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from Gender Identity Disorders
Treatment of Gender-Disturbed Children: Clinical Issues
Book Review: Gender Identity Disorder and Psychosexual Problems in Children
and Adolescents, by Kenneth Zucker, Ph.D. and Susan Bradley, M.D.
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 necessarily 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." The
reasoning they offer is, if adult homosexuality is
no longer considered disordered, why would its forerunner--Gender-identity Disorder in
Childhood--be a disorder?
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 labelling
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, crceated 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
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 threated by male aggression, and
therefore are inclined to discourage boisterous
behavior and normal agrression 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 threated 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 inadequcy 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
preceeded 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 sympathisized 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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