Gender Dysphoria, Gender Identity Disorder and Informed Consent

A mother, concerned for some time about her young son's preference for female friendships, lack of male playmates,identification with the feminine such as an 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 confusion problems, including, cross-dressing, exclusive cross-gender play, awkwardness with peers or siblings of the same sex or lack of same-sex friends should be treated as a sign that something may be wrong.  What's usually wrong with such a child is that due to a number of specific stressful factors the boy or girl has psychological conflicts that interfere with embracing the goodness of his masculinity or her femininity. 

Health professionals, educators and parents need to be aware that the child's conflicts may, in fact, may arise from an attempt to please a psychologically troubled mother or father.

Diagnosis of GID

The psychological conflict of young children identifying with the opposite sex and even desiring to become what they love, that is a sex opposite their own biological sex, is described as Gender Identify Disorder in the American Psychiatric Association’s Diagnostic and Statistical Manuals, including in DSM III (1983), DSM III R, DSM IV and DSM IV R. DSM V (2015) has described children who have failed to identity with their biological as having Gender Dysphoria.  This conflict was identified as a psychiatric disorder because of all the serious emotional, cognitive and behavioral suffering in these youth and the positive response to psychotherapy, as described by the leaders in the field Zucker and Bradley in Toronto. ( Zucker, K. & Bradley, S. (1995) Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. New York: Guilford Publications.)

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:

Unless treated, conflicts with embracing the goodness of masculinity or femininity can lead n adolescents and adults to a 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.

Study of  children and teenagers from gender identify center


A 2013 study from a gender identity service in Toronto that consisted of a sample of 577 children  (ages 3-12) and 253 adolescents (ages 13-20) reported a number of findings.

These included:

- a sharp increase in adolescent referrals starting with the 2004–2007 block and this increased even more so in the last block, 2008–2011.

- For the first six cohorts (1976–1999), the percentage of boys always exceeded 75%, with the sex ratio ranging from a low of 4.61:1 (1988–1991) to a high of 12:1 of boys to girls (1992–1995), but for the last three cohorts (2000–2011) hovered around 75%, with the sex ratio ranging from 2.77:1 (2000–2003) to 3.41:1 (2008–2011) of boys to girls.

-The adolescent sex ratios were closer to parity. Of note, there were two cohorts (1988–1991 and 2008–2011) when the number of girls exceeded the number of boys.

-The adolescent cases increased even more from the 2004–2007 cohort and and in the 2008-2011 cohort, the number of adolescent cases exceeded the number of child cases for the first time since the inception of their clinic in the mid-1970s.

- For the adolescents, data on sexual orientation were available for 248 patients. The percentage of girls classified as homosexual was greater than the percentage of boys classified as homosexual (76.0% vs. 56.7%).

For the children, 66.4% were in two-parent families at the time of assessment compared with 45.8% of the adolescents,

Another parameter that struck them as clinically important was that a number of youth commented that, in some ways, it was easier to be trans than to be gay or lesbian.

Along similar lines, they have also wondered whether, in some ways, identifying as trans has come to occupy a more valued social status than identifying as gay or lesbian in some youth subcultures. Perhaps, for example, this social force explains the particularly dramatic increase in female adolescent cases in the 2008–2011 cohort.

Another factor that impressed them in accounting for the increase in adolescent referrals pertained to youth with gender identify disorder who also had an autism spectrum disorder which has been reported from by others.

(Wood, H., et al. 2013. Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976-2011) Age, Sex Ratio, and Sexual Orientation. J. Sex & Marital Therapy, 39: 1-6.)

A center in the Netherlands reported the co-occurence of gender identify disorder and autism spectrum disorders (ASD) in a study of children and adolescents (115 boys and 89 girls, mean age.10.8)  The incidence of ASD was 7.8%.  The authors recommended a greater awareness finding and the challenges it generates in clinical management. (de Vries, AL, et. al. 2010. Autism spectrum disorders in gender dysphoric children and adolescents.  J Autism Dev Disord, 40: 930-6.)

Family Conflicts in youth with gender identity confusion/gender dysphoria

Drs. Zucker and Bradley in Toronto have been recognized as leaders in the study gender identity disorder.  They have identified a number of conflicts in the families of children with GID that included:

A composite measure of maternal psychopathology correlated quite strongly with Child Behavior Checklist indices of behavior problems in boys with GID.

The rate of maternal psychopathology is high by any standard and includes depression and bipolar disorder.

The boy, who is highly sensitive to maternal signals, perceives the mother's feelings of depression and anger.  Because of his own insecurity, he is all the more threatened by his mother's anger or hostility, which he perceives as directed at him. His worry about the loss of his mother intensifies his conflict over his own anger, resulting in high levels of arousal or anxiety. The father's own difficulty with affect regulation and inner sense of inadequacy usually produces withdrawal rather than approach.

              The parents have difficulty resolving the conflicts they experience in their own marital relations, and fail to provide support to each other. This produces an intensified sense of conflict and hostility.

              In this situation, the boy becomes increasingly unsure about his own self-value because of the mother's withdrawal or anger and the father's failure to intercede. This anxiety and insecurity intensify, as does his ange6.

These men (fathers) 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 inadequacy are the roots of this emotional withdrawal.

Fathers demonstrate depression and substance abuse disorder. ( Zucker KJ, Bradley SJ, Ben-Dat DN, Ho C, Johnson L, Owen A. (2003) Psychopathology in the parents of boys with gender identity disorder. J Am Acad Child Adolesc Psychiatry, 42:2–4).

Boys, who are particularly sensitive to maternal affect, can become anxious and fearful. Zucker and Bradley, noted that of 10 consecutive boys brought to their GID clinic for evaluation in every case the mother was suffering from some problem which made attachment to her son problematic.

Mothers may block separation, frowning when their sons display typically masculine behaviors, not smiling at their sons’ growing independence, and interfering with the father/son relationship. If the father tries to toss the son up in the air or engage in other rough-and-tumble play, the mother may grab the boy out of his father’s hands. The boy receives the message that his father is not trustworthy. In other cases, the father is cold or unavailable to the son.

            

The parents have difficulty resolving the conflicts they experience in their own marital relations, and fail to provide support to each other. This produces an intensified sense of conflict and hostility.

In this situation, the boy becomes increasingly unsure about his own self-value because of the mother's withdrawal or anger and the father's failure to intercede. This anxiety and insecurity intensify, as does his anger." (Kenneth Zucker, Susan Bradley Gender Identity and Psychosexual Problems in Children and Adolescents, NY: Gilford, 1995, p.262).

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 inadequacy are the roots of this emotional withdrawal."

Parental psychopathology among the parents of children with GID deserves thoughtful consideration

.

Also, Dr. Bradley has described additional maternal conflicts in these youth,

…boys with GID appear to believe that they will be more valued by their families or that they will get in less trouble as girls than as boys. These beliefs are related to parents’ experiences within their families of origin especially tendencies on the part of mothers to be frightened by male aggression or to be in need of nurturing, which they perceive as a female characteristic.

(Bradley, S. (2003) Affect Regulation and the Development of Psychopathology, NY: Guilford Press., p. 201-202.)

They also found that gender identity disorder youth had high rates of general behavior problems and poor peer relations.
(Zucker, KJ, Bradley, SJ, et al. 2012. Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. J Sex Marital Ther. 38: 151-89).

Other conflicts

In our clinical work a number of emotional conflicts have emerged. Some young males feel very insecure because of an inability to bond with other boys in playing sports. 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. Also, the absence of a father-role model in the home can contribute in some males to a profound weakness in male confidence, a difficulty in identifying with the goodness of masculinity and identity confusion.

Another cause of GID is seen in males who have special 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 and dresses and treats a boy as a female or a girl as a male.

In addition, a poor body image in a male as a result of being overly thin, small in stature or a lack of musculature can contribute to a profound sense of insecurity in one's masculinity, self-rejection or self-hatred in a culture obsessed with the body.. Cognitive distortions can then develop and include thinking that one's male body is inadequate and not truly masculine and that one would be happier with a female body.

Also, we have seen men who experience emotional and physical abuse by a father, brother and male peers at school and in the neighborhood that led to a negative identification of masculinity and later a rejection of masculinity. As children, these males felt safer in the female world and over identified with the goodness of femininity while harboring a cognitive distortion that masculinity is cruel and insensitive.  Such cognitive and emotional conflicts can lead to a desire to be female.

Confusion about sexual identity in young girls can develop as a result of the desire to please a father, who wanted an athletic child.  GID can also develop as a result of a lack of acceptance by same sex peers. This girls and teenagers are very lonely and isolated and can unconsciously believe that if they were male they would have more friends.  Failure to attach securely to and to identify with the mother can be another factor. These young girls fail to identify with their mothers and to embrace the goodness of their femininity. In some females excessive involvement in athletic activities can lead to an over identification with masculinity.

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 rigid cultural model of having large breasts and being thin. The lack of appreciation of the goodness and beauty of the female body and "genius" can lead to the fixed false thinking which is a delusion that a female is actually a male within a female's body.  Some of these females meet the criteria for a Body Dysmorphic Disorder.

Another factor in the development of GID and even a desire for Sexual Reassignment Surgery (SRS) in teenagers can be the result of traumatic experiences in the father relationship who overreacted in anger or who was physically or sexually abusive.  One father during a family therapy session with his daughter who was dressed as a male and who wanted SRS apologized to her for his excessive anger during her childhood.  He stated, "I am so sorry that I overreacted in anger as my father did.  I think that I put into you a fear of being hurt by males.  You may believe that if you have SRS you will feel safer and will be less likely to be hurt by a man."  He was surprised by his daughter's gentle response, "You may be right."

We have worked with other females who identified as males because of the severe rejection they experienced in early childhood by their father.  Unconsciously, they thought if they were males, they might finally gain his acceptance.  We have treated smaller numbers of males whose mothers rejected them because of their narcissism and addictions who unconsciously thought if they were females they might finally receive the love they had never received from their mothers.

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.)

Parents of children with GID

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).

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. 

The treatment of youth with transsexual confusion is effective.  

According to Dr. Zucker and Bradley:[6]

            The fantasy solution provides relief but at a cost.  They are unhappy children who are using their cross gender behaviors to deal with their distress. 

         

            Treatment goal is to develop same sex skills and friendships.

           In general 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.

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 has recommended that parents be trained in setting limits to the child's cross-gender behaviors by encouraging gender-neutral or sex-typed activities.  Parents can be shown how to encourage their child to find alternative activities they consider more gender-appropriate, such as same-sex peer interaction.  Parents are advised to provide empathic encouragement and not harsh imposition. (Zucker, KJ. 2006.  Gender identity disorder. In: Rutter M, Taylor, EA, editors.  Child and Adolescent Psychiatry, 4th ed.  Malden, Mass: Blackwell, pp. 737-753).

Drs. Kenneth J. Zucker and Susan Bradley, authors of the major book in the field, “Gender Identity Disorder,”[4] have been providing sensitive treatment to children with the precursor of transsexual conflicts. They have written that the goal of treatment is to develop skills associated with children of their own biological sex and friendships with such children. In one study they reported that 80% of  youth they treated were no longer gender dysphoric in their adolescence.  We have experienced similar clinical results in treating such children over the past 30 years.[5]

A loving and compassionate approach to these troubled children is not to support their difficulty 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.

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. 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 from 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.

Children can also learn to correct their cognitive distortions in regard to their natural goodness and beauty as a male or female.  The responses can including thinking:

 

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 in his masculinity.

The following interventions for boys with GID are helpful:

 

One five year old boy who identified strongly with his only friend in his neighborhood, as strong girl, told his parents that he was a girl not a boy.  Six months after the father had a job change to another city where his son developed male friendships, there was never again an identification with the feminine in this boy.  Healthy male friendships strengthened him in the goodness of his masculinity.  The development of healthy same sex friendship is one of the recommendations of Zucker and Bradley for such youth.

The following interventions for girls with GID are helpful:

 

We have also seen a resolution of gender confusion in young females when they developed good friendships with other girls and teenagers and when they identified more with their mothers than their fathers.  In other females a decreased obsession with their perceived weaknesses in their bodies and a greater appreciation for female beauty helped self-confidence grow and with a a decrease in transgender confusion.

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.

Also, the National Association for Research and Treatment of Homosexuality has an excellent review of GID available on its web site, http://www.narth.com/docs/GIDReviewKenZucker.pdf.

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, 26% had 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.

Gender Dysphoria/GID and Sexual Reassignment Surgery (SRS)

Youth with gender dysphoria/gender identity disorder today are being encouraged by parents, mental health professionals and physicians to consider the possibility of sexual reassignment surgery, as though surgery could actually change a youth's biological nature. The transsexual article on this site presents the serious health risks associated with sexual reassignment surgery and the alternative effective treatment of gender identity disorder.

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.)

Dr. Paul McHugh has also described his study of people with gender confusion over the past 40 years, 26 of which he spent as the Psychiatrist in Chief of Johns Hopkins Hospital in a 2015 article, Transgenderism: A pathogenic meme.

He wrote, "In fact, gender dysphoria - the official psychiatric term for feeling oneself to be of the opposite sex - belongs in the family of similarly disordered assumptions about the body, such as anorexia nervosa and body dysmorphic disorder.  Its treatment should not be directed at the body as with surgery and hormones any more than one treats obesity-fearing anorexic patients with liposuction."

He went on, "The treatment should strive to correct the false, problematic nature of the assumption and to resolve the psychological conflicts provoking it.  With youngsters, this is best done in family therapy."

Regrets over SRS

Dr. Renee Richards, a former professional tennis player has written that her transition failed to meet even her own expectations. She wrote, "I wish that there could have been an alternative way, but there wasn't in 1975. If there was a drug that I could have taken that would have reduced the pressure, I would have been better off staying the way I was -- a totally intact person. I know deep down that I'm a second-class woman. I get a lot of inquiries from would-be transsexuals, but I don't want anyone to hold me out as an example to follow. Today there are better choices, including medication, for dealing with the compulsion to crossdress and the depression that comes from gender confusion. As far as being fulfilled as a woman, I'm not as fulfilled as I dreamed of being. I get a lot of letters from people who are considering having this operation...and I discourage them all."

( Renee Richards, "The Liason Legacy", Tennis Magazine, March 1999).

Walt Heyer, who went through SRS, exposes the dark origins of the practice and its often tragic results in his article.  "Sex Change Surgery: What You Should Know".

Walter Heyer can also be heard discussing his experiences on Relevant Radio, June 3, 2015. http://relevantradio.com/audios/the-drew-mariani-show

 

Youth and parents have the right to be given informed consent about the highly effective treatment that has been available for decades for youth who have gender confusion and unhappiness. Mental health professionals, physicians and educators have a professional responsibility to acquire and communicate such knowledge and family members, clergy and elected officials a moral responsibility to do so.

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