Vietnam era Veterans and Co-occurring PTSD/S

Historical Experience as a whole and relevance to Social Work practice:

    Vietnam Veterans upon returning home presented the social work community with a variety of issues that required professional level assistance. These issues included homelessness, domestic violence, post-deployment readjustment, and substance abuse to name but a few. In keeping with the NASW code of ethics, Social Workers focus their skills on several areas of competence, but in particular, the Dignity and Worth of the Person, the value and importance of enhancing human relationships as relevant to the issues facing this population.
    Social Work plays a pivotal role in the delivery of services to the Vietnam Veterans. On the micro level, direct practice efforts strive to empower the individual through direct counseling by designing outcomes that advance personal efficacy.
    On the mezzo level Social Work partners with community organizations to broker support networks by connecting clients with medical and mental health services, mutual help groups, housing, and the appropriate social welfare programs designed to meet their needs.
    Macro level focus includes broad community planning, coordination, advocacy and integration of services on the federal, state, county and local levels. Social Work, because of its leadership, flexibility, and commitment to "Putting Veterans First", continues to thrive as a profession in the current health care environment.

Vietnam Veteran History of Advocacy    

Vietnam Veterans of America (VVA) is the only national Vietnam Veterans organization congressionally chartered and exclusively dedicated to Vietnam-era veterans and their families.
      By the late 1970s, there was as yet no legislation to address the needs of this particular segment of the Veteran’s population. In January 1978, a small group of Vietnam veteran activists came to Washington, D.C., to rally support for creating an advocacy organization devoted exclusively to the needs of Vietnam veterans. VVA, initially known as the Council of Vietnam Veterans, began its work. At the end of its first year of operation in 1979, the total assets were $46,506.

Addressing Congress, council members hoped to gain political support for creating supportive policy and programs to meet the specific needs of Vietnam veterans and their families. However, despite persuasive arguments before Congress, they failed to win even a single legislative victory. It became apparent that social justice arguments made by a small group alone would not be sufficient. The U.S. Congress would respond to the legitimate needs of Vietnam veterans only if they had political strength. Following an intensive strategic membership drive, the Council of Vietnam Veterans by 1979, had transformed into the service organization Vietnam Veterans of America.
Building further upon its advocacy successes, in 1983, VVA founded its associate legal services department, the Vietnam Veterans of America Legal Services (VVALS) organization to broker on behalf of Vietnam veterans seeking benefits and services from the government. Over the next several years VVA grew in size, stature, and prestige. VVA's professional membership services, veterans service, and advocacy work gained the respect of Congress and the veterans community. In 1986, VVA's exemplary work was granted a congressional charter, formalizing its legitimacy.

VVA’s mission is to promote the educational, economic, health, cultural, and emotional readjustment of the Vietnam-era veteran to civilian life. Relative to these goals, the organization’s practice skills are directed toward three realms: lobbying, mobilizing constituents, and engaging media support to realize its agenda. Legislative victories establishing the Vet Center system, passage of laws providing for increased job-training and job-placement assistance for unemployed and underemployed Vietnam-era veterans, laws assisting veterans suffering from Agent Orange exposure, and landmark legislation (i.e., Judicial Review of veterans claims) permitting veterans to challenge adverse VA decisions in court. All were enacted largely as a result of VVA's legislative efforts. Though much has been done, there is still so far to go to address the unmet needs of this population.

Comprehensive review of the literature about Vietnam Veterans and Post Traumatic Stress Disorder and Substance Use Disorder
 
The Vietnam War recalls the controversial treatment of veterans when they returned home, and the abuse encountered upon arrival only added to the already damaged psyches of many of the vets.  “Only the veterans of Vietnam have endured a concerted, organized, psychological attack by their own people” (Grossman, 1996, p. 280). This was the first time since the advent of televised media, that coverage of a war would inflame such a virulent public response. After the war subsided, eventually, the problems veterans were having post-deployment as they transitioned back to civilian life became self-evident.  However, it was not until 1980 that the term Post traumatic Stress Disorder became the branding that would identify this specific cluster of symptoms as a formal diagnosis in the Diagnostic Statistics Manual. 
    The DSM-IV-TR describes a traumatic stressor as “involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.” (American Psychiatric  Association, 2002, p. 463). It must involve a response of “intense fear, helplessness, or horror” and the resulting symptoms are what characterizes PTSD.
    The consideration of PTSD as a new diagnosis did not occur until many years after the Vietnam War veterans had returned home and tried to bring attention to their issues.  Even in 1980, there was still much to learn about Post Traumatic Stress Disorder.


In May of 2001, a comparative study done by the Department of United States Veterans Affairs released data on the Socioeconomic Status of Veterans and on VA Program Usage. This study compared veterans and non-veteran counterparts on several measures of socioeconomic status.
    Conclusions drawn from this study show that there were several contributing risk factors at play for Vietnam Veterans who were later diagnosed with PTSD following their release from combat duty. These include socioeconomic disadvantage, low education level, unemployment status, and poverty level and substance use. Education level seemed to figure prominently in that veterans with lower levels of education had a greater risk for mental health problems following exposure to trauma. Low education attainment when coupled with drug and alcohol usage increase potential for post traumatic stress disorder among veterans exposed to combat trauma.
    When considering the before and after profile of a young man who was enlisted during the time of the Vietnam War era it is helpful to take into account these social ecological factors contributing to shaping the pathway to post traumatic stress disorder.  This is  supported by the research done on Vietnam Veteran’s relative to the onset of post traumatic stress.  Soldiers who started using drugs during high school for recreational purposes would be most likely to continue engaging in the practice, however, under duress of active combat duty, the utility would shift from mere recreational usage to substance abuse in order to escape feelings associated with psychological distress associated with trauma. Therefore, they would likely become candidates for the progression of the disease and its later stage development into a state of disorder. At the time of this study, in the year 2001, those who were age 54 years of age at the time, would now be 64, well within the age range of those who had served. Upon release from the service, unaware of the progressive and debilitating nature of substance abuse on all the organisms health systems and sub systems, it is unlikely that those who returned to normal lives as civilians gave up the practice of use of substances to numb psychological pain. Discharged, addicted, and traumatized, their continued use only served to reinforced the advance toward disorder. 


The impact of military service on long-term health is reemerging as a vital policy question, particularly as the United States conducts concurrently several major military operations. Health professionals, based on findings of years of ongoing research projects specifically aimed at Vietnam Veterans note that significant numbers of retired military personnel representative of this era are experiencing problems that are detrimental to both their psychological and physical health.
    Substance abuse has become, among others, the primary coping mechanism for Vietnam Veterans who suffer from unresolved Post Traumatic Stress relative to commonly co-occurring diseases. For example, in one of the early papers in this literature, Card (1987) finds that Vietnam Veterans are much more likely to report problems associated with post traumatic stress disorder including ‘‘nightmares, loss of control of behavior, emotional numbing, withdrawal from the external environment, hyper-vigilance, anxiety, and depression.’’ Later, Jordan et al. confirm this finding (1991), further documenting that “exposure to combat in Vietnam is associated with higher prevalence of specific psychiatric disorders, including post traumatic stress disorder”. Dobkin and Shabini present evidence of a strong link between post traumatic stress disorder and substance abuse (The Health Effect of Military Service: Evidence for the Vietnam Draft, 2007) In “Vietnam Combat Veterans: Treatment Problems, Strategies and Recommendations, by J. Michael Murray, MS, and Tom Williams, PsychD,  the authors, who are themselves Vietnam veterans have interviewed or treated more than 2,000 combat veterans and their families and have found that 80% of the veterans seen have had alcohol related problems, further supporting the evidence presented by others, that these disorders are often correlated. 

 
The topic of Trauma, PTSD, and substance abuse are co-related according to the article titled ‘Post-traumatic stress disorder, drug dependence and suicidality among male Vietnam veterans with a history of heavy drug use” (2008). According to this article, generally speaking, PTSD and substance abuse problems are often diagnosed together.
    In the general population, up to three quarters of those who have survived violent trauma report substance abuse problems. Comparatively, 60-80% of Vietnam Veterans need of treatment for co-related diseases of PTSD substance abuse. Veterans over the age of 60 with PTSD are at higher risk for a suicide attempt where substance abuse and dependency problems co-exist with depression.  The significance of these findings are such that they indicate practical and clinical implications not only for the well-being of the veterans themselves, but for family members and the health care system at large.


The Practical Implications: different types of trauma result in the syndrome of PTSD, and the disease will manifest itself uniquely for each individual, since each individual has unique endogenous and exongenous variables impacting his circumstances. This implies that there is no single solution for treatment, and assessments will require interventions that often extend beyond the ken of a single discipline’s scope of field. Those in the mental health and medical services delivery field who will come in contact with these individuals will need to apply a psychological diagnostic skill set that incorporates a combination of substance abuse and recovery therapy, direct counseling services, group work, and family counseling, in addition to medical interventive techniques.
    Clinical Implications: The burden on the health care system is even larger when comorbid substance abuse exists (Virgo et al., 1999; Piette et al, 1997). Patients with both PTSD and SUD (substance use disorder) have a more severe clinical profile than those with either disorder alone The challenges across medical and psychological disciplines will require purposeful planning and building of therapeutic alliances that serve the intersecting health needs of this population. Practitioners in the Behavioral, Neurobiological, Medical disciplines must be integrated simultaneously to counter previously held assumptions that beginning trauma therapy before reduction or elimination of substance use will lead to an increase in substance use. This has not been found to be the case at all.  (Towards Integrated Treatments for PTSD and Substance Use Disorders, Suzy B. Gulliver, PhD (Director, Center of Excellence for research on Returning War Veterans, Waco TX ) and Laura E. Stoffen, BA. 

..........Social Workers have done much to support the needs of this population, however, much more can be done to help this population become a more visible and viable segment of the local community. By treating the community itself as a target system, Social Workers can team with other community social organizations and mental health and medical service professionals to advocate on behalf of Vietnam Veterans by creating community outreach programs to raise awareness and educate the community about the plight of the population.These advocacy groups could identify gaps in services/resources and put into effect systems changes that are responsive to veterans’ changing needs.
    Efforts at inclusivity include; inviting local Vietnam Vets organizations to participate in community picnics and parades, by hosting community events such as bingo’s, spaghetti dinners and fish fry’s, teaming them with local Boy Scout organizations in order to provide role models and good PR for future military involvement; this and similar activities will help this population establish a niche as a visible and important presence in the community.
      By breaking down the invisible curtain that separates this population behind a veil of mystique, social workers can help mediate the process of mainstreaming the population into the larger culture.

References

• Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use,  Journal of Drug and Alcohol Dependence 76S S31–S43. Rumi Kato Price et al. © 2004
• Post-Traumatic Stress Disorder and Substance Abuse in Vietnam Combat Veterans: Treatment Problems, Strategies and Recommendations. Journal of Subsrance Abuse Treatment. Vol. I, pp. 87-97.19.  J. Michael Jenlinek, MS,Tom Williams, PsyD ©1984
• Civilian Social Work: Serving the Military and Veteran Populations, Savinsky et al, 2009.
• Websites Referenced:
• United States Department of Veterans Affairs National Center for PTSD: http://www.ptsd.va.gov/public/pages/ptsd-alcohol-use.asp
• Substance Abuse and Mental Heal Services Administration (SAMHSA)
• http://www.samhsa.gov/MilitaryFamilies/
• http://www.oas.samhsa.gov/aging/chap9.htm: Utilization of Veterans' Health Services for Substance Abuse: A Study of Aging Baby Boomer Veterans Brenda M. Booth,* Ph.D.,
• Frederic C. Blow, Ph.D.
• National Survey on Drug Use and Health (NSDUH) http://www.oas.samhsa.gov/2k7/veteransDual/veteransDual.htm

Adolescent African American Males at Risk for Incarceration

    The charge to investigate how the underground economy and black male incarceration rates affect black males, their families, and the black community as a whole, has created an opportunity for enlightenment, specifically as it regards the factors that facilitate the circumstances under which this phenomenon occurs. 
    Taking into account the barriers of access to opportunity experienced by black males in economic and educational realms it stands to reason that, failing normal avenues of access,  an individual would fabricate, by any means available, the necessary pathway to survival.  It should come as a shock to no one that when jobs are scarce, people turn to alternative forms of “employment”, asserting their own ingenuity in order to do whatever is necessary to ‘make ends meet’.  Restricted from access to regular means of employment, black men in particular, in many cases, having been forced to accept the alternative, ultimately surrender to the only remaining option: a life of work that is “off the books”.
    Unfortunately the paucity of the situation did not begin with the inability to find a job. It began much sooner than that; it began with a breakdown somewhere in the educational system, a system rife with institutionalized racism, prejudice and discrimination. A system dominated by a perspective that underestimates the young black male student on all accounts. A system that ignores his potential contributions as inconsequential. A system that has failed him in the most important stage of his life, the one where, all things being equal, he would be given the necessary foundational tools ensuring his ability to compete in a legitimate marketplace.
    Ill-equipped and without the proper and necessary tools, he becomes bored, and shiftless, turns to recreational drug use, which further dulls his ambitions and destroys his dreams. When he does engage himself in the act of labor, it is often in an underground economy of some sort. He shovels snow, or mows lawns or runs errands for neighbors in order   to acquire a bit of mad money to cover the cost of cigarettes, and maybe a little bit of marijuana. Eventually, he turns from smoking drugs, to selling drugs, from washing cars, to stealing cars; from working at CoGo’s to robbing CoGo’s, from dating women, to selling women.
    Young, school drop out, underage, his life is now set, and he is doomed to repeat the cycle of adjudication and incarceration. This is the portrait of the young black male who is featured in the study that I did as an attempt to develop a profile of young Black adolescent males who are at risk for becoming incarcerated in the Criminal Justice System in their adult lives. As part of this study, 15 young Black males who are currently adjudicated as delinquents in Allegheny County Court system were solicited to voluntarily participate in an interview regarding certain aspects and influences impacting their lives. This interview was designed to serve as a non-scientific ‘pre-test’ for predicting potential future incarceration statistics. The questions asked in the interview were classified as two types: Objective and Subjective.
    The Objective set were of two types: 'yes or no' type questions, and other questions that asked about relationship dynamics. For example, they were asked about the expectations that were placed on them by their guardians, and they were asked what were the values that their family systems held dear. They were also asked their opinions about the importance of education and they were given the opportunity to rate the value of education on a 1 to 10 scale. They were asked to specify the behaviors that led to their adjudication and detention. They were asked about their drug use, sexual activity, parenthood status, and they were asked if they had relatives or friends who had been or who currently are incarcerated. The answers were assigned +/- values, and the scores were tallied to project which dynamic would likely have greater influence on their future life's course, if nothing happened to intervene and cause them to change direction.

Question Set #1 (Objective type)

Q2        2. How do you get along with those you reside with?
Q5        5. Do you have contact w/ parents?
Q6        6. Relationship w/ mother?
Q7        7. Relationship w/ father?
Q8        8. Relationship w/ authority ?
Q9        9. Family members involved w/legal system?
Q10        10. Friends involved w/ legal system?
Q11        11. Family members incarcerated
Q12        12. Victim of abuse?
Q15        15. On Welfare?
Q16        16. Charged with crime?
Q17        17. Ever shot anyone?
Q19        19. Family currently involved with CYS?
Q22        22. Suspended or expelled?
Q23        23. Diagnosed special needs?
Q25        25. Runaway from home?
Q26        26. Do you smoke?
Q27        27. Used drugs or alcohol?
Q28        28. Sexually active?
Q29        29. Tattoos or piercings?
Q30        30. Fathered any children?
Q31        31. Have you ever been hospitalized in a mental health facility?
Q32        32. Ever been diagnosed w/ depression?
Q33        33. Do you take medication to control behavior?
Q14        14. Own or rent?
Q18        18. How old at first contact w/ legal system?
Q20        20. How old are you?
Q21        21. Grade placement
Q24        24. Currently employed?
Q34        34. On a 1 to 10 scale, rate education

    The graphic chart figure 1, reflects aggregate data collected on these questions. The  bars in the positive range represent the number of positive values assessed, and the bars in the negative range represent the number of negative values assessed for each question in the Objective Set. (R1 + = the positive values reported for Respondent 1. R1 - = the negative values reported for Respondent 1, and etcetera). By looking at this information, one may ascertain the dominant dynamic forces influencing the individual’s life, either positive or negative, and thus recognize them as strong risk factors for predicting probability of increased risk in the future. 

(fig. 1)
    








The other set of questions were more informational and subjective. These asked about their age and level of education, their goals for the future, and the perceived barriers to meeting them.      Each question on the list was assigned either a neutral, positive or negative value for use in assessing the overall environmental and peripheral dynamics impacting on the formation of the young man's character. Positive influences were assumed to identify tendencies leading to functional behaviors, and negative or indifferent influences were assumed to identify influences that may possibly contribute to maladaptive social pathologies.   

Question Set #2 (Subjective and Informational)

    I feel it important to share the answers to these specific questions because they are pertinent to the subject matter, particularly regarding the types of household configurations of Black American Families, and because of the values, hopes and aspirations of this ethnicity.
   
    The choice of questions that would be included in the interview emerged from the concepts studied in our course content that served to illuminate the risks and resiliencies of the Black American Family. Certain questions were designed to reflect attributes that are historically characteristic of the Black American Family experience. For instance, the interviewees were asked to disclose their family structure. Their descriptions reflect those structures exemplified in the Billingsley text (Climbing Jacob’s Ladder, Chapter One).

Q1     List the people in your household

R1    6        mom, 2 brothers, sister, cousin; another sister lives in Phila w/ father
R2    4        mom, father, sister
R3    3        grandmother, father
R4    4        mom, stepfather, brother
R5    3        mom, stepfather
R6    2        mom
R7    2        mom
R8    7        mom, stepfather, sister, brother, 2 cousins
R9    3        grandmother (legal guardian since birth), aunt
R10    10        mom, stepfather , 2 brothers, 3 sisters, stepbrother, stepsister
R11    3        mom, brother
R12    6        mom, 2 brothers, 2 sisters
R13    5        mom, 3 sisters (live in shelter)
R14    4        mom, father, brother
R15    2        mom

    In the text, Billingsley lists four major structures of African American Family Types: 1. Married Couple with no children, 2. Married Couple with children, 3. Unmarried mother with children, and 4. Unmarried father with children.  The majority of those reported by the respondents fall into categories 2 and 3, with almost half falling into category 3. In Table I.3 on page 33-34 of the text, the author breaks down the family configurations into sub-types which he labels “Modified Nuclear” with alternative headship: 1. Natural Parent (Divorced, separated, widowed, never married parent) 2. Surrogate parent (lone adult raising grandchildren, nieces, nephews, foster children), 3. Natural Surrogate parent (Divorced, separated, widowed, never-married parents raising his/her own children, their cousins, or foster children). These conglomerates support the reports that African American Family patterns in less advantaged situations, have shifted from predominantly nuclear family types to those that form bonds based mainly on kinship through blood lines. Driven by the external pressures threatening the their stability, these families form mini-communities of mutual support, binding together to share resources and fill needs as social and  economic conditions work against their favor.    The values underlying these types of bonds seem to be lacking where delinquent behavior factors heavily in the equation. While 9 respondents reported no sense of important family values, 6 reported values such as mutual respect, honesty, trust and loyalty as being important. In cases where values are not identified, modeled, expected or instilled, risk for maladjusted behavior appears more prevalent. One wonders where is the breakdown of values transmission? Is it in lack of communication and cohesion and shared sense of identity between members? Is it lack of accountability or emotional/psychological disinvestment in functional familial roles? Does this lead to detachment and disenfranchisement from behaviors that otherwise belie the tendency to positive, cooperative social adjustment? 

Q4    What are your important family values?

R1    0        0
R2    1        mutual respect
R3    0        don't know
R4    2        respect, protect each other
R5    1        we just take care of ourselves
R6    1        honesty
R7    1        doing things for each other
R8    0        don't know
R9    0        don't know
R10    2        trust, loyalty
R11    0        don't know
R12    0        no answer
R13    0        none
R14    0        no response
R15    0        don't know

    In spite of a majority lack of shared values, the respondents report that work ethic is a strong component of the families in question. Each of the respondents reported an expectation placed upon them by their family guardians (though in some cases they were ignored, which speaks more about the character of the individual delinquent behavior).

Q3    What are the expectations they have of you?

R1    3        Sweeping, dishes, trash, clean room
R2    3        trash, clean room, home for dinner
R3    2        go to school, find a job
R4    3        house rules, chores, curfew, cleaning
R5    0        none
R6    3        chores; court requires curfew, but mom does not enforce it
R7    3        clean room, dishes, trash
R8    2        chores, curfew
R9    1        chores
R10    3        curfew, trash, help w/ younger kids
R11    2        curfew( ignores it), chores
R12    2        curfew, chores
R13    1        used to do chores before living in shelter           
R14    3        curfew, dishes, clean room
R15    1        chores

    Regarding the parental work ethic (which would be the strongest indicator of a positive influential modeling) all heads of household were employed except two. In cases of two parent households, both were employed, which again, displays the strong work ethic (even though additionally there were reported cases of access to welfare programs to supplement basic needs).
 

Q13     Who employed in the home?

R1    1        mom
R2    2        mom, dad
R3    1        dad
R4    2        mom, stepdad
R5    2        mom, stepfather
R6    2        mom
R7    1        mom
R8    2        mom, stepfather
R9    1        aunt
R10  1        stepfather
R11            no one
R13  2        mom, brother
R14            no one
R15  2        mom, dad

    Other questions which reflected the hopes and dreams for the future:

Q35     What are your goals for the future?

R1            go home, get into school, get a job
R2            get a job to provide for daughter
R3            just be left alone
R4            earn a diploma; get a job with something creative or artistic
R5            i have other stuff to deal with that's just as important as a diploma like staying off drugs
R6            food service work, finish school
R7            army
R8            get a degree, work in a trade
R9            get out
R10            get a job, help mom, his girlfriend and child
R11            graduate, get a job, join the military
R12            graduate, get a job
R13            go home
R14            graduate, get a job
R15            go home

Questions about impediments to realizing their dreams for the future:

Q36    Barriers from realizing goals?

R1            transportation, clothes
R2            clothing, interview skills, transportation
R3            being locked up; family don't like my decisions
R4            money
R5            none
R6            being in placement, eager to get out
R7            being locked up; money for school
R8            none
R9            none
R10            none
R11            probation
R12            being locked up, no family w/ money or education that can help
R13            none
R14            none
R15            probation

    In conclusion, this experiment was an attempt to show the relationship between delinquency and crime. The risk factors influencing the likelihood for a young black male adolescent’s future incarceration have obvious implications. The risk of incarceration grows among those suffering least access to education, wages and opportunity. Low education begets low wages, which begets low opportunity and this leads to the inability to fund the cost of basic living standards. As a result these men turn to crime, make contact with the underground economy, which eventually takes over their lives. Without a strong educational foundation as the basis for building upon positive opportunities, it is likely that the allure of the alternative offered in the underground economy will set up the individual for habitual involvement in socially unacceptable pursuits. The charge of the young black male is to face the fight that lies ahead of him: to rise up, confront and rebel against the institutional barriers that threaten ultimately to reduce or eliminate his ability to reach his fullest human potential.

   

Cultural Colonization and the Politics of Gender

    The New York times posted an article titled "David Reimer, 38, Subject of the John/Joan Case" on May 12, 2004, that revealed the hidden truth about the plight of a Canadian family who brought a set of twins, Bruce and Brian, into the world on August 22, 1965 only to have one of them unwittingly made a eunuch after a botched circumcision operation. The doctor who performed the operation was using a new cauterizing technique which unwittingly proceeded to burn off the entire organ. As a result of the mishap, Bruce Reimer became the first developmentally normal child to undergo a sex reassignment. And since he had been born an identical twin, the situation presented the perfect circumstances for monitoring the experiment with a built in matched control subject.
    Subsequently, since nothing could be done to undo the damage, and since reconstructive surgery was out of the question, the decision was made to remove his testicles. On the 'expert' advice of Dr. John Money of Johns Hopkins University, who was noted for his theories on sex and gender that stated infants are born psychosexually neutral,  the Reimers decided to raise Bruce as if he had been born a biological female, and keep the real truth 'hush-hush'. They renamed Bruce "Brenda" and began to raise him as if he were a biological female. They dressed him in skirts and dresses, and gave him girl toys to play with, but none of that seemed to matter to 'Brenda" who wanted to have nothing to do with it, later rejecting all of the attempts to feminize Bruce into a well adjusted biological female. Medical teams monitored the situation very closely over a period of several years, injecting Bruce with female hormones, fabricating a synthetic vagina, using the skin flap left over from the scrotum after his testicles were removed. The plan was ultimately to create an inner cavity so that 'Brenda' would appear more like other girls, and thus with more realistic features, better identify as the psychologically well adjusted biological female they were all trying to convince him/her that s/he was.
    Aside from the obvious tragic consequences of such a medical catastrophe, what most strongly piques my interest in this story is the issue that arises regarding the politics of the binary gender construction, framed by the themes of cultural gender variance as found in the text "Gender Diversity" by Serena Nanda. In this text she compares and contrasts the gamut of gender expressions across several cultures and continents. The comparisons that seem to be most striking are those that are made between vertically structured societies and those that are not.
    For example, in terms of gender, the indigenous cultures of North America, such as Native American tribes the Mojave and the Navajo, affirmed couple pairings and gender expressions that were outside the typical dimorphic patterns of Eurocentric cultures, which normatively included only hetero-normative mated pair models.
    The Navajos had a term for those not hetero-normatively oriented. These were called Nadleeh, and the name was used to specify those who in early childhood exhibited an orientation toward those occupational interests of the opposite gender. Boys who showed a gravitation toward crafts and domestic duties were accepted as part of this class. The same is said of the females who exhibited proclivities for interest in what were ordinarily considered male orientated tasks, such as hunting. Nanda tells us that “these would adopt almost all aspects of the opposite gender's dress, work, language and behavior”. The Mojave, whose gender variant counterparts were called Alyha (male) and Hwaume ( female variant) went even further, and adopted the physiological traits and status of the opposite gender as well.  Explorers, at their arrival on the continent and upon encountering what seemed to them to be behavioral abnormalities  condemned these practices as taboo as indeed they are in Eurocentric cultures. They labeled them 'berdeche', a derogatory term derived from the Arabic, meaning 'male prostitute'. However, the indigenous peoples simply knew nothing of such comparisons, and therefore no context was prevalent in which such objections would arise. In the minds of the indigenous, these were as much a part of the gender status quo as are their correlates in gender binary cultures; they did not see themselves as 'variant' in any degree, but rather as 'two-spirited', simply another presentation of gender. The idea here is that of multiple persuasions, rather than variation, which implies deviation from a norm.
    As it stands, one of the major differences between these cultures and its Eurocentric counterpart, is the manner in which the Europeans conflate gender and sex. This seems to have arisen from the ideology surrounding the practicalities in division of labor tasks where early on females, being restricted to 'home and hearth' type activities during gestational periods, were better fit to exercise the role of caregiver, keeping them close to camp and better prepared to serve domestic needs. Males, on the other hand, lacking in maternal ties to their offspring, yielded to the responsibilities closely associated with protection, hunting and foraging for food, which required more flexible mobility.
    As the fledgling European culture in its earlier developmental phase reveled in its flourishing humanism, compelled by its tendency to formulate scientific systems of taxonomy, and with culture as captive audience, the values related to dimorphic coupling became reinforced, and ultimately enshrined as cultural code. Transmitted institutionally from generation to generation, morality ultimately galvanized a social propriety that expected adherence to behavioral practices endemic to the particular cultural ethic, an ethic based on Judeo-Christian values. Broadly speaking, these values were imported during the process of colonization when Europeans migrated to other continents, imposing upon its inhabitants a new set of foreign values intended to supplant those that had sprung from their own organically adaptive needs set. While projecting their institutionalized biases onto the cultural practices of the indigenous peoples, the Europeans condemned as heretical their purely natural and normative behaviors. As a result, European “repression and the growing assimilation of sex/gender ideologies” forced the disappearance of gender variant roles.
    So, by the time the twins Bruce and Brian were born, their society was well established in its rules regarding acceptable gender roles having been appropriated histrionically and transmitted generationally. It was very clear to the twins' parents what was expected. It was very clear to the twins' parents what was expected. A body without a penis had to have a vagina. There was no in between, because in the back and whiteness of pink and blue culture such standards are set to serve a larger purpose, that being those of the dominant prevailing ethnocentric power base. And ethnocentric values, thy name is 'capitalism', with its characteristic division of labor, which forces all of its subjects to chose from one of two optional roles to serve that end. And thus, the first question asked of a subject upon its arrival in the world is "what is it?".  So when the Reimer family was given a medical prescription for how to solve the dilemma forced upon them by this twist of fate, they jumped at the only chance they had to ensure what was promised to be the best solution for ensuring Bruce's psychological and social adjustment.
    The problem is, Bruce never succeeded in adjusting to the course imposed for him. Internally, his own innate genetic make up would fight all therapeutic attempts to make him out to be what was inherently against his biological nature. Externally, he would resist his family's attempts to socialize him as a biological female. The doctors tried to force him/her to have the surgery to complete his feminization but he resisted emphatically. He both felt and lived with the conflict churning inside, knowing intuitively that something was not right. Against their protestations,  he wanted to rough house; he wanted to shave like his father; he dreamed of fixing cars. By the time he reached adolescence, in a moment of sheer stress and frustration, his father blurted out the truth, that he was not a girl; that he had been born biologically male, and revealed what happened during the circumcision.
    Most disconcerting about the case of Bruce and his twin brother Brian (his entire family actually), is that having to live with such conflict destroyed their lives, much in the same manner that colonization, by forcing suppression, obliterated the perceived anomalies of gender variant cultures. The infamous Dr. Money, supported by the institutions that he represented, colonized the Reimers to adjust to the prevailing ideas stemming from ideologies that endorsed dimorphic classification. A similar process happened in India with the Hijra and Sadin; it happened in Thailand with its Kathoey, and in the Philippines with its Bakla, Bantu and Bayot, transforming through assimilation cultures that at one point functioned efficiently within the frame of egalitarian and horizontal structure. Understandably, those cultures untouched by the enforced vagaries of capitalism seemed most prone to maintaining a consistent homeostasis. Not having to strive continuously to strike a balance on the fickle teeter-totter of market ambiguity, these cultures lived the best of both worlds as they strove to satisfy the most basic needs and desires of the human spirit relative to the objectives for meeting the needs of both the individual and the larger cultural community.
    As the world continues to evolve as a global culture, one can only wonder what inventions power mongers will create to further control, manipulate and exploit human capital to serve its own gains.....one can only wonder.
   
http://www.cbc.ca/news/background/reimer/