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Kenneth J. Zucker: Chapter 45. Gender Identity Disorder in Children, Adolescents, and Adults, in Gabbard’s Treatments
of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc.
DOI: 10.1176/appi.books.9781585622986.261477. Printed 5/10/2009 from www.psychiatryonline.com
Gabbard’s Treatments of Psychiatric Disorders > Part VIII. Sexual and Gender Identity Disorders >
Chapter 45. Gender Identity Disorder in Children, Adolescents, and
Adults
INTRODUCTION
Since its introduction to the psychiatric nomenclature in DSM-III (American Psychiatric Association
1980), the study of gender identity disorder (GID) in children, adolescents, and adults has
advanced on several fronts: 1) its phenomenology has been well described; 2) the reliability and
validity of the diagnosis have been established with reasonable success; 3) associated features
have been identified; 4) follow-up studies have tracked its natural history; and 5) various
etiological hypotheses have been examined (for reviews, see Cohen-Kettenis and Gooren 1999;
Cohen-Kettenis and Pfäfflin 2003; Zucker 2004, 2005a, 2005b, 2006a; Zucker and Bradley 1995).
Research on the treatment of GID has, however, been more variable. On the one hand, treatment of
children has received relatively little research attention. In the first three editions of this textbook
(Green 1995; Zucker 2001; Zucker and Green 1989), one will find not a single randomized,
controlled treatment trial. Such a trial has still not been conducted. There have, however, been
some treatment effectiveness studies, although much is lacking in these investigations. In general,
the practitioner must rely largely on the “clinical wisdom” that has accumulated in the case report
literature and the conceptual underpinnings that inform the various approaches to intervention. On
the other hand, the treatment literature on adolescents and adults has a stronger empirical footing,
which points to the efficacy of sex-reassignment surgery (SRS) in carefully selected patients.
RATIONALES FOR THERAPEUTIC INTERVENTION
Five rationales for intervention have been discussed in the treatment literature. In considering
these rationales, a developmental perspective will be adopted, taking into account the time of
clinical presentation (i.e., childhood, adolescence, or adulthood).
Reduction of Social Ostracism
Clinical and empirical evidence shows that children with GID are subject to social ostracism,
particularly in the peer group (Cohen-Kettenis et al. 2003; Zucker et al. 1997). Such ostracism is
one correlate of the general behavioral and emotional difficulties found in these children
(Cohen-Kettenis et al. 2003; Zucker and Bradley 1995). The experience of social ostracism appears
to be stronger for boys than for girls with GID, which is consistent with findings in the normative
developmental literature that cross-gender behavior has greater negative sequelae for boys than
for girls. Although there is now a greater acceptance of both transgendered youth and adults, in
postmodern Western countries and in some non-Western cultures (Herdt 1994; L. K. Newman
2002), social stigma and “victimization” experiences persist (Harper and Schneider 2003). The film
Boys Don’t Cry, in which Hilary Swank won an Academy Award for her role as Brandon Teena, tells
the story of Teena (born Teena Brandon), a female-to-male transsexual from Nebraska who was
raped and subsequently murdered in 1993 at the age of 21 years after two of his male friends
discovered that he was “really” a woman (Sloop 2000; Willox 2003).
Case Example 1
Norton was a 10-year-old boy with an IQ of 81. He lived with his lower-middle-class parents and an older
sister. Apart from his marked cross-gender behavior, which had been of long-standing duration, he was
very separation anxious, had notable academic learning problems, had been previously diagnosed with
attention-deficit/hyperactivity disorder, and was on Ritalin. His parents requested an assessment afterPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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previous involvement at another agency had not resulted in any major changes in Norton’s cross-gender
behavior. Social ostracism was of particular concern, as it appeared to be getting worse. In the
neighborhood, Norton had no close friends. At school, he was called “fag, gay, stupid.” When asked why
he was called stupid, Norton commented, “I’m not that good at math.” Norton knew what the words “fag”
and “gay” meant: “Like you kiss another boy or you sleep with another boy.” Norton was fairly
demoralized about his peer relations: “They don’t care about me, they don’t like me, they never do
anything for me.” He talked about feeling “unappreciated” and acknowledged having revenge fantasies
toward boys after episodes of teasing. The girls at school were much more rejecting of Norton than they
had been in the past—several girls tried to convince him, but to no avail, that he was really now too old
to be playing with them and that he should learn how to play with the other boys. Norton’s parents noted
that he had never had a close friend and that he complained of loneliness. Because of the teasing, the
parents contemplated withdrawing Norton from school and teaching him at home.
Because the phenomenon of peer group “gender segregation” is such a salient aspect of a child’s
social world (Maccoby 1998), treatment interventions designed to improve the same-sex peer
group relations of children with GID might not only alleviate short-term social distress but also
prevent the development of longer-term psychopathological sequelae.
Of course, it could be argued that the children who tease, reject, or bully youngsters with GID are
the ones who should be treated, not the “victim” (Feder 1997). Along the same lines, one could
argue that children should be encouraged to have greater acceptance and tolerance of variations in
the gender-role behavior of their peers (Nordyke et al. 1977), one of the underlying themes in the
critically acclaimed film Ma Vie en Rose (“My Life in Pink”) (Kline 1998). Although these are
legitimate ideas in theory, the situation is usually more complex in practice. To some extent, the
focus on improving the peer group relations of children with GID needs to be considered within the
context of a broader therapeutic plan, including a good formulation of why the child is having so
much difficulty in making friends with same-sex peers. Even so, this does not negate the
importance of efforts to minimize peer rejection and isolation from a macrosocial interventionist
perspective (Soutter 1996; Wilson et al. 2005). Indeed, for adolescents with GID, placement in high
schools that are more “friendly” or tolerant of transgendered youth has become increasingly
common, along the same lines of identifying gay-positive educational milieus.
Treatment of Underlying Psychopathology
Several theoretical perspectives hold that GID originates within the context of family factors or
psychopathology. Such factors include parental conflict and trauma related to gender identity
issues in their own life histories, attachment issues during early development, and general
parent–child relational characteristics. Let us consider several examples.
Some mothers of boys with GID experience what Zucker and Bradley (1995) characterized as
“pathological gender mourning” (see also Zucker et al. 1993a, 1994). During the pregnancy with
the proband, there is a strong desire to have a daughter. After the son is born, these mothers have
great difficulty in coping with the disappointment of not having had a child of the preferred sex, and
this disappointment appears to be transmitted to the boy in complex ways.
Case Example 2
Mark was a 4-year-old boy with an IQ of 111. He lived with his middle-class parents and an older brother.
During the pregnancy, his mother had desired a daughter and recalled being quite depressed after his
birth. She reported a preoccupation with not having had a daughter; for example, she reported vivid
night dreams in which she was pregnant with a girl. Upon awakening, she became depressed when she
realized that it was just a dream. Such dreams had recurred throughout Mark’s life. Mark was reported to
have been a very difficult infant, and his parents recalled that he could be soothed only if his mother held
him. He would cry frantically if held by his father. At the time of assessment, Mark’s mother described
him as very oppositional in his relationship with her, and she found parenting him to be extremely
challenging. Although he was markedly noncompliant and prone to intense temper tantrums, Mark alsoPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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appeared to be very attuned to his mother’s feelings. For example, when she talked about the family
getting a cat, Mark, who was then 2 years old, began to meow. Mother recalled that Mark began to
cross-dress in her clothes shortly after she verbalized how “nice” it would be to have a girl in the family.
During the mother’s individual interview, she was asked to talk about what the desire for a girl meant to
her. With a great deal of sadness, she said that “Boys grow up and leave their mothers . . . then I’ll be
alone.” She talked about how this left her feeling “like there is a hole in my heart . . . it will never be
filled.”
Coates and Person (1985) posited that separation anxiety, activated by uneven maternal
availability, plays a pivotal role in the development of GID in boys. According to this model, severe
separation anxiety precedes the feminine behavior of the boys, which emerges in order “to restore
a fantasy tie to the physically or emotionally absent mother. In imitating ‘Mommy [the boy]
confuse[s] ‘being Mommy’ with ‘having Mommy.’ [Cross-gender behavior] appears to allay, in part,
the anxiety generated by the loss of the mother” (Coates and Person 1985, p. 708).
Case Example 3
Harvey was a 10-year-old boy with an IQ of 69. He lived with his mother. His father had died in a
construction accident prior to his birth. When Harvey was 2 years old, his mother returned with him to
her country of origin. He was left in the care of his maternal grandmother and his mother returned to
Canada to work. He was reunited with his mother at the age of 5. At that time, she observed that he
engaged in extensive cross-gender behaviors, including cross-dressing. Harvey’s mother worked long
hours, and after school, Harvey was looked after by a neighbor. Harvey complained bitterly, but with
sadness as well, that he never got to see his mother: “She’s always working and on the weekends she is
too busy shopping.” When home alone, Harvey often would take his mother’s scarves, wrap them around
his head, and give them female names, and he would then talk to them, in a manner akin to an
imaginary friend.
Some parents of children with GID report traumas in their own lives that have gender-specific
features; for example, Zucker and Bradley (1995) noted that in their series of girls with GID, about
25% of the mothers had a history of severe and chronic sexual abuse, often intrafamilial. The
femininity of these mothers was compromised by this experience, which also rendered them quite
wary about men and masculinity and contributed to substantial sexual dysfunction. Regarding
intergenerational transmission, the message to the daughters seemed to be that being female was
unsafe.
Case Example 4
Heidi was a 5-year-old girl with an IQ of 100. She lived with her working-class parents. Heidi’s mother
reported a complex history of intrafamilial sexual abuse. She believed that sexual abuse was extensive in
her family of origin, involving many first- and second-degree relatives. In my view, some of the mother’s
account of sexual abuse appeared to be along the lines of recovered memories activated in the course of
individual psychotherapy. Heidi’s mother suffered from debilitating health problems, resulting in multiple
surgeries (some of which were likely unnecessary) and subsequent bed rest, and she met criteria for
multiple psychiatric diagnoses, including dysthymic disorder and borderline personality disorder. When
Heidi was 2 years old, her mother developed the belief that Heidi had been molested by her paternal
grandfather. There was no physical evidence of trauma to the genitals, and Heidi denied that her
grandfather had ever touched her: “My mom keeps telling me that he did something to me, but he didn’t.
I keep telling her this, but she doesn’t believe me.” Although the mother had consulted various
professionals about the matter, there had been no substantiation of the abuse. As her mother talked to
Heidi about how dangerous the situation was, Heidi’s behavior gradually transformed: she rejected
wearing feminine clothing, insisted that her hair be cut short to look like a boy’s, began to call herself by
a boy’s name, and expressed a wish to have a sex change. During the assessment, the mother
commented, “I wonder if I have scared her about being a girl. Maybe she looks at me and thinks, ‘I don’t
want to be like her.'” Despite this insight, Heidi’s mother found it exceedingly difficult to stop talkingPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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about the alleged sexual abuse, even though the parents had kept her from the grandfather for several
years.
In boys with GID, the father’s role has been considered contributory in several ways: by his sheer
absence (e.g., due to separation, divorce, or death); psychological distance by virtue of behavioral
characteristics or gross psychopathology that interferes with the ability to parent; systemic factors
that devalue his parenting role; and behaviors that frighten the boy. All of these factors are viewed
as impairing the boy’s capacity to identify with his father and thus weakening a masculine gender
identification (Stoller 1979).
Case Example 5
Hank was a 3-year-old boy with an IQ of 116. He lived with his lower-middle-class parents and an older
brother. Apart from behaviors consistent with GID, he was described by his parents as quite separation
anxious and very oppositional. He had great difficulty separating from his mother, both at nursery school
and at home. His noncompliant behavior often resulted in conflict with his parents. Hank constantly
tested limits and, at one point, exclaimed “I can do anything I want.” Hank’s father had a very close
relationship with his older son and they spent a lot of time together attending athletic events, including
team sports at which the son excelled. Prior to Hank’s birth, there had been complex marital difficulties,
partly related to the father’s increased use of recreational drugs and alcohol, and in fact, there had been
a brief marital separation as a result. Hank’s father reported having had very little to do with him during
his infancy and toddlerhood. This appeared related to Hank being experienced as a challenging baby to
look after (e.g., that he would be soothed only if mother and grandmother held him), father’s greater
comfort in relating to his older son, and his withdrawal from the family matrix secondary to his substance
abuse. As a result, Hank appeared to have very little connection to his father.
Within the framework of understanding GID in the context of family factors, it is argued that
attention to underlying issues that both precipitate and maintain the GID needs to be the focus of
therapeutic intervention (Di Ceglie 1998). In fact, some therapists who subscribe to this
perspective state that they do not focus their treatment on the cross-gender behavior per se or try
to alter it in any direct way (Bleiberg et al. 1986; Gilpin et al. 1979).
Treatment of Distress Associated With Gender Identity Disorder
In the DSM, the presence of a disorder, by definition, assumes that there is associated distress
and/or impairment. Although the assessment of distress in child psychiatric disorders, including
GID, is a complex task with little in the way of systematic empirical research (Zucker 1999a), many
child clinicians argue that the distress that is often observed in children with GID is a compelling
rationale for intervention. Children with GID can be observed to manifest such distress in various
ways: behavioral and ideational preoccupation with gender, verbal comments that reflect
unhappiness about gender, verbal and behavioral disparagement of sexual anatomy (Lothstein
1992), and so on (see Zucker et al. 1993b).
Case Example 6
Nathan was a 5-year-old boy with an IQ of 110. He lived with his middle-class parents and an older
sibling. Since the age of 2 years, he had shown the various behavioral signs of GID. He repeatedly told
his parents that he hated being a boy and that he wanted a vagina. He described other boys as “ugly and
mean.” For Christmas, he asked Santa Claus for only one present: “to turn me into a girl.”
In adolescents and adults, the strong sense of distress (gender dysphoria) is most commonly
manifested in the desire to align one’s body—via contrasex hormones and SRS (in females:
mastectomy, phalloplasty; in males: penectomy/castration; vaginoplasty)—with one’s psychological
gender.
Case Example 7Print: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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Samantha (“Sam”) was a 17-year-old girl with an IQ of 100. She lived with her lower-middle-class
mother and stepfather. She had a childhood history of girlhood masculinity, which her parents interpreted
as “tomboyism” because Samantha never voiced the desire to be a boy. After a period in early
adolescence of identifying as a lesbian, Samantha reported an increasingly strong feeling that she should
be a boy; in fact, she indicated that the idea of being a lesbian nauseated her: “Doc, to be honest,
lesbians make me sick. No offense. I got nothin’ against lesbians. It’s just not for me. I want to be
normal.” At the time of assessment, Sam recalled that she had found her pubertal development
extremely distressing. She was horrified when she began to menstruate and when she started to develop
breasts. Looking at her own feminized body was extremely difficult. As an example, Sam noted that when
she showered, she was compelled to look “straight ahead” and to count backward from 100. As these
feelings intensified, Sam reported a deepening sense of despair, acknowledged several episodes of
cutting herself, and reported struggling with suicidal feelings: “I can’t take it anymore.” Sam desired
masculinizing hormonal treatment, wanted her breasts removed, and asked for an operation that would
give her a “dick.”
Prevention of Gender Identity Disorder (Transsexualism) in Adulthood
A fourth rationale for the treatment of GID during childhood is that such treatment might prevent
its continuation into adolescence and adulthood. For some clinicians, there is little disagreement
about this, given the emotional distress experienced by adults with GID and the physically and
often socially painful measures required to align an adult’s phenotypic sex with his or her
subjective gender identity. In some respects, this rationale is consistent with general notions about
“prevention” or altering the natural history of a disorder.
Prevention of Homosexuality in Adulthood
Follow-up studies of boys with GID, largely untreated, indicate that homosexuality, not
transsexualism, is the most common long-term psychosexual outcome (Green 1987). Some parents
of children with GID request treatment, in part, with an eye toward preventing subsequent
homosexuality in their child.
Case Example 8
Abraham was a 4-year-old boy with an IQ of 117. He lived with his middle-class parents and several
siblings. Identification with ethnic heritage, including cultural traditions and religion, played a strong role
in the family’s life. In terms of political ideology, the father was conservative and the mother was liberal.
Beginning at around the age of 2 years, Abraham began to manifest the behavioral signs of GID. The
parents had been quite tentative in deciding how to deal with Abraham’s cross-gender behavior. After
reflecting on an article on GID provided to them by their pediatrician, the parents decided to have an
evaluation. During an intake telephone interview, Abraham’s mother commented: “I think I have a son
who is predisposed to homosexuality. . . . To be blunt, I want to steer my son in the direction of
heterosexuality.”
Among mental health professionals, the view that homosexuality per se is not a mental disorder is
fairly well accepted, although dissenters can still be found (see Drescher and Zucker 2006; Spitzer
2003). Given the relation between GID in childhood and a later homosexual orientation, critics have
questioned the therapeutic agenda of child clinicians. Regarding this matter, Green (1987) mused:
Should parents have the prerogative of choosing therapy for their gender-atypical son? Suppose that
boys who play with dolls rather than trucks, who role-play as mother rather than as father, and who play
only with girls tend disproportionately to evolve as homosexual men. Suppose that parents know this, or
suspect this. The rights of parents to oversee the development of children is a long-established principle.
Who is to dictate that parents may not try to raise their children in a manner that maximizes the
possibility of a heterosexual outcome? If that prerogative is denied, should parents also be denied the
right to raise their children as atheists? Or as priests? (p. 260)Print: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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Over the past 15 years or so, this rationale for treatment has been subject to even further scrutiny
(Minter 1999; Sedgwick 1991). Some critics, for example, have argued that clinicians, consciously
or unconsciously, accept the prevention of homosexuality as a legitimate therapeutic goal (Pleak
1999). Minter (1999) claimed, as have others (Burke 1996; Scholinski 1997a, 1997b), that some
adolescents in the United States have been hospitalized against their will because of their
homosexual orientation but under the guise of the GID diagnosis. To my knowledge, however, these
allegations have not been verified in any systematic manner, and I am personally aware of no such
case in which this has occurred (see also Meyer-Bahlburg 1999). Others have asserted, albeit
without direct empirical documentation, that treatment of GID results in harm to children who are
“homosexual” or “prehomosexual” (Isay 1997, 1999). Some clinicians have raised questions about
differential diagnosis, suggesting that there is not always an adequate distinction between children
who are truly GID versus those who are merely prehomosexual (Corbett 1996, 1998; Richardson
1996, 1999). In response to some of these concerns, the Human Rights Commission of the city and
county of San Francisco passed a resolution on September 12, 1996, that condemned “any
treatment designed to manipulate a young person’s . . . gender identity.”
The various issues regarding the relation between GID and homosexuality are complex, both
clinically and ethically. Three points, albeit brief, can be made. First, until it has been shown that
any form of treatment for GID during childhood affects later sexual orientation, Green’s (1987)
query about parental rights is moot. From an ethical standpoint, however, the treating clinician has
an obligation to inform parents about the state of the empirical database. Second, I have argued
elsewhere that some critics incorrectly conflate gender identity and sexual orientation, regarding
them as isomorphic phenomena (Zucker 1999b), as do some parents. Psychoeducational work with
parents can review the various explanatory models regarding the statistical linkage between
gender identity and sexual orientation (Bailey and Zucker 1995; Bem 1996) but should also discuss
their distinctness as psychological constructs. Third, many contemporary child clinicians emphasize
that the primary goal of treatment with children with GID is to resolve the conflicts that are
associated with the disorder per se, regardless of the child’s eventual sexual orientation.
Summary of Rationales
There are various rationales for offering treatment to children with GID. Some of these rationales
rest on firmer empirical or ethical grounds than others. At least four goals—elimination of peer
ostracism in childhood, treatment of other psychopathology, reduction of the felt distress, and
prevention of transsexualism in adulthood—are so obviously clinically valid and consistent with the
ethics of our time that they would constitute sufficient justification for therapeutic intervention. In
my view, the primary goal of avoiding adult homosexuality is, for a variety of reasons, considerably
more problematic, and the contemporary clinician must be sensitive to the myriad of therapeutic
and ethical issues that this matter raises. Thus, the treating clinician needs to think through these
issues carefully and to develop a working relationship with families that is sensitive, empathic, and
responsive to the complex reactions that matters pertaining to psychosexuality engender in most
people.
TREATMENT OF THE CHILD
Behavior Therapy
The literature contains 13 single-case reports that employed a behavior therapy approach to the
treatment of GID in children (12 boys, 1 girl), the majority of which are from Rekers and his
associates (for references, see Rekers 1985; Zucker 2001; for a detailed outline of the subject and
treatment characteristics of the case reports by Rekers and colleagues, see Zucker 1985, Table 15).
The classical behavioral approach assumes that children learn sex-typed behaviors much as they
learn any other behaviors and that sex-typed behaviors can be shaped, at least initially, by
encouraging some and discouraging others. Accordingly, behavior therapy for GID systematically
arranges to have rewards follow sex-appropriate behaviors and to have no rewards (or perhaps
punishments) follow sex-inappropriate behaviors. The behavioral targets of intervention havePrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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included a variety of cross-gender behaviors, including toy and dress-up play, role-playing,
exclusive affiliation with the opposite sex, and mannerisms. In addition, some treatments have
focused on behavioral deficiencies, such as poor athletic ability. None of the case reports focused
specifically on the child’s verbal statements or fantasies about wanting to be of the opposite sex.
Strictly speaking, therefore, the aim of the behavioral interventions has been to modify specific
overt sex-typed behaviors rather than gender identity or gender dysphoria.
One type of intervention employed has been termed differential social attention or social
reinforcement. As stated by Rekers and Lovaas (1974), the therapeutic goal of such an intervention
(for boys) was to “extinguish feminine behavior and develop masculine behavior” (p. 179). This
type of intervention has been applied in clinic settings, particularly to sex-typed play behaviors. The
therapist first establishes with baseline measures that the child (either when alone or in the
presence of a noninteracting adult) prefers playing with cross-sex toys or dress-up apparel rather
than same-sex toys or dress-up apparel. A parent or stranger is then introduced into the playroom
and instructed to attend to the child’s same-sex play (e.g., by looking, smiling, and verbal praise)
and to ignore the child’s cross-sex play (e.g., by looking away and pretending to read). Such adult
responses seem to elicit rather sharp changes in play behavior.
As noted by Rekers and colleagues, there have been two main limitations to the use of social
attention or reinforcement in treating cross-gender behavior. First, at least some of the children
studied reverted to cross-sex play patterns in the adult’s absence or in other environments, such as
the home—a phenomenon known as stimulus specificity (Rekers 1975). Second, there was little
generalization to untreated cross-sex behaviors—a phenomenon known as response
specificity. Rekers and Lovaas (1974) reported that the same limitations applied to the use of a
token economy system in which the child was given “points” for engaging in same-sex behaviors or
penalized points for engaging in cross-sex behaviors.
The problems of stimulus and response specificity have led behavior therapists to seek more
effective strategies of promoting generalization. One such strategy, self-regulation, has the child
reinforce himself or herself when engaging in a sex-typical behavior. This eliminates the necessity
of providing external reinforcement, which may not always be feasible. Blount and Stokes (1984)
suggested that by allowing the child to control his or her behavior, the “problems of generalization
from one setting to another and from the presence to the absence of external behavior change
agents may be avoided” (p. 196).
Rekers and Varni (1977a), (1977b) and Rekers and Mead (1979) reported on three cases in which
self-regulation procedures were employed. In one of these reports (Rekers and Varni 1977b), a
4-year-old boy was fitted with a wrist counter and told to press it only when playing with “boys’
toys.” This behavior was initially facilitated by “behavioral cuing,” in which the boy wore a
“bug-in-the-ear” device and was told when to press the counter. This self-monitoring procedure
resulted in substantial decreases in cross-sex play, and there was also some evidence of
generalization; however, as noted in detail elsewhere (Zucker 1985), the reports of Rekers and his
associates provide weak evidence for the claim that generalization is better promoted by
self-regulation than by social attention.
Evaluation of the Short-Term Effectiveness of Behavior Therapy
An overall examination of the case reports cited above, particularly those by Rekers and colleagues,
suggests that behavior therapy techniques do have some immediate effect on the sex-typed
behavior of children with GID. For example, Rekers and co-workers have provided short-term
follow-ups of their cases, ranging from 5 weeks to 3.5 years after treatment, using a variety of
formats: clinical interviews of the child and the family, home and school observations, and
psychological tests. The general picture painted by Rekers and colleagues is that all of their
patients showed reductions in cross-sex behavior by the end of treatment and that these reductions
were being maintained at follow-up. Presumably, the children were also no longer wishing to
change their sex; this is not always specifically stated, but it is likely that it can be safely inferred.Print: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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Although behavior therapy has had some success in treating children with GID, a few critical
comments are in order. First, it is obvious that behavioral improvements at follow-up cannot be
unequivocally attributed to the treatment intervention without the use of a comparison group of
untreated children to control for “spontaneous” remission or simple maturation effects. If the case
reports by Rekers and his group are examined closely, as was done elsewhere (Zucker 1985), it
becomes apparent that some of the changes noted at follow-up could not have been due solely to
treatment, because these changes had not appeared by the time treatment was completed—unless
one is willing to attribute the changes to “sleeper effects.” Second, behavior therapists have not
explained the apparent changes in gender identity (i.e., the child’s desire to be of the opposite sex),
which occurred even though this variable was not targeted for modification; this finding requires
explanation because the previously noted phenomenon of response specificity would lead one to
expect the retention of untreated behaviors. Finally, it is unclear whether the cases reported on can
be generalized to all children with GID; these cases may have been especially amenable to
treatment because of particular characteristics (e.g., low levels of general psychopathology, highly
motivated parents).
Evaluation of the Long-Term Effectiveness of Behavior Therapy
What do we know about the long-term outcome of children with GID treated by behavior therapy
techniques? Unfortunately, not very much. Rekers and his group have provided only hints of what
they have found over the long run. Rekers (1985) reported that more than 50 children had been
“comprehensively treated” and that follow-up results suggested “permanent changes in gender
identity.” From this, one assumes that there was an absence of gender dysphoria and no desire for
sex-reassignment surgery. Specific information, however, was not provided. Rekers et al. (1990)
provided group analysis of 29 boys treated by behavior therapy techniques. At a mean follow-up of
51 months after treatment, it was found that “completion” of treatment accounted for 20% of the
variance in change scores, as defined by a reduction in ratings of cross-gender identification.
Unfortunately, there have been no published reports on longer-term follow-ups that assess the
adolescent gender identity and sexual orientation of the 29 boys. It is of interest, therefore, that
Rekers (1986) claimed, without formal substantiation, that from “the result of my research studies,
it now appears that a preventive treatment for transvestism, transsexualism, and some forms of
homosexuality has indeed been isolated” (p. 28).
One final word about the behavioral approach to treatment is in order. It is of interest that the
behavior therapy literature has produced no new case reports for over 20 years, although its
principles are often used in broader treatment approaches that involve the parents (see “Treatment
of the Parents” subsection below). This publication gap is curious, because more contemporary
behavioral approaches, such as cognitive-behavioral therapy, are now used so widely in child
psychiatry with other disorders.
Behavior therapy with an emphasis on the child’s cognitive structures regarding gender could be an
interesting and novel approach to treatment. There is now a fairly large literature on the
development of cognitive gender schemas in nonreferred children (Martin et al. 2002). It is possible
that children with GID have more elaborately developed cross-gender schemas than same-gender
schemas and that more positive affective appraisals are differentiated for the latter than for the
former (e.g., in boys, “Girls get to wear prettier clothes” vs. “Boys are too rough”). A cognitive
approach to treatment might help children with GID to develop more flexible and realistic notions
about gender-related traits (e.g., “Boys can wear pretty cool clothes too” or “There are lots of boys
who don’t like to be rough”), which may result in more positive gender feelings about being a boy
or being a girl.
Psychotherapy
There is a large case report literature on the treatment of children with GID using psychoanalysis,
psychoanalytic psychotherapy, or psychotherapy, some of which is quite detailed and rich in
content (for references, see Zucker 2001; see also Clifford 1997; de Ahumada 2003; Knight 2003a,
2003b; Mehta 2002; Yanof 2000; Zients 2003). The psychoanalytic treatment literature is morePrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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diverse than the behavior therapy literature, including varied theoretical approaches to
understanding the putative etiology of GID (e.g., classical, object relations, self psychology);
nevertheless, a number of recurring themes can be gleaned from this case report literature.
Psychoanalytic clinicians generally emphasize that the cross-gender behavior emerges during the
“preoedipal” years; accordingly, they stress the importance of understanding how the GID relates
to other developmental phenomena salient during these years—for example, attachment (object)
relations and the emergence of the autonomous self. Oedipal issues are also deemed important, but
these are understood within the context of prior developmental interferences and conflicts.
Psychoanalytic clinicians also place great weight on the child’s overall adaptive functioning, which
they view as critical in determining the therapeutic approach to the specific referral problem.
Apart from the general developmental perspective inherent to a psychoanalytic understanding of
psychopathology, one might also add to this a gender-specific perspective on development (Martin
et al. 2002). Many developmentalists, for example, note that the first signs of normative gender
development appear during the toddler years, including the ability to correctly self-label oneself as
a boy or a girl. Some authors have even postulated a sensitive period for gender identity formation
(Money et al. 1957), which suggests a period of time in which there is a greater malleability or
plasticity in the direction that gender identity can move (Coates 1990). Thus, early gender identity
formation intersects quite neatly with analytic views on the early development of the sense of self
in more global terms. It is likely, therefore, that the putative pathogenic mechanisms identified in
the development of GID are likely to have a greater impact only if they occur during the alleged
sensitive period for gender identity formation (Coates and Wolfe 1995).
Some of the more common themes identified in the analytic literature are reviewed below.
Mother–Child Relations
Some case reports of boys noted that an actual physical loss of the mother (or a mother surrogate)
preceded the emergence of feminine behaviors (e.g., Gilpin et al. 1979; Wallach 1961). This loss
was understood to create a vulnerability in the child that, at least in part, was dealt with
defensively by resort to the use of behavioral enactments of gender representations (a “fetish” in
the older analytic literature) to cope with the loss of the mother. In this view, the goal of therapy
would be to help the child work through the loss of the attachment figure, which would presumably
then alleviate the internal pressure to engage in cross-gender reenactments of the lost mother.
In some other case reports, a psychological loss or withdrawal of the mother was deemed
important (e.g., Pruett and Dahl 1982). Coates (1985) reported a high rate of adverse life events
experienced by the mothers of boys with GID during the putative sensitive period for gender
identity formation. These events included physical and sexual assault, death of another child in the
family, and husbands’ extramarital affairs. Among others, Coates et al. (1991) and Schultz (1979)
have provided detailed accounts of this perspective. As noted earlier, the psychological
sequelae—separation anxiety, feminine behavior, and so on—are then the same as those for boys
who physically lose their mothers.
Other psychotherapists have explained feminine behavior in boys in precisely the opposite way:
Feminine identification is caused by an excessive closeness to the mother, not by an excessive
distance (e.g., Greenson 1966; Stoller 1966). In this view, the therapeutic task would be to help the
boy individuate from his mother. Finally, other clinicians report fluctuations between a distant or
unpredictably available mother and a mother who is periodically enmeshed with her son.
Case Example 9
Ricky was a 4-year-old boy with an IQ of 107. He lived with his middle-class parents. Ricky was described
by his mother as having been feminine “since the day he was born.” She stated that he was always drawn
to women, that he was attuned to their beauty, and that he had no men in his life. She described his
father as ineffectual and that she had to do “everything.” Ricky’s mother had deeply ambivalent feelings
about his cross-gender behavior. On the one hand, she was concerned that he was going to be teasedPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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and isolated; on the other hand, she did not think that there was anything “wrong” about his feminine
behavior, even the fact that Ricky insisted that he was a girl: “As long as he’s happy . . . if he wants to
become a woman, I’ll be there for him.” Her female friends expressed their concerns about Ricky’s
feminine preoccupations, but his mother’s view was that it was their problem. Ricky’s father felt that his
efforts to encourage his son to “act more like a boy” were viewed with disdain by his wife: “She thinks
that I’m macho just because I think it is inappropriate to let him wear a dress when we go out.” Ricky’s
mother said to his father that “You’re just upset that your son is, or will be, gay.” Ricky was unplanned
and his mother reported that she was miserable during the pregnancy. She gained a lot of weight, was
depressed, and chose not to fantasize about the baby: “I didn’t want it and I didn’t want to think about
it.” During his infancy, she reported extreme fatigue and had symptoms of depression: “All I wanted to
do was to sleep.” By the time Ricky was 2 years old, his mother reported that they “could read each
other’s mind . . . we’re like one person . . . I can finish his sentences and he can finish mine. . . . When I
look into his eyes, I see myself . . . we’re like twins.”
Father–Child Relations
The role of the father has received comment in many case reports. In a majority of these reports,
the father was described as physically absent or psychologically peripheral (e.g., Haber 1991) and
hence unavailable to counteract or buffer the distortions in the mother–son relationship. In other
reports, the father was described as severely disturbed and unpredictably aggressive and therefore
difficult for the son to identify with (e.g., Fischhoff 1964).
If the father is truly remote or psychologically disturbed in his own right, part of the therapeutic
task with the boy is to help him develop a more diverse perception of men and maleness and thus
to assimilate and work through the negative impact of the father’s psychopathology and build on
whatever strengths might exist in the father-son relationship or with other adult males. It is
possible that when the therapist is a male, transference phenomena (e.g., idealization,
identification) can be more readily used to facilitate a masculine identification.
Parental Encouragement of Cross-Gender Behavior
Stoller (1968) emphasized the effects of parental attitudes toward masculinity and femininity on
the child’s development. He argued that the mothers of extremely feminine boys had had gender
identity conflicts as children, which led them to devalue men and masculinity and that this
devaluation is felt by the young boy, who somehow comes to believe that his mother will reject him
if he is masculine but that he can preserve his relationship with her if he is feminine. Other reports
have also implicated mothers’ (or grandmothers’) encouragement of femininity and devaluation of
men in the development of GID in boys (e.g., Bleiberg et al. 1986; Loeb 1992). Although the
motivations that were judged to underlie this aspect of parental behavior appeared to vary
considerably, it is of interest that the proximal variable of parental tolerance or encouragement of
cross-gender behavior has been apparent in the intensive case reports offered by psychotherapists,
which converges with the observations of those who hold other theoretical perspectives (see
Zucker and Bradley 1995).
Eclectic Psychotherapy
Influenced by Stoller’s (1968) claim that extremely feminine boys did not experience internalized
conflict—and thus were not amenable to psychoanalysis—Green et al. (1972) developed a more
eclectic and multimodal approach to the psychotherapy of boys with GID (for references, see
Zucker 2001). The therapeutic approach of Green et al. (1972) had four stated objectives: 1)
developing a relationship of “trust and affection” between the boy and a male therapist, 2)
heightening parental concern regarding the boy’s femininity, 3) increasing the father’s involvement
in the boy’s life, and 4) sensitizing the parents to the dynamics of their own relationship in order to
alter the mother–son overcloseness and the father’s peripheral role in the family. The aim of the
therapy was intended to help feminine boys “understand” the motives for their cross-gender
behavior and to indicate to such boys that being masculine is “good.” Thus, approval was given forPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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“any signs of masculinity” in either overt behavior or fantasy.
Evaluation of the Effectiveness of Psychotherapy
An overall examination of the available case reports suggests that psychotherapy, like behavior
therapy, does have some beneficial influence on the sex-typed behavior of children with GID.
However, the effectiveness of psychoanalytic psychotherapy, like that of behavior therapy, has
never been demonstrated in an outcome study comparing children randomly assigned to treated
and untreated conditions. Moreover, many of the cases cited above did not consist solely of
psychoanalytic treatment of the child. The parents were often also in therapy, and in some of the
cases, the child was an inpatient and thus exposed to other interventions. It is impossible to
disentangle these other potential therapeutic influences from the effect of the psychotherapy alone.
What do we know about the long-term outcome of children with GID treated with psychotherapy
techniques? Again, not very much. There has been very little in the way of published long-term
follow-up reports assessing gender identity, sexual orientation, and general adaptive functioning.
Group Therapy
Another approach to the treatment of boys with GID has involved group therapy. Green and Fuller
(1973) reported on the group treatment of seven boys (age range 4–9 years). Each of these boys
was reported to be aware, in varying degrees, “of the reason for his inclusion in the group.” Weekly
sessions were held in a recreational area with a male therapist who verbally reinforced the boys for
nonfeminine, socially competent behaviors and verbally admonished them for feminine behaviors.
At these sessions, the boys themselves often criticized one another for feminine behaviors. It was
reported that both parental narratives and behavioral ratings of the boys indicated “change on a
variety of parameters” concerned with cross-gender identification. Detailed analyses were not,
however, available.
Bates et al. (1975) employed group therapy with gender-problem boys who were mainly between
the ages of 8 and 13 years. Their program emphasized the encouragement of masculine behavior
and general social skills. In contrast to the approach of Green and Fuller (1973), feminine behavior
was not explicitly discouraged. Both modeling by the therapists and more structured behavior
modification techniques were used. Concurrent with the children’s group, the parents also met in
groups, with one of the main goals being to work on ways to improve the father-son relationship.
Although systematic data were not recorded, Bates et al. (1975) felt that the boys showed
“recognizable improvement . . . both in terms of social skills development and in the development
of masculine interests and abilities” (p. 154). Parent and verbal reports indicated similar changes in
the neighborhood and at school, including “less interest in cross-dressing, doll play, and imitating
females.”
Meyer-Bahlburg (2002) also emphasized the role of the peer group in facilitating behavioral
change. The main strategy in Meyer-Bahlburg’s treatment protocol was to have the parents of boys
with GID arrange consistent “play dates” for their sons with other boys. Many boys with GID avoid
boys as playmates and are often anxious about involvement in rough-and-tumble play. If the
parents of such boys are able to find other boys whom their sons do not experience as too
threatening, those boys could serve as role models for the development of more gender-typical play
and activities. Meyer-Bahlburg (2002) indicated that this approach appeared effective in reducing
cross-gender behavior after a short time and that the boys were able to develop successfully the
friendships they formed in this way. Unfortunately, detailed information was lacking.
Treatment of the Parents
Two rationales have been offered for parental involvement in treatment. The first emphasizes the
hypothesized role of parental dynamics and psychopathology in the genesis or maintenance of the
disorder. From this perspective, individual therapy with the child will probably proceed more
smoothly and quickly if the parents are able to gain some insight into their own contribution to
their child’s difficulties. Many clinicians who have worked extensively with gender-disturbedPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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children subscribe to this rationale (Coates and Wolfe 1997; Green et al. 1972; L. E. Newman 1976;
Stoller 1978; Zucker 2006b). In this context, it is important to note that a treatment plan requires
an assessment of the parents as much as it does of the child, as is the case with many child
psychiatric disorders. Assessment of psychopathology and the marital relationship in the parents of
children with GID reveals great variability in adaptive functioning, which may well prove to be a
prognostic factor (for review, see Marantz and Coates 1991; Zucker and Bradley 1995, 2000).
The second rationale is that parents will benefit from regular formalized contact with the therapist
to discuss day-to-day management issues that arise in carrying out the overall therapeutic plan.
Work with parents can focus on setting limits with regard to cross-gender behavior, such as
cross-dressing, cross-gender role and fantasy play, and cross-gender toy play, and, at the same
time, attempting to provide alternative activities (e.g., encouragement of same-sex peer relations
and involvement in more gender-typical and neutral activities). In addition, parents can work on
conveying to their child that they are trying to help him or her feel better about being a boy or a girl
and that they want their child to be happier in this regard. Some parents, especially the
well-functioning and intellectually sophisticated ones, are able to carry out these recommendations
relatively easily and without ambivalence. Many parents, however, require ongoing support in
implementing the recommendations, perhaps because of their own ambivalence and reservations
about gender identity issues (see, e.g., L. E. Newman 1976).
Case Example 10
Harry was a 4-year-old boy with an IQ of 121. He had an older brother and lived with his parents, who
were of a lower-middle-class background. At the time of assessment, his parents were about to separate.
During Harry’s life, his parents’ relationship had deteriorated as a result of many issues, including an
affair on his father’s part, multiple disagreements about lifestyle and parenting issues, and his mother’s
deteriorating psychiatric state, which had required inpatient treatment after a suicide attempt when
Harry was around 18 months old. Harry had displayed signs of cross-gender behavior since the age of 2
years, including compulsive and frantic cross-dressing and the verbalized desire to become a girl. His
mother expressed marked ambivalence about treating Harry’s GID: “This is who he is . . . if I tell him not
to, I will destroy his basic essence.” Exploration of the mother’s life history revealed many reasons for
her ambivalence about men and masculinity. She had grown up in a family in which her father was
largely absent, she had been gang-raped at the age of 13 years (following which she had developed a
severe eating disorder), and in her relationship with her husband, she had found sexual intimacy
increasingly aversive. For Harry’s mother, fantasy aggression (e.g., sword play, squirt-gun play) was
equated with real aggression, and she worried that if such behavior was encouraged in Harry that he
would develop into a rapist. Apart from the mother’s ambivalence about masculinity, she also enjoyed
Harry’s “feminine side”: he would often brush her hair and bring her tea when she was depressed and
bedridden. Thus, there was suggestive evidence that Harry took care of his mother and that, in her mind,
there was the risk of losing Harry if he became more autonomous from her, which was equated with his
becoming more masculine.
Technical Aspects of Limit Setting
In my experience, there are some technical aspects of limit setting that are often misunderstood.
Thus, the role of limit setting in treatment requires some consideration of conceptual and
contextual issues. A common error committed by some clinicians is to simply recommend to parents
that they impose limits on their child’s cross-gender behavior without attention to context. This
kind of authoritarian approach is likely to fail, just like it will with regard to any behavior, because
it does not take into account systemic factors, both in the parents and in the child, that contribute
to symptom perpetuation. At the very least, a psychoeducational approach is required, but in many
cases, limit setting needs to occur within the context of a more global treatment plan. From a
psychoeducational point of view, one rationale for limit setting is that if parents allow their child to
continue to engage in cross-gender behavior, the GID is, in effect, being tolerated, if not reinforced.
Another rationale for limit setting is that it is an effort to alter the GID from the “outside in,” whilePrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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individual therapy for the child can explore the factors that have contributed to the GID from the
“inside out.” At the same time that they attempt to set limits, parents also need to help their child
with alternative activities that might help consolidate a more comfortable same-gender
identification. As noted earlier, encouragement of same-sex peer group relations can be an
important part of such alternatives. Some boys with GID develop an avoidance of male playmates
because they are anxious about rough-and-tumble play and fantasy aggression. Such anxiety may
be fueled by parent factors (e.g., where mothers conflate real aggression with fantasy aggression)
but may also be fueled by temperamental characteristics of the child (Zucker 2000a). Efforts on the
part of parents to be more sensitive to their child’s temperamental characteristics may be quite
helpful in planning peer group encounters that are not experienced by the child as threatening and
overwhelming. It is not unusual to encounter boys with GID who have a genuine longing to interact
with other boys but, because of their shy and avoidant temperament, do not know how to integrate
themselves with other boys, particularly if they experience the contextual situation as threatening.
Over time, with the appropriate therapeutic support, such boys are able to develop same-sex peer
group relationships and, as a result, begin to identify more with other boys.
Another important contextual aspect of limit setting is to explore with parents their initial
encouragement or tolerance of the cross-gender behavior. Some parents will tolerate the behavior
initially because they have been told, or believe themselves, that the behavior is “only a phase”
that their child will grow out of or that “all children” engage in such behavior. For such parents,
they become concerned about their child once they begin to recognize that the behavior is not
merely a phase (Zucker 2000b). For other parents, the tolerance or encouragement of cross-gender
behavior can be linked to some of the systemic and dynamic factors described earlier (see, e.g.,
Walters and Whitehead 1997). In these more complex clinical situations, one must attend to the
underlying issues and work them through. Otherwise, it is quite likely that parents will not be
comfortable in shifting their position.
Case Example 11
Shawn was a 7-year-old boy with an IQ of 115. He lived with his middle-class parents and an older
sibling. Since the age of 3, Shawn had engaged in all of the behaviors that comprise the GID diagnosis.
Shawn’s mother spoke on a regular basis with her pediatrician, who reassured her that the behaviors
were “normal” for a boy “until” the ages of 6 or 7 years. Prior to the referral, Shawn was cross-dressing;
when his mother spoke to him about it, he became tearful and said, “Mom, I just can’t let go of wanting
to be a girl.” Apart from the GID, Shawn was emotionally labile and prone to temper tantrums when he
did not get his own way. Shawn’s parents had a close marital relationship and generally functioned well.
The one clear area of disagreement in their relationship concerned Shawn’s cross-gender behavior. In
general, the father deferred to the mother with regard to parenting issues. Shawn’s mother did not know
if limit setting was an appropriate approach to take with her son, and the advice of the pediatrician
reassured her that his behavior was “only a phase.” During the assessment, it became apparent that
Shawn’s father had been “boiling” for many years with regard to his wife’s tolerance and encouragement
of the cross-gender behavior. The parents were stalemated on this issue, and the mother would covertly
buy Shawn Barbie dolls. The increase in Shawn’s felt distress about being a boy and the recent increase
in social ostracism led the mother to rethink her position. Clinical observation indicated that Shawn was
very attuned to his mother’s position on various matters. Once she began to verbalize to Shawn that she
wanted him to feel happier about being a boy, he rather easily stopped cross-dressing in her clothes,
stopped playing with Barbie dolls, and, with parental support, began to develop close friendships with
other boys. With the shift in the family system, Shawn and his father were able to develop mutual
interests and began to spend much more time together, which they both immensely enjoyed.
Although many contemporary clinicians have stressed the important role of working with the
parents of children with GID, one can ask if there is any empirical evidence that this is effective.
Again, systematic information on the question is scanty. The most relevant study (Zucker et al.
1985) found some evidence that parental involvement in therapy was significantly correlated with a
greater degree of behavioral change in the child at a 1-year follow-up, but this study did not makePrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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random assignment to different treatment protocols, so one has to interpret the findings with
caution.
Supportive Treatments
In the past few years, clinicians critical of conceptualizing marked cross-gender behavior in
children as a disorder have provided a dissenting perspective to the treatment approaches
described so far (Menvielle and Tuerk 2002; Menvielle et al. 2005; Pickstone-Taylor 2003;
Rosenberg 2002). These clinicians appear to conceptualize GID or pervasive gender-variant
behavior from an essentialist perspective (i.e., that it is fully constitutional or congenital in origin)
and are skeptical about the role of psychosocial or psychodynamic factors (Bradley and Zucker
2003). Although Menvielle and Tuerk (2002) suggest that it might be helpful to set limits on
pervasive cross-gender behaviors that may contribute to social ostracism, they note that their
treatment (offered in the context of a parent support group) was aimed “not at changing the
children’s behavior, but at helping parents to be supportive and to maximize opportunities for the
children’s adjustment” (p. 2002). Menvielle et al. (2005) have taken a somewhat stronger position,
arguing that “[t]herapists who advocate changing gender-variant behaviors should be avoided” (p.
45).
Because comparative treatment approaches are not available, it is not possible to say whether or
not this supportive or “cross-gender affirming” approach will result in both short-term and
long-term outcomes any different from the more traditional approaches to treatment. The
supportive approach does, however, highlight a variety of theoretical and clinical disagreements,
which will only be resolved by more systematic research on therapeutics.
TREATMENT OF THE ADOLESCENT
Among adolescents with GID, there are two major subgroups of patients. The first subgroup
consists of adolescents with a childhood history of GID (or its subclinical manifestation). The
second subgroup consists of adolescents with a childhood and/or adolescent onset of fetishistic
cross-dressing. Only treatment of the first subgroup will be discussed here. The reader is referred
to Zucker and Bradley (1995) and Zucker and Blanchard (1997) for consideration of the second
subgroup.
In adolescents with GID, there are three broad clinical issues that require evaluation: 1) the
phenomenology pertaining to the GID itself, 2) sexual orientation, and 3) psychiatric comorbidity.
Apart from the GID itself, gender-dysphoric adolescents with a childhood onset of cross-gender
behavior typically have a homosexual orientation (i.e., they are attracted to members of their own
“birth sex”). Some such adolescents may not report any sexual feelings, but follow-up will typically
find the emergence of same-sex attractions. Thus, the clinician must evaluate simultaneously two
dimensions of the patient’s psychosexual development: current gender identity and current sexual
orientation.
The psychotherapy treatment literature on adolescents with GID has been very poorly developed
and is confined to a few case reports (for references, see Wren 2002; Zucker 2001). In general, the
prognosis for adolescents resolving the GID is more guarded than it is for children. This state of
affairs is similar to other child psychiatric disorders: the longer a disorder persists, the likelihood
lessens that it will remit, with or without treatment. From a clinical management point of view, two
key issues need to be considered: 1) some adolescents with GID are not particularly good
candidates for therapy because of comorbid disorders and general life circumstances; 2) some
adolescents with GID have little interest in psychologically oriented treatment and are quite
adamant about proceeding with hormonal and surgical sex reassignment. Zucker et al. (2002)
found that, compared with children with GID, adolescents with GID were less intelligent, had more
general behavioral difficulties, were more likely to come from a lower socioeconomic background,
and were more likely to come from a broken home.
Prior to recommending hormonal and surgical interventions, many clinicians encourage adolescents
with GID to consider alternatives to this invasive and expensive treatment. One area of inquiry can,Print: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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therefore, explore the meaning behind the adolescent’s desire for sex reassignment and whether
there are viable alternative lifestyle adaptations. The most common area of exploration in this
regard pertains to the patient’s sexual orientation. Some adolescents with GID recall that although
they always felt uncomfortable growing up as boys or as girls, the idea of “sex change” did not
occur to them until they became aware of homoerotic attractions. For some of these youngsters,
the idea that they might be gay or homosexual is abhorrent.
Case Example 12
Carlos was a 14-year-old boy with an IQ of 122. He lived with his mother, who was of a
lower-middle-class background, and an older sister. His father had died after a long illness when Carlos
was 9 years old. Carlos had a childhood history of cross-gender behavior (e.g., female peer group
affiliation, cross-dressing) and an avoidance of rough-and-tumble play and group sports. Retrospectively,
it did not appear that he would have met formal diagnostic criteria for GID. As Carlos entered
adolescence, his peer group relations became more problematic. He was aware of sexual feelings for
other boys, and his former female friends had become less interested in socializing with him, as they
were now dating other boys. Carlos alternated between describing himself as “transsexual” and “gay.”
The idea that he might be gay was very distressing to him, and he held the view that if he had a sex
change, he would be “normal” because his sexual orientation would then be heterosexual. His mother
supported the idea of a sex change because her religious views were that homosexuality was against
“God’s will.”
For some such adolescents, psychoeducational work can explore their attitudes and feelings about
homosexuality. Group therapy, in which such youngsters have the opportunity to meet gay
adolescents, can be a useful adjunct in such cases. In some cases, the gender dysphoria will resolve
and a homosexual adaptation ensues. For other adolescents, however, a homosexual adaptation is
not possible and the gender dysphoria does not abate.
For adolescents in whom the gender dysphoria appears chronic, there is considerable evidence that
it interferes with general social adaptation, including general psychiatric impairment, conflicted
family relations, and dropping out of school. For these youngsters, therefore, the treating clinician
can consider two main options: 1) management until the adolescent turns 18 and can be referred to
an adult gender identity clinic or 2) “early” institution of contrasex hormonal treatment.
Gooren and Delemarre–van de Waal (1996) recommended that one option with gender-dysphoric
adolescents is to prescribe puberty-blocking luteinizing hormone–releasing agonists (e.g., depot
leuprolide or depot triptorelin) that facilitate more successful passing as the opposite sex. Thus, for
example, in male adolescents, such medication can suppress the development of secondary sex
characteristics, such as facial hair growth and voice deepening, which make it more difficult to pass
in the female social role. Cohen-Kettenis and van Goozen (1997), (1998) reported that early
cross-sex hormone treatment for adolescents younger than 18 years, judged free of gross
psychiatric comorbidity, facilitates the complex psychosexual and psychosocial transition to living
as a member of the opposite sex and results in a lessening of the gender dysphoria. Although such
early hormonal treatment is controversial (see Beh and Diamond 2005; Spriggs 2004), it may well
be the treatment of choice once the clinician is confident that other options have been exhausted.
To date, the best data on long-term outcomes in adolescents come from the Dutch group in Utrecht.
Cohen-Kettenis and van Goozen (1997) reported that 22 (66.6%) of 33 adolescents went on to
receive SRS. At initial assessment, the mean age of the 22 adolescents who received SRS was 17.5
years (range: 15–20 years). Of the 11 who did not receive SRS, 8 were not recommended for it
because they were not diagnosed with transsexualism (presumably the DSM-IV [American
Psychiatric Association 1994] diagnosis of GID); the 3 remaining patients were given a diagnosis of
transsexualism, but the “real-life test” (i.e., living for a time as the opposite sex prior to the
institution of contrasex hormonal treatment and surgery) was postponed because of severe
concurrent psychopathology and/or adverse social circumstances. These data suggest a very high
rate of persistence of GID, which is eventually treated by SRS. It should be noted that thePrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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persistence rate could be even higher than 66%, since Cohen-Kettenis and van Goozen did not
provide follow-up information on the 11 patients who were not recommended to proceed with the
real-life test or were unable to implement it.
In another study, Smith et al. (2001) reported that 20 (48.7%) of 41 other adolescent patients
went on to receive SRS. At initial assessment, the mean age of the 20 adolescents who received
SRS was 16.6 years (range: 15–19 years). For the 21 who did not receive SRS (mean age: 17.3
years; range: 13–20 years), the reasons were similar to those reported in the earlier study. Data
from Smith and colleagues suggest that a substantial number of the patients who did not receive
SRS were still gender-dysphoric at the time of the follow-up assessment, which occurred, on
average, 4.3 years later.
TREATMENT OF THE ADULT
As clinicians became familiar with the natural history of GID as it extended into adulthood, it
became apparent that, by and large, it was largely refractory to psychotherapeutic treatments
(Chiland 2000; Oppenheimer 1991; Quindoz 1998). Although GID may wax and wane in some
individuals (Marks et al. 2000), it has never been established that GID remits as a function of
systematic psychological treatments. Accordingly, many programs agree that SRS is the treatment
of choice for carefully selected patients.
Since the establishment of either hospital or university-based gender identity clinics for adults in
the 1960s (Cohen-Kettenis and Walinder 1987; Petersen and Dickey 1995), clinicians have played
an important “gatekeeping” role in evaluating requests by adults for SRS. Over the years, the Harry
Benjamin International Gender Dysphoria Association (HBIGDA) has issued a series of guidelines
pertaining to standards of care (Meyer et al. 2001), including the kinds of training required of the
mental health care provider, the role of psychotherapy, physical interventions (reversible, partially
reversible, and irreversible), and the “real life” experience—that is, the patient tries out living in
the cross-gender role for a period of time prior to the institution of physical treatments (see also
Schaefer et al. 1995).
There have now been many reviews of the effectiveness of SRS, and it is apparent that the vast
majority of adults who receive this treatment do not regret it (Blanchard and Sheridan 1990;
Blanchard et al. 1989; Green and Fleming 1990; Lawrence 2003; Pauly 1981; Pfäfflin and Junge
1998). Given the radical nature of SRS, this outcome is rather remarkable. Many studies have
shown that there is progressive improvement in the patient’s psychosocial well-being, including the
diminution of gender dysphoria, as the patient moves through the gender reorientation process.
One of the better demonstrations of the effectiveness of SRS was the study by Mate-Kole et al.
(1990). To my knowledge, this is the only study in the literature that involved random assignment:
patients who were considered eligible for SRS were either given an “early” surgical date or placed
on a waiting list to receive it. A follow-up assessment of the early-treated group—conducted, on
average, 21 months postsurgery—compared the functioning of this group with that of the control
patients, all of whom were still on the waiting list to receive surgery. The early-treated group
showed statistically significant improvements from baseline to follow-up on a variety of
psychosocial indicators, whereas the wait-list group showed no significant improvements.
Although the effectiveness of SRS is now well established, a number of contemporary clinical issues
remain contentious. First, because some patient activists resist any type of waiting period for SRS,
there is a continued discourse about the role of the real-life experience. Such patients may well
succeed in receiving at least some types of treatments (e.g., contrasex hormones) “on demand”
from physicians who do not adhere to the HBIGDA guidelines. Accordingly, there is a need to
determine whether this nontraditional approach to treatment results in different outcomes in terms
of psychosocial well-being. Second, it should be recognized that not all adult patients who request
SRS are judged to be appropriate candidates for it. Unfortunately, much less is known about the
natural history of such patients than is known about those for whom SRS is recommended. Finally,
a contemporary issue concerns the fact that there may be a broader spectrum of individualsPrint: Chapter 45. Gender Identity Disorder in Children, Adolescents, a… http://www.psychiatryonline.com/popup.aspx?aID=261481&print=yes…
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struggling with gender identity issues who are seeking at least some kind of physical treatment.
One example of this is the recently described phenomenon of “tranny boys” among young lesbian
women, in whom, for example, there appears to be a desire for “partial” sex reassignment (e.g.,
mastectomy but not masculinizing hormone treatment) (McCarthy 2003). At present, it is not really
known the extent to which these women differ from more traditionally classified female-to-male
transsexuals, but the evidence to date calls for caution in differential diagnosis and consideration of
how best to provide clinical care.
CONCLUSION
At present, the treatment literature is fairly clear that most adults who receive SRS are satisfied
with this form of intervention. New data on adolescents also show that carefully selected patients
benefit from physical treatments. Taken together, the evidence from these two groups suggests
that gender dysphoria is relatively unlikely to remit without at least some type of physical
intervention. In contrast, the prospective literature on children with GID shows that its natural
history does not invariably result in a persistence into adolescence and adulthood (Drummond
2006; Green 1987; Zucker and Bradley 1995). Indeed, desistance of GID is the most common
outcome. Because of this disjunction between patients first seen in childhood versus those first
seen in adolescence/adulthood, many child clinicians offer a trial of psychosocial intervention or at
least a period of “watchful waiting.” Unfortunately, the treatment literature on children lacks the
systematic rigor that characterizes the adult literature regarding the effectiveness of SRS. It is
hoped that this gap will be filled in the years to come.
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Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.
Course Content
Introduction to Gender Identity: Concepts and Definitions
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Defining Gender Identity
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Historical Perspectives on Gender Identity
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The Role of Language in Gender Identity
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Quiz: Concepts and Definitions of Gender Identity
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Intersectionality and Gender Identity
Historical and Cultural Perspectives on Gender
Exploring Gender Dysphoria: Diagnosis and Experiences
Therapeutic Approaches to Gender Identity Disorders
Integrating Perspectives: Future Directions in Gender Identity Understanding
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