A clinical approach to childhood gender identity disorder.

This article offers a review of gender identity disorder (G.I.D.) with a case presentation of a four-year-old boy. The youngsters' cross-gender behavior, concomitant diagnoses, treatment, parental input, and transitional objects are considered. The necessity of boundaries and limits at home and in therapy, guidance to parents and their involvement in individual and family therapy is stressed. The clinical material directs our understanding of gender identity disorder to the theory of conflict/defense as the most clinically useful, leading to a psychoanalytically-oriented therapy as the most promising approach. In recent decades the interest in sexual disorders has increased, leading to the assessment and treatment of youngsters' difficulties, such as gender identity disorders (G.I.D.) and the development of G.I.D. clinics. This article will attempt to present some data about the development of gender identity disorders in children and adolescents from a clinical perspective with a case presentation. GENDER IDENTITY DEVELOPMENT A brief summation of gender identity development might be useful here, beginning with the early genital phase. The early genital phase,1 between 15 and 19 months, consists of heightened genital sensitivity in both sexes with repetitive direct manual genital self-stimulation, or indirect approaches with rocking and thigh pressure, etc. This is followed by erotic arousal with a pleasurable facial expression, accompanying autonomie excitation, and erections in boys and lubrication in girls.2 The children initiate body contact with the mother during or after such stimulation. After the onset of this phase, there is visual and tactile curiosity about differences in anatomy between the sexes, with efforts to explore one's own, and others' genitals including adults', animals' and dolls'. Both sexes usually have mild preoccupal castration reactions with the awareness of the anatomical differences.1 At this juncture, divergent lines of development for males and females become observable. Boys now show: profound denial of the anatomical differences from females; visual avoidance of female genitals until about three or four years of age; increased motor activity; and a delay or inhibition in symbolic fantasy play and body image integration. They become more active and very interested in mobile and transportation toys.1 Disidentification3 (the little boy's need to distance himself from the symbiotic fusion with mother) appears to be part of this denial. Girls shift their attachment from the mother to the father and exhibit an increased erotization and coyness to him. A few weeks after they become aware of sex differences, their direct masturbation decreases markedly, but there is more indirect masturbation and an increased attachment to dolls and doll play.1 The girls do not have denial of the differences in anatomy. By age two, children's sex-typed toy preferences are established and they can distinguish the sex of adults in photos. At 18-37 months, children are able to label young children's gender, and they display knowledge of sex role stereotypes for toys. Between two-and-a-half and three years children can regularly differentiate gender of children in photos. Gender discrimination increases with age, with a marked transition between 27 and 32 months.4 By two-and-a-half they know their own gender clearly. Ordinarily, as children progress developmentally into adolescence they achieve certainty about their gender so that it becomes accepted as undoubted and is usually largely unconscious and not an issue. THE DIAGNOSIS OF GENDER IDENTITY DISORDER DSM-R-III5 lists the following diagnostic criteria for G.I.D. for the female: (1) persistent and intense distress about being a girl and desires to be a boy or insistence that she is a boy; and (2) either a persistent marked aversion to normative feminine clothing and insistence on cross-dressing, or a persistent repudiation of female anatomic structures with assertions that she has (or will grow) a penis, or rejection of urinating in a sitting position, or assertions that she does not want to grow breasts or menstruate; and (3) she has not yet reached puberty. …