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Sample Letters to the DSM-V Task Force of the American Psychiatric Association
We feel it is essential that the APA open up the Sexual and Gender Identity Disorders Work Group to include professionals representing broader clinical and research perspectives. We ask trans-affirming professionals and clinicians to write the APA with specific recommendations for nomination to the work group and advisory panel. Here are some sample letters to the American Psychiatric Association DSM-V Task Force.
Our
Recommendation
page contains biographical information and curriculum vitae for suggested nominees. Letters may be addressed to names listed on the
Contact APA
page.
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Arlene Istar Lev L.C.S.W., C.A.S.A.C.
To my respected colleagues:
For the past few months I have been engaged in a virtual maelstrom of
email and phone conversations regarding the American Psychiatric
Association's Work Group that has convened to address the Sexual and
Gender Identity Disorders section in the long awaited DSM IV. It is my
understanding that the APA is committed to maintaining an "open"
process, and willing to hear feedback from the professional
communities that are impacted by the outcome of the Sexual and Gender
Identity Disorders Work Group and will be utilizing the next edition
of the DSM in our clinical work.
It is no secret to the Sexual and Gender Identity Disorders Work Group
that there is impassioned debate regarding the Gender Identity
diagnoses, and concern about the continued pathologization of
transgender, transsexual, and gender non-conforming adults and
children. We have all witnessed the enraged fury of trans-activists
over the appointment of Drs. Zucker and Blanchard to the Committee,
and the astonishing 9000 signatures on a poorly written and
ill-informed petition requesting their removal. Although clinical
decision-making should not be determined by political pressure
(however well-intentioned), the fact that so many people who are
impacted by the Sexual and Gender Identity Disorders Work Group's
decisions believe that some members of the Work Group are hostile to
their basic civil rights, should be of serious concern to the American
Psychiatric Association.
I enter these discussions trying to balance and address numerous
clinical and scholarly concerns. I am a Social Worker and Family
Therapist by training. For over twenty years, I have been teaching a
graduate level course that on psychopathology, utilizing the DSM as
our primary textbook. As an educator, I am conversant in the language
of the DSM regarding the strengths, weaknesses, and complications of
many diagnostic categories, not just GID. As a Family Therapist and
Gender Specialist, I evaluate and assess transgender and transsexual
people for medical referrals, and serve on the Standards of Care
Committee of the World Professional Association of Transgender Health,
focusing specifically on issues of assessment and medical referral -
areas impacted greatly by diagnostic classifications.
Additionally, I have spent the past thirty years of my life working
for social justice, and it is this vision that guides my clinical work
and scholarly pursuits, since - as research has shown - mental
stability is greatly impacted by environmental pressures and societal
bias. I am the author of two books that addresses transgender issues,
including Transgender Emergence, a book which won the American
Psychological Association's (Division 44) Book of the Year Award in
2006, and was noted as a Book of Special Merit by the Society for Sex
Therapy and Research (SSTAR). I outline in my book a non-pathologizing
treatment perspective that utilizes a developmental model of
transgender identity formation and examines the particular role of
social stigma in the lives of those with atypical gender expressions.
I have authored an article that specifically examines these issues
(Disordering Gender Identity: Gender Identity Disorder in the
DSM-IV-TR, that is published in The Journal of Psychology and Human
Sexuality, 17 (3/4), 2005), which will be sent to the attention of the
Dr. Zucker and will hopefully be distributed to the Work Group members.
Clinicians, scholars, and researchers from diverse fields are guided
by the diagnostic criteria in the DSM. However, the DSM is not simply
a diagnostic tool, but also influences socio-political and judicial
decision-making, as well as impacts treatment considerations and
insurance reimbursement for services. The issues the Sexual and Gender
Identity Disorders Work Group are faced with are complex, and gender
non-conforming people will be affected not only therapeutically, but
medically and legally by the final resolutions determined by the
Sexual and Gender Identity Disorders Work Group. Questions of civil
rights and social justice are woven into clinical issues in this
section of the DSM in a way that impacts no other APA Work Group.
It is essential that all of those impacted by the Sexual and Gender
Identity Disorders Work Group ultimate conclusions feel that the team
represents the diversity and complexity of issues impacting the
revision and reform of GID. However, many professionals are concerned
that Sexual and Gender Identity Disorders Work Group, as it is
currently convened, does not represent their clinical perspectives and
treatment methods. Evidence-based practice depends not only on extant
scientific research, but also the "best practices" of clinicians. In
light of these concerns, I have been working with a number of other
professionals, across diverse disciplines, that would like to see the
Sexual and Gender Identity Disorders Work Group expanded to include a
greater range of clinical and research perspectives.
It is with this goal, that I am recommending that the following
professionals be added to the Sexual and Gender Identity Disorders
Work Group. They have all agreed to serve as Members of the Work Group
or as Advisors. I am attaching small biographies of their skills and
background, copies of the Curriculum Vitae's and their contact
information.
I strongly encourage the Sexual and Gender Identity Disorders Work
Group to take seriously the criticisms that have been levied to the
APA by both trans-activists and skilled and experienced clinicians,
researchers, and scholars. Addressing the complex issues we are faced
with regarding both diagnostic criterion for the therapeutic treatment
of human beings experiencing distress related to gender issues and the
equally important struggles of a burgeoning community's efforts
towards self-determination and civil rights requires a balanced
committee that represents the many perspectives and voices emanating
at this seminal moment in history.
My recommendations are listed below.
Sincerely,
Arlene Istar Lev L.C.S.W., C.A.S.A.C.
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
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Michele Angello, Ph.D.
To Whom It May Concern:
I am a psychotherapist and gender specialist who has been working with gender-variant clients for 10 years. I am also a member of a coalition of clinical psychologists, psychiatrists, academics, and independent scholars who are concerned about the limited breadth of perspective that the committees focusing on revisions to the DSM-IV in the areas of Gender Identity Disorder and Paraphilias have.
In my clinical practice, I have witnessed a significant paradigm shift with regard to gender-variant individuals, including transsexual, transgender and cross-dressing people, which is particularly apparent when reflecting back on the experiences of these individuals at the time when the DSM-IV was published in 1994 and the DSM IV-TR in 2000. To a great degree, the clients I see do not feel as disenfranchised or socially isolated. The degree to which they feel shame and anxiety appears to have diminished substantially in comparison to what others may have been feeling when the diagnoses of Gender Identity Disorder and Transvestic Fetishism were created or elaborated upon. With this in mind, it stands to reason that the constructs reinforced by these diagnoses as they are currently written are not scientific or provable outside of a damaging and repressive social context. These social changes suggest that a different consciousness must be brought to bear on the analyses of these diagnostic criteria in order to avoid bias and prejudice.
I respect the fact that the professionals currently appointed to the committees have significant experience and specific expertise, but I strongly believe that these topics deserve a broader base of more diverse experience that is represented on the committees. My practice primarily consists of transsexual individuals for whom medical treatment is beneficial, yet most of these individuals do not have any pathological impairment. I would like to make certain that committee members are aware that this is the experience of many people and that this experience will be taken into account as the diagnoses are reviewed and potentially revised. I would also like to trust that your committee members are consciously aware of the social and legal ramifications of any criteria they are considering. And finally, I would like to offer the following individuals as additional committee members and/or advisors to your current committees in the spirit of broadening the base of experience upon which to draw as the DSM-V takes shape:
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
I hope you will contact any of these individuals and invite them to serve as advisors to your committees. Also, please feel free to contact me directly for further information. Thank you for your consideration and for the effort you are investing in organizing the revision.
Warm Regards,
Michele Angello, Ph.D.
Wayne, PA
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Reid Vanderburgh, M.A., L.M.F.T.
To Whom It May Concern:
In the seven years I have been in practice, my clientele has consisted almost exclusively of transgender people and/or their partners, spouses and family members. I have worked with about 350 transgender clients, and have only met a handful who meet most of the diagnostic criteria for Gender Identity Disorder listed in the current edition of the DSM, leading me to conclude through clinical experience that the diagnosis is not useful to me as it stands today.
In countries with healthcare systems covering transition processes, however, some version of GID may be a more useful diagnostic mechanism for those seeking physical transition. Further, insurance companies in the United States may eventually follow suit, necessitating some form of diagnostic criteria for those who seek hormone therapy and/or surgery. My concern is that the current criteria do not reflect the reality of most of my clients' lived experience of their original gender identity assignment.
In my experience, those of my clients who are well-versed in the medical model and come in self-diagnosing Gender Identity Disorder are more depressed, and experience more stress around self-acceptance and a possible transition, than do those who view their process as reflective of innate gender identity. Many of the DSM "symptoms" of GID reflect other people's negative reactions to those who are not entirely comfortable with the gender assigned them at birth, reflecting a social context reminiscent of the inclusion of homosexuality in the DSM until its 1973 removal.
There is no rigorous science behind the inclusion of GID in the DSM, as there was not for the inclusion of homosexuality. There is also no rigorous science behind the movement to remove GID from the DSM. There is, however, the clinical experience of those who work with significant numbers of transgender people and witness their blossoming after facing their true selves, whether that means physical transition or not. In my professional opinion, the voices of these clinicians need more representation on the DSM-V Task Force committee responsible for reviewing the various GID diagnostic categories, to help ensure that the discussion is holistic in nature, taking into account the life experience of transgender clients. To this end, it would be helpful for the committee to consult with a variety of clinicians with extensive experience working with transgender clients. I would recommend the following clinicians for inclusion on the committee, either in the capacity of full committee members or as advisors to the committee:
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
Reid Vanderburgh, MA, LMFT
Portland Oregon
www.transtherapist.com
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Virginia Erhardt, Ph.D.
To Whom It May Concern:
I am a licensed Clinical Psychologist and a writer on issues related to gender identity, particularly in the sphere of the impact of gender variance upon relationships. I have been a gender specialist in the Atlanta area for 12 years and have worked with nearly 300 individuals of gender-dissonant/gender nonconforming experience and their loved ones.
I believe that more often than not gender-variant people are unfairly pathologized, stigmatized, and marginalized by society in general and by many mental health professionals. The hundreds of letters I have written during the past ten years, referring clients for hormones and surgeries; supporting name changes and transitions on the job, have used descriptive language about life experience and feelings rather than diagnoses of Gender Identity Disorder. I do not believe that gender dissonance should be seen as a mental illness.
If Gender Identity Disorder is to stay in the American Psychiatric Association's upcoming 5th edition of the Diagnostic and Statistical Manual, I do have some suggestions for change. I advocate reform of the title, diagnostic criteria, and supporting text. I believe that as long as it is to be included in the manual, the diagnosis of Gender Identity Disorder should be placed outside of the section that includes sexual dysfunctions and paraphilias since it involves very different phenomena. While I don't expect removal in this revision, I hope that some day, rather than a psychiatric diagnosis, a more relevant, physiological, medical diagnosis will be available for people with gender dissonance.
I strongly suggest that the Transvestic Fetishism diagnosis be removed from the DSM. The Fetishism diagnosis itself is sufficient. I do think, however, that the Fetishism diagnosis should be modified. I believe that Criterion C should be deleted from Fetishism, the descriptive material should be rewritten to exclude mention of Transvestic Fetishism and it should be made perfectly clear that Criteria A and B must both be present in order for someone to qualify for a Fetishism diagnosis. It would make sense to me to include several items that have nothing to do with women's clothing as examples of nonliving objects at the end of Criterion A (for instance, shoes, not necessarily women's shoes, pies in the face, diapers). The focus upon women's clothing seems odd and unbalanced to me, given that there are many other nonliving fetish objects. I believe that it is natural for a person who enjoys cross-dressing or wants to transition to enjoy, at times, erotic thoughts that include their own feminized or masculinized selves. That, in my opinion, should not be pathologized. It should be made clear that for many individuals who engage in it, cross-dressing is not a fetish.
Due to my interest in the upcoming revisions, I am a member of a coalition of clinical psychologists, psychiatrists, academics, and independent scholars who are concerned about the limited perspectives represented by the composition of the Committees focusing on revisions to the DSM-IV in the areas of Gender Identity Disorder and Paraphilias that are relevant to gender-variant behavior.
I am aware that since the DSM-IV was published in 1994 and DSM-IV-TR in 2000, significant social change has occurred with respect to gender-variant individuals, including transsexual, transgender, and cross-dressing people. To a great degree, the people I see in my practice are no longer socially isolated or ostracized; shame and anxiety tend to be less significantly issues than they were when the diagnoses of Gender Identity Disorder and Transvestic Fetishism were created or elaborated upon. Therefore, I believe that the constructs reinforced by these diagnoses as they are currently written are not scientific or provable outside of a damaging and repressive social context. With the social changes we have seen, and self-reports of my clients, my clinical experience suggests that significantly different consciousness must be brought to bear on the analyses of these diagnostic criteria in order to avoid bias and prejudice.
I appreciate the significant experience and specific expertise that the extensively published professionals currently appointed to the committees have, yet I strongly believe that the topics about which I am concerned deserve a broader base of more diverse experience than is currently represented on the committees. For example, I see clients for whom I know that transsexual medical treatment will be extremely beneficial, yet these individuals do not have any pathological impairment. I would like to know that this type of human experience will be taken into account as the diagnoses are reviewed and potentially revised. I would like to know that the committee has members who are consciously aware of the social and legal ramifications of any criteria they are considering. To this end, I would like to offer the following suggestions for additional committee members and/or advisors to your committees in the spirit of broadening the base of experience upon which to draw as DSM-V takes shape:
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
I hope that you will contact any of these individuals and invite them to serve on or as advisors to, your committees. Also, please feel free to contact me for further information. Thank you for your consideration and for the effort you are investing in organizing the revision.
Very Best Regards,
Dr. Virginia Erhardt
Decatur, Georgia
www.virginiaerhardt.com
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lore m. dickey, M.A.
David J. Kupfer, M.D., Chair, DSM-V Task Force
Darrel A. Regier, M.D.,Vice Chair, DSM-V Task Force
c/o William E. Narrow, M.D., Research Director, DSM-V Task Force
American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
Drs. Kupfer, Regier, and Narrow:
I am writing to express my concern about express my concern about the current make-up of the Work Group and Advisory Committee for the Sexual and Gender Identity Disorders in the DSM-V. It is my understanding that the process for the development of the DSM-V is supposed to be more transparent than it has been in the past, and yet I and others have had difficulty getting information about who is involved in the development process and how new diagnostic criteria will be established. I am also concerned because, while I do not know any of the people on the Work Group personally, I am aware of some of them professionally and I have grave concerns about the state of diagnosis especially as it relates to Gender Identity and Paraphilias.
I should probably state at the outset of this letter that I am myself a female-to-male transsexual who identifies as a kink-positive gay man. Prior to transition I identified as a lesbian, and thus I have a long history in the LGBT community. Additionally, I am a fourth-year PhD student in a Counseling Psychology program. The strengths-based approach that Counseling Psychology takes toward diagnosis and treatment certainly informs my work and opinions.
I have a number of concerns about the diagnoses related to gender identity. My main concern is that the committee of experts that has been assembled tends to represent a fairly narrow and conservative view of transgender care. I am not willing to subject future clients to continued pathologization because their gender expression does not fit a narrow set of expectations.
Gender identity is a very personal issue and clients should not be subjected to many of the practices that are currently considered the standard of care. I know that the DSM is about diagnosis and not treatment. But I don’t think transgender identities should be considered to be a mental health disorder.
I am asking that you consider the named individuals on the following page for inclusion on the Work and/or Advisory Groups. Please make an effort to broaden the perspective of the committee by including people who believe that harm reduction and informed consent are viable (and healthy) manners for working with transgender clients.
Sincerely,
lore m. dickey, MA
cc: Dr. Kenneth Zucker
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
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Sample Letter From Multiple Professionals
by Jamison Green, M.F.A.
To Whom It May Concern:
We are a coalition of clinical psychologists, psychiatrists, academics, and independent scholars who are concerned about the composition of the Committees focusing on revisions to the DSM-IV in the areas of Gender Identity Disorder and Paraphilias that are concerned with gender-variant behavior.
We would like to point out that since the DSM-IV was published in 1994 and DSM-IV-TR in 2000, significant social change has occurred with respect to gender-variant individuals, including transsexual, transgender, and cross-dressing people. No longer are these people (in large part) socially isolated or ostracized; no longer are they as filled with shame or anxiety as they were when the diagnoses of Gender Identity Disorder and Transvestic Fetishism were created or elaborated upon. We believe that the constructs reinforced by these diagnoses as they are currently written are not scientific or provable outside of a damaging and repressive social context. With the social changes we have seen, our clinical experience tells us that significantly different consciousness must be brought to bear on the analysis of these diagnostic criteria to weed out bias and prejudice.
We have no doubt that the professionals currently appointed to the committees have significant experience and specific expertise, but we strongly feel that these topics deserve a broader base of diverse experience than is currently represented on the committees. For example, many of us see clients for whom we know that transsexual medical treatment will be most beneficial, yet these individuals do not have any pathological impairment, and we would like to know that this experience will be taken into account as the diagnoses are reviewed and potentially revised. We would like to know that your committee members are consciously aware of the social and legal ramifications of any criteria they are considering. To this end, we would like to offer the following suggestions for advisors to your committees in the spirit of broadening the base of experience upon which to draw as DSM-V takes shape:
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
We hope that you will contact any of these individuals and invite them to serve as advisors to your committees. Also, please feel free to contact any of us who have signed below for further information. Thank you for your consideration.
Very Best Regards,
names of concerned professionals
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Sample Letter on Childhood Diagnostic Issues
by Francoise Susset, M.A.
To the current members of the Sexual and Gender Identity Disorders Work Group:
I am writing as a psychologist and member of a coalition of clinical psychologists, psychiatrists, academics, and independent scholars who are concerned about the composition of the Sexual and Gender Identity Disorders Work Group focusing on revisions to the DSM-IV as it pertains to gender-variant behavior.
For the past 10 years, the focus of my clinical work has been gender-variant pre-pubescent children and their families and am currently conducting research on the experience of these families. I am a member of the international association WPATH and of its Canadian counterpart, CPATH.
I have numerous concerns in regards to the many diagnoses you will be reviewing. However, based on my experience and the experience of many clinicians who work with these populations, one diagnosis, Gender Identity Disorder in children poses unique challenges. Without denying the contribution of certain members of your committee to the understanding of the phenomenon of childhood gender variance, it is important to recognize that the existing criteria, as amended from the DSM III-R, have been criticized by clinicians and researchers alike for their lack of rigor. These changes have lead to a significantly increased risk of pathologizing children’s behaviors simply because they fall outside a narrowly defined normative spectrum. As a result of these revisions, not only is there a greater chance of diagnosing non-pathological behavior, but also of drawing questionable conclusions from research findings based on broad and poorly defined populations.
Certain facts seem almost universally accepted in the field of childhood GID:
- Most gender non-conforming children, without any clinical intervention, will, by the age
of 8 or 9, conform to the expected gender presentation.
- The great majority of these children will discover at puberty that they are homosexual
and not transsexual.
- Most of these children do not suffer from their gender expression but rather from the
effects of violence, stigmatization and lack of appropriate response from adults
responsible for their protection.
According to the criteria set forth within the DSM as to what constitutes a mental disorder,
it seems reasonable to seriously question the continued pathologization of childhood
gender non conformity. For an excellent in-depth summary of the issues surrounding this
diagnosis, I recommend the following article: Bartlett, N. H. Vasey, P. L., et Bukowski, W.
M. (2000). Is gender identity disorder in children a mental disorder? Sex Roles, 43, 753-
785.
I strongly urge the Sexual and Gender Identity Disorders Work Group to broaden its
perspective and include other prominent voices in the revision of the diagnosis of GID and
in particular, childhood GID. As a coalition we recommend the following specialists:
Edgardo Menvielle, M.D.
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
Michele Angello, Ph.D.
987 Old Eagle School Road, Ste. 719
Wayne, PA 19087
Dan Karasic, M.D.
Clinical Professor of Psychiatry
1001 Potrero Ave., Suite 7M
San Francisco, CA 94110
Herbert Schreier, M.D.
Department of Psychiatry
Children's Hospital Research Center
Oakland California 94609
Diane Ehrensaft, Ph.D.
445 Bellevue Avenue Suite 302
Oakland, California 94610
Gail Knudson M.D., M.P.E., F.R.C.P.C.
Clinical Assistant Professor of Psychiatry
University of British Columbia
Department of Sexual Medicine
Respectfully yours,
Francoise Susset, M.A.
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