Gender Identity Disorder in Children and Adolescents - Treatment of the Parents

Two rationales have been offered for parental involvement in treatment. The first emphasizes the hypothesized role of parental dynamics and psychopathology in the genesis or maintenance of the disorder. From this perspective, individual therapy with the child will probably proceed more smoothly and quickly if the parents are able to gain some insight into their own contribution to their child's difficulties. Many clinicians who have worked extensively with gender-disturbed children subscribe to this rationale (Coates and Wolfe 1997; Green et al. 1972; Newman 1976; Stoller 1978). In this context, it is important to note that a treatment plan requires as much an assessment of the parents as it does of the child, as is the case with many child psychiatric disorders. Assessment of psychopathology and the marital relationship in the parents of children with GID reveals great variability in adaptive functioning, which may well prove to be a prognostic factor.

The second rationale is that parents will benefit from regular, formalized contact with the therapist to discuss day-to-day management issues that arise in carrying out the overall therapeutic plan. Work with parents can focus on the setting of limits with regard to cross-gender behavior, such as cross-dressing, cross-gender role and fantasy play, and cross-gender toy play and, at the same time, attempting to provide alternative activities (e.g., encouragement of same-sex peer relations and involvement in more gender-typical and neutral activities). In addition, parents can work on conveying to their child that they are trying to help him or her feel better about being a boy or a girl and that they want their child to be happier in this regard. Some parents, especially the well-functioning and intellectually sophisticated ones, are able to carry out these recommendations relatively easily and without ambivalence. Many parents, however, require ongoing support in implementing the recommendations, perhaps because of their own ambivalence and reservations about gender identity issues.

Case Example 10
Harry was a 4-year-old boy with an IQ of 121. He had an older brother and lived with his parents, who were of a lower-middle-class background. At the time of assessment, his parents were about to separate. During Harry's life, his parents' relationship had deteriorated as a result of many issues, including an affair on his father's part, multiple disagreements about lifestyle and parenting issues, and his mother's deteriorating psychiatric state, which had required inpatient treatment after a suicide attempt when Harry was around 18 months old. Harry had displayed signs of cross-gender behavior since the age of 2 years, including compulsive and frantic cross-dressing and the verbalized desire to become a girl. His mother expressed marked ambivalence about treating Harry's GID: "This is who he is...if I tell him not to, I will destroy his basic essence." Exploration of the mother's life history revealed many reasons for her ambivalence about men and masculinity. She had grown up in a family in which her father was largely absent, she had been gang-raped at the age of 13 years (following which she had developed a severe eating disorder), and, in her relationship with her husband, she had found sexual intimacy increasingly aversive. For Harry's mother, fantasy aggression (e.g., sword play, squirt-gun play) was equated with real aggression, and she worried that if such behavior was encouraged in Harry that he would develop into a rapist. Apart from the mother's ambivalence about masculinity, she also enjoyed Harry's "feminine side": he would often brush her hair and bring her tea when she was depressed and bedridden. Thus, there was suggestive evidence that Harry took care of his mother and that, in her mind, there was the risk of losing Harry if he became more autonomous from her, which was equated with him becoming more masculine.