Follow-up studies of boys with GID, largely untreated, indicate that homosexuality, not transsexualism, is the most common long-term psychosexual outcome (Green 1987). Some parents of children with GID request treatment, in part, with an eye toward preventing subsequent homosexuality in their child.
Case Example 8
Abraham was a 4-year-old boy with an IQ of 117. He lived with his middle-class parents and several siblings. Identification with ethnic heritage, including cultural traditions and religion, played a strong role in the family’s life. In terms of political ideology, the father was conservative and the mother was liberal. Beginning at around the age of 2, Abraham began to manifest the behavioral signs of GID. The parents had been quite tentative in deciding how to deal with Abraham’s cross-gender behavior. After reflecting upon an article on GID provided to them by their pediatrician, the parents decided to have an evaluation. During an intake telephone interview, Abraham’s mother commented: “I think I have a son who is predisposed to homosexuality….To be blunt, I want to steer my son in the direction of heterosexuality.”
Among mental health professionals, the view that homosexuality per se is not a mental disorder is fairly well accepted (Friedman 1988; Spitzer 1981; Stoller 1980), although dissenters can still be found (Nicolosi 1991; Socarides 1990). Given the relation between GID in childhood and a later homosexual sexual orientation, critics have questioned the therapeutic agenda of child clinicians. Regarding this matter, Green (1987) mused:
Should parents have the prerogative of choosing therapy for their gender-atypical son? Suppose that boys who play with dolls rather than trucks, who role-play as mother rather than as father, and who play only with girls tend disproportionately to evolve as homosexual men. Suppose that parents know this, or suspect this. The rights of parents to oversee the development of children is a long-established principle. Who is to dictate that parents may not try to raise their children in a manner that maximizes the possibility of a heterosexual outcome? If that prerogative is denied, should parents also be denied the right to raise their children as atheists? Or as priests? (p. 260)
Over the past 10 years or so, this rationale for treatment has been subject to even further scrutiny (Minter 1999; Sedgwick 1991). Some critics, for example, have argued that clinicians, consciously or unconsciously, accept the prevention of homosexuality as a legitimate therapeutic goal. Minter (1999) claimed, as have others, that some adolescents in the United States are being hospitalized against their will because of their homosexual sexual orientation but under the guise of the GID diagnosis. To my knowledge, however, these allegations have not been verified in any systematic manner, and I am personally aware of no such case in which this has occurred. Others have asserted, albeit without direct empirical documentation, that treatment of GID results in harm to children who are “homosexual” or “prehomosexual”. Some clinicians have raised questions about differential diagnosis, suggesting that there is not always an adequate distinction between children who are truly GID versus those who are merely prehomosexual. In response to some of these concerns, the Human Rights Commission of the city and county of San Francisco passed a resolution on September 12, 1996, that condemned “any treatment designed to manipulate a young person’s…gender identity….”
The various issues regarding the relation between GID and homosexuality are complex, both clinically and ethically. Three points, albeit brief, can be made. First, until it has been shown that any form of treatment for GID during childhood affects later sexual orientation, Green’s (1987) query about parental rights is moot. From an ethical standpoint, however, the treating clinician has an obligation to inform parents about the state of the empirical database. Second, I have argued elsewhere that some critics incorrectly conflate gender identity and sexual orientation, regarding them as isomorphic phenomena, as do some parents. Psychoeducational work with parents can review the various explanatory models regarding the statistical linkage between gender identity and sexual orientation, but also discuss their distinctness as psychological constructs. Third, many contemporary child clinicians emphasize that the primary goal of treatment with children with GID is to resolve the conflicts that are associated with the disorder per se, regardless of the child’s eventual sexual orientation.
There are various rationales for offering treatment to children with GID. Some of these rationales rest on firmer empirical or ethical grounds than others. At least four goals - elimination of peer ostracism in childhood, treatment of other psychopathology, reduction of the felt distress, and prevention of transsexualism in adulthood - are so obviously clinically valid and consistent with the ethics of our time that they would constitute sufficient justification for therapeutic intervention. In my view, the primary goal of avoiding adult homosexuality is, for a variety of reasons, considerably more problematic, and the contemporary clinician must be sensitive to the myriad of therapeutic and ethical issues that this matter raises. Thus, the treating clinician needs to think through these issues carefully and to develop a working relationship with families that is sensitive, empathic, and responsive to the complex reactions that matters pertaining to psychosexuality engender in most people.
Revision date: July 5, 2011
Last revised: by Andrew G. Epstein, M.D.