Gender Identity Disorder
Gender Identity Disorder
A mother, concerned for some time about her young son's effeminate manner, lack of male playmates, and interest in Barbie dolls, finally decides to ask the pediatrician if these are signs of a potential problem.
The pediatrician is reassuring and states: "This is just a phase. It’s nothing to worry about. He will grow out of it." Unfortunately, the pediatrician is probably wrong. Gender identity problems, including effeminate mannerisms, cross-dressing, exclusive cross-gender play, and lack of same-sex friends should be treated as a sign that something may be very wrong. What's usually wrong with such a child is that due to a number of specific stressful factors the boy or girl has serious difficulties in embracing the goodness of his masculinity or her femininity.
Diagnosis of GID
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV TR) describes Gender Identity Disorder as a strong and persistent cross-gender identification with at least four of the following:
- repeated stated desire to be of the opposite sex
- in boys a preference for cross-dressing or simulating female attire and, in girls, wearing stereotypical masculine clothing with a rejection of feminine clothing such as skirts
- strong and persistent preferences for cross-sex role in play
- strong preference for playmates of the opposite sex
- intense desire to participate in games and past times of the opposite sex.
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
Emotional conflicts in chldren with GID
Boys who exhibit such symptoms before they enter school are more likely to be unhappy, lonely and isolated in elementary school; to suffer from separation anxiety, depression, and behavioral problems; to be victimized by bullies and targeted by pedophiles; and to experience same-sex attraction in adolescence. If they engage in homosexual activity as adolescents, they are more likely than boys who do not, to be involved in drug and alcohol abuse or prostitution; to attempt suicide; to contract a sexually transmitted disease; or to develop a serious psychopathology as an adult. A small number of these boys will become transvestites or transsexuals.
A loving and compassionate approach to these troubled children is not to support their diffculty in accepting the goodness of their masculinity or femininity, which is being advocated in the media and by many health professionals who lack expertise in GID, but to offer them and their parents the highly effective treatment which is available.
Origins of GID
GID origins are complex and multi-factorial. Some young male children who lack eye-hand coordination and, are not confident playing sports, don’t join male peers in athletic activities because of fear of being rejected. Such rejection can be subtle in that boys who are not proficient in sports may not be invited to join in team play, a major form of male bonding in childhood, simply because they can’t help the team. The fear of rejection however, often leads them to turn to girls for friendship. For some this leads to over identification with these friends and the development of feminine traits in speech and in mannerisms. Symptoms of effeminacy and strong identification with females can intensity eventually leading to the development of a gender identify disorder. (See Gender Identity Disorder article at www.narth.com.) Also, the absence of a father-role model in the home can contribute in some males to identity confusion.
A less common cause of GID is seen in males who have powerful artistic and creative gifts that lead to a strong attraction to the beauty in the female world and to an identification with femininity. This artistic response can begin early in childhood and can lead to a desire to be female. In rare cases, a parent wanting a child to be of the opposite sex, dresses and treats a boy as a female or a girl as a male. In addition some boys act in a feminine manner because they perceive their fathers as giving preferential treatment to an older sister. By acting like a sister they unconsciously hope to gain more attention and acceptance from the father.
GID in young girls can develop the desire to please a parent as well as the lack of acceptance by same sex peers. This results in low self-esteem and later self-hatred. Failure to attach securely to and to identify with the mother can be another factor. These young girls have no support to, or for other reasons, fail to to embrace the goodness of their femininity. Young females who don’t identify with their femininity, are "tom boys" and are overly involved in athletic activities can be difficult to identify in a culture which is so supportive of their involvement with sports.
In addition in a culture in which young females are influenced to think that their femininity is determined primarily by their bodies, girls can develop a negative view of themselves if their bodies don’t fit the cultural model of being thin. Then, a lack of acceptance by female peers and a hatred of one’s body and ultimately of one’s femininity can develop. Some of these females meet the criteria for a Body Dysmorphic Disorder.
GID and Genes
Dr. George Rekers at the University of S. Carolina Medical Schools studied 70 boys who were given thorough medical and psychological evaluations including chromosome analysis. No chromosomal abnormalities were found. (Rekers G, et al (1979). Genetic and physical studies of male children with psychological gender disturbances, ( Psychological Medicine 9: 373-375.)
GID children and their parents
The evaluation of parents of children with GID is essential in the treatment plan. Drs. Zucker, Bradley and colleagues in a 2003 study found that the rate of maternal psychopathology was high by any standard and included depression and bipolar disorder. The fathers particularly demonstrated depression and substance abuse disorder. They recommended that parental conflicts and psychopathology among the parents of children with GID deserved thoughtful consideration. (Zucker K, Bradley, S. et al. 2003. Psychopathology in parents of boys with gender identity disorder. J. Amer. Acad. Of Child & Adolesc. Psychiatry 42: 2-4).
Furthermore, in their textbook, Gender Identity Disorder, they noted that the composite measure of maternal psychopathology correlated quite strongly with Child Behavior Checklist indices of behavior problems in boys with GID.
Zucker and Bradley observe that fathers of gender-disturbed boys tend to go along with their wives' tolerance of cross-gender behaviors, despite their inner discomfort with this tolerance. "These men are often easily threatened and feel inadequate themselves. These qualities appear to make it very difficult for them to connect with sons who display non-masculine behavior." Withdrawing from their feminine sons, "they often deal with their conflicts by overwork or distancing themselves from their families..." The fathers' difficulty expressing feelings, and their inner sense of inadeqaucy are the roots of this emotional withdrawal.
In our experience we have found it important to strengthen the confidence of fathers in their self-giving to sons with GID and to identify the reasons in particular why a mother would want to feminize her son, encourage cross dressing and even later support transsexual surgery in some cases.
Treatment of GID
Gender Identity Disorder in children is a highly treatable condition. The majority of children treated by those with expertise in this area are able to embrace the goodness of their masculinity or femininity. Over the past 30 years, Dr. Kenneth Zucker, a psychologist and head of the gender-identity service at the Center for Addiction and Mental Health in Toronto, has worked with about 500 preadolescent gender-variant children. In his studies, 80 percent grow out of the behavior, but 15 to 20 percent continue to be distressed about their gender and may ultimately change their sex. Dr. Zucker tries to "help these kids be more content in their biological gender" by encouraging same-sex friendships and activities like board games that move beyond strict gender roles." (www.nytimes.com/2006/12/02/us/02child.html.)
However, according to Zucker and Bradley, "parental ambivalence is, in most cases part of the problem." Parents, particularly mothers, who might rationalize that it is "cute" to have a boy wear female clothing, often ignore or excuse obvious appearances of effeminacy in males. These psychologists encourage early intervention to prevent the suffering of isolation, unhappiness and low self-esteem that children with GID experience. This also helps to avoid a later poorly understood desire some may have for sex change surgery.
"In general," they say, "we concur with those who believe that the earlier treatment begins, the better. ...It has been our experience that a sizable number of children and their families can achieve a great deal of change." They also state, "In these cases, the gender identity disorder resolves fully, and nothing in the children's behavior or fantasy suggest that gender identity issues remain problematic.... All things considered, however, we take the position that in such cases clinicians should be optimistic, not nihilistic, about the possibility of helping the children to become more secure in their gender identity." (Zucker K, & Bradley S. 1995. Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. New York: Guilford Publications, 1995, p.281 and p.282.)
Children are born with a drive to seek love and acceptance by each parent, as well as siblings and peers. If this need is met, children develop an acceptance of their masculinity or femininity. When this developmental task is successfully completed, the child is free to choose gender atypical activities. Boys and girls with gender identity problems are not freely experimenting with gender atypical activities. They are constrained by deep insecurities and fears and are reacting against the reality of their own sexual identity, usually as a result of failing to experience love and acceptance from the parent of the same sex or same sex peers. Obtaining the history of the child’s emotional development, of his relationships with each parent and same sex peers, of his parents’ marital relationship and of his parents’ mental health is essential in the evaluation of these anxious children.
Therapy is not directed toward forcing a sensitive or artistic boy to become a macho-sports fanatic, but helping a boy to grow in confidence, appreciate the goodness of his masculinity, and be happy with his birth gender.
The following interventions for boys with GID are helpful:
- increasing quality time for bonding with the father
- increasing affirmation of the son's masculine gifts by the father
- participating in and support for the son's creative efforts by the father
- encouraging same sex friendships and diminishing time with opposite sex friends
- coaching the son in the development of athletic confidence and skills if possible
- slowly diminishing play with opposite sex toys
- encouraging the boy to be thankful for his special male gifts
- slowly leading the boy into team play if the athletic abilities and interest improve
- working at forgiving boys who may have hurt him
- communicating with other parents whose children have been treated successfully for GID and who have come to appreciate and to embrace the goodness of their masculinity and femininity
- addressing the emotional conflicts in a mother who wants her son to be a girl
- in those with faith, encouraging thankfulness for one's special God-given masculine gifts.
The following interventions for girls with GID are helpful:
- encouraging the daughter to appreciate the goodness and beauty of her femininity, including her body
- encouraging same sex friendships and activities
- increasing the mother-child quality time
- encouraging parental praise of their daughter
- working with the daughter to forgive peers who have hurt her
- encouraging pursuit of a balance in athletic activities
- addressing conflicts in parents who want her to be a boy
- in those with faith, encouraging thankfulness for one’s special God-given femininity
An article in which a father discusses the healing process of his son's GID can be a source of understanding and encouragement to parents, www.ncregister.com/site/article/15350.
GID, Cross Dressing and Schools
Some parents who, in fact, wish that their son were a daughter (or the reverse) sometimes, allow such a GID child to go to school dressed as the opposite sex, rather than seek treatment for the child's psychiatric condition. Unfortunately today some schools support such pathologic behavior and mislabel such a child as a transgender even though there is no such child diagnosis in the psychiatric diagnostic manual. (www.philly.com/inquirer/local/pa/chester/20080503_School_challenge__Transgender_student_is_age_9.html.)
A medical response to the harmful support of cross dressing in schools by principals, school superintendents and parents is available at www.narth.com.
Also, Dr. Zucker, based on his work with these children and his research also disagrees with the "free to be" approach with young children and cross-dressing in schools and in public. Superintendents and school districts should insist that parents who want their child to attend school dressed in opposite sex clothing be required to have the child evaluated by a mental health evaluation. This would enable a child with gender identity disorder to enter treatment in a timely fashion. Permitting behavior such as cross-dressing may simply enable and reinforce a serious psychiatric disorder. In addition principals and superintendents are best advised to not permit or tolerate any cross-dressing in schools. Not only will this further harm a child with GID, but will cause other children to suffer confusion and distress.
GID and Mental Illness
In one study of 120 Dutch children ages 4 to 11 with GID 52% of the children diagnosed had one or more diagnoses in addition to GID. Thirty seven percent had anxiety disorders and 23% had behavioral disruptive disorders. (Wallien, M.S., et al (2007) Psychiatric co-morbidity among children with gender identity disorder. J Am Acad Child Adolesc Psychiatry, 46:1307-14.) In another study 129 Dutch psychiatrists reported on 225 patients with GID. The report noted that 79% had personality disorders, had 26% mood disorders and 24% had psychotic disorders. (Campo J, et al. 2003. Psychiatric co-morbidity of Gender Identity Disorders: a survey among Dutch psychiatrists Am J Psychiatry. 160, 7:1332-6.)
GID and Health Professionals
Parents need to be cautious in choosing a mental health professional to consult for this condition. Many parents have had experiences with professionals who have refused to diagnose GID even though the child's behaviors met criteria for this disorder. Instead, they misdiagnose the child as transgender and ask the parents to support rather than treat cross gender desires and behaviors. They also fail to explore the child's same sex peer relationships or to present the psychiatric literature which demonstrates that it is possible to help these children learn to embrace the goodness of their gender and establish healthy same sex friendships. Such advice is often traumatic to the parents and ultimately harmful to the child.
Most pediatricians have little knowledge of gender identity disorder because it is often not taught in their pediatric training. Such a policy is indefensible because GID is an acknowledged psychiatric disorder in children that is associated with significant emotional suffering. Hopefully, this "politically correct" policy of these pediatric training programs will one day be replaced by solid medical science as pediatricians should provide information and initial guidelines for the treatment of GID.
GID vs. Transgender Child
Some medical centers are unfortunately going further and providing hormone treatments to GID children whom they label as transgender. A pediatric specialist at Children's Hospital Boston has recently begun a clinic for boys who feel like girls and girls who want to be boys. He offers his patients, some as young as 7 years, counseling about the "naturalness" of their feelings, and hormones to delay the onset of puberty. These drugs stop the natural process of sexual development that would make it more surgically difficult to have a sex alteration later in life. This theoretically allows the child and adolescent patients more time to decide whether they want to make the change. This physician alleges that those whom he labels as transgender children are deeply troubled by a lack of understanding of their feelings and have a high level of suicide attempts. He told the Boston Globe that he has never seen any patient make a suicide attempt after they've started hormonal treatment. (www.bioedge.org/index.php/bioethics/bioethics_article/8167/.)
While this physician is accurate in his interpretation of the literature that children with GID and transgender ideation are deeply troubled, his claims of a high level of suicide attempts in children with GID is not substantially supported by that same literature. What is supported is that most children who are treated for their feelings of being of the opposite sex improve remarkably and experience a resolution of their serious emotional and behavioral pain and conflict. All children with cross gender feelings should be evaluated for GID before any hormonal treatment is considered. This pediatrician also fails to consider the potentially serious side effects attributable to taking these hormones in childhood.
Paul McHugh, M.D., University Distinguished Service Professor of Psychiatry and past Chair of Psychiatry at Johns Hopkins University, has a much different view of the attempt to change the sex of children. (www.mercatornet.com/articles/experimenting_with_childrens_sexual_identity.) His studies of transgender surgery brought the procedures to an end there. He has stated that, "Treating these children with hormones does considerable harm and it compounds their confusion. Trying to delay puberty or change someone's gender is a rejection of the lawfulness of nature."
Dr. McHugh studied those who sought transsexual surgery at Johns Hopkins and also wrote, "I have witnessed a great deal of damage from sex-reassignment. The children transformed from their male constitution into female roles suffered prolonged distress and misery as they sensed their natural attitudes. Their parents usually lived with guilt over their decisions second-guessing themselves and somewhat ashamed of the fabrication, both surgical and social, they had imposed on their sons. As for the adults who came to us claiming to have discovered their true sexual identity and to have heard about sex-change operations, we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them for surgery and for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it." Surgical Sex, First Things, November 2004.
Dr. Cohen-Kettenis, a psychiatrist at a transsexual treatment center for adolescents in the Netherlands wrote in the major journal of child psychiatry that, "The percentage of children coming to our clinic with GID as adolescents wanting sex reassignment is much higher than the reported percentages in the literature." She went on to write, "We believe treatment should be available for all children with GID, regardless of their eventual sexual orientation."(Gender Identity Disorder in the DSM? J Am Acad Child & Adolesc Psychiatr. 2001. 40:391.)
Hopefully, physicians and mental health professionals will follow such professional advice and offer the appropriate evaluation for children with GID.
In our professional opinion the vast majority of children who express a wish to be of the opposite sex have GID and have the right to the highly effective treatment that is available for this disorder.