Gender indentity disorders in children and adolescents are uncommon and complex conditions. They are often associated with emotional and behavioural difficulties. Intense distress is often experienced, particularly in adolescence. Treatment and prevention of the emotional and behavioural problems are essential, even if the atypical gender development remains unchanged.
Changes in cultural attitudes in our society have raised awareness of the problems that an increasing number of people experience in the area of gender identity. Many adults with gender identity disorders describe difficulties in childhood. Often they complain of having been very unhappy children and at times desperate teenagers, and that their suffering had not been recognised early enough by parents and professionals. It is therefore important to be able to identify problems in this area as an early age and to provide appropriate help.
Before 1955, the word 'gender' had been confined almost excusively to the domain of grammar to indicate male or female when defining nouns, pronouns and adjectives. Gender had hardly been used in literature. The first definition of the term 'gender role' was given by John Money in an article on 'Hermaphroditism, gender and precocity in hyperadrenocorticism: psychological findings' published in the Bulletin of the John Hopkins Hospital in 1955. Money wanted to differentiate a set of feelings, assertions, and behaviours which identified a person as being a boy or a girl, a man or a woman, from the contrasting conclusion one could have reached by considering only their gonads. The gender role in the cases described was consistant in the vast majority with thier rearing. The term 'gender identity' appeared in the middle 1960's in association with the establishment of a gender identity study group at the University of California. Stoller defines it as:
'A complex system of beliefs about oneself: a sense of one's masculinity and femininity. It implies nothing about the origins of that sense(e.g. whether the person is male or female). It has, then, psychological connotations only: one's subjective state.'
The concept of gender identity and role having been formulated, it became possible to make sense of, and give order to, conditions which had, until then, been ill-defined and poorly understood. Incongruity between the biological sex and the psychological and behavioural manifestations of gender identity indicated the presence of a gender identity disorder.
A.....A strong and persistant cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).
In Children the disturbance is manifested by four (or more) of the following :
In adolescents and adults, the disturbance is manifested by symptoms such as stated desire to be the other sex, frequent passing as the other sex, desire to live and be treated as the other sex, or the conviction that he/she has the typical feelings and reactions of the other sex.
B.....Persistant discomfort with his/her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following: in boys, the assertion that his penis and testes are disgusting or will disappear, or assertion that it would be better not to have a penis, or aversion towards rough-and-tumble play and rejection of male stereotypical toys, games and activities; in girls, the rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion towards normative female clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g. request for hormones, surgery or other procedures to physically alter sexual characteristics or to simulate the other sex) or belief that he/she was born the wrong sex.
C.....The disturbance is not concurrent with a physical intersex condition.
D.....The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
Over the past 20 years, four diagnostic models have been proposed:
1.....Diagnostic and Statistical Manual of Mental Disorders-IV(DSM-IV) (American Psychiatric Association, 1994)
This sets criteria for children, adolescents and adults. It requires that four criteria are satisfied for the diagnosis to be made. Criteria A and B (Last section) refer to two aspects of the gender identity disorder: A to evidence of cross-gender identification and B to the experience of discomfort about the biological sex and the feeling of inappropriateness in the gender role of that sex.
2.....International Classification of Diseases - 10 (ICD-10)(World Health Organisation, 1992). In this classification there is no distinction between criteria A and B and 'the diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient'.
3.....Rosen et al's (1997) distinction between cross-gender identification and gender behaviour disturbance. This classification has proved unsatisfactory as a large number of children (71%) present both characteristics (Bentler et al, 1979).
4.....Stoller's (1968) diagnosis of 'male childhood transsexualism'. This is based on the presence in a boy of 'a fixed belief that he is a member of the opposite sex and will grow up to develop the anatomical characteristics of the opposite sex'. Case 1 (later on this page) illustrates an initial clinic presentation.
The incidence of childhood cross-gender identification in the general population and in the psychiatric population has not yet been definitely established. The studies that have been carried out have used different criteria, such as single behaviours or identity statements. No large- scale investigation with standardised criteria, such as those of DSM-IV, has yet been conducted.
Zuger and Taylor (1969) interviewed the mothers of boys approximately 7 years old with regard to the presence of six cross-gender behaviours (table 1).
Table 1 shows the percentage of positive occurances for each behaviour had been occurring or when it started. Zuger and Taylor also showed that these behaviours were not frequent in a given child (73% never engaged in any of them).
Feinblatt and Gold (1976) found that out of 193 children referred to a Connecticut Child Guidance Clinic, 4 boys and three girls (3.6%) were referred primarily because of 'gender role inappropriate behaviour'.
The epedemiological behaviour suggest that 'extreme forms of cross-gender behaviour are uncommon among boys in the general population' (Zucker 1985). One could fairly confidently say that cross-gender behaviour is not 'a common phase in boyhood behaviour' (Green 1968). There is insufficient epedemiological research regarding girls to be able to make a similar statement.
| Table 1. Maternal Report of cross-gender behaviour in boys aged approximately 7 years old. | |||||
|---|---|---|---|---|---|
| Behaviour | Number | % Positive occurance | |||
| Desire to be female | 46 | 7 | |||
| Feminine Dressing | 95 | 13 | |||
| Wearing Lipstick | 94 | 7 | |||
| Doll Playing | 95 | 15 | |||
| Preference for girl playmates | 41 | 2 | |||
| Aversion to boy's games | 93 | 3 | |||
From Zuger and Taylor (1969).
The most scientifically accurate follow-up study has been conducted by Green (1987). 'Two thirds of 66 males in the original "feminine boy" group have been interviewed in adolescence or young adulthood. Three-fourths of them are homosexual or bisexual'. Only one boy in this study has had a transsexual outcome.
Zucker (1985) has put together all the long-term follow-up studies of cross-gender identified children referred to mental health professionals. Table 2 shows the results.
Money and Russo (1981), explaining the low incidence of a transsexual outcome, suggest that 'the natural history of transsexualism is disrupted by the child's contact with the mental health profession' (Zucker 1985).
Green et al (1987) examined five groups of behaviours in boys: role/doll play, cross-dressing, female peers, rough and tumble play and wish to be a girl. They found that doll play and role play as a girl associated more strongly with a homosexual outcome.
| Table 2. Long-term follow-up studies of children with gender identity disorders | |||||
|---|---|---|---|---|---|
| Outcome | No. of cases | % of total cases | |||
| Transsexual | 5 | 5.3 | |||
| Homosexual of bisexual | 43 | 45.7 | |||
| Transvestite (heterosexual) | 1 | 1.1 | |||
| Heterosexual | 21 | 22.3 | |||
| Uncertain | 24 | 25.5 | |||
| Total | 94 | 100 | |||
From Zucker (1985).
Coates et al (1985) have shown that children with gender identity disorders also present separation anxiety, depression and emotional and behavioural difficulties. In a number of cases referred to our clinic, learning difficulties and school refusal are also present. In a small percentage of cases, child sexual abuse has been associated with a gender identity disorder. Suicidal attempts in adolescence are frequent and this is how adolescents with gender identity disorders come to professional attention in some cases.
No single cause has yet been found with certainty for the development of a gender identity disorder. Hereditary (Bailey and Pillard, 1991) and genetic factors (Hamer et al, 1993) have been identified for male homosexuals. Their contribution to the development of gender identity disorders in children is unclear and further research is needed.
Hormonal influences on the brain during fetal life have been suggested. Androgens would masculinise the brain at the critical period of 6 weeks in fetal life.
In humans it has been found that the third interstitial nucleus of the anterior hypothalmus is larger in the male. Levay (1991) has shown that in the brain of homosexual men this nucleus is similar in size to that of women and about half the volume of that in heterosexual men.
However, these factors on their own may be insufficient to produce a gender identity disorder.
Stoller (1968) has described particular family constellations which associate with gender identity disorders in boys and girls. For the boy there is an over-close relationship to mother and a distant father. For the girl there is a depressed mother during the early months of the child's development and a father who is absent and does not support the mother, but pushes the child to assuage the mother's depression.
Marantz and Coates (1991) have described very early maternal influences negatively affecting the early development of the child.
Blieberg et al (1986) have linked the development of gender identity disorders in some children to their inability to mourn a parent or an important attachment figure in early childhood.
The parents' wish for a child of the other sex or direct parental pressure in rearing the child in the gender role opposite to the biological sex is not sufficient on its own to produce a marked gender identity disorder.
A number of authors, e.g. Money (1992) and Coates et al (1991), would agree that many of these factors need to be present at the same time and work together during a critical period to produce a full-blown gender identity disorder. This would explain the rarity of the condition (Case 2).
Behaviour therapy, individual psychotherapy, family therapy and group therapy have been used with these children and their families. Their efficacy is unclear.
As the aetiology of gender identity disorder is unclear and probably multi-factorial, at our clinic we have developed a model of management in which altering the gender identity disorder per se is not a primary therapeutic objective. Our primary therapeutic objectives are the developmental processes which, on clinical and research experience, seem to have been negatively affected in the child (Table 3).
| Table 3. - Primary Therapeutic Aims | |||||
|---|---|---|---|---|---|
| To foster recognition and non-judgemental acceptance of the gender identity problem | |||||
| To ameliorate associated emotional, behavioural and relationship difficulties (Coates et al 1985) | |||||
| To break the cycle of secrecy | |||||
| To activate interest and curiosity by exploring the impediments to them | |||||
| To encourage exploration of mind-body relationships by promoting close collaboration among professionals with a different focus in their work, including a paediatric endocrinologist | |||||
| To allow mourning processes to occur (Bleiberg et al, 1986) | |||||
| To enable the capacity for symbol formation and symbolic thinking (Segal, 1957) | |||||
| To promote separation and differentiation | |||||
| To enable the child or adolescent and the family to tolerate uncertainty in the area of gender identity development | |||||
From Di Ceglie (1992).
It is possible that by targetting and improving the developmental processes which may underpin gender development, the gender identity disorder itself will be affected in a secondary way and will not lead to an atypical gender identity development in adulthood. The aims outlined in Table 3 above, could be achieved through various psychotherapeutic interventions ranging from individual to family and group therapy. Social and educational interventions are also useful. It is important that these are well co-ordinated and integrated in a comprehensive management plan.
Some of these aims are more relevant in certain cases. A brief illustration is given of how these therapeutic objectives could be tackled in clinical work (Cases 3,4 and 5); for a more detailed account see Di Ceglie (1992).
The recognition and non-judgmental acceptance of the gender identity problem, which is not the result of the child's conscious choice, is important. Without this the child would experience feelings of rejection, psychological splitting processes would increase to cope with it, and no further therapeutic work could be undertaken. Group work for parents of children with gender identity disorders can be very helpful in this respect, as it confronts the parents with the fact that their problem is not unique.
In some cases an inability to mourn relevant attachment figures has interfered with gender identity development. Enabling mourning to occur may alter secondarily an atypical gender identity development, as shown in Case 3.
The inner experience of gender confusion in children and adolescents is similar to that described by Spooner in Harold Pinter's play No Man's Land (Pinter 1991): 'You are in no mans land. Which never moves, which never changes, which never grows older, but which remains forever, icy and silent.' Therapeutic endeavours with these children and adolescents may help them to tolerate living in their distressing condition without becoming involved in self-destructive activities or anti-developmental patterns of interaction until a solution to the identity conflict is found.
I am grateful to Dr. John Byng-Hall, Dr Sebastian Kraemer, Mrs Margot Waddell and our Gender Identity Development Team for their helpful comments.
William, aged 8 years, was referred to the gender identity development clinic by his mother. In her letter she wrote: "William has been having problems with the boys at school. This has been going on for about 18 months, but the seriousness of the situation has only just come to light. He is suffering a lot of verbal abuse, i.e. being called poof, cissy, pervert. The headmaster did take steps to stop this, but the problem cropped up again with a different set of boys. There has been a great deal of discussion between myself and the teachers. They feel that they are trying to stop this victimisation by their boys, but feel that William's own behaviour is in part to blame. On the last occasion, the problem was exacerbated by William wearing Mascara into school. We are having other problems with William, i.e. his schoolwork is suffering very badly and there are behavioural problems at home. Both my husband and I believe the situation is deteriorating and we need professional help and advice as we feel rather out of our depth."
At the assessment interviews, William said that since the age of 4 or 5 years he had very much wished he was a girl. He had been secretly dressing up in his mother's clothes. He liked to play with dolls and cuddly toys and fantasised that he was the mother feeding them. He played weddings and liked to be in the role of the bride. At school he wanted to play with girls and avoided becoming involved with rough-and-tumble play or other activities with the boys.
Laura, aged 9 years, felt that she was a boy. She had a well-stablished gender identity disorder, and had even asked her mother if she could have a sex change. Her mother suffered from congenital adrenal hyperplasia, a condition which required continuous corticosteroid treatment and she had continued therapy with prednisone during her pregnancy with Laura, which might have had a masculinising effect on the brain of the fetus. A second girl, 3 years younger than Laura, has a normal gender development in spite of the fact that her mother was on the same hormone regimen during pregnancy. A boy of 12 years, from a previous marriage, had a normal gender development to date. The mother, however, reports that after the delivery of Laura she was depressed, but her husband seemed unaware of this. The family had also had a complicated house move during the last months of her pregnancy. These factors were absent in the case of her younger sister.
During the join assessment with the paediatrician, Laura showed with great pride the muscles in her arms which in her view were very big, and, while flexing them, she said that when she was older with big muscles she could protect her mothr.
John, aged 8 years, presented with a well-established gender identity disorder. His maternal grandmother had looked after him from the age of 6 months until he was 5 years, as his mother had to be away often for her work. The grandmother involved him in many activities, including cooking and tidying up the house. After her sudden death in hospital, John developed a gender identity disorder. He could not talk about his loss or even mention her, but he concretely identified with her and persistantly wished to continue with all the activities in exactly the same way as he had done with her. Family therapy, focusing on a family tree constructed over many sessions, enabled the narrative of his experiences with his grandmother to be developed. The clinical features of his gender identity disorder gradually reduced in intensity and disappeared.
In this case, the psychological work focused not only on mourning processes, but it also removed the secrecy about his gender problem, it engendered curiosity about its origins and established a link between his atypical gender development and the way he had coped with the loss of his grandmother. Symbol formation was stimulated as he could now have mental pictures of her and memories of the past, rather than concretely identifying with his grandmother and becoming her. Increased contact with his father seemed also to play an important role.
Christine was believed to be a boy at birth by her mother. She even saw a small penis. She then thought that this boy had been changed into a girl by a 'black magic' spell of her mother-in-law's. She went on, however, to treat this child as a boy, expecting her to turn into a boy at some point. Her father colluded with her mother's false belief. At puberty, this girl was rather isolated from her peer group and when asked if she was a boy or a girl she would always say that she did not know. Individual therapy to help her to separate from her mother and father, revealed that she could see herself as a girl and did not present a serious identity disorder. The parents were also seen, separately from her. Christine is now a teenager and has had a number of boyfriends.
In this case, individual therapy, associated with parental counselling and social support involving social services and the school staff, focused primarily on enabling separation and differentiation from the mother to occur. Christine clearly realised that her mother had psychological problems. her social relationships improved and in turn her female gender identity development was strengthened.
Mark, aged 16 years, presented a gender identity disorder of a transsexual type. He hated his male body intensely. Socially isolated and in despair, he had attempted suicide. Since the age of 3 or 4 years he had felt he was a girl. At the age of 7 years his father sexually abused him and this experience confirmed to him that he was a girl as at that time he thought that men were only sexually attracted to women. At the time of the referral he felt that his body should be changed immediately as he could not bear living in a contradictory situation. There was also a possibility of further suicidal attempts.
A structured therapeutic programme, also involving consultation with a paediatric endocrinologist, made him feel that mind and body had been taken into consideration, and helped him to tolerate a transitional phase of uncertainty by containing his feelings of despair. It also supported his hope that the incongruence between his mind and body would eventually be overcome. At this age, exploration of the patients expectations, gender identity and roles, body image, perception of him/herself and other people become the necessary preparation to a referral to a gender identity service for adults at the age of 18 years. No irreversible physical intervention should be undertaken before this age.
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