Book Review

Gender Identity Disorder

Kenneth Zucker is well-known and much-published in the area of gender- identity disorder (GID) in children; his new book, with co-author Susan Bradley, provides some quite useful information.

Sexual-reorientation therapists have repeatedly observed that homosexuals exhibit an internal sense of same-sex deficit--even though this deficit is not extreme enough to diagnose as gender-identity disorder. Yet this book is of value to such clinicians for several reasons: the family histories associated with childhood GID are closely related to the common developmental pathways leading to homosexuality; and as research has shown, the majority of gender-disordered children grow up to be homosexual or bisexual. Furthermore, sexual-reorientation therapists are sometimes asked to work with prehomosexual children, and it is important to understand the arguments for and against such treatment.

Because GID children are usually prehomosexual, gay-activist groups have been working to remove the GID category from the Diagnostic and Statistical Manual, labeling such treatment "homosexual genocide." Their reasoning is, if homosexuality is not considered a problem in adulthood, why would there be justification for considering GID a disorder in childhood?

Arguing against the idea that treatment constitutes genocide, Zucker and Bradley quote Richard Green, who states, quite persuasively:

"The rights of parents to oversee the development of children is a long-established principle. Who is to dictate that parents may not try to raise their children in a manner that maximizes the possibility of a heterosexual outcome? If that preogative is denied, should parents also be denied the right to raise their children as atheists? Or as priests?"

To defend the concept that GID is a disorder, Zucker and Bradley must first attempt to define what a disorder IS--not an easy subject, these days, on which to build a consensus. They quote Spitzer and Endicott's useful definition--a psychological condition characterized by "distress, disability and disadvantage." Clearly, this is a standard by which childhood GID could qualify as a disorder.

They also quote King's (1945) simple and useful definition of the term "normal"--"that which functions according to its design"--which could also be considered as the basis for labeling GID a disorder. (Although the authors do not say this, homosexuality would also be considered disordered by such a definition.)

Family Histories of Gender-Disturbed Boys. Zucker and Bradley book quote Stoller's (1975) description of the gender-disturbed boy's relationship with his mother--"a blissful symbiosis." In a case history of one extreme case, Stoller says:

"From the first...[the] mother felt a supreme oneness with this boy, and...she did everything possible...never to allow that blissful feeling, created by his closeness, to be interrupted...This mother's intimacy in fact contained those micro-behaviors...so difficult for the outsider to see but [that] make for profound human relationships--the way two people look into each other's eyes, the intensity of their embraces, the extra moment's lingering of a touch...In order to keep him close, the mother had him with her constantly...he followed her when she went to the bathroom, and was with her when she bathed or showered....[the boy] never quite learned where his mother left off and he began."

Stoller concluded with his now-famous dictum: "The more mother and the less father, the more femininity."

Zucker and Bradley then describe an alternative hypothesis, by Coates, to Stoller's "blissful mother-son symbiosis." Coates found severe mother-son stress to be more significant than maternal over-intimacy. Coates believed feminine behavior in boys often represented a "defensive fusion" with the mother as a result of a severe trauma in her life.

Zucker and Bradley conclude that, in both sexes, childhood cross-gender behavior results from intense frustration and stress within the family-- either from outside events, or frustrating interactions between the child and his or her parents--during the early developmental period when the child should be developing a coherent sense of self as appropriately male or female.

Temperamentally, the gender-disturbed child is likely to be particularly sensitive to parental affect due to a "constitutional vulnerability to high arousal in stressful or challenging situations." They hypothesize that this may be the same temperamental variable which makes gender- disturbed boys avoid rough-and-tumble play. Such boys generally feel inadequate as males, and have problems interacting with their male peers.

"Other specific factors within the boys may be that they are unusually attractive, and have rather exquisite sensory sensitivities..." Mothers of such boys, the authors say, often feel especially threatened by male aggression, and therefore are inclined to discourage boisterous behavior and normal aggression in their sons. Out of their own intense need for nurturing, the mothers often encouraged feminine-type reciprocal nurturance behaviors in their sons.

They describe Green's observation of the characteristics for boys: an avoidance of rough-and-tumble play, parental failure to discourage cross-gender behaviors, and parental (especially paternal) unavailability.

The authors observe that fathers of gender-disturbed boys tend to go along with their wives' tolerance of cross-gender behaviors, despite their inner discomfort with this tolerance. "These men are often easily threatened and feel inadequate themselves. These qualities appear to make it very difficult for them to connect with sons who display nonmasculine behavior." Withdrawing from their feminine sons, "they often deal with their conflicts by overwork or distancing themselves from their families..." The fathers' difficulty expressing feelings, and their inner sense of inadequacy are the roots of this emotional withdrawal. Zucker and Bradley note that Green found a correlation between less father-son shared time during the first two years of the gender-disturbed boy's life, and later homosexuality.

In terms of treatment, the authors believe that "the parents' valuing of their son as a male and discouragement of cross-gender behaviors allows a gradual relinquishing of the defensive solution and a building of confidence in a same-sex identity."

Zucker-Bradley are critical of Bell, Weinberg and Hammersmith's interpretation of data in their classic 1981 study, Sexual Preference: Its Development in Men and Women--a study which has long been used to defend homosexuality as normal. They say, "Although this may come as a surprise to some readers, the data obtained from the Bell et al. study were actually consistent with the data obtained from the clinical researcher [Bieber, etc.] that preceded it...detached- hostile father, for example, was deemed relatively characteristic of 52% of white homosexual men and 37% of white heterosexual men--a finding quite similar to the overlap in the Bieber et al. (1962) data..."

Zucker and Bradley attribute the distortion of this finding to the politicization of science, saying the interpretation of Bell et al's data was "clearly colored by political correctness."

Family Histories of Gender-Disturbed Girls. Of the 26 girls in Zucker and Bradley's sample, nearly 77% had mothers with histories of depression, and all had been depressed in their daughters' infant or toddler years. "Thus, during the hypothesized sensitive period for gender-identity development, the mothers of the girls in our sample were quite vulnerable from a psychiatric point of view," they write.

The authors continue:

"[O]ne consequence of this vulnerability was that the girls had difficulty in forming an emotional connection to their mothers. In some instances, it seemed to us that a girl either failed to identify with her mother, or disidentified from her mother because she perceived her mother as weak, incompetent, or helpless. In fact, many of the mothers devalued their own efficacy and regarded the female gender role with disdain...In a smaller number of cases, it seemed that the daughter's 'significant medical illness' or difficult temperament during infancy had impaired her relationship with her mother...Six of the mothers had a history of severe and chronic sexual abuse of an incestuous nature. The femininity of these mothers had always been clouded by this experience, which rendered them quite wary about men and masculinity and created substantial dysfunction in their sexual lives. In terms of psychosocial transmission, the message to the daughters seemed to be that being female was unsafe. The mothers had a great deal of difficulty in instilling in their daughters a sense of pride and confidence about being female.

"Another factor of importance is a daughter's experience of severe paternal or male sibling aggression. Such aggression had been directed at the mothers, at the girls, or at both, in 12 of the 26 families. In these cases, the classic mechanism of 'identification with the aggressor' seemed relevant to the girls' cross-gender identification...many girls with gender-identity disorder are preoccupied with power, aggression and protection fantasies."

"...The fathers [of gender-disturbed girls] particularly view females as less adequate and tend to reinforce masculine qualities in their daughters...fathers may also be overtly aggressive or abusive. The mothers often feel inadequate themselves and are unable to redress this balance by standing up for their children, in the same way that they have difficulties standing up for themselves." Mothers of gender-disturbed girls "often feel acutely put down by their husbands." The daughter perceives the marital conflict as a situation in which the mother is unable to defend herself, and feels the need to be her protector by identifying with the male aggressor. Like the boy, the gender-disturbed girl tends to be temperamentally vulnerable, and therefore particularly sensitive to her parents' feelings.

Therapeutic Intervention. In spite of the politically sensitive connection between childhood gender-identity disorder and adult homosexuality, Zucker and Bradley believe treatment of childhood GID can be both "therapeutic and ethical." They base their case on several points, claiming that treatment affords the following benefits:

1. A reduction in social ostracism by peers;
2. An opportunity to relieve the psychopathology which has been documented to be associated with GID, both in the child and within the family;
3. The prevention of later transsexualism;
4. The prevention of homosexuality in adulthood. On this controversial point, Zucker believes treatment is justified for social reasons--but he is doubtful about there being justification to prevent homosexuality for religious reasons.

On Religiously-Based Psychotherapy. In a 1984 book review of George Rekers' Growing Up Straight (1982) and Shaping Your Child's Sexual Identity (1982), Zucker was, in fact, strongly critical of the introjection of Rekers' religious philosophy into his clinical work. He attacked Rekers for using "religious rhetoric" to defend his views. Zucker spoke cynically about Rekers' ideals, saying: "What is perhaps most disappointing about these two books is the idyllic view of family life and human conduct for which the author longs."

In a clear misunderstanding of traditional Judeo-Christian philosophy, Zucker added, "One has to wonder how Rekers will feel toward his child patients, should they grow up not to be straight." Zucker makes two implications--first, that an ethical therapist must not discuss-- actually, must not even hold--any strong personal convictions about what constitutes a healthy family or sexual life; and second, that such a therapist will be unable to feel empathy toward clients who do not succeed in meeting this ideal.

Zucker fails to acknowledge that his own life-philosophy will have an influence on his clients. This philosophy, it seems, coincides with the popular view that there is no therapeutic goal higher than that of feeling "comfortable" about oneself--a philosophy which would evidently be used to dissuade a client from working toward a demanding philosophical goal (heterosexuality) because the therapist thought it would be more compassionate to persuade him to settle for a condition he does not accept (homosexuality). Similarly, Zucker and Bradley are sympathetic toward the parent who seeks to prevent homosexuality in his child because it will create social difficulties, but they are clearly skeptical about supporting the parent who seeks to prevent homosexuality in his child because of the family's religious values.

This is, of course, not a "neutral" position--for the religious counselor, Zucker and Bradley, and indeed, all therapists hold personal values about what psychological conditions should simply be embraced and accepted, and what therapeutic goals are actually worth pursuing.

Zucker and Bradley are not the only prominent spokesmen who see a case for treatment of GID, and thus an attempt toward prevention of homosexuality. Judd Marmor--who argued forcefully in the 1973 debate that homosexuality should not be considered a disorder--has also said that "the issue of preventing [homosexual] development is a legitimate one." In the same vein as Zucker and Bradley, Marmor sympathized with the desire to avoid homosexual development because of its social disadvantages, but he has spoken scornfully of "pious religionists" who reject homosexuality for personal religious reasons-- questioning their sincerity and theological consistency, and implying an underlying motive of bigotry.

Zucker and Bradley believe the clinician should work toward helping clients establish a positive gay identity if they fit the following description: they have a history of gender-identity disorder or masculine inadequacy; they have felt little arousal toward females; and they are reasonably comfortable with a gay identity.

If the client is experiencing both heterosexual and homosexual arousal, they believe the clinician should take a neutral stance and help the client clarify his own sexual orientation, using the philosophy that the client's "comfort level" offers the best directional guide for treatment.

Zucker and Bradley recognize a very important point missed by most gay activists--that homosexual attractions in adolescence may represent nothing more than transitory idealization of same-sex individuals, rather than a deep-seated sexual orientation. Their goal is to help the client find his "real"--i.e., most deep-seated on a feeling and fantasy level--sexual orientation.

One important question remains in this book: can treatment of the gender-disturbed child prevent future homosexuality? Although there are "no formal empirical studies demonstrating that therapeutic intervention in childhood alters the developmental path toward either transsexualism or homosexuality," nevertheless Zucker and Bradley maintain a cautious optimism, saying there is some "indirect support" for the efficacy of treatment.

They discuss the success rate of therapy with children, as reported by Rekers. Rekers says that follow-up results of over 50 gender-disturbed children suggest permanent changes in gender identity, and he believes that a preventive treatment for "transvestism, transsexualism, and some forms of homosexuality has indeed been isolated," although Zucker and Bradley express mild skepticism due to the lack of formal substantiation of this conclusion.

They describe the therapeutic approaches of Green, Newman and Stoller (1972), who work with the feminine boy to help him understand the motives for his behavior and reinforce signs of developing masculinity. The therapist who works with the boy is male, and he solicits the help of the boy's father. They also describe ways of bringing the child's family into the therapy, as well as the use of peer-group sessions.

Zucker and Bradley conclude: "It has been our experience that a sizable number of children and their families achieve a great deal of change. In these cases, the GID resolves fully, and nothing in the children's behavior or fantasy suggest that gender-identity issues remain problematic...All things considered, we take the position that in such cases a clinician should be optimistic, not nihilistic, about the possibility of helping the children to become more secure in their gender identity."

Updated: 8 February 2008

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