Child and Adolescent Psychiatrist specialising in the treatment and support of gender dysphoric children and adolescents
If you are a transsexual person reading this article, the chances are you remember being aware of your gender dysphoria - or some sense of being "different" - from a very early age. It is also highly likely that you felt unable to communicate this to anyone and tried to hide and deny your inner turmoil during childhood, adolescence and possible many years of adult life. That’s the way the world was when you were a child. But largely thanks to the tireless and enthusiastic work of one man, things are beginning to change for today’s young Britons.
Dr Domenico Di Ceglie trained as a doctor in Italy, but when he began more specialised training in psychiatry, he formed the opinion that London offered far broader opportunities to study and came here in 1974. He became involved in working with the National Health Service in the UK and apart from regular lecture trips to his home land he has lived and worked in London ever since. Perhaps this explains why, although Italy has a psychiatric service for adult transsexual people, Britain is known as a leading centre for the study and support of children and adolescents showing signs of gender dysphoria - or atypical gender identity development, as he also calls it.
In the early 1980s Dr Di Ceglie had referred to him a patient who aroused his curiosity, someone claiming that she was a boy but in a female body. His offer of psychotherapy was accepted and as the sessions progressed that first patient challenged many preconceptions. Dr Di Ceglie’s colleagues were saying that she was confused about her gender, but he discovered that she seemed to be very clear that she was a boy, he was the one who would at times become confused. When the sessions came to an end she said perhaps it had all come too late for her and she wondered why her parents had not sought help for her as a child.
This planted a seed and became the groundwork for development of an NHS service for young people who might be widely different in background and expression, but who all demonstrate a deep concern with their gender identity. When Dr Di Ceglie became consultant in child psychiatry in Croydon he started a small workshop there for children with gender identity disorders and soon became convinced of the need for such a service. In 1989 the Gender Identity Development Clinic opened at St George’s Hospital, which in 1992 organised the first international conference on the subject. In 1996 the clinic transferred to the Tavistock and Portman Trust where it remains today, based at the Portman Clinic in London.
In talking about his work, what comes over very powerfully is that Dr Di Ceglie has no boxes to put his patients in and no expectations of how their sessions at the clinic might progress or end up. Nothing is designed to persuade the young patients either toward or away from acknowledging themselves to be transsexual. All the focus of the work is on enriching the quality of life for each individual, no matter what their sexuality, gender identity or other individualities.
He says it is rare for him to see a child before the age of five or six, but after that his patients are roughly divided half and half between pre- and post-pubescent, with the division usually around the age of 12. Pre puberty he sees more boys that girls, but the number of girls increases after that. He cannot give more than a hypothesis as to why this might be, but assumes it is easier to see the condition in young boys, as society is more comfortable to label girls as tomboys and not necessarily as showing gender identity problems.
He says that quite a number of parents bring their children because they notice they are different from other children and want to be able to respond to this in an appropriate way. The Gender Trust regularly receives calls for help from young people who say they cannot talk about how they are feeling with their parents, and Dr Di Ceglie’s clinic does accept adolescents who self refer. But all cases are dealt with on the basis of team work, and an essential part of this is to involve the parents in the process.
"Part of our work is to facilitate family communication," Dr Di Ceglie says. "It can be an intense experience for parents. We run groups for parents as a way for them to share their experiences and perhaps lose some of their pre-conceptions. They may start off in opposition but when they get some understanding of the issues involved they become more accepting. Sometimes parents have to come to terms with the fact that their child is not going to be the child they want them to be, and to understand that the more intense their expectations of their child the more difficult it will be for the child to come to terms with who and what he or she really is. Generally the earlier you intervene the better. It gives parents more time to come to terms with what they may see as their loss.
"At first the teenager may be the one who is keener, and the parents have to learn to become more accepting. In some children the condition will persist and they continue into adult life as transsexual. But the child can shift and suddenly no longer want it. It may be a transient experience they are going through or it may not, we don’t know, we just have to work with it. To understand atypical gender identity development I sometimes use the metaphor of having a strong and unusual vocation. Take the child who says ‘the only thing I want to do is be a priest’. You don’t know if they will stick with that and grow up to have a vocation in the priesthood, or if they will change. You just have to go with it."
Dr Di Ceglie likes to tell the story of a Belgian monk who was in charge of a monastery in Mexico. He developed an interest in psychotherapy and formed a group to explore with the monks their motivation for entering the monastery. As a result of these sessions two thirds of them abandoned their ‘vocation’ and left - apparently the Vatican soon put a stop to that group!
The message of this story is that when you create an environment in which people can explore their issues and motivations it allows them the possibility of shifting, changing and moving on. The core of Dr Di Ceglie’s work is to challenge The Cycle of Secrecy which can keep people locked in certain thought and behaviour patterns including their perception of self.
The model of teamwork at the clinic may include the child’s school where appropriate, particularly in younger children as it has proved easier to work with the more accepting ethos of a primary school rather than the larger environment and fierce peer pressure encountered in many secondary schools. In some cases they may make arrangements for the child to attend a special educational unit where the environment is more protected, but this is more likely where there are additional serious behaviour problems as these units tend to be geared towards dealing with anti social behaviour.
Dr Di Ceglie is convinced that there is no one simple reason for the development of gender dysphoria. "Identity is much more complex, there is more than one determinant," he says. The Guidance for Management of The Royal College of Psychiatrists (1998) supports this, stating gender identity disorders in children and adolescents involve psychological, biological, family and social issues.
A sense of isolation is a common factor among children referred to the clinic. "It is like the isolation of a foreigner who finds it difficult to communicate because he has problems with the language and the culture," Dr Di Ceglie explains. It may be the consequence of an unusual experience, or of a trauma such as the death of a close relative, or alternatively it may come from more primary problems in communicating.
To address all these issues, the clinic has developed an integrated programme which aims to allow the young person the benefit of space and time to discover what are the relevant issues and explore, together with their family, ways to reduce the number of difficulties they are experiencing. They proceed in stages, and at any point things may shift and change.
In some cases they may introduce some wholly reversible intervention in the form of hypothalamic blockers which suppress the production of oestrogens or testosterone and produce a state of biological neutrality. This would be done in consultation with the whole care team, including social workers and a paediatrician who would need to assess the appropriate point in the young person’s physical development. This is likely to be around the age of 15-16, it cannot be done before the growth spurt around puberty because of risk to bone development and osteoporosis. This would not be agreed as appropriate unless the young person showed themselves convinced they wanted to transition, and yet Dr Di Ceglie has noted that between a quarter and a third of those who receive this treatment end up choosing not to progress on to gender transition. "It is difficult to know why this might be," he says.
"“If a child has an issue around identity it is important for them to explore what it is. And it is much better that they look at it at 14 rather than at 44. If done in an appropriate way it can benefit most children and teenagers. In cases where there is a risk of suicide we offer as much support as possible. Adolescents experience things so intensely they may not be able to see a solution or the solution may seem unattainable. This is present in quite a proportion of those we see at the clinic, but when they feel supported it gives them a sense of direction and helps them."
At 18 the patient must leave the safe supportive environment of the clinic and transfer to the much tougher world of the adult gender clinic. This transition can be difficult, and a member of the team may go along at first to offer continuity. But it is only in the adult services that the adolescent who has remained convinced of his gender identity can receive hormone treatment and surgery to complete gender transition.
What happens to these people? Do they proceed to transition? Has their time at the Portman Clinic helped them to prepare for it? Do they adjust socially and go on to lead fulfilled lives in their new gender role? These are questions which Dr Di Ceglie would dearly love to see answered, but at present this research cannot be carried out unless financial backing is found. Meanwhile he not only continues to run the clinic, but is actively pressing to increase the amount of time allocated to it, reflecting the ever growing number of children and young people being referred. As a child psychiatrist he is totally convinced of the value of working at an early age with children showing signs of gender dyphoria.
"Humans are complex individuals, one area will affect another," he said. "Working with a child offers more flexibility to try and expand their capacity to deal with issues. I see the richness that these things bring, because, when you are dealing with identity issues, being able to handle interaction makes the world a much richer place than one where everything is put into boxes. Our work is about expanding potentials rather than reducing people to stereotype patterns, enabling people to make use of what they have or to compensate for their deficits."
© The Gender Trust 2003
With thanks to the Gender Trust for allowing us to publish this article (which first appeared in Gems News, Spring 2003) on the Mermaids website.