Treatment of Underlying Psychopathology

Several theoretical perspectives suggest that GID in children originates within the context of family factors or psychopathology. Such factors include parental conflict and trauma related to gender identity issues in their own life histories, attachment issues during early development, and general parent-child relational characteristics. Let us consider several examples.

Some mothers of boys with GID experience what Zucker and Bradley (1995) characterized as “pathological gender mourning”. During the pregnancy with the proband, there is a strong desire to have a daughter. After the son is born, these mothers have great difficulty in coping with the disappointment of not having had a child of the preferred sex, and this disappointment appears to be transmitted to the boy in complex ways.

Case Example 3
Mark was a 4-year-old boy with an IQ of 111. He lived with his middle-class parents and an older brother. During the pregnancy, his mother had desired a daughter and recalled being quite depressed after his birth. She reported a preoccupation with not having had a daughter; for example, she reported vivid night dreams in which she was pregnant with a girl. Upon awakening, she became depressed upon realizing that “it was just a dream.” Such dreams had recurred throughout Mark’s life. Mark was reported to have been a very difficult infant, and his parents recalled that he could be soothed only if his mother held him. He would cry frantically if held by his father. At the time of assessment, Mark’s mother described him as very oppositional in his relationship with her, and she found parenting him to be extremely challenging. Although he was markedly noncompliant and prone to intense temper tantrums, Mark also appeared to be very attuned to his mother’s feelings. For example, when, at age 2, she talked about the family getting a cat, Mark began to meow. Mother recalled that Mark began to cross-dress in her clothes shortly after she verbalized how “nice” it would be to have a girl in the family. During the mother’s individual interview, she was asked to talk about what the desire for a girl meant to her. With a great deal of sadness, she said that “Boys grow up and leave their mothers…then I’ll be alone.” She talked about how this left her feeling “like there is a hole in my heart…it will never be filled.”

Coates and Person (1985) posited that separation anxiety, activated by uneven maternal availability, plays a pivotal role in the development of GID in boys. According to this model, severe separation anxiety precedes the feminine behavior of the boys, which emerges in order “to restore a fantasy tie to the physically or emotionally absent mother. In imitating ‘Mommy [the boy] confuse[s] ‘being Mommy’ with ‘having Mommy.’ [Cross-gender behavior] appears to allay, in part, the anxiety generated by the loss of the mother” (Coates and Person 1985, p. 708).

Case Example 4
Harvey was a 10-year-old boy with an IQ of 69. He lived with his mother. His father had died in a construction accident prior to his birth. When Harvey was 2 years old, his mother returned with him to her country of origin. He was left in the care of his maternal grandmother and his mother returned to Canada to work. He was reunited with his mother at the age of 5. At that time, she observed that he engaged in extensive cross-gender behaviors, including cross-dressing. Harvey’s mother worked long hours and, after school, Harvey was looked after by a neighbor. Harvey complained bitterly, but with sadness as well, that he never got to see his mother: “She’s always working and on the weekends she is too busy shopping.” When home alone, Harvey often would take his mother’s scarves, wrap them around his head, and give them female names, and he would then talk to them, in a manner akin to an imaginary friend.

Some parents of children with GID report traumas in their own lives that have gender-specific features; for example, Zucker and Bradley (1995) noted that in their series of girls with GID about 25% of their mothers had had a history of severe and chronic sexual abuse, often intrafamilial. The femininity of these mothers was compromised by this experience, which also rendered them quite wary about men and masculinity and contributed to substantial sexual dysfunction. Regarding intergenerational transmission, the message to the daughters seemed to be that being female was unsafe.

Case Example 5
Heidi was a 5-year-old girl with an IQ of 100. She lived with her working-class parents. Heidi’s mother reported a complex history of intrafamilial sexual abuse. She believed that sexual abuse was extensive in her family of origin, involving many first- and second-degree relatives. In my view, some of the mother’s account of sexual abuse appeared to be along the lines of recovered memories activated in the course of individual psychotherapy. Heidi’s mother suffered from debilitating health problems, resulting in multiple surgeries (some of which were likely unnecessary) and subsequent bed rest, and met criteria for multiple psychiatric diagnoses, including dysthymic disorder and borderline personality disorder. When Heidi was 2, her mother developed the belief that Heidi had been molested by her paternal grandfather. There was no physical evidence of trauma to the genitals, and Heidi denied that her grandfather had ever touched her: “My mom keeps telling me that he did something to me, but he didn’t. I keep telling her this, but she doesn’t believe me.” Although the mother had consulted various professionals about the matter, there had been no substantiation of the abuse. As her mother talked to Heidi about how dangerous the situation was, Heidi’s behavior gradually transformed: she rejected wearing feminine clothing, insisted that her hair be cut short to look like a boy’s, began to call herself by a boy’s name, and expressed a wish to have a sex change. During the assessment, the mother commented, “I wonder if I have scared her about being a girl. Maybe she looks at me and thinks ‘I don’t want to be like her.’ ” Despite this insight, Heidi’s mother found it exceedingly difficult to desist in talking about the alleged sexual abuse, despite the fact that the parents had kept her from the grandfather for several years.

In boys with GID, the father’s role has been considered contributory in several ways: by his sheer absence (e.g., due to separation, divorce, or death); psychological distance by virtue of behavioral characteristics or gross psychopathology that interferes with the ability to parent; systemic factors that devalue his parenting role; and behaviors that frighten the boy. All of these factors are viewed as impairing the boy’s capacity to identify with his father and thus weakening a masculine gender identification (Stoller 1979).

Case Example 6
Hank was a 3-year-old boy with an IQ of 116. He lived with his lower-middle-class parents and an older brother. Apart from behaviors consistent with GID, he was described by his parents as quite separation anxious and very oppositional. He had great difficulty separating from his mother, both at nursery school and at home. His noncompliant behavior often resulted in conflict with his parents. Hank constantly tested limits and, at one point, exclaimed “I can do anything I want.” Hank’s father had a very close relationship with his older son and they spent a lot of time together attending athletic events, including team sports at which the son excelled. Prior to Hank’s birth, there had been complex marital difficulties, partly related to the father’s increased use of recreational drugs and alcohol, and, in fact, there had been a brief marital separation as a result. Hank’s father reported having had very little to do with him during his infancy and toddlerhood. This appeared related to Hank being experienced as a challenging baby to look after (e.g., that he would be soothed only if mother and grandmother held him), father’s greater comfort in relating to his older son, and his withdrawal from the family matrix secondary to his substance abuse. As a result, Hank appeared to have very little connection to his father.

Within the framework of understanding GID in the context of family factors, it is argued that attention to the underlying issues that both precipitate and maintain the GID needs to be the focus of therapeutic intervention (Di Ceglie 1998a; Villar et al. 1965). In fact, some therapists who subscribe to this perspective state that they do not focus their treatment on the cross-gender behavior per se or try to alter it in any direct way (Bleiberg et al. 1986; Gilpin et al. 1979).

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Revision date: June 18, 2011
Last revised: by David A. Scott, M.D.