Gender Identity Disorder in ChildrenBy Richard P. Fitzgibbons, M.D.
A mother, concerned for some time about her 4-year-old son's effeminate mannerisms, lack of male playmates, and interest in Barbie dolls, finally decides to ask the pediatrician if these are signs of a problem. She is particularly worried that her husband has become increasingly upset and alienated from their son. The pediatrician is reassuring: "This is just a phase nothing to worry about. He will grow out of it." Unfortunately, the pediatrician is probably wrong. Gender identity problems, including cross-dressing, exclusive cross-gender play, and a lack of same-sex friends should be treated as a symptom that something may be very wrong. 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 behavior 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; or to contract a sexually transmitted disease, such as HIV/AIDS; or to develop a serious psychological problem as an adult. A small number of these boys will become transvestites or transsexuals. The good news is that if the gender identity problems are identified and addressed and if both parents cooperate in the solution, many of the negative outcomes can be prevented. According to Dr. Kenneth Zucker and Susan Bradley, experts in the treatment of gender identity problems in children, treatment should begin as soon as possible. ...In general we concur with those who believe that the earlier treatment begins, the better.1 The effeminacy in some boys is so pronounced that parents may assume the problem is genetic or hormonal, but experts report that children assumed to have a biological problem responded positively to therapeutic intervention: According to Rekers, Lovaas, and Low: When we first saw him, the extent of his feminine identification was so profound (his mannerisms, gestures, fantasies, flirtations, etc., as shown in his "swishing" around the home and the clinic, fully dressed as a woman with a long dress, wig, nail polish, high screechy voice, slatternly, seductive eyes) that it suggested irreversible neurological and biochemical determinants. After 26 months follow-up, he looked and acted like any other boy. People who viewed the video taped recordings of him before and after treatment talk of him as "two different boys."3 Children need to feel good about their gender identity. Healthy psychological development requires that a little boy be able to recognize that there are two sexes and he is male, he is like other boys, and will grow up to be a man and possibly a father, not a woman and a mother. Additionally he needs to feel good about being a boy and becoming a man. He needs to believe that his mother and father are happy that he is a boy and expect him to become a man and he needs to feel accepted as a boy by other boys. If a boy feels inadequate in his masculine identity, identifies with his mother instead of his father, feels that he would like to be a girl, those around him should not pass this off as non-stereotypical behavior. There is a reason why this boy is not developing a healthy masculine identity and that reason should be discovered and addressed. One often hears boys with gender identity problems called "girlish," but if one observes their behavior carefully, one sees that they do not resemble healthy little girls of the same age, but imitate adult women. For example, while doll play for healthy girls includes mother/baby play and fashion/dress up play, boys with gender identity problems focus almost exclusively on fashion/dress up. Some may be fixated on characters such as the Disney villianesses -- the wicked stepmother in Snow White or Cruella de Ville from 101 Dalmations. While healthy girls combine outdoor physical activities with more sedate play, boys with gender identity problems are often unreasonably afraid of injury, avoid rough and tumble play, and dislike group sports. Cross-dressing and cross-gender fantasy in boys is often passed off by the family as a sign that the boy is a "great actor" or has a "wonderful imagination." Family members fail to understand that a boy who never takes the part of male character, but always plays a female is revealing a deep ambivalence toward his own masculinity. Therapy can help the boy and his family understand why he feels more confident, comfortable, and accepted when he is fantasizing that he is a female. Today, many adults try very hard not to impose rigid gender stereotypes on young children, but this push for gender openness can lead parents to ignore the symptoms of gender identity conflict. Children with gender identity problems DO NOT inhabit a gender-neutral world where boys and girls play with the same toys. These troubled children reject certain types of play and clothing precisely BECAUSE it is associated with their own gender, and they adopt activities because they are associated in their mind with the opposite sex. Boys with serious gender identity problems may use female clothing to gain acceptance or soothe anxiety become angry and upset when deprived of these objects. Some parents may ask "What is wrong with a boy playing with dolls?" The answer is that the problem is as much what he is not doing -- learning how to be a boy among boys -- as it was what he is doing -- escaping into a female world. Parents need to be concerned when a child openly expresses a dissatisfaction with his or her sex. such as when a boy says "I want to be a girl" or when a girl insist she is a boy. One extremely effeminate boy when asked, "Do you want to be like your daddy when grown up?" responded "I don't want to be grown up." Such statements should be taken as symptoms that something is very wrong. Although the boy may feel or even express the desire to grow up to be a woman, he is male and will grow up to be a man. Children are born with a drive to seek love and acceptance by each parent, 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 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. 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 and be happy he is a boy. Effeminacy, cross-gender play, and cross dressing are not the only signs that there may be a problem. Some boys suffer from a chronic sense of being inadequate in their masculinity , but do not imitate female behavior. These boys may exhibit an almost phobic reaction to rough and tumble play and an intense dislike of team sports because of poor eye-hand coordination. This inability to relate to other boys leads to isolation, profound unhappiness, and often depression. Gender identity problems also occur among girls, although the problem is less common. In some cases a father may be pleased with his daughter's success in athletics and ignore her phobic reaction to dresses or anything feminine. Girls with gender identity problems may believe that being a boy will make them safe from abuse. What should a parent do if they think that there might be a problem? First, they should take any repeated problematic behaviors as a cry for help. If their pediatrician ignores their concerns, they should find a therapist who is trained in the treatment of gender-identity problems. Parents can read on the subject -- books such as Zucker and Bradley's Gender Identity and Psychosexual Problems in Children and Adolescence, which offers a complete review of the problem. Consistent cross-gender behaviors are a sign that the child believes he or she would be better off' as the opposite sex. According to Bradley and Zucker, "This fantasy solution' provides relief, but at a cost." These are unhappy children who are using these behaviors defensively to deal with their distress.4 Parents sometimes try on their own to stop the overt behavior, but forcing a frightened child to engage in behaviors in which he feels inadequate or fearful is not the solution. The therapist can work with the child and the parents to uncover the root cause of the emotional conflicts, sso that the problem can be addressed and resolved. It is true that without treatment certain manifestations of gender identity conflicts, such as fantasy fashion doll play in boys or open cross-dressing may disappear by the time the child is eight or nine years old, but these coping mechanisms are often replaced by other less overt expressions of an underlying gender identity problem. Once the problem goes "underground" it will be more difficult to treat. Some people may avoid treatment because they believe that gender identity problems are a sign that the child was "born homosexual" and that the parents should simply accept this outcome as inevitable and encourage the child to accept a homosexual identity. Given the positive results of early intervention, the profound unhappiness of these children during elementary school, and the massive problems which accompany same-sex attraction in adolescence, parents should do everything possible to help their child resolve even minor gender identity problems. Catholic parents need to be particularly concerned. The Church's teaching on homosexual activity is clearly stated in the Catechism of the Catholic Church, "homosexuals acts are intrinsically disordered... Under no circumstances can they be approved" (CCC 2357). For a Catholic trying to be obedient to God, temptations to same-sex activity are a source of deep pain. Treatment of adolescents or adults is possible, but difficult and the outcome is not assured. It is far better to prevent the problem or treat it in early childhood. Those who would like to understand more about same-sex attractions can find information on the website of the Catholic Medical Association (www.cathmed.org) in a report entitled Homosexuality and Hope. If a boy grows up happy and confident about his masculine identity -- with a mother who supports his manly development, a close loving relationship with his father, same-sex friends in childhood, and is protected from vicious bullying and sexual predators -- the chances are minimal that he will experience same-sex attraction in adolescence. Even if one or two items on the above list are missing, the chances are still small that the boy will become homosexually involved as an adult. Generally, the histories of men engaging in same-sex behaviors reveal a history of cumulative problems: significant peer rejection, low self-esteem, a distant father, an overprotective or controlling mother, victimization by bullies, or sexual abuse. Fortunately these conflicts can be resolved, and the masculine identity can be strengthened and then embraced. {1} Zucker, Kenneth and Susan Bradley (1995) Gender Identity Disorder and Psychosexual Problems in Children and Adolescents. N.Y.: Guilford Press, p.281. {2} .(p.282) {3} Rekers, G., Lovaas, O., Low, B. (1974) Behavioral treatment of deviant sex role behaviors in a male child. Journal of Applied Behavioral Analysis. 7: 134 - 151. {4} Bradley, S., Zucker, K. (1998) Drs. Bradley and Zucker reply. Journal of the American Academy of Child and Adolescent Psychiatry. 37, 3: 244 - 245.
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The
following article appeared in the June 2001 issue of the Catholic
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