Gender Identity Disorder - Treatment of the Adolescent

As compared to the corresponding literature on both children and adults, the clinical and research literature on adolescents with GID is quite small. Among adolescents with GID, there are two basic subgroups of patients. The first subgroup consists of adolescents with a childhood history of GID (or its subclinical manifestation). The second subgroup consists of adolescents with either a childhood and/or adolescent onset of fetishistic cross-dressing. Only treatment of the first subgroup will be discussed here. The reader is referred to Zucker and Bradley (1995) and Zucker and Blanchard (1997) for consideration of the second subgroup.

In adolescents with GID, there are three broad clinical issues that require evaluation: 1) the phenomenology pertaining to the GID itself, 2) sexual orientation, and 3) psychiatric comorbidity. Apart from the GID itself, gender-dysphoric adolescents with a childhood onset of cross-gender behavior typically have a homosexual orientation (i.e., they are attracted to members of their own "birth sex"). Some such adolescents may not report any sexual feelings, but follow-up of such patients will typically find the emergence of same-sex attractions. Thus, the clinician must evaluate simultaneously two dimensions of the patient's psychosexual development: current gender identity and current sexual orientation.

The treatment literature on adolescents with GID has been very poorly developed and is confined to a few case reports (Barlow et al. 1973; Bradley 1980; Davenport and Harrison 1977; Dulcan and Lee 1984; Kronberg et al. 1981; Lothstein 1980; Meyenburg 1999; Morra 1998; Newman 1970; Philippopoulos 1964; Reyes 1998; Westhead et al. 1990). In general, the prognosis for adolescents resolving the GID is more guarded than it is for children. In some respects, this state of affairs is similar to other child psychiatric disorders: the longer a disorder persists, the likelihood lessens that the disorder will remit, with or without treatment. From a clinical management point of view, two key issues need to be considered: 1) some adolescents with GID are not particularly good candidates for therapy because of comorbid disorders and general life circumstances; 2) some adolescents with GID have little interest in psychologically oriented treatment and are quite adamant about proceeding with hormonal and surgical sex reassignment. Bradley and Zucker (1997) found that, compared with children with GID, adolescents with GID were less intelligent, had more general behavioral difficulties, were more likely to come from a lower socioeconomic background, and were more likely to come from a broken home.

Prior to recommending hormonal and surgical interventions, many clinicians encourage adolescents with GID to consider alternatives to this invasive and expensive treatment. One area of inquiry can, therefore, explore the meaning behind the adolescent's desire for sex reassignment and if there are viable alternative lifestyle adaptations. The most common area of exploration in this regard pertains to the patient's sexual orientation. Some adolescents with GID recall that they always felt uncomfortable growing up as boys or as girls, but that the idea of "sex change" did not occur until they became aware of homoerotic attractions. For some of these youngsters, the idea that they might be gay or homosexual is abhorrent.