"Reparative Therapy" Still Being Used on Gender-Variant Kids

I was surprised to read, in this entry on Shiva's blog, that today, in 2008, children who display gender-atypical behavior can be put through intensive behavior-modification regimes to get the "correct" gender role drilled into them.

When I saw that, I had a strange sense of deja vu. A lot of the rhetoric used in support of these therapies --- and the actual treatment itself --- strongly resembles the language and techniques used in George Alan Rekers and O. Ivar Lovaas's now-infamous 1974 use of painful punishments to suppress young boys' preferences for feminine clothing and activities.

Here is Kenneth Zucker (whose invitation to speak before England's Royal Society of Medicine is the occasion for Shiva's post) on the necessity of preventing children from growing up to become transsexual or transgendered (quoted in J. Michael Bailey's 2003 book The Man Who Would Be Queen):

Zucker thinks that an important goal of treatment is to help the children accept their birth sex and to avoid becoming transsexual. His experience has convinced him that if a boy with GID (Gender Identity Disorder) becomes an adolescent with GID, the chances that he will become an adult with GID and seek a sex change are much higher.
...
Failure to intervene increases the chances of transsexualism in adulthood, which Zucker considers to be a bad outcome. ... Why put boys at risk for this when they can become gay men happy to be men?

Now, here's Lovaas and Rekers, in 1974:

It appears to be the case, in boys at least, that substantial deviation from appropriate sex-role behavior at age 5 yr leads to substantial gender problems in adulthood in the majority of cases (cf. Green and Money, 1969). Adult cross-gender problems not only develop early in childhood, but also contribute developmentally to difficulties in social relationships, so that by adulthood, the syndrome is frequently accompanied by other serious emotional, social and economic maladjustments. ... A third reason for treating (gender-variant children) is that intervention on deviant sex-role development in childhood may be the only effective manner of treating (i.e., preventing) serious forms of sexual deviance in adulthood ...

I don't detect much difference at all between those two passages in terms of the fundamental attitude toward unusual gender expressions or sexualities. Both stress that "deviance" must be nipped in the bud, extinguished while the person is still a malleable child, that society might be spared the *horror* of a gender-variant adult. Really, the only thing that suggests to me that these are not passages from the same era is the inclusion in the first quote of gay manhood as an acceptable outcome for a feminine boy. (I'm sure that Rekers and Lovaas would have considered that, too, a "maladjustment").

As I said in a comment on Shiva's post, the same bigotry towards gender variance is evident now as was common thirty-five years ago; the line separating acceptable difference from pathology has just moved a little.

Sanity Prevails at NIH

I read today in the Kansas City Star that the NIH's Trial to Assess Chelation Therapy for coronary artery disease had been suspended. This comes after I read last week that NIMH's similar study of chelation therapy for autistic children had also been stopped altogether. While the TACT has only been put on hold, with no new subjects being recruited, until an independent review board authorized by the Department of Health and Human Services's Office for Human Research Protections has investigated its informed-consent procedures and made sure the subjects were actually informed of all the relevant risks of the medication they'd be taking (I blogged before that they were not), the autism study has been cancelled altogether.

Why did they just now realize that chelation with DMSA is dangerous, and should not be used on children who do not have lead poisoning*? According to this article, the results of this 2007 study convinced a NIMH review board that the risks of giving DMSA to children with normal blood and tissue lead levels were greater than they had previously thought. The study, done with rats, showed that exposure to DMSA in rats without any previous exposure to lead impaired those rats' performance on tests of attention and learning.

From the study's discussion of the results:

The present study also revealed the unexpected finding that a single 3-week course of succimer treatment during early development produced lasting dysfunction in cognition and arousal regulation in rats not previously exposed to Pb. Note that these four behavioral tests were administered across a 7-month period following cessation of succimer treatment, suggesting lasting brain changes. ... These various impairments were similar in magnitude to those produced by the High-Pb exposure. (Emphasis mine).

Faced with this new information, NIMH decided to cancel the study and instead use its funding to pursue other autism-related research topics.

While I am gratified that the NIH decided not to go forward with either of these irresponsible investigations, I remain puzzled as to why they even approved them in the first place. In the case of the autism study, there is already a huge body of evidence showing no relation between heavy-metal poisoning and autism, and in the case of the TACT, the medication being studied was contraindicated for the category of patient making up the entire study population! And this information didn't even make it into the consent form. They should have quashed these studies while they were still in the planning stage.

*Yes, lead, not mercury. While there are a few cases of DMSA being used to treat mercury and arsenic poisoning, they do not constitute sufficient evidence that it is safe and effective for use with those metals. Consequently, DMSA has only been FDA-approved to treat lead poisoning.

On Drawing

I've always liked to draw, and always been fairly good at it. For a while I wondered if I might be a drawing savant, but decided my drawing skill had changed and developed too much for that. For me to be a savant, I would have to have started drawing with much more detail and grasp of perspective than I did.

Even if I wasn't a savant, I still wonder if my autism hasn't played a role in shaping my drawing ability and making me like to draw. I don't draw the same kinds of things most autistic artists do --- I think of autistic artists as all choosing to draw the sort of sprawling, imposing cityscapes that Stephen Wiltshire draws, while I draw mostly human figures*, with occasional natural landscapes. I do tend to draw insanely detailed line drawings, with very dark and heavy lines, though. Also, I've always drawn pictures piecewise --- do small parts one by one, in great detail, and see if they fit together --- which sometimes gives me trouble with proportions. But I have even more trouble when I try to sketch out a general plan for a picture; when I do that, things quickly get too large. It seems the only way I can stay on the paper is to keep the part I'm working on very small. This difficulty maintaining scale looks a bit like the fragmentation observed by Fein, Lucci and Waterhouse in their 1990 study comparing 34 autistic children to 32 normal children in their ability to reproduce drawings of geometric figures they were given and their ability to draw a child freehand. (If you can access the full article, it includes some sample drawings.) I also can draw about equally well from memory, from direct observation and from photographs, although my ability to draw something from memory depends on my understanding of what I see. I don't have a perfect photographic memory, so conceptual understanding of the structure of whatever I'm trying to draw is needed to fill the gaps in my memory of it. That can go the other way, too; as I draw something, I usually come to understand it better.

That's probably the biggest difference between my drawing and a savant's drawing: for me, drawing is a long, intense, highly intellectual process, while they just seem to bang them out automatically.

*I was interested to see this article, which apparently unearths an autistic drawing savant who prefers to draw human figures, and also who doesn't draw from memory. She is also female, which led me to wonder if this might be another sex difference within autism --- just as autistic girls tend to be more interested in pretending and fiction writing and art than autistic boys, maybe female autistic artists tend to choose different subject matter for their pictures. Most of the famous drawing savants are boys and men, after all...

Study: Women Do Better Than Men on Citalopram

Via The F-Word, I found this article on Science Daily describing one of the largest studies ever done on sex differences in response to antidepressant drugs. The study was published in the online version of the Journal of Psychiatric Research, and I was unable to get to it from the journal's website, which apparently only archives the print version.

This study differs from most previous studies of sex differences in antidepressant response in that it is larger (it enrolled 2,876 participants, while most of the studies it references enrolled only a few hundred or less), less selective in terms of the kind of patient it enrolled (previous studies, mostly clinical trials, tended to exclude a lot of potential participants, like those with additional co-morbid psychiatric disorders, who might introduce confounding factors, which means that their sample populations were not very representative of the general antidepressant-taking public), and uses three depression rating scales, scored by independent raters.

The study found that, while the women had more severe depressive symptoms, earlier age of onset, more overall life stress (they were poorer, more likely to be black or Hispanic, and slightly more likely to be divorced), and more likely to have family histories of depression, drug and alcohol abuse, and suicide, and more likely to have personal histories of attempting suicide, they had a significantly greater chance of seeing their depression go away entirely (29.4% of women vs. 24.1% of men). This is even though the women had higher rates of co-morbid anxiety disorders, which another study associates with poorer response to antidepressants.

The authors cite one other study with a large sample size: this 2005 study followed 5,452 patients who were given sertraline for their depression. They found no sex differences in patient response, but they were using a much lower (subtherapeutic) dose, and were dealing with different demographics than Young et al had. Also, Young et al failed to use a control group, and failed to blind either the study participants or the raters. They therefore acknowledge that the placebo effect could be boosting their response rate, though they claim the placebo effect works on both sexes equally, so theoretically should not disrupt a study of sex differences.

Though their study was not designed to pinpoint a mechanism for the observed difference in response, the authors propose that, as has been shown in other primates, estrogen acts in several ways to boost serotonin levels. One way you might investigate that would be to study the response of a large group of women to an SSRI, and compare the remission rates of, say, postmenopausal and premenopausal women, or women on hormonal birth control versus not. If it is estrogen, you would expect to see differences between women along those lines.

One final thing: while searching the Journal of Psychiatric Research's website for the original article, I happened across this article, which argues that large sample sizes in antidepressant trials tend to skew the results, probably due to a loosening of the criteria near the end of the recruitment phase. Not sure what to make of that; I had always thought that, with clinical trials, bigger was better, or at least more indicative of a drug's effect on the general population.


Thiels C, Linden M, Grieger F, & Leonard J (2005). Gender differences in routine treatment of depressed outpatients with the selective serotonin reuptake inhibitor sertraline. International clinical psychopharmacology, 20 (1), 1-7 PMID: 15602108

Young EA, Kornstein SG, Marcus SM, Harvey AT, Warden D, Wisniewski SR, Balasubramani GK, Fava M, Trivedi MH, & John Rush A (2009). Sex differences in response to citalopram: a STAR*D report. Journal of psychiatric research, 43 (5), 503-11 PMID: 18752809

Unintentionally Hilarious Quote of the Day

This one comes courtesy of the Kansas City Star's Business section, in this mini-review of a new book, Leadership and the Sexes.

Subtitled Using Gender Science to Create Success in Business, this book goes beyond the stereotypes in sharing what the latest scientific studies reveal about male/female brain differences. My "a-ha" moment: Men's brains are wired to more often enter a rest or zone-out state.

I had to laugh aloud at that. "Don't bother those busy men with all your lady-prattle, dearie, you don't want to bore them!" I wonder if they looked at whether men were able to attend longer to the words of superiors as opposed to peers or underlings, or to other men as opposed to women?

Don't get me wrong, I love neuroscience, and think more research into the ways that human brains do differ could give us valuable insights into human relations, individual psychology and ways to maximize human happiness. I tend to be very skeptical, though, when the differences neuroscience "discovers" correspond to existing notions of race or gender. Are women really so much more empathic than men, or is it that we are more likely to be in support roles (secretaries, nurses, assistants, receptionists) than working independently or calling the shots? I think it's lazy research just to look at men's and women's brains and assume any difference you find there must be innate. Given what we know about the effect of habit on the architecture of the brain, we should be particularly vigilant about controlling for life experience in these kinds of studies.

There's a particularly instructive cautionary example of this sort of shoddy writing in recent memory: when Louann Brizendine first published her opus The Female Brain in 2006, she claimed in its pages that women spoke an average of 20,000 words per day to men's 7,000. Imagine that! Almost three times as many words. That would certainly go a long way toward explaining the inter-gender communication problems that are the basis for so many movies and sitcoms, if only it were true. It turns out Brizendine just made that number up. When called on it, she backed down some, saying she meant that women used more "communication events" (words, but also gestures, facial expressions and other such ephemera) than men per day. Sadly, that turns out to be wrong, too.

I think the persistence of the "women talk more than men" meme and the conventional wisdom that men just don't listen very well are related, and both have to do with the marginalization of women's speech. Men won't listen to women if they think they don't have to (and you don't really have to listen to someone lower than you in a hierarchy; you can always ask them to repeat it, send you a memo or, ultimately, blame them for your ignorance of whatever they were trying to tell you), and, as long as women are seen as illegitimate newcomers to the public sphere, any speech uttered by a woman will be seen as excessive, because men will be used to her silence, or her absence.

Because I am an Arty Aspie ...

... I saw this picture and decided I had to cut it out and save it, and then paint my own version of it, sans suitcase.

Why did this picture speak to me? Well, without the suitcase to provide an excuse for her twirling, the Lady in Blue is just spinning for the sake of spinning. She's taking solitary pleasure in the sensation of motion, the feel of her skirts swirling around her, and of her hair streaming out behind her head. She's in her own world, completely absorbed in what her senses are telling her.

She is stimming, in other words.

Thank You, Sarah Palin

I have conflicting feelings about Sarah Palin. As an environmentalist, I am alarmed at her desire to open the ANWR for drilling (and the rest of the Alaskan wilderness to drilling, logging, mining, commercial fishing and whatever other ways exist to turn tundra and forest into dollars), at her dismissal of efforts to protect the salmon, beluga whale and polar bear, and at her endorsement (and practice) of shooting wolves while sitting in an airplane. As a feminist, I am discouraged by her opposition to keeping legal abortion the law of the land, and dismayed by her endorsement of one-word sex education (The word? "Don't."). As a bisexual woman and general LGBTQ ally, I am saddened that she does not consider everyone's committed relationships worthy of civic recognition. Finally, as the proud holder of a science degree, I do not want anyone sympathetic to creationist crankery allowed within fifty feet of the White House (or the House, or the Senate, or any state legislatures, governor's mansions, local school boards ...).

In fact, if it weren't for this:

Children with special needs inspire a special love. To the families of special-needs children all across this country, I have a message: For years, you sought to make America a more welcoming place for your sons & daughters. I pledge to you that if we are elected, you will have a friend & advocate in the White House.

... I would have no trouble recognizing her as anathema to everything I consider important.

Even with this avowed support for families with disabled children (which I believe, due to her personal connection to the issue and her past endorsement of the ADA as "one of the most compassionate and successful civil-rights laws in American history," is sincere), I do not think a McCain/Palin administration would necessarily bring about a kinder, gentler America for disabled people, for all the reasons ABFH lists. Indeed, McCain/Palin's commitment to cutting domestic spending and sticking with a market-based health-care system seem to indicate that lower- and middle-income families with disabled members couldn't count on much help from their administration, should they be elected.

However, there is one invaluable service Sarah Palin has done for disabled Americans, and will continue to do throughout her hypothetical Vice Presidency, and as long as she remains in the public eye. She has used her bully pulpit to speak lovingly and optimistically of her son, Trig; to call him a blessing rather than a burden, and to acknowledge his "special challenges" without bemoaning the normal baby she might have had, or making lists of things Trig will never be able to do, or calling for the eradication of Down syndrome in general.

Autism advocacy groups could learn a lot from her.

Hyperlexia?

Since I first encountered the term in the autism literature, I figured I was probably hyperlexic. After all, I have a humongous vocabulary* and have always read and written compulsively. No-brainer, right? Hyperlexia: too much language!

This definition makes it look less like anything I've got: my ability to get the gist of a passage has always matched my vocabulary, and the wiki stipulates that general comprehension must lag word recognition. Now, the American Hyperlexia Association's webpage says that the diagnostically relevant discrepancy is between written and spoken language --- and, indeed, I retain much more of, and notice finer details in, what I read than what I hear. Similarly, I am far more articulate in print than I am in person or on the phone. Some of it is because I can take more time in choosing the words, but in media like instant messaging the advantage in editing is negligible. Yes, you can proofread and rephrase before you send an IM, but the conversation is happening in real time, so you can hardly spend a day picking just the right synonym for "ridiculous" that adequately renders all the subtle shades of contempt and exasperation you want to convey. (Not that anyone I know has ever spent a day doing that ...)

There is also an enlightening discussion of hyperlexia in the comments on this post of Ballastexistenz's.

*I've gotten to Level 50 on Free Rice, and typically hover around Levels 47-49. I also got a 770 on the Verbal SAT; the three questions I missed were all sentence-ordering questions.

Happy Blogiversary to Me!

I've been blogging for exactly one year now, it seems. As I've never had a blogiversary before, I don't know what one ususally does to celebrate it, so I will just make something up.

...

I know! I'll make my blogiversary a time to revisit my first and second entries, which lay out the general scheme of the blog as I first envisioned it, and try to chart the blog's progress along that path (or branching off of it, as the case may be). It will be a time of reflection and introspection. And cake.

Well, the most obvious divergence from the initial plan is the inclusion of posts that aren't about books. I mostly did that because, if I only posted after I finished a book having to do with autism, I'd be posting only once every month or two.

Another thing that follows somewhat from that is that I've brought a lot more of myself to the blog than I had initially intended. In blogging about autism research, I bring the scientific part of myself to the front, and in blogging about feminism and about my own life, I allow more of my personality, philosophy and ethics to show through. I do not think these are bad things.

In my second entry, I have a list of themes I hoped to track through their various permutations in different works. I've only gotten to some of these, though I definitely have posts waiting about others. Also, it was part of my general plan to review a bunch of books before jumping into compare-and-contrast mode.

By far, I've written the most posts about autism and gender. I've also managed to write a fair amount about empathy and metaphor, and maybe obliquely dealt with distance in these posts. I haven't done much with the idea of first contact, or anything at all with narrative.

I also think I'm slowly adding another theme to the list: context. This refers both to the environment through which a given autistic character moves, and its effect on him or her, but also the extent to which the whole society in which he or she lives defines autism (and, by extension, the character). I think sci-fi is most conducive to this kind of analysis, if only because sci-fi writers make up whole societies, so they have to spend more time describing them than plain old fiction writers, who are free to restrict their scope to the characters' private lives.

I'm also gearing up to do another series of posts, this time on basic autism science. Look out, Internet!

Thoughts on the "Extreme-Male-Brain" Theory of Autism

I've been skeptical of Simon Baron-Cohen's Extreme Male Brain theory of autism ever since I first heard about it; my thought then was that, even granting that there are two distinct, gender-specific cognitive styles, the likelihood is much greater that autistic cognition would differ radically from both than that it would resemble one or the other.

(I think the example I was reading about when I had that thought was navigation: supposedly, men navigate using a mental map, while women use landmarks. "Well," I thought, "I navigate by playing a mental video of myself walking the route I'm supposed to take." Landmarks are part of it, but equally important is remembering turns and orientation. And both of those approaches are a lot more abstract than mine --- the archetypal man constructs a mental map he works from, and the archetypal woman remembers a list of landmarks. I record a complete visual memory of myself walking the entire route, and play bits of it back at will. It's less efficient, but more comprehensive.)

Over the course of the long article I linked to in the first paragraph, Baron-Cohen develops a concept of the male brain autistics are supposed to exemplify: it excels at mathematical reasoning, navigation and spatial reasoning, spotting single elements within larger visual wholes (e.g., the Embedded Figures Task), rotating objects, and aiming and targeting projectiles, and does poorly at verbal tasks, inferring another person's state of mind, cooperation and social judgment. It is also more strongly lateralized than the female brain, with a smaller corpus callosum and more exaggerated handedness. The female brain, by contrast, specializes in language, empathy and cognitive dexterity (e.g., rapidly coming up with a list of objects that are blue, or a list of words beginning with a given letter, or quickly categorizing or matching objects).

As Baron-Cohen suggests, this theory would quite neatly wrap up the past decade's major observations about autistic cognition: deficits* in theory of mind, central coherence and executive function. As defined above, Baron-Cohen's "male" brain type encompasses all three of these: poor theory of mind is practically written into the definition of the male brain (it is, after all, defined in opposition to the highly empathic female brain), so that one's a freebie; weak central coherence is evident in the male brain's focus on detail at the expense of broader patterns, and you would expect executive function to be weaker in someone with a strongly lateralized, weakly interconnected brain than in someone whose brain is more unified.

Unless Baron-Cohen can prove that all these variables (sex, language ability, empathy, brain lateralization, autism etc.) are directly related, all his theory will have accomplished will be redefining normal maleness as a state of mild autism. So far, the evidence is inconclusive. Yes, the few male-female differences in cognitive style that exist (male advantage in mentally rotating 3-D objects, female advantage in verbal fluency) are consistent with Baron-Cohen's ideas of the male and female brains, but other areas he predicted would show differences haven't, or have shown them inconsistently (empathy, mathematical and language ability, interest in social vs. mechanical stimuli) --- and even the differences that have been shown to exist are small ones, with a substantial zone of overlap between the sexes.

Language ability is also quite readily shown to be independent of social understanding by the example of Asperger syndrome. Baron-Cohen conflates autism with Asperger syndrome in his article, and speaks of both as involving a delay or impairment in language acquisition and use. This isn't true; one of the diagnostic criteria for Asperger syndrome is that language acquisition must occur on time or precociously. Baron-Cohen places AS on a continuum between the normal male brain and the "classically autistic" brain, which is problematic given AS's normal or superior verbal capacities and its higher male-to-female ratio (9:1, as opposed to 4:1 in classical autism).

Neuroanatomically, the theory is on ground as shaky as it is in cognitive psychology. Baron-Cohen invokes differences in the size of the corpus callosum to explain the contrast between the strongly lateralized male brain and the adapatable, bilateralized female brain, ascribing the female advantage in verbal fluency to speedy communication between hemispheres. Unfortunately, this 1997 meta-analysis of 49 studies and this current study indicate that there is no difference between male and female corpora callosa that cannot be accounted for by overall differences in brain size --- which favor men. Also, autistic people (who are definitely less fluent overall in their use of language than NTs) tend to display very weak brain lateralization and handedness, which Baron-Cohen acknowledges.

I can understand the appeal of a theory relating male gender and autism --- it would explain both the preponderance of men on the spectrum and the trouble many female autistics have fitting into the feminine social role. I think it would ultimately obscure more than it illuminated, though, both about autism and about the nature of gender. Defining maleness as mild autism would enshrine in biology a very culturally specific ideal of geeky masculinity, and legitimize (again, via biology) the delegation of all familial and relationship responsibilities to women, who, after all, have specialized nervous systems that can handle all that stuff.

*Autism research tends to find "deficits" in autistic cognition wherever it goes looking for them, even when the actual results indicate an autistic advantage --- e.g., findings that we tend to do better on visual-search tasks getting interpreted as showing "defects in central coherence," "can't see the forest for the trees."