seminal theoretical work from the 1960s through the 1980s and its emphasis on "self-socialization."

Studies of children with GD have shown that they are more likely than control children to mislabel themselves as of the other gender and to also show a

"developmental lag" in cognitive gender constancy (Zucker et al., 1999). Perhaps this early cognitive mislabeling of gender contributes to their cross-gender identification, although the reasons why such mislabeling occur is unclear. It could, for example, be argued that there is some kind of interactive effect between gender cognitions and the strong interest in cross-gendered behavior.

A second aspect of the cognitive-developmental literature pertains to the observation that young children have rather rigid, if not obsessional, interests in engaging in sex-typed behavior: for girls, Halim et al. (2013) dubbed this the "pink frilly dress"

phenomenon. Halim et al. argued that this gender rigidity was part of the young childs effort to master gender categories and to securely (affectively) place him- or herself in the "right" category. Parents of such children do not particularly encourage the rigidity, but they also do not discourage it, and there is the assumption that such rigidity will wane over developmental time and that there will be a concomitant increase in gender flexibility.

Halim et al.s (2013) observations jibe rather nicely with empirical data suggesting that many children with GD show very focused and intense cross-gendered interests (VanderLaan et al., in press). If these early cross-gendered intense interests are reinforced rather than ignored or compensated for by efforts to increase gender-flexible thinking and behavior, perhaps this contributes to their continuation and an increase in 225

the likelihood that a cross-gender identity will persist.

A multifactorial model of gender development can take into account biological predisposing factors, precipitating factors, and perpetuating (maintenance) factors.

Because so much is still not even known about normative gender development (Fausto-Sterling, Garcia Coll, & Lamarre, 2012), clinicians, patients, and their families vary in how much weight (or variance) each of these factors is given. At one extreme, some would argue that biological factors account for the bulk of the variance; at the other extreme, some would argue that psychosocial factors are most influential (see Zucker & Bradley, 1995, Chs. 6–7). As noted by Nieder and Richter-Appelt (2011), the propensity for practicing clinicians (and clients) to utilize dichotomous "either/or" paradigms in conceptualization is a common problem that should be avoided.

**APPROACHES TO TREATMENT**

**Children**

If one studies the follow-up literature on children with GD, current data show that: 1. The majority of children, when followed up in adolescence or adulthood, no longer have GD and are relatively content with a gender identity that matches their birth sex (for boys, 97.8%, n = 44, Green, 1987); 79.7%, n = 59, Wallien & Cohen-Kettenis, 2008; 87.8%, n = 139, Singh, 2012; for girls, 88%, n = 25, Drummond, Bradley, Peterson-Badali, & Zucker, 2008; 50%, n = 18, Wallien & Cohen-Kettenis, 2008). For children who show a persistence of their GD, almost all are sexually attracted to members of their natal sex; however, because these youth identify as members of the other gender, their subjective sexual identity is heterosexual or "straight."

2\. The majority of children with GD, especially boys, in whom the GD has desisted are sexually attracted to members of their natal sex and identify as gay.

3\. A minority of children with GD for whom it has desisted are sexually attracted to the opposite sex and identify as heterosexual or "straight." Thus, to date, the most common long-term outcome for children with GD, especially boys, is a homosexual/gay sexual identity with no continued occurrence of GD.