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from Gender Identity Disorders
Gender Identity Disorder in Children
By Richard P. Fitzgibbons, M.D.
NARTH Scientific Advisory Board Member
The following article appeared in the June 2001 issue of the Catholic magazine, Lay Witness.
To order a copy of the magazine, call 1-800-MYFAITH.
A mother, concerned for some time about her 4-year-old son's effeminate mannerisms, lack of
male playmates, and interest in Barbie dolls, finally decides to ask the pediatrician if these are signs of
a problem. She is particularly worried that her husband has become increasingly upset and
alienated from their son.
The pediatrician is reassuring: "This is just a phase nothing to worry about. He will grow out of
it." Unfortunately, the pediatrician is probably wrong. Gender identity problems, including
cross-dressing, exclusive cross-gender play, and a lack of same-sex friends should be treated as a symptom
that something may be very wrong.
Boys who exhibit such symptoms before they enter school are more likely to be unhappy, lonely
and isolated in elementary school; to suffer from separation anxiety, depression, and behavior
problems; to be victimized by bullies and targeted by pedophiles; and to experience same-sex attraction
in adolescence.
If they engage in homosexual activity as adolescents, they are more likely than boys who do not
to be involved in drug and alcohol abuse or prostitution; to attempt suicide; or to contract a
sexually transmitted disease, such as HIV/AIDS; or to develop a serious psychological problem as an adult.
A small number of these boys will become transvestites or transsexuals.
The good news is that if the gender identity problems are identified and addressed and if both
parents cooperate in the solution, many of the negative outcomes can be prevented. According to
Dr. Kenneth Zucker and Susan Bradley, experts in the treatment of gender identity problems in
children, treatment should begin as soon as possible.
...In general we concur with those who believe that the earlier treatment begins,
the better.1
...It has been our experience that a sizable number of children and their families
can achieve a great deal of change. In these cases, the gender identity disorder
resolves fully, and nothing in the children's behavior or fantasy suggest that gender
identity issues remain problematic....
All things considered, however, we take the position that in such cases clinicians
should be optimistic, not nihilistic, about the possibility of helping the children to
become more secure in their gender identity.2
The effeminacy in some boys is so pronounced that parents may assume the problem is genetic
or hormonal, but experts report that children assumed to have a biological problem responded
positively to therapeutic intervention: According to Rekers, Lovaas, and Low:
When we first saw him, the extent of his feminine identification was so profound
(his mannerisms, gestures, fantasies, flirtations, etc., as shown in his "swishing" around
the home and the clinic, fully dressed as a woman with a long dress, wig, nail polish,
high screechy voice, slatternly, seductive eyes) that it suggested irreversible
neurological and biochemical determinants. After 26 months follow-up, he looked and acted like
any other boy. People who viewed the video taped recordings of him before and after
treatment talk of him as "two different
boys."3
Children need to feel good about their gender identity. Healthy psychological development
requires that a little boy be able to recognize that there are two sexes and he is male, he is like other boys,
and will grow up to be a man and possibly a father, not a woman and a mother. Additionally he needs
to feel good about being a boy and becoming a man. He needs to believe that his mother and father
are happy that he is a boy and expect him to become a man and he needs to feel accepted as a boy
by other boys.
If a boy feels inadequate in his masculine identity, identifies with his mother instead of his
father, feels that he would like to be a girl, those around him should not pass this off as
non-stereotypical behavior. There is a reason why this boy is not developing a healthy masculine identity and
that reason should be discovered and addressed.
One often hears boys with gender identity problems called "girlish," but if one observes their
behavior carefully, one sees that they do not resemble healthy little girls of the same age, but imitate
adult women. For example, while doll play for healthy girls includes mother/baby play and
fashion/dress up play, boys with gender identity problems focus almost exclusively on fashion/dress up. Some
may be fixated on characters such as the Disney villianesses -- the wicked stepmother in
Snow White or Cruella de Ville from 101
Dalmations. While healthy girls combine outdoor physical activities
with more sedate play, boys with gender identity problems are often unreasonably afraid of injury,
avoid rough and tumble play, and dislike group sports.
Cross-dressing and cross-gender fantasy in boys is often passed off by the family as a sign that
the boy is a "great actor" or has a "wonderful imagination." Family members fail to understand that
a boy who never takes the part of male character, but always plays a female is revealing a deep
ambivalence toward his own masculinity. Therapy can help the boy and his family understand why
he feels more confident, comfortable, and accepted when he is fantasizing that he is a female.
Today, many adults try very hard not to impose rigid gender stereotypes on young children, but
this push for gender openness can lead parents to ignore the symptoms of gender identity conflict.
Children with gender identity problems DO NOT inhabit a gender-neutral world where boys
and girls play with the same toys. These troubled children reject certain types of play and
clothing precisely BECAUSE it is associated with their own gender, and they adopt activities because
they are associated in their mind with the opposite sex. Boys with serious gender identity problems
may use female clothing to gain acceptance or soothe anxiety become angry and upset when deprived
of these objects.
Some parents may ask "What is wrong with a boy playing with dolls?" The answer is that the
problem is as much what he is not doing -- learning how to be a boy among boys -- as it was what
he is doing -- escaping into a female world.
Parents need to be concerned when a child openly expresses a dissatisfaction with his or her
sex. such as when a boy says "I want to be a girl" or when a girl insist she is a boy. One extremely
effeminate boy when asked, "Do you want to be like your daddy when grown up?" responded "I
don't want to be grown up." Such statements should be taken as symptoms that something is very
wrong. Although the boy may feel or even express the desire to grow up to be a woman, he is male and
will grow up to be a man.
Children are born with a drive to seek love and acceptance by each parent,
siblings and peers. If this need is met, children develop an acceptance of
their masculinity or femininity. When this developmental task is
successfully completed, the child is free to choose gender atypical
activities. Boys and girls with gender identity problems are not freely
experimenting with gender atypical activities. They constrained by deep
insecurities and fears and are reacting against the reality of their own
sexual identity, usually as a result of failing to experience love and
acceptance from the parent of the same sex or same sex peers. Therapy is not
directed toward forcing a sensitive or artistic boy to become a macho-sports
fanatic, but helping a boy to grow in confidence and be happy he is a boy.
Effeminacy, cross-gender play, and cross dressing are not the only signs that there may be a
problem. Some boys suffer from a chronic sense of being inadequate in their masculinity , but do
not imitate female behavior. These boys may exhibit an almost phobic reaction to rough and tumble
play and an intense dislike of team sports because of poor eye-hand coordination. This inability to
relate to other boys leads to isolation, profound unhappiness, and often depression.
Gender identity problems also occur among girls, although the problem is less common. In
some cases a father may be pleased with his daughter's success in athletics and ignore her phobic
reaction to dresses or anything feminine. Girls with gender identity problems may believe that being a
boy will make them safe from abuse.
What should a parent do if they think that there might be a problem? First, they should take
any repeated problematic behaviors as a cry for help. If their pediatrician ignores their concerns,
they should find a therapist who is trained in the treatment of gender-identity problems. Parents can
read on the subject -- books such as Zucker and Bradley's
Gender Identity and Psychosexual Problems in Children and
Adolescence, which offers a complete review of the problem.
Consistent cross-gender behaviors are a sign that the child believes he or she would be better off'
as the opposite sex.
According to Bradley and Zucker, "This fantasy solution' provides relief, but at a cost."
These are unhappy children who are using these behaviors defensively to deal with their
distress.4
Parents sometimes try on their own to stop the overt behavior, but forcing a frightened child
to engage in behaviors in which he feels inadequate or fearful is not the solution. The therapist
can work with the child and the parents to uncover the root cause of the emotional conflicts, sso that
the problem can be addressed and resolved.
It is true that without treatment certain manifestations of gender identity conflicts, such as
fantasy fashion doll play in boys or open cross-dressing may disappear by the time the child is eight or
nine years old, but these coping mechanisms are often replaced by other less overt expressions of
an underlying gender identity problem. Once the problem goes "underground" it will be more
difficult to treat.
Some people may avoid treatment because they believe that gender identity problems are a sign
that the child was "born homosexual" and that the parents should simply accept this outcome as
inevitable and encourage the child to accept a homosexual identity. Given the positive results of
early intervention, the profound unhappiness of these children during elementary school, and the
massive problems which accompany same-sex attraction in adolescence, parents should do everything
possible to help their child resolve even minor gender identity problems.
Catholic parents need to be particularly concerned. The Church's teaching on homosexual activity
is clearly stated in the Catechism of the Catholic Church, "homosexuals acts are intrinciscally
disordered... Under no circumstances can they be approved" (CCC 2357). For a Catholic trying to
be obedient to God, temptations to same-sex activity are a source of deep pain. Treatment of
adolescents or adults is possible, but difficult and the outcome is not assured. It is far better to prevent
the problem or treat it in early childhood. Those who would like to understand more about
same-sex attractions can find information on the website of the Catholic Medical
Association (www.cathmed.org) in a report entitled
Homosexuality and Hope.
If a boy grows up happy and confident about his masculine identity -- with a mother who
supports his manly development, a close loving relationship with his father, same-sex friends in
childhood, and is protected from vicious bullying and sexual predators -- the chances are minimal that he
will experience same-sex attraction in adolescence. Even if one or two items on the above list are
missing, the chances are still small that the boy will become homosexually involved as an adult.
Generally, the histories of men engaging in same-sex behaviors reveal a history of
cumulative problems: significant peer rejection, low self-esteem, a distant father, an overprotective or
controlling mother, victimization by bullies, or sexual abuse. Fortunately these conflicts can be
resolved, and the masculine identity can be strengthened and then embraced.
{1} Zucker, Kenneth and Susan Bradley (1995) Gender Identity Disorder and
Psychosexual Problems in Children and Adolescents. N.Y.: Guilford Press, p.281.
{2} .(p.282)
{3} Rekers, G., Lovaas, O., Low, B. (1974) Behavioral treatment of deviant sex role behaviors in a male child. Journal of Applied Behavioral Analysis. 7: 134 - 151.
{4} Bradley, S., Zucker, K. (1998) Drs. Bradley and Zucker reply. Journal of the American Academy of Child and Adolescent Psychiatry. 37, 3: 244 - 245.
Updated: 8 February 2008
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