Gender Identity Disorder and Transsexual Issues
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 pastimes 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 children with GID
Boys who exhibit such symptoms before they enter school are more likely to be unhappy, lonely, and isolated in elementary school. They often suffer from separation anxiety, depression, and behavioral problems and become targets to be victimized by bullies and even pedophiles. Often they experience same-sex attraction in adolescence and if they engage in homosexual activity. they are more likely than boys who do not, to be involved in drug and alcohol abuse or prostitution. They are also at greater risk to attempt suicide; to contract a sexually transmitted disease; or to develop a serious psychological disorder 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 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.
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 intensify 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 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 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.
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 and a failure to appreciate the goodness of one's masculinity. The developmental faliure in appreciating the goodness in one's masculinity lead to an identification with femininity. Cognitive distortions can then develop and include thinking that one's mae 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 masculinity while harboring a cognitive distortion that masculinity is cruel and insensitive. Such cognitive and emotional conflicts can lead to a desire to be female.
GID in young girls can develop as a result of the desire to please a father, who wanted an athletic child. Overinvolvment in athletic competition can lead to an overidentification with masculinity. 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. 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 fail to identify with their mothers and 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 places increasing importance on athletic success in females.
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. Then, a lack of acceptance by female peers and a hatred of one's body and ultimately of one's femininity can develop with a desire to become male. 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 famliy 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 communicated as my father did, that is with too much anger and not enough praise and cheerfulness. I think that I have 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).
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.
Boys, who are particularly sensitive to maternal affect, can become anxious and fearful. Zucker and Bradley, experts in Gender Identity Disorder, which is often a precursor of Same Sex Attraction, 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.
According to Susan Bradley:
… 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. (Susan Bradley, Affect Regulation and the Development of Psychopathology, NY: Guilford Press, 2003, p. 201-202)
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. In their book, Gender Identity and Psychosexual Problems in Children and Adolescents, Zucker and Bradley posit that:
"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 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."
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 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:
- "I can grow to be appreciate the goodness of my body and masculinity and femininity,"
- "I can be thankful for my special masculinity or femininity,"
- "I can grow to feel more comfortable with those of the same sex."
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:
- 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.
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.
Pope Benedict and Gender
Pope Benedict commented on the dangers associated with the current use of the term gender. He stated, "It (The Church) has a responsibility for the created order and ought to make this responsibility prevail, even in public. And in so doing, it ought to safeguard not only the earth, water, and air as gifts of creation, belonging to everyone. It ought also to protect man against the destruction of himself. What is necessary is a kind of ecology of man, understood in the correct sense. When the Church speaks of the nature of the human being as man and woman and asks that this order of creation be respected, it is not the result of an outdated metaphysic. It is a question here of faith in the Creator and of listening to the language of creation, the devaluation of which leads to the self-destruction of man and therefore to the destruction of the same work of God. That which is often expressed and understood by the term “gender”, results finally in the self-emancipation of man from creation and from the Creator. Man wishes to act alone and to dispose ever and exclusively of that alone which concerns him. But in this way he is living contrary to the truth, he is living contrary to the Spirit Creator.
The tropical forests are deserving, yes, of our protection, but man merits no less than the creature, in which there is written a message which does not mean a contradiction of our liberty, but its condition. The great Scholastic theologians have characterized matrimony, the life-long bond between man and woman, as a sacrament of creation, instituted by the Creator himself and which Christ without modifying the message of creation has incorporated into the history of his covenant with mankind. This forms part of the message that the Church must recover the witness in favour of the Spirit Creator present in nature in its entirety and in a particular way in the nature of man, created in the image of God. Beginning from this perspective, it would be beneficial to read again the Encyclical Humanae Vitae: the intention of Pope Paul VI was to defend love against sexuality as a consumer entity, the future as opposed to the exclusive pretext of the present, and the nature of man against its manipulation," Pope Benedict XVI, Christmas address to the Curia, 12/22/08.
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.)
A 2011 Swedish study on follow for patients after sex reassignment found considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Their findings suggested that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism and places the patients at risk for severe psychiatric illnesses, (Lichtenstein, D.C., 2011).
I coauthored an article on sexual reassignment surgery for the oldest medical moral journal in the United States, the Catholic Medical Association's Linacre Quarterly. Below is the abstract of this article.
The Psychopathology of “Sex Reassignment” Surgery:Assessing Its Medical, Psychological, and Ethical Appropriateness
Richard Fitzgibbons, M.D., Philip M. Sutton, and Dale O’Leary
National Catholic Bioethics Quarterly 9.1 (Spring 2009): 109–137.
Abstract. Is it ethical to perform a surgery whose purpose is to make a male look like a female or a female to appear male? Is it medically appropriate? Sexual reassignment surgery (SRS) violates basic medical and ethical principles and is therefore not ethically or medically appropriate. (1) SRS mutilates a healthy, non-diseased body. To perform surgery on a healthy body involves unnecessary risks; therefore, SRS violates the principle primum non nocere, “first, do no harm.” (2) Candidates for SRS may believe that they are trapped in the bodies of the wrong sex and therefore desire or, more accurately, demand SRS; however, this belief is generated by a disordered perception of self. Such a fixed, irrational belief is appropriately described as a delusion. SRS, therefore, is a “category mistake”—it offers a surgical solution for psychological problems such as a failure to accept the goodness of one’s masculinity or femininity, lack of secure attachment relationships in childhood with same-sex peers or a parent, self-rejection, untreated gender identity disorder, addiction to masturbation and fantasy, poor body image, excessive anger, and severe psychopathology in a parent. (3) SRS does not accomplish what it claims to accomplish. It does not change a person’s sex; therefore, it provides no true benefit. (4) SRS is a “permanent,” effectively unchangeable, and often unsatisfying surgical attempt to change what may be only a temporary (i.e., psychotherapeutically changeable) psychological/psychiatric condition.
Hopefully, physicians and mental health professionals will provide informed consent to youth with GID and offer the appropriate evaluation. 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.