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Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

By its title, Sex and Gender announced a conceptual breakthrough in distinguishing basic elements of human experience. In Robert Stoller's first book, patients illustrating this divergence were lucidly presented. Transvestites and the newly publicized transsexuals were two examples. Clinical and dynamic distinctions between the two formed a basis for Stoller's criteria for patient selection for "sex change." They remain current. The complex identity of the intersexed was described with sensitivity and insight. It, too, remains timely. An innovative description of the genesis of boyhood transsexualism was presented in considerable detail. This finding is less commonly reported today but is also not looked for. Stoller was sympathetic to the request for sex change. He credited a biological contribution to the development of masculinity and femininity. Both stances were remarkable for a psychoanalyst. Robert Stoller introduced the term "gender identity." It is now our vocabulary when we articulate this bedrock of personhood.

Atypical handedness patterns, i.e., persons being less exclusively right-handed, have been found previously in large samples of male and female homosexuals and in small samples of male and female transsexuals compared to controls. The posited role of prenatal androgen influencing both cerebral hemispheric dominance and psychosexual development warrants further study with large samples of transsexuals. 443 male-to-female transsexuals and 93 female-to-male transsexuals were studied for their use of the right or left hand in six common one-handed tasks. Both male and female transsexuals were more often nonright-handed than male and female controls were. Results suggest an altered pattern of cerebral hemispheric organisation in male and female transsexuals.

Several adult male members of a sadomasochistic sex club were arrested for violating a U.K. statute passed in 1861 – The Offences Against the Person Act. The sex acts spanned a 10-year period and were videotaped. They involved manipulation of the genitalia with hot wax, sand paper, fish hooks, and needles. The sexual interactions were consensual. This analysis tracks the case from trial, to the Court of Appeal, to the House of Lords, and on to the European Court of Human Rights. It examines whether or not these sexual behaviors should be protected under a right to privacy. It contrasts state concerns of bodily harm, albeit consented to, in sex with those incurred in sport.

The Archives of Sexual Behavior: An Interdisciplinary Research Journal will attempt to bring together findings from the several academic disciplines investigating human sexuality. Research data on sexual behavior are emerging at an accelerating rate. Inspection of the past year’s Index Medicus and Psychological Abstracts reveals hundreds of noteworthy papers published throughout the world addressed directly to this subject. They were from psychologists, psychiatrists, neuroendocrinologists, ethologists, psychoanalysts, geneticists, and social scientists. Unfortunately for the student of sexual behavior, these papers were published in literally dozens of journals, rendering it a practical impossibility to maintain a scholarly awareness of that material. An additional deficiency in effective communication among these investigators derives from man’s inefficient system of language. Of the scores of innovative papers published last year, one-third were in a variety of languages other than English. The Archives of Sexual Behavior hopes to be the first journal to collate effectively research contributions of consistently high caliber from scholars throughout the world. It hopes to incorporate, among others, the research strategies of the clinician, including the psychoanalyst and behavior therapist, with the perspective of the social scientist and the findings of the laboratory investigator. Associate Editors and members of the Editorial Board have been selected to maximize this potential. The Archives of Sexual Behavior will also translate selected non-English-language research papers and make them available in summary form to an English-language readership. How did I become Founding Editor in 1971? I was chosen because of the fatherly confidence of Robert Stoller and the confidence that Seymour Weingarten had in Bob. Seymour had been Bob’s editor at Science House when Sex and

An interview designed to assess a respondent's experience with erotic material in photographs, films, and books, during adolescence and adulthood, was administered to convicted male rapists, pedophiles, homosexuals, transsexuals, heavy pornography users, and two nondeviant contrast groups. One nondeviant group was composed of whites matched for the sex offender group; the other was composed of ghetto and middle-class blacks. Adolescent exposure to erotica was significantly less for all deviant and offender groups compared to the nondeviants. During adulthood, the sex offenders and transsexuals continued to report less exposure to erotic stimuli than controls. The homosexuals and users, however, both report greater exposure during adulthood. As adolescents, the control group, rapists, and heavy users were excited to masturbate by the erotic materials more than the other groups. As adults, the controls and rapists showed a sharp decrease in being excited to masturbate to erotica while the users' rate remained high and the homosexuals' rate rose. Less than a quarter of the respondents in any group imitated sexual behavior seen in the erotic material immediately or shortly after its viewing. The hypothesis that extent of exposure during adolescence to erotica is positively associated with the later emergence of sexual pathology is not borne out by this study. The nondeviant, non-sex-offender groups sampled had had significantly greater exposure to erotic materials during adolescence than the deviants, convicted sex offenders, or heavy adult users of pornography.

Ten (10) sets of siblings or parent-child pairs concordant for gender identity disorder (transsexualism) or gender identity disorder and transvestitism are reported. For concordant gender identity disorder, there is one set of male monozygotic twins; three sets of non-twin brothers; one brother-and-sister pair; one set of sisters; and one father and son. With gender identity disorder and transvestism, there is one transsexual father with a gender dysphoric; transvestic son; one transvestic father with a gender dysphoric, transvestic son; and one transvestic father with a transsexual daughter. The emerging technology of genetic markers makes collation of such families a potentially valuable resource for unraveling the origins of atypical gender identity.

Whereas hormonal and surgical sex change have been increasingly refined and accepted medically during the past 40 years, legal protections have only recently received attention. This overview focuses on employment, medical treatment, and civil status as male or female in the United States and the United Kingdom. Employment protection in the UK is assured since a court decision in 1994, but in the U.S. is generally uncertain and inconsistent between states. Health care, including surgery, under the UK National Health Service, is assured since a court decision in 1996. In the U.S., the absence of a national insurance program and the reluctance of private insurers to fund treatment remains an obstacle. Military personnel and prisoners are provided treatment in the UK but there is no military-provided treatment in the U.S. and prison treatment is limited. Change in birth certificate sex status is available in the UK since 2004. This permits heterosexual marriage as a person of the reassigned sex. In the U.S., whereas nearly all states permit birth certificate modification, obstacles remain to recognition across state jurisdictions. Some states forbid marriage for a transsexual as a person of their reassigned sex. This can impact on transsexuals as parents.

This letter addresses two papers by the DSM-V Sexual and Gender Identity Disorders Workgroup member Ray Blanchard published in this Journal (Blanchard, 2009; Blanchard et al., 2009). Having been active in the 1970s struggle to remove homosexuality from the DSM (Green, 1972), a success that cured millions of their mental disorder, I am appalled that the ranks of the disordered may swell, once more in consequence of sexual orientation. As a psychiatry professor and graduate of Yale Law School, I hope I understand the domain of both disciplines. The DSM proposal trespasses their boundary. Concern is expressed that‘‘the current definition of pedophilia is excluding from specific diagnosis a considerable proportion of men who have a persistent preference for humans at an incomplete stage of physical development’’(Blanchard et al., 2009). Whence the 11th commandment, Thou shalt not have sex with those not fully mature? The Commandment could have been carved: Thou shalt not have sex with those before reproductive capacity. This would permit sex with some 13-year-olds. In several European countries, the age of legal consent to have sex falls within the range proposed for the DSM as signifying mental disorder for the older participant. The age of consent is 14 in Albania, Austria, Bulgaria, Croatia, Estonia, Germany, Hungary, Italy, Lithuania, and Serbia and 13 in Spain (www.avert.org). If the general culture is accepting of participation by the younger party, but psychiatry pathologizes participation by the older party, then the mental health profession pronounces a moralistic standard and, if successful, becomes an agent of social control (Moser & Kleinplatz, 2005). The American Psychiatric Association (APA) is an organization representing a profession still striving for scientific respectability. The parody of science masquerading as democracy made a laughing stock of psychiatry and the APA when it held a popular vote by its membership on whether homosexuality should remain a mental disorder (Bayer, 1981). Decreeing in a few years time that 19-year-olds who prefer sex with 14-year-olds (5 years their junior) have a mental disorder, as proposed for DSM-V (Blanchard, 2009), will not enhance psychiatry’s scientific credibility. A series of biased terms or logically frail arguments are provided for including hebephilia as a mental disorder. First, the terminology stamped on younger participants in sexual interactions loads the dice in favor of criminalizing (though not pathologizing) sex with early teens.‘‘The modal age of victims of sexual offences in the United States is 14 years; therefore, the modal age of victims falls within the time frame of puberty’’ (Blanchard, 2009). What constitutes victimhood? Is a victim a person who experienced trauma consequent to a sexual interaction or a willing participant who did not experience an untoward reaction but could not consent legally? Logical slippage is demonstrated: ‘‘In anonymous surveys of social organizations of persons who acknowledge having an erotic interest in children, attraction to children of pubescent ages is more frequently reported than is attraction to those of prepubescent ages’’(Blanchard, 2009) So? This does not show that the attraction is a mental disorder. Further,‘‘In samples of sexual offenders recruited from clinics and correctional facilities, men whose offense histories or assessment results suggest erotic interests in pubescents sometimes outnumber those whose data suggest erotic interest in prepubertal children’’ (Blanchard, 2009). So? This, too, does not show that the attractions or interactions reflect mental disorder, though contact is a R. Green (&) Department of Psychological Medicine, Imperial College, London W6 8RF, UK e-mail: richard.green@ic.ac.uk

This article summarizes the discussions and recommendations of the DSM-IV Subcommittee on Gender Identity Disorders, a subcommittee of the Child Psychiatry Work Group, regarding diagnostic issues. The issues reviewed include placement in the nomenclature, the concept of a spectrum of gender dysphoria rather than discrete levels of symptomatology, criticisms of current diagnostic criteria, subtyping by sexual orientation, and proposed changes in diagnostic criteria for the current DSM-III-R diagnoses of Gender Identity Disorder of Childhood, Transsexualism, and Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type.

I am delighted to return to Cambridge University and to Caius College where, through the good offices of Joe Herbert , I was privileged to spend a sabbatical year. But this pleasure is overshadowed by a n o t h e r t h i s meeting marks the first decade of the International Academy of Sex Research. Attending this meeting is very significant for me. It was also difficult. To be here, I sacrificed lecture and study time from my first weeks as a student at the Yale Law School. Only somewhat confused in this new venture when I left two days ago, I expect to be totally bewildered when I return two days hence. But whatever the course of ms; career during the hext years, I will always reflect with pride on two professional accomplishments. These are paramount to me because they are my l egac ies they will live beyond my hour upon this s t a g e or the grander one. One accomplishment was the founding of the journal, Archives of Sexual Behavior. The other was the founding of the organization, the International Academy of Sex Research. At last year's meeting, the ninth, it became apparent to me that the Academy had come of age. It is so well established and "taken for granted" that many newer members know little of its inception. At that meeting, individual members told me they had just learned that I had "started this whole thing." I was shocked, realizing that history becomes "ancient" so quickly. This, then, is a good time for memorializing the inception of the Academy. Why and how was it started? Who were the first members? What were the earliest goals? In the beginning, there was the Society for the Scientific Study of Sex. Then there was the American Association of Sex Educators, Counselors, and TheraNsts. (I saw them and said thev were not "~ood.") These or~anizations'

Two types of single-parent households and their effects on children ages 3-11 years were compared. One type comprised 50 homosexual mothers and their 56 children, and the other was a group of 40 heterosexual mothers and their 48 children. There were 30 daughters and 26 sons of homosexual mothers and 28 daughters and 20 sons of heterosexual mothers. The sexual identity and social relationships of the children were assessed in relation to the sexual orientation of the mothers. The samples consisted of families from rural and urban areas in 10 American states. All have lived without adult males (18 years or older) in the household for a minimum of 2 years (average 4). Families with heterosexual mothers were matched to families with homosexual mothers on age and race of mother; length of mother and child separation from father; educational level and income of mother; and number, age, and sex of children. Data are reported from childrens' tests designed to provide information on general intelligence, core-morphologic sexual identity, gender-role preferences, family and peer group relationships, and adjustment to the single-parent family. No significant differences were found between the two types of households for boys and few significant differences for girls. Concerns that being raised by a homosexual mother might produce sexual identity conflict and peer group stigmatization were not supported by the research findings. Data also revealed more similarities than differences in parenting experiences, marital history, and present living situations of the two groups of mothers. The postulated compromised parental fitness of lesbian mothers, commonly asserted in child custody cases, is not supported by these data.

A longitudinal research project on atypical and typical psychosexual development in male children has been ongoing for 7 years. During this period, 60 boys, referred in consequence of extensive cross-gender behavior, and these boys' parents have been evaluated. Fifty of the families have been demographically matched with families in which the boy shows typical gender-role behavior. The rationale behind the study rests on the retrospectively recalled childhood behaviors of adult males with an atypical sexual identity. The majority of transsexuals, transvestites, and homosexually-oriented adult males recall their childhood as characterized by a preference for the clothes, toys, games, and companionship of girls and, in the case of transsexuals, the wish to be a girl (Benjamin, 1966; Stoller, 1968; Green and Money, 1969; Saghir and Robins, 1973; Green, 1974; Prince and Bentler, 1972). None of these studies was prospective, raising the question of validity of the recalled data. The research design described here utilizes a sample of males behaving in the way these atypical adults recall from their boyhoods plus a contrast sample whose behavior is like that recalled by most sexually typical adult males. Cfinical interviews of a sampling of the feminine boys and behavioral descriptions of the boys provided by their parents have been reported (Green, 1974). Until now, there has been no reporting of the demographic characteristics

Two samples of female children with diverse patterns of sex-typed behaviors are described. Fifty traditionally sex-typed and 49 nontraditionally sex-typed girls are contrasted. Their age range is 4-12 years. They are widely divergent on sex-typed preferred toys, gender of peer group, participation in sports, roles taken in playing house, and stated wish to be a boy. Their parents do not differ on age, marital status, religion, or number of children. These descriptions provide the baseline for a forthcoming series of papers describing the development of these divergent patterns of sex-typed behaviors and the association of these early patterns with later psychosexual and psychosocial attributes.

Two pairs of monozygotic twins discordant for gender identity are described. The first set are 8-year-old males, one of whom enjoys doll play, cross-dressing, and taking the role of a female in fantasy games. His brother shows no feminine behavior, enjoys sports, and is more masculine in gestures and speech. The second set are 24-year-old females, one of whom wants to undergo sex-change surgery to male status. Her cotwin is a feminine woman desirous of marrying and bearing children. Differential childhood experiences are described for the cotwins. These highlight environmental influences, which may contribute to variances in masculinity and femininity, when genetic influences are held relatively constant.

Children from the first 2 years of life show an awareness that they are either male or female. Later they usually behave in ways culturally appropriate to this awareness. Still later they exhibit a preference for sexual partners of one or the other sex. These three developmental phases, (1) core-morphologic identity, (2) gender role behavior, and (3) sexual partner orientation, constitute sexual identity, a basic personality feature. My concern is with how sexual identity develops. Many strategies exist for answering this question; some will be reviewed here.

Histocompatibility-Y (H-Y) antigen, the presumptive inducer of the mammalian testis, is present in the cells of normal males and not in the cells of normal females. Recent reports have implied that patients with transsexualism exhibit H-Y antigen phenotypes at variance with those of normal males and females and, thus, that H-Y serology might provide a tool for the diagnosis and study of the transsexual condition. We therefore evaluated blood and testicular cells from 21 male-to-female transsexuals using conventional and monoclonal H-Y antibodies. We found no evidence of abnormal H-Y phenotype. Five of the patients were interviewed postoperatively by two examiners and rated for the diagnosis of transsexualism. Three of the five were rated primary transsexual by one or both examiners, and two were rated secondary transsexual.