Complex post-traumatic stress disorder

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https://en.wikipedia.org/wiki/Complex_post-traumatic_stress_disorder 

 

Complex post-traumatic stress disorder
Specialty	Psychology

Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological and narcissistic (child) abuse and physical abuse and neglect, chronic intimate partner violence, victims of prolonged workplace or school bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, and defectors of cults or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.
C-PTSD has also been referred to as DESNOS or Disorders of Extreme Stress Not Otherwise Specified.

Some researchers believe that C-PTSD is distinct from, but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder. Its main distinctions are a distortion of the person's core identity and significant emotional dysregulation. It was first described in 1992 by an American psychiatrist and scholar, Judith Herman in her book Trauma & Recovery and in an accompanying article. The disorder is included in the World Health Organization's (WHO) eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). The C-PTSD criteria has not yet gone through the private approval board of the American Psychiatric Association (APA) for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Complex PTSD is also recognized by the United States Department of Veterans Affairs (VA), Healthdirect Australia (HDA), and the National Health Service (NHS).

Symptoms

Children and adolescents

The diagnosis of PTSD was originally developed for adults who had suffered from a single-event trauma, such as rape, or a traumatic experience during a war. However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, and a disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who caused the [please edit unfinished sentence]. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.

The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Dr. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as betrayal, defeat or shame.

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioural characteristics in seven domains:

• Attachment – "problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states"
• Biology – "sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems"
• Affect or emotional regulation – "poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes"
• Dissociation – "amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events"
• Behavioural control – "problems with impulse control, aggression, pathological self-soothing, and sleep problems"
• Cognition – "difficulty regulating attention; problems with a variety of 'executive functions' such as planning, judgement, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with 'cause-effect' thinking; and language developmental problems such as a gap between receptive and expressive communication abilities."
• Self-concept – "fragmented and disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self".

Adults

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or older siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.  This can become a pervasive way of relating to others in adult life, described as insecure attachment. This symptom is neither included in the diagnosis of dissociative disorder nor in that of PTSD in the current DSM-5 (2013). Individuals with Complex PTSD also demonstrate lasting personality disturbances with a significant risk of revictimization.

Six clusters of symptoms have been suggested for diagnosis of C-PTSD:

• alterations in regulation of affect and impulses;
• alterations in attention or consciousness;
• alterations in self-perception;
• alterations in relations with others;
• somatization;
• alterations in systems of meaning.

Experiences in these areas may include:

• Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
• Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
• Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
• Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
• Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
• Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.

Diagnostics

C-PTSD was under consideration for inclusion in the DSM-IV but was not included when the DSM-IV was published in 1994. Neither was it included in the DSM-5. Post traumatic stress disorder continues to be listed as a disorder.

Differential diagnosis

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) was included in the DSM-III (1980), mainly due to the relatively large numbers of American combat veterans of the Vietnam War who were seeking treatment for the lingering effects of combat stress. In the 1980s, various researchers and clinicians suggested that PTSD might also accurately describe the sequelae of such traumas as child sexual abuse and domestic abuse. However, it was soon suggested that PTSD failed to account for the cluster of symptoms that were often observed in cases of prolonged abuse, particularly that which was perpetrated against children by caregivers during multiple childhood and adolescent developmental stages. Such patients were often extremely difficult to treat with established methods.

PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD.

C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. DSM-IV (1994) dissociative disorders and PTSD do not include insecure attachment in their criteria. As a consequence of this aspect of C-PTSD, when some adults with C-PTSD become parents and confront their own children's attachment needs, they may have particular difficulty in responding sensitively especially to their infants' and young children's routine distress—such as during routine separations, despite these parents' best intentions and efforts. Although the great majority of survivors do not abuse others, this difficulty in parenting may have adverse repercussions for their children's social and emotional development if parents with this condition and their children do not receive appropriate treatment.

Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested. C-PTSD better describes the pervasive negative impact of chronic repetitive trauma than does PTSD alone. PTSD can exist alongside C-PTSD, however a sole diagnosis of PTSD often does not sufficiently encapsulate the breadth of symptoms experienced by those who have experienced prolonged traumatic experience, and therefore C-PTSD extends beyond the PTSD parameters.

C-PTSD also differs from continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.

Traumatic grief

Traumatic grief or complicated mourning are conditions where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.

For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.

Similarities to and differentiation from borderline personality disorder

C-PTSD may share some symptoms with both PTSD and borderline personality disorder. However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:

Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.

However, C-PTSD and BPD have been found by researchers to be completely distinctive disorders with different features. Notably, C-PTSD is not a personality disorder. Those with C-PTSD do not fear abandonment or have unstable patterns of relations; rather, they withdraw. They do not struggle with lack of empathy. There are distinct and notably large differences between Borderline and C-PTSD and while there are some similarities – predominantly in terms of issues with attachment (though this plays out in completely different ways) and trouble regulating strong emotional effect (often feel pain vividly), the disorders are completely different in nature – especially considering that C-PTSD is always a response to trauma rather than a personality disorder.

While the individuals in the BPD reported many of the symptoms of PTSD and CPTSD, the BPD class was clearly distinct in its endorsement of symptoms unique to BPD. The RR ratios presented in Table 5 revealed that the following symptoms were highly indicative of placement in the BPD rather than the CPTSD class: (1) frantic efforts to avoid real or imagined abandonment, (2) unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) markedly and persistently unstable self-image or sense of self, and (4) impulsiveness. Given the gravity of suicidal and self-injurious behaviors, it is important to note that there were also marked differences in the presence of suicidal and self-injurious behaviors with approximately 50% of individuals in the BPD class reporting this symptom but much fewer and an equivalent number doing so in the CPSD and PTSD classes (14.3 and 16.7%, respectively). The only BPD symptom that individuals in the BPD class did not differ from the CPTSD class was chronic feelings of emptiness, suggesting that in this sample, this symptom is not specific to either BPD or CPTSD and does not discriminate between them.
Overall, the findings indicate that there are several ways in which Complex PTSD and BPD differ, consistent with the proposed diagnostic formulation of CPTSD. BPD is characterized by fears of abandonment, unstable sense of self, unstable relationships with others, and impulsive and self-harming behaviors. In contrast, in CPTSD as in PTSD, there was little endorsement of items related to instability in self-representation or relationships. Self-concept is likely to be consistently negative and relational difficulties concern mostly avoidance of relationships and sense of alienation.

In addition 25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was so diagnosed compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, Borderline Personality Disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each. BPD may be confused with C-PTSD by some without proper knowledge of the two conditions because those with BPD also tend to suffer from PTSD or to have some history of trauma.

In Trauma and Recovery, Herman expresses the additional concern that patients who suffer from C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. However, those who develop C-PTSD do so as a result of the intensity of the traumatic bond – in which someone becomes tightly biolo-chemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, imbedded in their personality over the years of trauma – a normal reaction to an abnormal situation.

Treatment

While standard evidence-based treatments may be effective for treating post traumatic stress disorder, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. According to the United States Department of Veteran Affairs:

The current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.

The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Dr. Julian Ford and Dr. Bessel van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). According to Courtois & Ford, for DTD to be diagnosed it requires a

history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses of other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.

Since C-PTSD or DTD in children is often caused by chronic maltreatment, neglect or abuse in a care-giving relationship the first element of the biopsychosocial system to address is that relationship. This invariably involves some sort of child protection agency. This both widens the range of support that can be given to the child but also the complexity of the situation, since the agency's statutory legal obligations may then need to be enforced.

A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:

• Identifying and addressing threats to the child's or family's safety and stability are the first priority.
• A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
• Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
• All phases of treatment should aim to enhance self-regulation competencies.
• Determining with whom, when and how to address traumatic memories.
• Preventing and managing relational discontinuities and psychosocial crises.

Adults

Trauma Recovery Model - Judith Herman

Dr. Judith Lewis Herman, in her book, Trauma and Recovery, proposed that a complex trauma recovery model that occurs in three stages:

1. establishing safety,
2. remembrance and mourning for what was lost,
3. reconnecting with community and more broadly, society.

Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship.

Complex trauma means complex reactions and this leads to complex treatments. [need reference] Hence, treatment for C-PTSD requires a multi-modal approach.

It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six suggested core components of complex trauma treatment include:

1. Safety
2. Self-regulation
3. Self-reflective information processing
4. Traumatic experiences integration
5. Relational engagement
6. Positive affect enhancement

The above components can be conceptualized as a model with three phases. Every case will not be the same, but one can expect the first phase to consist of teaching adequate coping strategies and addressing safety concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.

Neuroscientific and Trauma Informed Interventions

In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. Dr. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse.

Use of Evidence Based Treatment and Its Limitations

One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence based practice as a criteria for reimbursement. Cognitive behavioral therapy, prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence based intervention. These treatments are approved and endorsed by the American Psychiatric Association, the American Psychological Association and the Veteran's Administration.

While standard evidence-based treatments may be effective for treating standard post traumatic stress disorder, treating Complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat. The United States Department of Veterans Affairs acknowledges,

the current PTSD diagnosis often does not fully capture the severe psychological harm that occurs with prolonged, repeated trauma. People who experience chronic trauma often report additional symptoms alongside formal PTSD symptoms, such as changes in their self-concept and the way they adapt to stressful events.

For example, "limited evidence suggests that predominantly cognitive behavioral therapy (an evidenced based treatment)[is]effective, [it does not] suffice to achieve satisfactory end states, especially in Complex PTSD populations". 

Treatment Challenges

It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories. 

Survivors with complex trauma often struggle to find a mental health professional who is properly trained in trauma informed practices. They can also be challenging to receive adequate treatment and services to treat a mental health condition which is not universally recognized or well understood by general practitioners. 

Dr. Allistair and Dr. Hull echo the sentiment of many other trauma neuroscience researchers (including Dr. Bessel van der Kolk and Dr. Bruce D. Perry) who argue:

Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing."

Complex post trauma stress disorder is a long term mental health condition which is often difficult and relatively expensive to treat and often requires several years of psychotherapy, modes of intervention and treatment by highly skilled, mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.

Recommended Treatment Modalities and Interventions

There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy) there are many therapeutic interventions used by mental health professionals to treat post traumatic stress disorder. As of February 2017, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:

1. cognitive behavioral therapy (CBT) and trauma focused CBT
2. cognitive processing therapy (CPT)
3. cognitive therapy (CT)
4. prolonged exposure therapy (PE)

The American Psychological Association also conditionally recommends

1. brief eclectic psychotherapy (BEP)
2. eye movement desensitization and reprocessing (EMDR) 
3. narrative exposure therapy (NET)

While these treatments have been recommended, there is still on-going debate regarding the best and most efficacious treatment for complex PTSD. Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidenced based. Some of these additional interventions and modalities include:

1. biofeedback
2. dyadic resourcing (used with EMDR)
3. emotionally focused therapy
4. emotional freedom technique (EFT) or tapping 
5. Equine-assisted therapy
6. expressive arts therapy
7. internal family systems therapy
8. dialectical behavior therapy(DBT)
9. family systems therapy
10. group therapy
11. neurofeedback
12. psychodynamic therapy
13. sensorimotor psychotherapy
14. somatic experiencing
15. yoga, specifically trauma-sensitive yoga

Arguments Against Complex PTSD Diagnosis

Though acceptance of the idea of complex PTSD has increased with mental health professionals, the fundamental research required for the proper validation of a new disorder is currently insufficient.  The disorder was proposed under the name DES-NOS for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder. Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research. 

One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. Conversely, an article published in BioMed Central has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.

Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It is also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences. In the diagnosis of PTSD, the definition of the stressor event is narrowly limited to life-threatening events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. By broadening the stressor criterion, an article published by the Child and Youth Care Forum claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM. 

One of the primary arguments for a new disorder has been the claim that individuals who experience complex post traumatic stress symptomatology are often misdiagnosed, and as a consequence may be given inappropriate or inadequate treatment interventions.

The movement to recognize complex PTSD has been criticized for approaching the process of diagnostic validation backwards. The typical process for validation of new disorders is to first publish case studies of individual patients who manifest all of these issues and clearly demonstrate how they are different from patients who experienced different types of traumas. There are no known case reports with prospective repeated assessments to clearly demonstrate that the alleged symptoms followed the adverse events. Then the next step would be to conduct well-designed group studies.^{[citation needed]} Instead, supporters of complex PTSD have pushed for recognition of a disorder before conducting any of the prospective repeated assessments that are needed.

Intersex people and military service in the United States

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Intersex_people_and_military_service_in_the_United_States

The regulations regarding the service of intersex people in the United States Armed Forces are vague and inconsistent due to the broad nature of humans with intersex conditions. The United States Armed Forces as a whole does not officially ban intersex people from service but does exclude many based on the form of their status. Policies regarding all intersex people are not addressed formally although depending on the type of sex variation some intersex people are allowed to serve.

History

When the skeleton of Casimir Pulaski, a famed American Revolutionary War general, was exhumed and studied, several female features were found which led to speculation that Pulaski was likely intersex.

Between 1905 and 1945, the term "hermaphroditism" was used as a general term to refer to several urological conditions which made someone unable to enrol as a cadet at West Point Military Academy. Barring of people with actual "hermaphroditic" diagnosable medical conditions dates back at least as far back as 1951. In 1988 most forms of so called "true hermaphroditism" and "pseudohermaphroditism" excluded a person from serving in the military.

Policies and treatment

People born with non-standard genital anatomy or ambiguous genitalia are largely excluded from military service. This practice is believed to have been first introduced in 1961, alongside a ban on transvestites. According to a 2007 report from the Michael D. Palm Center, there is a long list of disqualifying genital differences that are used to bar individuals from service. For example, having one undescended testicle can make a man ineligible for service.

Enclosure 4 of "Induction in the Military Services; dated April 10, 2010" instruction, entitled "Medical Standards For Appointment, Enlistment, Or Induction", is the one that identifies the preclusion of some intersex people from serving in the military.

• Paragraph 14. (Female Genitalia), subparagraph e.:

History of major abnormalities or defects of the genitalia such as change of sex (P64.5) (CPT 55970, 55980), hermaphroditism, pseudohermaphroditism, or pure gonadal digenesis (752.7).

• Paragraph 15. (Male Genitalia), subparagraph l.:

History of major abnormalities or defects of the genitalia such as change of sex (P64.5) (CPT 55970, 55980), hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis (752.7).

According to The Crimson, the military's policy on genital differences is explicitly discriminatory. Despite the steady increase of other previously excluded members into the military since the repeal of "Don't ask, don't tell", there has not been much change with respect to the status of intersex people. Military medical policies still prevent intersex people from serving uncloseted. However, the military does provide some surgeries for intersex people which they deem 'medically necessary' as opposed to 'cosmetic'. The Veterans Health Administration does distinguish between surgeries for transgender individuals and intersex persons. In 2015, this allowed intersex persons to receive medically necessary treatment that was still prohibited for transgender people. This was because of the belief that intersex surgery caused "fewer practical concerns". However, a history of genital surgery prior to service is considered an acceptable reason to discharge a service member. The acceptance of transgender individuals in 2016 by the Armed Forces did not touch on intersex people and they are still subject to specific reviews before enlistment, as noted before.

The updated version of DoDI 6130.03's genital guidelines are as follows:

• Female Genitalia:

History of major abnormalities or defects of the genitalia, such as hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis.

• Male Genitalia:

History of major abnormalities or defects of the genitalia such as hermaphroditism, pseudohermaphroditism, or pure gonadal dysgenesis.

The subsequent attempt at banning transgender troops by President Donald Trump in 2017 also did not touch on the state of intersex personnel, and it was unclear if the ban would have any intentional or unintentional effects on them.

Intersex activist and Navy veteran Dana Zzyym has expressed that their family's military background made it out of the question for them to be associated with the queer community as a youth due to the prevalence of homophobia in the armed forces. Their parents hid Zzyym's status as intersex from them and Zzyym discovered their identity and the surgeries their parents had approved for them by themselves after their Navy service. Zzyym is the first veteran to be issued a gender-neutral passport.

Opinions

In 2010, Republican representative Duncan D. Hunter implied that intersex people were always banned from service. However, this claim was contradicted by a veteran who stated that they were allowed to serve openly and be deployed to Desert Storm as an intersex woman. Activist Autumn Sandeen also refuted Hunter's claims in a statement on her blog. In contrast, another response to Hunter was from Choire Sicha of The Awl who stated that "intersex people aren’t welcome to serve, but no one’s quite sure how and why", but did not elaborate on if they believed this referred to all conditions or just visible ones. Along with trans and non-heterosexual people, Hunter includes intersex people on his list of queer groups which he believes to be unfit for service because he holds the belief that they would disrupt unit cohesion. At the time when speaking about the subject he referred to intersex people by the term "hermaphrodites", which drew criticism from several intersex advocates and allies since it is a medically inaccurate term for a human being and is seen as a slur in the 20th century. His comments were also mocked on the NPR comedy news show Wait Wait... Don't Tell Me! which joked about his opinion on the subject, claiming that including intersex people would be advantageous to the military, since they could "pursue enemies into both men’s and women’s restrooms". This joke was poorly received by some, including writers of ShadowProof, who stated that it was both insulting to intersex people and a play on the negative stereotype of trans people as potential bathroom sexual predators, and Queerty. Hunter's comments were also ridiculed by the cast of the FOX News show Red Eye who felt that his comments were merely about his dislike of homosexuals and not really about how intersex people would affect the military. They stated that since there are so few intersex people the question was not very relevant to the subject of "Don't ask, don't tell" which they felt was what Hunter was trying to imply. The cast of The Tony Kornheiser Show dismissed Hunter's concerns as well, expressing too that the number of intersex people that exist who want to join the military could not be enough to disrupt any operations.

In 2007, the Palm Center released a report concluding that most of the military's beliefs about intersex people were myths and that neither intersex nor transgender peoples' medical problems posed any barrier to effective service. The study also argues that the rigidity of sexual difference, gender roles, and sexuality are "becoming increasingly less absolute," which could raise questions regarding the admission, retention, training, housing, and other services of intersex individuals in the armed forces. Publications by the United States National Center for Biotechnology Information recommends that intersex individuals be allowed to serve in the armed forces, but not combat units.

Veterans

Intersex veterans are entitled to "medically necessary" surgeries. When transgender people were banned from receiving sex reassignment surgery, intersex people were also banned from these surgeries. This meant that someone who was in the military presenting as male in their records could not transition to a female identity with help from the United States Department of Veterans Affairs, even if they were always predominantly female in all but writing.

By service

United States Air Force

Many U.S. Air Force recruiters think that intersex people should be disqualified from service due to "the expected increased demand for medical treatments" but intersex persons are still allowed to serve in the Civil Air Patrol.

United States Army

In the U.S. Army, the official policy is that individuals who identify as intersex or have other sex-related disorders are medically problematic and/or psychologically disturbed; hence, they are not eligible to serve.

United States Coast Guard

Intersex people are allowed to serve in the Coast Guard Auxiliary. However, they must choose to be represented as either "male" or "female" on their records.

United States Marine Corps

The USMC takes the same stance as the Army, disqualifying both intersex people and transgender people from service.

United States Navy

In 2008, many U.S. Navy recruiters believed that intersex people should be disqualified from service, mainly due to the expectation that they would cause increased demand for medical treatment.

ROTC

The Reserve Officers' Training Corps is obliged to follow the guidelines set by the military and has rejected intersex youth because of this. This, along with their exclusion of transgender people, has led to criticism from and of schools such as Harvard which did not allow the ROTC until "Don't ask, don't tell" was repealed in 2010, but welcomed them afterwards. The critics argue that the return of the ROTC to campus violates the school's non-discrimination clause.

Intersex in history

From Wikipedia, the free encyclopedia

 

Intersex, in humans and other animals, describes variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies". Intersex people were historically termed hermaphrodites, "congenital eunuchs", or even congenitally "frigid". Such terms have fallen out of favor, now considered to be misleading and stigmatizing.

Intersex people have been treated in different ways by different cultures. Whether or not they were socially tolerated or accepted by any particular culture, the existence of intersex people was known to many ancient and pre-modern cultures and legal systems, and numerous historical accounts exist.

Ancient history

Sumer

A Sumerian creation myth from more than 4,000 years ago has Ninmah, a mother goddess, fashioning humanity out of clay. She boasts that she will determine the fate – good or bad – for all she fashions:

Enki answered Ninmah: "I will counterbalance whatever fate – good or bad – you happen to decide.
Ninmah took clay from the top of the abzu [ab: water; zu: far] in her hand and she fashioned from it first a man who could not bend his outstretched weak hands. Enki looked at the man who cannot bend his outstretched weak hands, and decreed his fate: he appointed him as a servant of the king. (Three men and one woman with atypical biology are formed and Enki gives each of them various forms of status to ensure respect for their uniqueness)
...Sixth, she fashioned one with neither penis nor vagina on its body. Enki looked at the one with neither penis nor vagina on its body and gave it the name Nibru (eunuch(?)), and decreed as its fate to stand before the king.

Ancient Judaism

In traditional Jewish culture, intersex individuals were either androgynos or tumtum and took on different gender roles, sometimes conforming to men's, sometimes to women's.

Ancient Islam

By the eighth century CE, records of Islamic legal rulings discuss individuals known in Arabic as khuntha. This term, which has been translated as "hermaphrodite," was used to apply to individuals with a range of intersex conditions, including mixed gonadal disgenesis, male hypospadias, partial androgen insensitivity syndrome, 5-alpha reductase deficiency, gonadal aplasia, and congenital adrenal hyperplasia.

In Islamic law, inheritance was determined based on sex, so it was sometimes necessary to attempt to determine the biological sex of sexually ambiguous heirs. The first recorded case of this sort has been attributed to the seventh-century Rashidun caliph named 'Ali, who attempted to settle an inheritance case between five brothers in which one brother had both a male and female urinary opening. 'Ali advised the brothers that sex could be determined by site of urination in a practice called hukm al-mabal; if urine exited the male opening, the individual was male, and if it exited the female opening, the individual was female. If it exited both openings simultaneously, as it did in this case, the heir would be given half of a male inheritance and half of a female inheritance. Later, in the thirteenth century CE, Shafi'i law expert Abu Zakariya al-Nawawi ruled that an individual whose sex could not be determined by hukm al-mabal, such as those with urination from both openings or those with no identifiable sex organs, was assigned the intermediary sex category khuntha mushkil.

Both Hanafi and Hanbali lawmakers also recognized that puberty could clarify a new dominant sex in intersex individuals who were labeled khuntha, male, or female in childhood. If a khuntha or male developed female secondary sex characteristics, performed vaginal sex, lactacted, menstruated, or conceived, this person's legal sex could change to female. Conversely, if a khuntha or female developed male secondary sex characteristics, performed penetrative sex with a woman, or had an erection, their legal sex could change to male. This understanding of the effect of puberty on intersex conditions appears in Islamic law as early as the eleventh century CE, notably by Ibn Qudama.

In the sixteenth century CE, Ibrahim al-Halabi, a member of the Hanafi school of jurisprudence in Islam, directed slave owners to use special gender-neutral language when freeing intersex slaves. He recognized that language manumitting "males" or "females" would not directly apply to them.

Ancient South Asia

The Tirumantiram Tirumular recorded the relationship between intersex people and Shiva.

Ardhanarishvara, an androgynous composite form of male deity Shiva and female deity Parvati, originated in Kushan culture as far back as the first century CE. A statue depicting Ardhanarishvara is included in India's Meenkashi Temple; this statue clearly shows both male and female bodily elements.

Due to the presence of intersex traits, Ardhanarishvara is associated with the hijra, a third sex category that has been accepted in South Asia for centuries. After interviewing and studying the hijra for many years, Serena Nanda writes in her book Neither Man Nor Woman: The Hijras of India as follows: "There is a widespread belief in India that hijras are born hermaphrodites [intersex] and are taken away by the hijra community at birth or in childhood, but I found no evidence to support this belief among the hijras I met, all of whom joined the community voluntarily, often in their teens."

According to Gilbert Herdt, the hijra differentiate between "born" and "made" individuals, or those who have physical intersex traits by birth and those who become hijra through penectomy, respectively. According to Indian tradition, the hijra perform a traditional song and dance as part of a family's celebration of the birth of a male child; during the performance, they also inspect the newborn's genitals to verify its sex. Herdt states that it is widely accepted that if the child is intersex, the hijra have a right to claim it as part of their community. However, Warne and Raza argue that an association between intersex and hijra people is mostly unfounded but provokes parental fear. The hijra are mentioned in some versions of the Ramayana, a Hindu epic poem from around 300 BCE, in a myth about the hero Rama instructing his devotees to return to the city Ayodhya rather than follow him across the city's adjacent river into banishment. Since he gives this instruction specifically to "all you men and women," his hijra followers, being neither, remain on the banks of the river for fourteen years until Rama returns from exile.

In the Tantric sect of Hinduism, there is a belief that all individuals possess both male and female components. This belief can be seen explicitly in the Tantric concept of a Supreme Being with both male and female sex organs, which constitutes "one complete sex" and the ideal physical form.

Ancient Greece

According to Leah DeVun, a "traditional Hippocratic/Galenic model of sexual difference – popularized by the late antique physician Galen and the ascendant theory for much of the Middle Ages – viewed sex as a spectrum that encompassed masculine men, feminine women, and many shades in between, including hermaphrodites, a perfect balance of male and female". DeVun contrasts this with an Artistotelian view of intersex, which argued that "hermaphrodites were not an intermediate sex but a case of doubled or superfluous genitals", and this later influenced Aquinas.

In the mythological tradition, Hermaphroditus was a beautiful youth who was the son of Hermes (Roman Mercury) and Aphrodite (Venus). Ovid wrote the most influential narrative of how Hermaphroditus became androgynous, emphasizing that although the handsome youth was on the cusp of sexual adulthood, he rejected love as Narcissus had, and likewise at the site of a reflective pool. There the water nymph Salmacis saw and desired him. He spurned her, and she pretended to withdraw until, thinking himself alone, he undressed to bathe in her waters. She then flung herself upon him, and prayed that they might never be parted. The gods granted this request, and thereafter the body of Hermaphroditus contained both male and female. As a result, men who drank from the waters of the spring Salmacis supposedly "grew soft with the vice of impudicitia". The myth of Hylas, the young companion of Hercules who was abducted by water nymphs, shares with Hermaphroditus and Narcissus the theme of the dangers that face the beautiful adolescent male as he transitions to adult masculinity, with varying outcomes for each.

Ancient Rome

Hermaphroditus in a wall painting from Herculaneum (first half of the 1st century AD)

 

Pliny notes that "there are even those who are born of both sexes, whom we call hermaphrodites, at one time androgyni" (andr-, "man," and gyn-, "woman", from the Greek). However, the era also saw a historical account of a congenital eunuch.

The Sicilian historian Diodorus (latter 1st-century BC) wrote of "hermaphroditus" in the first century BCE:

Hermaphroditus, as he has been called, who was born of Hermes and Aphrodite and received a name which is a combination of those of both his parents. Some say that this Hermaphroditus is a god and appears at certain times among men, and that he is born with a physical body which is a combination of that of a man and that of a woman, in that he has a body which is beautiful and delicate like that of a woman, but has the masculine quality and vigour of man. But there are some who declare that such creatures of two sexes are monstrosities, and coming rarely into the world as they do they have the quality of presaging the future, sometimes for evil and sometimes for good.

Isidore of Seville (c. 560–636) described a hermaphrodite fancifully as those who "have the right breast of a man and the left of a woman, and after coitus in turn can both sire and bear children." Under Roman law, as many others, a hermaphrodite had to be classed as either male or female. Will Roscoe writes that the hermaphrodite represented a "violation of social boundaries, especially those as fundamental to daily life as male and female."

In traditional Roman religion, a hermaphroditic birth was a kind of prodigium, an occurrence that signalled a disturbance of the pax deorum, Rome's treaty with the gods. But Pliny observed that while hermaphrodites were once considered portents, in his day they had become objects of delight (deliciae) who were trafficked in an exclusive slave market.^[31] According to historian John Clarke, depictions of Hermaphroditus were very popular among the Romans:

Artistic representations of Hermaphroditus bring to the fore the ambiguities in sexual differences between women and men as well as the ambiguities in all sexual acts. ... (A)rtists always treat Hermaphroditus in terms of the viewer finding out his/her actual sexual identity. ... Hermaphroditus is a highly sophisticated representation, invading the boundaries between the sexes that seem so clear in classical thought and representation.^[32]

In c.400, Augustine wrote in The Literal Meaning of Genesis that humans were created in two sexes, despite "as happens in some births, in the case of what we call androgynes".

Historical accounts of intersex people include the sophist and philosopher Favorinus, described as a eunuch (εὐνοῦχος) by birth. Mason and others thus describe Favorinus as having an intersex trait.

A broad sense of the term "eunuch" is reflected in the compendium of ancient Roman laws collected by Justinian I in the 6th century known as the Digest or Pandects. Those texts distinguish between the general category of eunuchs (spadones, denoting "one who has no generative power, an impotent person, whether by nature or by castration", D 50.16.128) and the more specific subset of castrati (castrated males, physically incapable of procreation). Eunuchs (spadones) sold in the slave markets were deemed by the jurist Ulpian to be "not defective or diseased, but healthy", because they were anatomically able to procreate just like monorchids (D 21.1.6.2). On the other hand, as Julius Paulus pointed out, "if someone is a eunuch in such a way that he is missing a necessary part of his body" (D 21.1.7), then he would be deemed diseased. In these Roman legal texts, spadones (eunuchs) are eligible to marry women (D 23.3.39.1), institute posthumous heirs (D 28.2.6), and adopt children (Institutions of Justinian 1.11.9), unless they are castrati.

Middle Ages

An illustration from a 13th-century manuscript of the Decretum Gratiani

In Abnormal (Les anormaux), Michel Foucault suggested it is likely that, "from the Middle Ages to the sixteenth century ... hermaphrodites were considered to be monsters and were executed, burnt at the stake and their ashes thrown to the winds."

However, Christof Rolker disputes this, arguing that "Contrary to what has been claimed, there is no evidence for hermaphrodites being persecuted in the Middle Ages, and the learned laws did certainly not provide any basis for such persecution". Canon Law sources provide evidence of alternative perspectives, based upon prevailing visual indications and the performance of gendered roles. The 12th-century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails" ("Hermafroditus an ad testamentum adhiberi possit, qualitas sexus incalescentis ostendit.").

In the late twelfth century, the canon lawyer Huguccio stated that, "If someone has a beard, and always wishes to act like a man (excercere virilia) and not like a female, and always wishes to keep company with men and not with women, it is a sign that the male sex prevails in him and then he is able to be a witness, where a woman is not allowed". Concerning the ordination of 'hermaphrodites', Huguccio concluded: "If therefore the person is drawn to the feminine more than the male, the person does not receive the order. If the reverse, the person is able to receive but ought not to be ordained on account of deformity and monstrosity."

Henry de Bracton's De Legibus et Consuetudinibus Angliae ("On the Laws and Customs of England"), c. 1235, classifies mankind as "male, female, or hermaphrodite", and "A hermaphrodite is classed with male or female according to the predominance of the sexual organs."

The thirteenth-century canon lawyer Henry of Segusio argued that a "perfect hermaphrodite" where no sex prevailed should choose their legal gender under oath.

Early modern period

The 17th-century English jurist and judge Edward Coke (Lord Coke), wrote in his Institutes of the Lawes of England on laws of succession stating, "Every heire is either a male, a female, or an hermaphrodite, that is both male and female. And an hermaphrodite (which is also called Androgynus) shall be heire, either as male or female, according to that kind of sexe which doth prevaile." The Institutes are widely held to be a foundation of common law. 

A few historical accounts of intersex people exist due primarily to the discovery of relevant legal records, including those of Thomas(ine) Hall (17th-century United States), Eleno de Céspedes, a 16th-century intersex person in Spain (in Spanish), and Fernanda Fernández (18th-century Spain). 

In 2019 the Smithsonian Channel aired a documentary "American's Hidden Stories: The General was Female?" with evidence that Casimir Pulaski, the important American Revolutionary War hero, may have been intersex. 

In a court case, heard at the Castellania in 1774 during the Order of St. John in Malta, 17-year-old Rosa Mifsud from Luqa, later described in the British Medical Journal as a pseudo-hermaphrodite, petitioned for a change in sex classification from female. Two clinicians were appointed by the court to perform an examination. They found that "the male sex is the dominant one". The examiners were the Physician-in-Chief and a senior surgeon, both working at the Sacra Infermeria. The Grandmaster himself who took the final decision for Mifsud to wear only men clothes from then on.

Maria Dorothea Derrier/Karl Dürrge was a German intersex person who made their living for 30 years as a human research subject. Born in Potsdam in 1780, and designated as female at birth, they assumed a male identity around 1807. Traveling intersex persons, like Derrier and Katharina/Karl Hohmann, who allowed themselves to be examined by physicians were instrumental in the development of codified standards for sexing.

Mid modern period

Bronze statue of Lê Văn Duyệt in his tomb

 

During the Victorian era, medical authors introduced the terms "true hermaphrodite" for an individual who has both ovarian and testicular tissue, verified under a microscope, "male pseudo-hermaphrodite" for a person with testicular tissue, but either female or ambiguous sexual anatomy, and "female pseudo-hermaphrodite" for a person with ovarian tissue, but either male or ambiguous sexual anatomy.

Historical accounts including those of Vietnamese general Lê Văn Duyệt (18th/19th-century) who helped to unify Vietnam; Gottlieb Göttlich, a 19th-century German travelling medical case; and Levi Suydam, an intersex person in 19th-century USA whose capacity to vote in male-only elections was questioned. 

The memoirs of 19th-century intersex Frenchwoman Herculine Barbin were published by Michel Foucault in 1980. Her birthday is marked in Intersex Day of Remembrance on 8 November.

Contemporary period

The Phall-O-Meter satirizes clinical assessments of appropriate clitoris and penis length at birth.

 

The term intersexuality was coined by Richard Goldschmidt in the 1917 paper Intersexuality and the endocrine aspect of sex. The first suggestion to replace the term 'hermaphrodite' with 'intersex' came from British specialist Cawadias in the 1940s. This suggestion was taken up by specialists in the UK during the 1960s. Historical accounts from the early twentieth century include that of Australian Florrie Cox, whose marriage was annulled due to "malformation frigidity".

Since the rise of modern medical science in Western societies, some intersex people with ambiguous external genitalia have had their genitalia surgically modified to resemble either female or male genitals. Surgeons pinpointed intersex babies as a "social emergency" once they were born. The parents of the intersex babies were not content about the situation. Psychologists, sexologists, and researchers frequently still believe that it is better for a baby's genitalia to be changed when they were younger than when they were a mature adult. These scientists believe that early intervention helped avoid gender identity confusion. This was called the 'Optimal Gender Policy', and it was initially developed in the 1950s by John Money. Money and others controversially believed that children were more likely to develop a gender identity that matched sex of rearing than might be determined by chromosomes, gonads, or hormones. The primary goal of assignment was to choose the sex that would lead to the least inconsistency between external anatomy and assigned psyche (gender identity).

Since advances in surgery have made it possible for intersex conditions to be concealed, many people are not aware of how frequently intersex conditions arise in human beings or that they occur at all. Dialog between what were once antagonistic groups of activists and clinicians has led to only slight changes in medical policies and how intersex patients and their families are treated in some locations. Numerous civil society organizations and human rights institutions now call for an end to unnecessary "normalizing" interventions.

The first public demonstration by intersex people took place in Boston on October 26, 1996, outside the venue in Boston where the American Academy of Pediatrics was holding its annual conference. The group demonstrated against "normalizing" treatments, and carried a sign saying "Hermaphrodites With Attitude". The event is now commemorated by Intersex Awareness Day.

In 2011, Christiane Völling became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention. In April 2015, Malta became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people.