As a point of departure, let us consider five rationales for intervention that have been discussed in the treatment literature to date.
Reduction of Social Ostracism
There is both clinical and empirical evidence that children with GID are subject to social ostracism, particularly in the peer group and as they get older (Zucker 1990; Zucker et al 1997a). Such ostracism is one correlate of the general behavioral and emotional difficulties found in these children (Zucker 1990; Zucker and Bradley 1995). The experience of social ostracism appears to be stronger for boys than for girls with GID, which is consistent with findings in the normative developmental literature that cross-gender behavior has greater negative sequelae for boys than for girls (Zucker et al. 1995).
Case Example 1
Toni was a 6-year-old girl with an IQ of 123. She lived with her middle-class parents and an older sibling. Toni had all of the signs of GID, including an “obsession” with the mechanics of sex reassignment surgery (after neighborhood boys told her that she should get a “sex change,” her parents had described to her what such surgery comprised). Toni’s parents sought an assessment for several reasons, including the increase in social ostracism and rejection that she was experiencing in the peer group. At the time of assessment, Toni had an “ambiguous” physical appearance, so that the usual phenotypic social markers of gender (hair and clothing styles) could not be used reliably by others (Fridell et al. 1996; McDermid et al. 1998). At school, Toni began spelling her name as “Tony.” She preferred to play with boys and had, over the past couple of years, lost her popularity among the girls. Toni seemed troubled by this, stating that she did not understand why the girls had become uncertain whether she was a boy or a girl. Indeed, the teacher reported that several of the children in Toni’s class seemed anxious and troubled, not being sure if Toni was a boy or a girl.
Case Example 2
Norton was a 10-year-old boy with an IQ of 81. He lived with his lower-middle-class parents and an older sister. Apart from his marked cross-gender behavior, which had been of long-standing duration, he was very separation anxious, had notable academic learning problems, had been previously diagnosed with attention-deficit/hyperactivity disorder, and was on Ritalin. His parents requested an assessment after previous involvement at another agency had not resulted in any major changes in Norton’s cross-gender behavior. Social ostracism was of particular concern, as it appeared to be getting worse. In the neighborhood, Norton had no close friends. At school, he was called “fag, gay, stupid.” When asked why he was called stupid, Norton commented, “I’m not that good at math.” Norton knew what the words “fag” and “gay” meant: “Like you kiss another boy or you sleep with another boy.” Norton was fairly demoralized about his peer relations: “they don’t care about me, they don’t like me, they never do anything for me.” He talked about feeling “unappreciated,” and acknowledged having revenge fantasies toward boys after episodes of teasing. The girls at school were much more rejecting of Norton than they had been in the past - several girls tried to convince him, but to no avail, that he was really now too old to be playing with them and that he should learn how to play with the other boys. Norton’s parents noted that he never had had a close friend and that he complained of loneliness. Because of the teasing, the parents contemplated withdrawing Norton from school and teaching him at home.
Because the phenomenon of peer group “gender segregation” is such a salient aspect of a child’s social world (Maccoby 1998), treatment interventions designed to improve the same-sex peer group relations of children with GID might not only alleviate short-term social distress, which is often acutely painful, but also prevent the development of longer-term psychopathological sequelae.
Of course, the case could be made that it is the children who tease, reject, or bully youngsters with GID that should be treated, not the “victim” (Feder 1997; Thorne 1993). Indeed, bullies are often targeted for treatment, if one reads carefully the child clinical literature on peer group relationships. Along the same lines, one could argue that children should be encouraged to display greater acceptance and tolerance of variations in the gender-role behavior of their peers (Nordyke et al. 1977), one of the underlying themes in the critically acclaimed film Ma Vie en Rose (“My Life in Pink”). Although these are legitimate ideas in theory, the situation is usually more complex in practice. To some extent, the focus on improving the peer group relations of children with GID needs to be considered within the context of a broader therapeutic plan, including a good formulation of why the child is having so much difficulty in making friends with same-sex peers. Even so, this does not negate the importance of efforts to minimize peer rejection and isolation from a macrosocial interventionist perspective (George 1998; Soutter 1996).
Revision date: July 6, 2011
Last revised: by Dave R. Roger, M.D.