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Alex-Iantaffi-BP.jpgAlex Iantaffi, PhD, was one of five speakers invited to present at an annual conference for the College of Sexual and Relationship Therapists (COSRT), held at Regent's College in London, UK, on November 2, 2013.

Iantaffi presented, "Mindfulness in Motion: Using a body-based, narrative approach to sex therapy," which was based on the findings of a pilot study he conducted with at PHS with Sara Mize, PhD1. The study's scope was to explore the feasibility and acceptability of a sensorimotor therapeutic intervention for women's sexual health groups, with a significant mindfulness component. Initial findings indicated that, compared with pre intervention scores, overall mindfulness scores significantly improved following the intervention. In line with prior studies, the qualitative results indicated that participants found mindfulness skills to be particularly useful and transferable to their daily lives. Iantaffi provided attendees with examples of how to apply these approaches to individual and group therapy.

The conference was connected to a two-volume special issue of the journal Sexual and Relationships Therapy2 focusing on mindfulness and sexuality.

COSRT is an organization based in London that focuses on training, research, education, and regulation to enable sexual and relationship therapists to provide the most effective therapeutic treatments to the public.

Mize, S., & Iantaffi, A. (2013). The Place of Mindfulness in a Sensorimotor Intervention to Improve Women's Sexual Health. Sexual and Relationship Therapy 1-2(3-76). doi: 10.1080/14681994.2013.770144

Sexual and Relationship Therapy, Special Issue: Mindfulness and Sexuality, Volume 28, Issues 1 - 2, 2013.

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Faculty profile: Cesar Gonzalez, PhD

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Cesar-Gonzalez-13-BP.jpgCesar Gonzalez, PhD, is feeling inspired after an intensive two-week training on randomized clinical trials. The course will undoubtedly impact his research on the topics of gender dysphoria, severe mental illness, treatment engagement, and the application of integrative psychological treatments among vulnerable populations.
 
Cesar-Gonzalez-NIH-BP.jpgGonzalez was selected as a fellow for the National Institutes of Health's Thirteenth Annual Summer Institute on Randomized Behavioral Clinical Trials held in Warrentown, Virginia, July 14 - 26, 2013. The training focused on the planning, design, and execution of randomized clinical trials involving behavioral interventions. "The faculty and fellows at the Summer Institute made the experience so unique and memorable. Conducting randomized clinical trials on behavioral interventions allows us to advance practice and theory. My hope is to build on interventions that work to increase the well-being of disadvantaged and marginalized populations, such as transgender individuals."

Cesar Gonzalez, PhD, is a psychologist, researcher, and educator at the Program in Human Sexuality. Gonzalez completed his postdoctoral fellowship at PHS in 2010, and joined PHS as a clinical psychologist and researcher on the All Gender Health Online research project where he helped develop an interactive web-based intervention for sexual health. Since then he has been promoted to Research Associate and in 2012 to Assistant Professor (research-track).

In recent years Gonzalez has been recruited for several international consultations including assisting in the development and translation of the Spanish Examination for Professional Practice in Psychology (EPPP) for the Association of State and Provincial Psychology Boards. He currently serves as a representative of the National Latina/o Psychological Association for the American Psychological Association's International Network on LGBTQ Issues in Psychology. In the past Gonzalez has served as a consultant to the Pan American Health Organization on promoting comprehensive healthcare to gay men and men who have sex with men in Latin American and the Caribbean.

Gonzalez is board certified in clinical psychology by the American Board of Professional Psychology. He is currently receiving his Advanced Certification in Schema Therapy (by the International Society of Schema Therapy through the Cognitive Therapy Center of NY/NJ), an innovative and evidence-based approach for treating complex psychological conditions and personality disorders. Gonzalez received his BA in psychology from the University of Arizona and received his PhD in clinical psychology from Alliant International University, Los Angeles. His clinical training includes behavioral medicine, severe mental illness, child and family therapy, and the assessment of learning differences. He served as director of evaluation and research at Bienestar Human Services, Inc., a non-profit organization serving Latino, HIV-infected/affected, GLBT individuals, where he evaluated HIV prevention programs and conducted community research on HIV/AIDS. He continues his passion for non-profit work by serving on the board of directors of Family Tree Clinic in St. Paul, MN. Gonzalez is an editorial board member of the International Journal of Transgenderism and is a fellow of the American Academy of Clinical Psychology. He is recipient of National Institute of Health's Loan Repayment Program award. Gonzalez is bicultural, and is bilingual in English and Spanish.

Recent publications by Gonzalez include:

Gonzalez, C. A., Bockting, W.O., Beckman, L., & Durán, R. E. (2012). Agentic and communal personality traits: Their associations with depression and resilience among transgender women. Sex Roles: A Journal of Research, 67(9), 528-543. doi: 10.1007/s11199-012-0202-y

Willoughby, B.L.B., Hill, D.B., Gonzalez, C.A., Lacorazza, A., Macapagal, R.A., Barton, M.E., & Doty, N.D. (2011). Who Hates Gender Outlaws? A Multisite and Multinational Evaluation of the Genderism and Transphobia Scale. International Journal of Transgenderism, 12(4), 254-271. doi: :10.1080/15532739.2010.550821

Photo: National Institutes of Health's Summer Institute on Randomized Behavioral Clinical Trials

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Coleman-&-Bowbeer-BP.jpgWe are excited to announce the new Michael E. Metz Fellowship in Couples' Sexual Health that will help prepare postdoctoral fellows for a career that will combine clinical and scholarly endeavors in the area of couples' sexual health.

The Metz Fellowship was created with a generous gift from Hildy Bowbeer to honor the life and work of her husband, Michael E. Metz, PhD. Metz was a nationally respected psychologist and couples therapist, who for 12 years served on the faculty of PHS and directed the relationship and sex therapy program. Metz passed away in March 2012.

Bowbeer said, "Mike was not only committed to couples' sexual health in his own clinical and research work, but was also passionate about training the next generation of scholars and therapists in this field. I'm thrilled to be able to help PHS carry on his legacy in this way."

The Metz Fellowship is a two-year program that will follow the training model of our postdoctoral fellowship, but the Metz Fellow will focus her or his clinical work on couples' sexual health. Bowbeer's gift will enable the Metz fellow to dedicate thirty percent of their time to research in the area of couples' sexual health. "This is a great opportunity for a postdoctoral fellow to have more time to focus on research and scholarly work," said Eli Coleman, PhD, director.

As a clinician Metz worked with more than 6,000 couples, addressing and resolving relationship and sexual problems, improving their quality of life. He authored 4 books and more than 60 professional articles and book chapters in the areas of couple intimacy, relationship conflict styles, sexual health, sexual medicine, and cognitive-behavioral features of satisfying relationships. He conceptualized the "Good Enough Sex Model" which was greeted with great appreciation. Throughout his career, Metz received many awards and honors.

Now accepting applications for fall 2013
http://z.umn.edu/metz

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Alex Iantaffi, PhD, joins faculty

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Alex-Iantaffi-2-BP.jpgResearcher, clinician, and educator Alex Iantaffi, PhD, joined the faculty at PHS on January 2, 2013.

Iantaffi is an assistant professor and a licensed marriage and family therapist, who originally trained in the United Kingdom as a systemic psychotherapist. Iantaffi has most recently worked on HIV research in the Department of Epidemiology at the University of Minnesota. In 2008 he came to the US from the UK to work on his postdoctoral fellowship at PHS, while serving as the project coordinator for the research project All Gender Health Online.

"We welcome Alex back to PHS. He is a great addition to our faculty, strengthening our research program and helping with clinical and teaching activities as well," said Eli Coleman, PhD, director.

Iantaffi is currently principal investigator for a study, funded by the National Institutes of Health, on Deaf Men who have Sex with Men (DMSM), HIV testing, prevention, and technology titled "D-P@RK." This study aims to overcome health disparities to HIV testing for DMSM through the development of Internet-based screening and prevention tools. The long-term objective of this line of research is to improve HIV screening, prevention, treatment, and access for Deaf people, by developing innovative, culturally and linguistically accessible Internet-based methods and interventions. The project has begun recruiting DMSM and individuals who have experience working with DMSM around issues of sexual health and/or HIV prevention, testing, and treatment.

Iantaffi has been the Editor-in-Chief for the Journal of Sexual and Relationship Therapy since June 2007, receiving its first impact factor in 2011. His therapeutic work is currently focused on transgender and gender non-conforming youth, and their families; sexuality, and relationships. Iantaffi has conducted research, and published on gender, disability, sexuality, deafness, education, sexual health, HIV prevention, and transgender issues. His scholarly work has been increasingly focused on issues of intersectionality and sexual health disparities. Iantaffi serves on the Transgender Commission leadership team as a past co-chair, as well as vice-chair on the Board of Directors at PFund, host for the GLBT Host Home Program, and core organizer for the newly formed Minnesota LGBTQ Health Collaborative.

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Rosemary-Munns-BP.jpgRosemary Munns, PsyD, assistant professor, is the new coordinator of Sexual Offender Treatment at PHS.

Munns will bring her extensive skills in corrections, psychology, and sexual offender treatment to the role of coordinator. For more than a decade Munns has worked with sexual offenders in individual and group therapy through all stages of their treatment from assessment through after care. For many years, she has also worked with a therapy group for their partners. "Rose has extensive experience in this area and we are fortunate to have her take a leadership role in this treatment program," said Eli Coleman, PhD, director.

Munns is leading an effort to coordinate the types of data that is collected by sexual offender treatment providers throughout Minnesota. Munns said, "The first step in getting an accurate understanding sexual offender treatment in Minnesota and a clear picture of treatment effectiveness is for programs to collect the same types of data on their clients." Munns is proposing quarterly meetings with key constituents to develop this project.

PHS offers a Sexual Health Systems Model approach to sexual offender treatment that Munns believes works well for clients and their families. Munns does intend to make some changes in the training of postdoctoral fellows in sexual offender treatment. She would like to offer fellows a glimpse into other treatment environments including prison and civil commitment locations.

Beyond her work with sexual offenders, Munns has extensive clinical experience in assessment and treatment of substance abuse, working in correctional settings with juvenile delinquents and adults, as well as inpatient and outpatient psychiatry. Her areas of interest are sexual dysfunctions, relationship and sex therapy, transgender issues, abuse recovery, compulsive sexual behavior, sexual orientation, and HIV counseling. Munns received her PsyD from the Minnesota School of Professional Psychology and was a postdoctoral fellow at PHS.

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Katie-Spencer-BP.jpg
Katie Spencer, PhD, assistant professor, is the new coordinator of Transgender Health Services at PHS. Spencer is eager to continue to bring the program in line with current best practices in transgender care, increase operational transparency, and deepen community collaborations.

Spencer believes that, "In recent years there has been a huge and welcomed shift in health care for transgender and gender nonconforming individuals. Across the nation and locally more physicians and mental health providers are being trained to provide quality care for transgender and gender nonconforming patients, which increases access for trans clients. Part of our role is to continue to engage in cutting-edge research, training, and clinical service to break down barriers to competent care for trans clients. We have also seen a ground swell in community organizations that provide support to individuals across the gender spectrum. It is an exciting time to be in transgender health care, with multiple opportunities for collaboration, capacity building, and expanding the framework of how we provide trans clients the best holistic health care."

Over the last month Spencer has started to systematically incorporate the recommendations from the revised Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People as well as science-based research on trans health into the operations of the Center for Sexual Health. This process includes updating staff and patient materials as well as clinical procedures. She is also meeting with community organizations, community health care providers, and colleagues in the region to discuss possible collaborations and partnerships. Spencer will be reviving a community advisory board to focus on the Transgender Health Services program. Spencer's longer-term goals include developing a patient peer mentor program, revamping the group therapy model, and creating a community support space for patients and families that would include a library or resource materials on health, legal, and social support issues.

Spencer believes in empowering patients to have more say in their own and their community's care, revising our model of care to reflect patient-centered, patient-informed, and collaborative models of care, consistent with feedback from trans health care advocates and research on best outcomes for patient care. Spencer said, "My goal is to build on our successes in developing innovative research and public policy in the area of transgender health and incorporate these principles into a strong and cohesive framework that supports all aspects of our work in clinical care, new research, and community advocacy."

In addition to her clinical work, Spencer works with multiple community organizations working to educate about LGBT healthcare issues and primarily transgender healthcare. She works with the Minnesota Trans Youth Support Network on the Community Hormone Access Project, partnering with community advocates and trans youth to develop community based hormone protocols for transgender care, in hopes to increase access to competent care and hormone provision for trans youth. She recently participated in the development of a theatre educational project for high schools on transgender youth issues. Spencer provides training, education, and consultation on sexual health and transgender issues, and has worked with the Family Tree Clinic, Face to Face Health and Counseling Services, Fairview Clinics, the University of North Dakota, and the Minneapolis Veterans Administration. Spencer often speaks about the intersections of LGBT rights and impact on wellbeing, and recently presented a First Friday Forum for the Minnesota Psychological Association on the psychological research on same sex marriage.

Spencer received her MA and PhD in counseling psychology from the University of Missouri-Columbia. She received her BA in women's studies and psychology from the University of Wisconsin-Madison. Her internship was completed at the University of Illinois-Chicago Counseling Center, and she was a postdoctoral fellow at PHS. She has a strong interest social justice, and education and training of therapists and medical providers in sexual health and transgender health care competency. Her primary clinical practice is working with transgender and gender non-conforming, adolescents, and adults, women's sexual health, and LGBT sexual health and wellbeing. She co-facilitates several groups, including the gender exploration group for youth and their families, the women's sexual health group, and transgender adult interpersonal groups. She has experience working with compulsive sexual behavior and general sexual dysfunction concerns. Her research and clinical interests focus on cultural competency in working with LGB and transgender populations, LGBT sexual health, sex therapy with LGBT couples, trans youth, and feminist embodied approaches to sexual health.

Spencer became coordinator of Transgender Health Services in October 2012, when the former coordinator Walter Bockting, PhD, joined the Initiative for LGBT Health a new program at the New York Psychiatric Institute and the Columbia University.

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Momentum against reparative therapy

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Spitzer-BP.jpgIn recent months public momentum has been building against reparative therapy for individuals who are gay, lesbian, and bisexual. For more two decades organizations and associations that work with mental health professionals have been advising that sexual orientation change efforts are not likely to work and that these efforts may be harmful to patients.

Recently several incidents have brought this issue into the headlines. First, two leaders of organizations that have promoted reparative therapy have publically stated that sexual orientation change does not work, and they have apologized for the harm that their work may have caused to individuals: John Smid, former director of Love in Action,* October 2011 on Hardball with Chris Matthews and Alan Chambers, director of Exodus International, January 2012 at the Gay Christian Network conference. Since then Exodus International has shifted its stance on reparative therapy. In a blog post dated June 19, 2012, Chambers states that Exodus International is "no longer an organization that associates with or promotes therapeutic practices that focus on changing one's attraction." The organization states that they will now focus on helping individuals to reconcile their faith and same-sex attractions by not acting on those attractions.

In May 2012, the Archives of Sexual Behavior published a letter to the editor from Robert Spitzer, MD, retracting his study about the effectiveness of reparative therapy published by the journal in 2003.** In his letter Spitzer concluded, "I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some 'highly motivated' individuals." Since 2003 Spitzer's study has been held up by organizations and even international governments as scientific proof that sexual orientation change is possible. Ironically, in 1973 Spitzer lead the efforts to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. Gabriel Arana, a writer for The American Prospect broke this story in April 2012 in his article "My So-Called Ex-Gay Life."

Currently the California Legislature is considering a bill that would make reparative therapy for individuals under the age of 18 illegal and require adults seeking conversion therapy to sign informed consent forms indicating that they understand the potential dangers, including depression and suicide, and that reparative therapy has no medical basis. The bill SB 1172 passed the House on May 30, 2012, and is now under active consideration in the Assembly. The bill states that

• Under no circumstances shall a mental health provider engage in sexual orientation change efforts with a patient under 18 years of age.

• Any sexual orientation change efforts attempted on a patient under 18 years of age by a mental health provider shall be considered unprofessional conduct and shall subject a mental health provider to discipline by the licensing entity for that mental health provider.

The bill's author Senator Ted Lieu said, "Under the guise of a California license, some therapists are taking advantage of vulnerable people by pushing dangerous sexual orientation-change efforts. These bogus efforts have led in some cases to patients later committing suicide, as well as severe mental and physical anguish. This is junk science and it must stop." Lieu went on to say, "Being lesbian or gay is not a disease or mental disorder for the same reason that being a heterosexual is not a disease or a mental disorder. The medical community is unanimous in stating that homosexuality is not a medical condition."

On May 17, 2012, the International Day Against Homophobia and Transphobia, the Pan American Health Organization released a statement outlining the dangers or reparative therapy, psychopathologization, and homophobia. The statement concludes, "A therapist who classifies non-heterosexual patients as 'deviant' not only offends them but also contributes to the aggravation of their problems. 'Reparative' or 'conversion therapies' have no medical indication and represent a severe threat to the health and human rights of the affected persons. They constitute unjustifiable practices that should be denounced and subject to adequate sanctions and penalties." The document makes recommendations of how homophobia and ill-treatment can be overcome through the efforts of governments, academic institutions, professional associations, media, and civil society organizations.

In 2009 the American Psychological Association issued a report based on two years of work that stated that sexual orientation change efforts can pose critical health risks to gay, lesbian, and bi-sexual patients and advised patients to avoid such treatments (see PHS Newsletter articles "APA warns against telling clients their sexual orientation can be changed," and Eli Coleman's "Letter from the Chair in Sexual Health September 2009").

*As of March 15, 2012, the organization Love in Action changed its name to Restoration Path.

**Spitzer, R. (2012). Spitzer Reassesses His 2003 Study of Reparative Therapy of Homosexuality. Archives of Sexual Behavior, 41 (4), 757. doi: 10.1007/s10508-012-9966-y

PHOTO:  Robert Spitzer, MD, Courtesy of Truth Wins Out, from Spitzer's video apology

 

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APA-BP.jpgWalter Bockting, PhD, was appointed to the American Psychological Association (APA) Task Force on Guidelines for Psychological Practice with Transgender and Gender Non-conforming Clients.  

Earlier, Bockting also served on the APA Task Force on Gender Identity and Gender Variance that released a report in 2008 that made several recommendations, including the recommendation to develop practice guidelines.  The new guidelines will help psychologists and students develop cultural competence for working with transgender clients and their families.

The group had their first face-to-face meeting February 10-12, 2012, in Atlanta, GA.  Bockting described the meeting as very productive.  He said, "Our task came into focus when we heard from individuals from the Atlanta transgender community about what is important to them and the challenges they have faced in their interactions with psychologists.  These guidelines are long overdue."  Once the guidelines are published, the next step will be to develop training for psychologists and students to develop their competence in treating transgender individual with respect and sensitivity.

The task force is a joint effort between Division 44 and the American Psychological Association Committee on Lesbian, Gay, Bisexual, and Transgender Concerns.  Group members include lore m .dickey (co-chair), Anneliese A. Singh (co-chair), Walter Bockting, Sand Chang, Kelly Ducheny, Laura Edwards-Leeper, Randall Ehrbar (PHS postdoctoral fellowship alumnus), Max Fuhrmann, Michael Hendricks, and Ellen Magalhaes.

In January 2012 the APA published practice guidelines in several areas, including revised "Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients."

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Peter-Eckman-MD-BP.jpgThe faculty of the Program in Human Sexuality invite you to explore the latest in sexual health research. PHS faculty, postdoctoral fellows, and research collaborators will present their work at our monthly faculty research presentations.

Join us: Noon-1 pm at PHS, 1300 South 2nd Street, Room 142, Minneapolis, MN 55454.

Reserve your seat today--email phsresearch@umn.edu

April 11, 2012
Peter M. Eckman, MD
Assistant Professor of Medicine, Cardiovascular Division

"Sexual Function in Heart Failure Patients with Left Ventricular Assist Device"

Left ventricular assist devices (LVADs) are an important therapeutic option for patients with end-stage heart failure, and more than 600 have been implanted at the University of Minnesota since 1995. Unfortunately, little is known about the impact of these devices on the sexual health of recipients. We surveyed patients with LVADs at 7 centers around the United States to learn about their sexual health. Preliminary results suggest preserved desire coupled with impairments in arousal and orgasm. Multivariate analysis suggests that age and medical comorbidities are important factors in predicting impaired sexual health after LVAD.

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Standards-of-Care-BP.jpgThe World Professional Association for Transgender Health (WPATH) released a newly-revised edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC), on September 25, 2011, at the WPATH conference in Atlanta. This is the seventh version of the SOC.  The original SOC were published in 1979.  Previous revisions occurred in 1980, 1981, 1990, 1998 and 2001.

The SOC is considered the standard document of reference on caring for the transsexual, transgender, and gender nonconforming population. The newly-revised SOC will help health professionals better understand how they can offer the most effective care to these individuals.  The SOC focuses on primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services and hormonal and surgical treatment.

"The latest 2011 revisions to the SOC realize that transgender, transsexual, and gender nonconforming people have unique health care needs to promote their overall health and well-being, and that those needs extend beyond hormonal treatment and surgical intervention," said SOC Committee Chair, Eli Coleman, PhD, Professor and Director at Program in Human Sexuality, University of Minnesota. 

"The previous versions of the SOC were always perceived to be about the things that a trans person must do to satisfy clinicians, this version is much more clear about every aspect of what clinicians ought to do in order to properly serve their clients. That is a truly radical reversal . . . one that serves both parties very well," said Christine Burns, SOC International Advisory Committee Member.

More than any other version, 2011 revisions also recognize that gender nonconformity in and of itself is not a disorder and that many people live comfortable lives without having to seek therapy or medical interventions for gender confusion or unhappiness.

This version provides more detailed clinical guidelines to address the health care needs of children, adolescents, and adults with gender dysphoria who need assistance with psychological, hormonal, or surgical care. 

In addition to clearly articulating the collaborative relationship needed between transsexual, transgender, and gender nonconforming individuals and health care providers, the new, 2011 revisions provide for new ways of thinking about cultural relativity and culture competence. 

The document includes a call to advocacy for professionals to promote public policies and legal reforms that promote tolerance and equity for gender and sexual diversity.  This document recognizes that well-being is not obtained through quality health care alone but a social climate that eliminates of prejudice, discrimination, and stigma and promotes a positive and tolerant society that embraces sexual and gender diversity.

WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a professional organization devoted to the understanding and treatment of gender identity disorders.  As an international multidisciplinary professional Association the mission of WPATH is to promote evidence based care, education, research, advocacy, public policy and respect in transgender health.

The World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version.  Retrieved from http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

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Katherine Rachlin, PhD, visited the University of Minnesota campus on March 26, 2010, to deliver a key note address and an informal talk at PHS. Rachlin presented "Challenging Assumptions About Identity Expression" at the Beyond the Boxes: Emerging Trends in LGBTQ Mental Health conference hosted by the U of M GLBTA Programs Office, Queer Student Cultural Center, and the Minnesota LGBT Therapists Network.

Rachlin is a gender specialist and sex therapist in private practice in New York, NY. In her address to mental health care providers, heath care professionals, educators, and the public, Rachlin discussed the assumptions regarding gender identity and gender expression that providers and educators make about the transgender individuals that they serve. She explored the many ways that mental health providers can be helpful to individuals seeing support for gender-related issues. Rachlin said,

Beyond the boxes - we do not think only in terms of people who transition or people who don't transition. We think in terms of self expression and choices--whatever that expression is. Gender queer people often have gender presentations that challenge gender norms just as transsexual people may strive to achieve an expression that conforms to gender norms. The common theme is expression. Often we assume that choices of expression are exclusively driven by internal identity. But that is not the case. Choices regarding expression are highly complicated and driven by many factors other than identity. In therapy, it is important to acknowledge that identity and choices are separate. Embrace identity and be practical about choices. It is traumatic for a transman told that he is not truly male because he does not want surgery or the transwoman told that she is not really a woman because she does not want to come out at work and risk losing her job. The connection between identity and transition choices pervades traditional thinking about transgender mental health and is reflected in our laws which often state that people will not be recognized as another gender until they change their bodies. Gender queer people may be forced to choose an expression that does not reflect the complexity of their internal identity because living outside the binary may be too difficult. . . .  I believe that we don't give enough weight to personality variables in determining transition choice. Variables such as the tolerance for ambiguity or uncertainty, tolerance for risk, tolerance for discomfort, need for affiliation, need for approval, extroversion and introversion, inclination towards conformity, dependency or independence, values regarding self-sacrifice, religious obligations, family obligations, feelings about medicine, doctors, and surgery . . . all of these may affect the decisions one makes regarding their gender expression, though they are not about gender at all!

During her visit to PHS Rachlin shared with faculty and staff that as a therapist she enjoys helping individuals, couples, and families become more comfortable with themselves and their own sexuality and said, "I am inspired by seeing people do the thing that seemed impossible to do when the started therapy." In addition to her gender work, Rachlin specializes in multiple partner relationships and strives to help families negotiate ways to make it work.

Rachlin is a member of the Board of Directors for the World Professional Association for Transgender Health (WPATH), and expressed excitement about the direction of that organization and its contributions toward supporting transgender health care world wide. Rachlin has presented her work at national and international conferences. Most recently, she delivered a speech titled "A Fresh Look at The WPATH Standards of Care" at the IFGE conference in Washington DC. One of her recent articles pending publication is "Challenging Cases for Experienced Therapists - A Clinical Dialogue," written with Arlene Istar Lev, LCSW-R, CASAC after a presentation they gave at GLAP's conference in New York City. Another article pending publication is "Hysterectomy Experiences of Female-to-Male Transgender Individuals," written with Griffin Hansbury, MSW, and Seth Pardo, MA.  
 
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Letter from the Chair in Sexual Health

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Coleman-Chr-BP.jpgThe American Psychiatric Association (APA) has concluded a first step in revising the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association by releasing proposed new classifications and criteria for the next revision of the DSM due to be released in 2013. At the same time, the World Health Organization (WHO) is undergoing its own process of revising its International Classifications of Diseases (ICD). The sexual and gender diagnoses are sure to spark intense debate. Sexual and gender disorders can be barriers to sexual health. Access to care for these disorders can lead to improvements in sexual health. At the same time, pathologizing normative sexual behavior and gender expressions can lead to stigma, discrimination, and poor sexual and other health outcomes. What is considered a disorder by these organizations has an enormous impact on all of us.

We know from history that psychiatrists once classified masturbation, oral sex, and homosexuality as perversions. With new knowledge regarding human sexuality, these were removed from the category of "sexual disorders." While the American Psychiatric Association declassified homosexuality in 1973, it was not until 2001 that the Chinese Psychiatric Association did so.

At present, there is quite a bit of concern and disagreement about the existing diagnostic categories and criteria for the sexual and gender diagnoses. Several national health boards have broken from the ICD and have declassified previously classified "disorders." For example, Denmark removed sadomasochism from their classification system in 1995, and as of January 1, 2009, Sweden declassified dual-role transvestism, gender identity disorder of childhood, fetishism, sadomasochism and multiple disorders of sexual preference. They retained transsexualism in order to preserve medical and psychological treatment for this condition (Pink News, 2008).

In February 2010, Norway followed suit and declassified these same "disorders" from their national health board. In February 2010, France became the first country in the world to remove transsexualism from its official list of mental disorders but has retained under a special category the ability for individuals with severe gender dysphoria to received appropriate treatment. The French Health Ministry has already agreed to push other countries in the European Union to drop transsexualism from their lists of mental disorders (Time, 2010). As noted in the article below, Cuba has recommended that transsexualism be removed from the ICD as well.

Last revised in 2000, there seems to be a general feeling that revision of ICD is necessary because of advances in knowledge, a deep concern about balancing the restriction of sexual freedoms and pathologizing normal variations in sexual and gender expressions, and the need to define pathological states for research purposes and access to care (and the right to the best possible care).

There is certainly intense concern regarding ridding the ICD of old and pejorative terms such as impotence, frigidity, premature ejaculation, nymphomania and satyriasis and excessive sexual drive.

A fundamental shift has been suggested in classification of sexual dysfunctions according to the traditional Kaplan/Masters and Johnson model of sexual response. This has mostly been driven by research on female sexual functioning and dysfunction that challenges the old assumption of parallelism of sexual response. Many argue that there is a fundamental difference in sexual response and dysfunctions in men and women are fundamentally different and therefore need different diagnostic criteria. Also, as we further understand the interplay between psychogenic and organic factors, many believe that there is a false dichotomy between organic and psychogenic factors in sexual dysfunction and perhaps in the other sexual and gender disorders. Sexual disorders may involve multiple psychological, interpersonal, and biologic/organic causes, and these influences are not always separate entities. They challenge the prevailing notion that organic sexual problems can be separated from psychogenic problems. There have been suggestions to creating a different category for sexual problems, eliminating the "dependence" of psychiatry and the stigma of a mental illness.

The debate over the paraphilias and whether to retain fetishism, transvestic fetishism, sadism and masochism will be contentious. The proposed new category of hypersexual disorder is clearly an attempt to recognize that some "normal" sexual activity can become excessive, driven, compulsive and in some ways "addictive." The potential misuse (and threat of over pathologization) of this category is enormous and there are also still fundamental questions regarding pathophysiology and nomenclature. And the debate over gender identity disorders will loom even larger. Clinicians, physicians, and researchers have made many important recommendations. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to satisfy anyone on either side of the debate. The APA has responded to some of these recommendations but the stigmatizing nature of the proposed revisions still remains. Changing gender identity disorder to gender incongruence has not seemed to be received well by many on either side of the debate.

I am pleased that the faculty of the Program in Human Sexuality have been involved in this debate and that their research has been used to inform the revision process. Having just reviewed and made recommendations to the WHO regarding proposed revisions to the ICD sexual and gender diagnoses, I am very aware of how difficult this task will be. It will be very challenging for the APA and WHO to find the right balance in the revision of the sexual and gender diagnoses in the DSM-V and ICD-11. Both bodies have opened up the revision process to public discussion and debate (DSM and ICD).

In considering the revisions, sexual health and rights need to be taken into consideration. Based on work from the World Association for Sexual Health (WAS), I offer these guiding principles.

1.    Recognition and treatment of sexual and gender disorders is a basic sexual and human right.

2.    DSM and ICD should take into consideration the sexual rights of individuals as it considers pathologizing sexual behaviors or gender expressions and individuals' right to freedom to express their full sexual potential, as well as to freedom from sexual coercion, exploitation, and abuse. The individual has a right to individual decisions and behaviors as long as they do not intrude on the sexual rights of others.

3.    Sexual and gender diagnoses should not be used in any way to support any forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability.

4.    Sexual and gender diagnoses should not be used in any way to pathologize the derivement of sexual pleasure, including autoeroticism, as a source of physical, psychological, intellectual and spiritual well being.

5.    Sexual and gender diagnose should not be used in any way to pathologize those who decide to marry or not, to divorce, and/or to establish other types of responsible sexual associations.

6.    Sexual and gender diagnoses should not be used in any way to infringe on the individuals right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation.

7.    The DSM and ICD sexual and gender diagnoses should support the right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders.

8.    There has not been enough research into the understanding or treatment of female sexual dysfunctions and that a gender perspective is needed.

9.    A lack of scientifically valid information concerning sexual function within the general population is pervasive and the negative impact of this ignorance is felt around the world.

10.    Given the importance of adequate sexual functioning for general sexual health, overall health and well-being, and the health of interpersonal relationships, the updating of the DSM and ICD is welcomed to recognize the distinctions between normal range of sexual and gender expression, and the concerns, problems, and dysfunction and disorders that require intervention. Appropriate sexual health services must be made available throughout the world.

11. Given the concern about "Americanization of mental illness," as an international classification of diseases (Watters, 2010a, b), ICD will need to pay particular attention to the influence of culture and globalization in arriving at a classification system that will meet the needs of the world.

I welcome your comments and encourage you to express your opinions to the APA before April 10, 2010 and to the WHO.

Pink News. Sweden removes transvestism and other 'sexual behaviours' from list of diseases November 19, 2008 Accessed from the Internet on March 14, 2010, http://www.pinknews.co.uk/news/articles/2005-9616.html/

Time. In France, Transsexuals Celebrate a Small Victory. March 1, 2001. Accessed from the Internet on March 14, 2010 at http://www.time.com/time/world/article/0,8599,1968767,00.html?xid=rss-topstories

Watters, E. (2010a)The Americanization of Mental Illness. New York Times Magazine, January 8, 2010. Accessed from the Internet on March 14, 2010 at http://www.nytimes.com:80/2010/01/10/magazine/10psyche-t.html?scp=1&sq=ethan%20water&st=cse

Watters, E. (2010b). Crazy Like Us: The Globalization of the American Psyche. New York: Free Press.

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