Gender Identity Disorder - Treatment of the Child

	Tweet

Behavior Therapy

The literature contains 13 single-case reports that employed a behavior therapy approach to the treatment of GID in children (12 boys, 1 girl), the majority of which are by Rekers and his associates. For a detailed outline of the subject and treatment characteristics of the case reports by Rekers and colleagues, see Zucker (Table 15).

The classical behavioral approach assumes that children learn sex-typed behaviors much as they learn any other behaviors and that sex-typed behaviors can be shaped, at least initially, by encouraging some and discouraging others. Accordingly, behavior therapy for GID systematically arranges to have rewards follow sex-appropriate behaviors and to have no rewards (or perhaps punishments) follow sex-inappropriate behaviors. The behavioral targets of intervention have included a variety of cross-gender behaviors, including toy and dress-up play, role-playing, exclusive affiliation with the opposite sex, and mannerisms. In addition, some treatments have focused on behavioral deficiencies, such as poor athletic ability. None of the case reports focused specifically on the child’s verbal statements or fantasies about wanting to be of the opposite sex. Strictly speaking, therefore, the aim of the behavioral interventions has been to modify specific overt sex-typed behaviors rather than gender identity or gender dysphoria.

One type of intervention employed by Rekers and his associates has been termed differential social attention or social reinforcement. As stated by Rekers and Lovaas (1974), the therapeutic goal of such an intervention (for boys) was to “extinguish feminine behavior and to develop masculine behavior” (p. 179). This type of intervention has been applied in clinic settings, particularly to sex-typed play behaviors. The therapist first establishes with baseline measures that the child (either when alone or in the presence of a noninteracting adult) prefers playing with cross-sex toys or dress-up apparel rather than same-sex toys or dress-up apparel. A parent or stranger is then introduced into the playroom and instructed to attend to the child’s same-sex play (e.g., by looking, smiling, and verbal praise) and to ignore the child’s cross-sex play (e.g., by looking away and pretending to read). Such adult responses seem to elicit rather sharp changes in play behavior.

As noted by Rekers and colleagues, there have been two main limitations to the use of social attention or reinforcement in treating cross-gender behavior. First, at least some of the children studied reverted to cross-sex play patterns in the adult’s absence or in other environments, such as the home - a phenomenon known as stimulus specificity (Rekers 1975). Second, there was little generalization to untreated cross-sex behaviors - a phenomenon known as response specificity. Rekers and Lovaas (1974) reported that the same limitations applied to the use of a token economy system in which the child was given “points” for engaging in same-sex behaviors or penalized points for engaging in cross-sex behaviors.

The problems of stimulus and response specificity have led behavior therapists to seek more effective strategies of promoting generalization. One such strategy, self-regulation, has the child reinforce himself or herself when engaging in a sex-typical behavior. This eliminates the necessity of providing external reinforcement, which may not always be feasible. Blount and Stokes (1984) suggested that by allowing the child to control his or her behavior, the “problems of generalization from one setting to another and from the presence to the absence of external behavior change agents may be avoided” (p. 196).

Rekers and Varni (1977a, 1977b) and Rekers and Mead (1979) reported on three cases in which self-regulation procedures were employed. In one of these reports (Rekers and Varni 1977b), a 4-year-old boy was fitted with a wrist counter and told to press it only when playing with “boys’ toys.” This behavior was initially facilitated by “behavioral cuing,” in which the boy wore a “bug-in-the-ear” device and was told when to press the counter. This self-monitoring procedure resulted in substantial decreases in cross-sex play, and there was also some evidence of generalization; however, as noted in detail elsewhere (Zucker 1985, pp. 124-125), the reports of Rekers and his associates provide weak evidence for the claim that generalization is better promoted by self-regulation than by social attention.

Evaluation of the Short-Term Effectiveness of Behavior Therapy
An overall examination of the case reports cited above, particularly those by Rekers and his colleagues, suggests that behavior therapy techniques do have some immediate effect on the sex-typed behavior of children with GID. For example, Rekers and his co-workers have provided short-term follow-ups of their cases, ranging from 5 weeks to 3.5 years after treatment, using a variety of formats: clinical interviews of the child and the family, home and school observations, and psychological tests. The general picture painted by Rekers and his colleagues is that all of their patients showed reductions in cross-sex behavior by the end of treatment and that these reductions were being maintained at follow-up. Presumably, the children were also no longer wishing to change sex; this is not always specifically stated, but it is likely that it can be safely inferred.

Although behavior therapy has had some success in treating children with GID, a few critical comments are in order. First, it is obvious behavioral improvements at follow-up cannot be unequivocally attributed to the treatment intervention without the use of a comparison group of untreated children to control for “spontaneous” remission or simple maturation effects. If the case reports by Rekers and his group are examined closely, as was done elsewhere (Zucker 1985), it becomes apparent that some of the changes noted at follow-up could not have been due solely to treatment, because these changes had not appeared by the time treatment was completed - unless one is willing to attribute the changes to “sleeper effects.” Second, behavior therapists have not explained the apparent changes in gender identity (i.e., the child’s desire to be of the opposite sex), which occurred even though this variable was not targeted for modification; this finding requires explanation because the previously noted phenomenon of response specificity would lead one to expect the retention of untreated behaviors. Finally, it is unclear whether the cases reported on can be generalized to all children with GID; these cases may have been especially amenable to treatment because of particular characteristics (e.g., low levels of general psychopathology, highly motivated parents).

Evaluation of the Long-Term Effectiveness of Behavior Therapy
What do we know about the long-term outcome of children with GID treated by behavior therapy techniques? Unfortunately, not very much. To date, Rekers and his group have provided only hints of what they have found over the long run. Rekers (1985) reported that more than 50 children had been “comprehensively treated” and that follow-up results suggested “permanent changes in gender identity.” From this, one assumes that there was an absence of gender dysphoria and no desire for sex-reassignment surgery. Specific information, however, was not provided. Rekers et al. (1990) provided group analysis of 29 boys treated by behavior therapy techniques. At a mean follow-up of 51 months after treatment, it was found that “completion” of treatment accounted for 20% of the variance in change scores, as defined by a reduction in ratings of cross-gender identification. Unfortunately, there have been no published reports on longer-term follow-ups that assess the adolescent gender identity and sexual orientation of the 29 boys. It is of interest, therefore, that Rekers (1986) claimed, without formal substantiation, that from “the result of my research studies, it now appears that a preventive treatment for transvestism, transsexualism, and some forms of homosexuality has indeed been isolated”.

One final word about the behavioral approach to treatment is in order. It is of interest that the behavior therapy literature has produced no new case reports for almost 20 years although its principles are often used in broader treatment approaches that involve the parents (see “Treatment of the Parents” subsection below). This publication gap is curious, because more contemporary behavioral approaches, such as cognitive-behavior therapy, are now used so widely in child psychiatry with other disorders.

RELATED STORIES:
Gender Identity Disorder: Eclectic Psychotherapy   Gender Identity Disorder - Treatment of the Adolescent   Rationales for Therapeutic Intervention   Gender Identity Disorder: Mother-Child Relations   Gender Identity Disorder in Children and Adolescents - Group Therapy   Gender Identity Disorder - Treatment of the Child - Psychotherapy   Treatment of Underlying Psychopathology   Prevention of Homosexuality in Adulthood   Treatment of Distress Associated With Gender Identity Disorder   Gender Identity Disorder in Children and Adolescents   Gender Identity Disorder in Children and Adolescents - Treatment of the Parents   Prevention of Gender Identity Disorder (Transsexualism) in Adulthood   Gender Identity Disorder: Father-Child Relations

Comments

[ + Post Your Own ]

Now you're in the public comment zone. What follows is not Armenian Medical Network's stuff; it comes from other people and we don't vouch for it. A reminder: By using this Web site you agree to accept our Terms of Service. Click here to read the Rules of Engagement.

There are no comments for this entry yet. [ + Comment here + ]