Influenced by Stoller’s (1968) claim that extremely feminine boys did not experience internalized conflict - and thus were not amenable to psychoanalysis - Green et al. (1972) developed a more eclectic and multimodal approach to the psychotherapy of boys with GID. The therapeutic approach of Green et al. (1972) had four stated objectives: 1) developing a relationship of “trust and affection” between the boy and a male therapist, 2) heightening parental concern regarding the boy’s femininity, 3) increasing the father’s involvement in the boy’s life, and 4) sensitizing the parents to the dynamics of their own relationship in order to alter the mother-son overcloseness and the father’s peripheral role in the family. The aim of the therapy was intended to help feminine boys “understand” the motives for their cross-gender behavior and to indicate to such boys that being masculine is “good.” Thus, approval was given for “any signs of masculinity” in either overt behavior or fantasy.
Sex of the Therapist
A “technical” question that often is asked in the psychotherapy of children with GID is whether the therapist’s sex should match that of the child. It has been argued that male therapists would be most therapeutic for boys with GID, because the close relationships of such children have usually been with women. Similarly, it has been argued that female therapists would be best for girls with GID, whose normal feminine identification with the mother has been impaired by the mother’s depression and by her devaluation of her own femininity.
The foregoing arguments seem plausible; however, it could also be argued that an opposite-sex therapist has the potential to “correct” distortions that have developed in the child’s relationship with his or her opposite-sex parent. In any case, there have been no systematic studies demonstrating that the sex of the therapist makes any difference, and the most important qualification of the therapist is probably that he or she feel comfortable with the content issues arising in the treatment of children with GID.
An overall examination of the available case reports suggests that psychotherapy, like behavior therapy, does have some beneficial influence on the sex-typed behavior of children with GID. However, the effectiveness of psychoanalytic psychotherapy, like that of behavior therapy, has never been demonstrated in an outcome study comparing children randomly assigned to treated and untreated conditions. Moreover, many of the cases cited above did not consist solely of psychoanalytic treatment of the child. The parents were often also in therapy, and, in some of the cases, the child was an inpatient and thus exposed to other interventions. It is impossible to disentangle these other potential therapeutic influences from the effect of the psychotherapy alone.
What do we know about the long-term outcome of children with GID treated with psychotherapy techniques? Again, not very much. There has been very little in the way of published long-term follow-up reports assessing gender identity, sexual orientation, and general adaptive functioning.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD