Gender Identity Disorder In Adolescence: Outcomes Of Psychotherapy

INTRODUCTION

Gender identity disorder (GID) is characterized by strong and persistent cross-gender identification and by persistent discomfort with one's sex. In adolescents, the disturbance is manifested by such symptoms as a stated desire to be the other sex, a desire to live or be treated as the other sex, attempts to pass as the other sex, or the conviction that one has the typical feelings and reactions of the other sex (DSM-IV: Criterion A).

Most children with GID display less overt cross-gender behaviors with time and, by late adolescence, GID usually is no longer present. However, for some adolescents, gender confusion or dysphoria becomes chronic, and they may develop a clearer cross-gender identification. They become preoccupied with getting rid of primary and secondary sex characteristics, and may request hormonal treatment or sex reassignment surgery (DSM-IV: Criterion B).

The prevalence of GID in childhood and adolescence is not known, but it is a rare phenomenon. Only special treatment centers report significant numbers of patients. In Europe, such treatment centers have been established in London, England; Utrecht, the Netherlands; and Frankfurt, Germany. In North America, special gender identity programs have been established in Toronto and New York City, and at the University of California-Los Angeles, Johns Hopkins University in Baltimore, and Case Western University in Cleveland. The larger number of GID patients in North America may reflect a less permissive attitude toward gender nonconformity; in Europe, a more tolerant attitude generally prevails. For example, at the Frankfurt clinic, it is not unusual to see parents who do not consider their child's obvious GID symptoms to be a problem and who refuse any therapy.

There is a modest amount of literature describing psychotherapy with patients who initially desired sex reassignment. Since it is the purpose of this paper to encourage psychotherapy and discourage premature sex reassignment measures, these reports, providing examples of different treatment approaches, are summarized here.

Review of the Literature

Philippopoulos (1964) presented the case of a seventeen-year-old female diagnosed with transvestism. Today, the diagnosis would be different, either transsexualism (ICD-10) or gender identity disorder (DSM-IV). Philippopoulos treated this patient over a six-month period, three to four times a week, for a total of 112 psychoanalytic psychotherapy sessions. The patient began to identify herself as female and continued to live as a woman. A follow-up visit five years after terminating treatment showed a stable feminine self-identity.

Kirkpatrick and Friedmann (1976) described psychoanalytic psychotherapy with a nineteen-year-old male and an eighteen-year-old female with GID. The male patient was seen twice weekly for fifteen weeks, and the female patient was seen twice weekly for over two and a half years. Both patients abandoned their wish for sex reassignment and continued to live as homosexuals.

Davenport and Harrison (1997) discussed the twenty-month inpatient treatment of a female who was fourteen and a half years old. Kronberg et al. (1981) reported on a fifteen-year-old female whose inpatient treatment lasted for several months. In both cases, psychotherapy was combined with behavior modification and active encouragement to live as female. The patients did continue to live as females, and Kronberg et al.'s patient began a heterosexual relationship.

Barlow, Reynolds, and Agras (1973) and Barlow, Abel, and Blanchard (1979) described the successful behavior modification of a male transsexual. The patient was first seen when he was seventeen years old, and was living as a heterosexually oriented male six and a half years later.

Sex Reassignment

If psychotherapy fails to end the patient's desire for sex reassignment, most treatment centers recommend undergoing the procedure. In general, treatment centers require the patient to be an adult, but some allow sex reassignment for adolescents. Usually, the patient must successfully pass a "real life test" in which he or she lives in the desired gender role for one year. After that trial period, hormone treatment is started (estrogens and/or antiandrogens for male patients and androgens for female patients). Surgical procedures follow. In male patients, the penis and testes are removed and a neovagina is created, along with epilation of male hair growth and corrective plastic surgery of the larynx. In female patients, mastectomy and hysterectomy are performed and the ovaries are removed; in some cases, phalloplasty is also performed.

Newman (1970), at the UCLA Gender Identity Clinic, concluded that a profound cross-gender orientation beyond childhood is irreversible. If, in adolescence, alternative diagnoses are ruled out and a diagnosis of transsexualism can unequivocally be made, then an experimental trial in the new gender role is indicated. After successfully living in the new gender role for a minimum of one continuous year, the patient can be considered a candidate for sex reassignment surgery.

A gender identity clinic for children and adolescents was started in 1987 at the University of Utrecht. Adolescent patients first go through an extensive diagnostic phase, which takes from several weeks to several years to complete. If the diagnosis is transsexualism, patients have to pass through a second diagnostic phase, the "real life diagnostic test." During this phase, some adolescents are treated with sex hormones. It is argued that early hormone treatment can prevent emotional suffering. Male patients will have more difficulty passing as females if facial and body hair growth are unsuppressed, while female patients experience anguish mainly because of menstruation (Cohen-Kettenis, 1994). Thus, males receive cyproterone acetate to prevent the development of secondary sex characteristics, while females receive lynestrenol to suppress menstruation.

CASE EXAMPLES

Christa

Christa was a clear-cut example of transsexuality. When she was seventeen, her parents brought her to the Frankfurt University Child and Adolescent Psychiatric Outpatient Clinic. They had requested therapy because of Christa's persistent wish for sex reassignment. Christa reported that she had always felt herself to be a boy, refusing to wear female clothes or play with girls.

Born out-of-wedlock, Christa had been raised by her maternal grandmother along with her mother's younger sister and two younger brothers. When Christa was twelve years old, her grandmother died; she then went to live with her mother, who had married and given birth to two other daughters.

Christa lived two lives: at home and at work, she grudgingly passed as a female, but otherwise she lived as a male. She had a steady girlfriend who was fully aware of the situation and who hoped, too, that sex reassignment would be performed. The girlfriend's parents, however, did not know Christa's biological sex, and considered her to be their future son-in-law.

Christa readily accepted that she had to wait two years before medical sex reassignment measures would be considered. She believed that the waiting period was a reasonable requirement.

Christa lived in a rural area, about an hour's drive from the clinic. Her therapy sessions were scheduled every other week and, over the course of two years, she appeared regularly and always on time. In a quiet manner, she talked about her life, which she took as it came. She did not like to reflect on her past; in her opinion, "all these old stories" did not help her. She said she never had any doubts that her decision to live as a male was the right one. Conflicts arose only when she encountered resistance, mainly from her mother, who opposed her desire to become male. However, her mother finally gave in and, recently, even bought male clothes for Christa.

The grandmother's two sons were victims of a rare genetic disorder affecting only males: they lacked teeth and hair. Thus, Christa perceived herself as being the only "real man" in the family. In her therapy sessions, she revealed that the grandfather had been unfaithful to her grandmother, as well as physically abusive, and Christa felt she had to protect her grandmother.

After completing two years of psychotherapy, Christa was referred to the Frankfurt University Institute for Sexual Science, where she would continue to receive therapy and eventually undergo the procedure for sex reassignment.

Sandra

Sandra was seventeen years old and wanted sex reassignment when first seen at the Frankfurt University Child and Adolescent Psychiatric Outpatient Clinic. She dressed and behaved in a pronouncedly masculine way and demanded to be addressed by her self-chosen male first name. She reported that she had never felt herself to be a girl, and even during childhood had thought that something was wrong with her. When Sandra was thirteen, she saw a television program on transsexualism and became convinced that this was her problem. She said she had always been sexually interested in girls and for a while had tried to live as a lesbian, but soon felt that this was not the solution.

As a baby, Sandra was sent to her maternal grandparents in Greece, where she lived until she was thirteen years old. Her biological father was an alcoholic who had physically abused her mother; they eventually divorced.

Sandra had many fights with her mother and stepfather regarding her lifestyle. Her mother had even threatened to kill her if she did not change. Consequently, Sandra moved into an apartment provided by the Bureau of Child Welfare.

A few days before her first session, Sandra made a suicide attempt by cutting her wrist. She reported that she had felt nobody could help her. Sandra agreed to undergo analytic psychotherapy for at least one year, and weekly sessions were begun. However, she appeared regularly for her sessions only for the first few months.

During psychotherapy, Sandra spent a considerable amount of time talking about her large number of girlfriends. She always emphasized the importance of her current relationship, but each week she had a different girlfriend. Relationships that were described at first as "deep and meaningful" rapidly fell apart. Although she was sexually active, she avoided direct genital stimulation by her girlfriends.

There was a clear element of splitting in Sandra's relationship with her parents: she devalued her mother and overidealized her stepfather. (In the initial phase of therapy, she overidealized her therapist as well.) Sandra felt that her mother had abandoned her as a little, helpless baby. She stated that her mother did not understand her problems at all, while her stepfather, on the other hand, did understand her. She felt she could discuss everything with him. Sandra described recurrent nightmares in which she tried to fight off a person who was attempting to invade her body. After interpreting these nightmares as representing something terrible that had happened to her, Sandra recalled being the victim of a humiliating gang rape as a child.

After three months of therapy, Sandra became impatient and demanded to have sex reassignment performed immediately. She especially wanted to have her breasts removed.

Sandra became increasingly depressed. She revealed that she had always tried to present herself as an easygoing and happy person, but that inside she felt terribly sad. She said she was always thinking of all the terrible things that had happened to her. In therapy, she never stopped voicing the conviction that she was a transsexual, and continued to demand sex reassignment.

Sandra was no longer able to sleep alone. She stated that she missed her mother's love and hoped to receive such "mothering" from an older girlfriend, whom she began to seek. She attempted to work in a kindergarten so she could give to children the love that she had missed as a child.

Unexpectedly, Sandra stopped coming for therapy and broke off all contact with the clinic. It was later learned that she had moved to the countryside with an older female friend, where they lived as a lesbian couple.

Martin

Martin was seventeen years old when he was first brought by his social worker to the Frankfurt University outpatient clinic. The social worker believed that Martin had a severe case of GID.

Martin came to the first session in a grossly overdone female outfit: a flaming red flamenco-style dress. He also wore heavy makeup and spoke and behaved in a hyperfeminine manner. He demanded to be addressed as Countess von Lange. He immediately reported that sex was very important to him and gave detailed accounts of his sexual preferences.

Martin's mother was an IV drug user who recently died of AIDS. His father was an alcoholic who was currently living in a nursing home, but because of brain damage no longer recognized his son. Beginning at age four, Martin had been placed with different foster families or a children's home. He had had to leave each of them because of aggressive behavior. He was homeless for some time, sleeping under bridges or in group dormitories, where he sought sex partners. On several occasions he had been beaten for refusing to engage in anal intercourse. The Department of Social Welfare was able to find a small apartment for him, and he was currently trying to finish school and begin training in a profession.

Martin was seen irregularly over the course of two years of therapy. Initially, he wanted to participate only if he could undergo immediate sex reassignment surgery, and his social worker had to exert considerable pressure to get him to continue visiting the clinic. It soon became clear that Martin did not want genital surgery but rather plastic surgery on his face and neck to look more feminine. It was unimaginable for him to give up his penis. By the third session, he began dressing as a male, but he continued to cross-dress on occasion (the cross-dressing clearly had a fetishistic purpose). His sexual interests were exclusively homosexual, and he did not expect his partners to take him to be a female.

This situation remained unchanged for over a year and a half. Regular and more intensive psychotherapy was recommended because of Martin's lack of a stable, internalized superego and his inability to form stable object relations. However, it was not possible to engage him in therapy on a regular basis.

Holger

Holger was thirteen years old when first seen as a psychiatric outpatient at the Frankfurt University clinic. His mother was worried about his sexual development because he had been discovered wearing panty hose. Panty hose put Holger in a state of great sexual excitement, but his fantasies were exclusively heterosexual.

Holger complained that only women were allowed to wear beautiful and colorful clothes. If he had a choice, he would prefer to be female. He spoke about his wish to be changed by surgeons into a female, hoping to have his male genitals replaced by female ones and also to have his male chromosomes removed.

His mother described him as being very reclusive, with few peer contacts. Psychological evaluation showed a high resistance to dealing with emotional problems, libidinal wishes, and intimacy issues. Diagnoses of GID and incipient borderline personality disorder were made.

Holger lived too far away from Frankfurt University to be easily treated at the Child and Adolescent Psychiatric Clinic on a regular basis. He was referred to a psychotherapist in his home town, who saw him for forty sessions in only two and a half months. After that, he received yearly follow-up sessions at the Frankfurt clinic.

Holger seemed to be highly ambivalent about striving to separate from his parents. His fetishistic interests were interpreted as an expression of this conflict. In therapy, Holger was actively encouraged to become more independent. A special focus was on his relationship with his father, whom he admired greatly, yet at the same time against whom he competed (to do better in the bond market, for example).

Great improvement in Holger's social abilities was apparent in the follow-up sessions. He had found some close friends, and in school had become a student officer. He had abandoned all desire to be female, his fetishistic interests had disappeared, and he was developing a clearly heterosexual identity.

CONCLUSIONS

The case examples demonstrate that the outcome of GID in adolescence may vary widely. If adolescents present with clear-cut symptoms of transsexualism, most will have sex reassignment procedures performed eventually. However, there are patients such as Sandra who will give up their wish for sex reassignment. For this reason, it is important not to start irreversible measures, or even the administration of hormones, too quickly. Further, rapid agreement for sex reassignment would signal that the therapist (who should maintain a neutral position) supports the patient's desire for a sex change.

Although gender identity is laid down during the first years of life, and intrapsychic conflicts leading to GID also date back to these early years, the clinical picture may vary widely in later life. An adult who was treated by the author did not find a solution until middle age. This clearly transsexual, biologically male patient gave up the wish for surgical sex reassignment but continued to live as a female (Meyenburg, 1992).

It could be argued that a thorough diagnotic assessment should make it possible to sort out patients for whom sex reassignment is inappropriate. The cases of Martin and Holger are examples of such patients. Although both presented themselves initially as cases of GID, it was concluded after completing the diagnostic assessment that Martin was an effeminate homosexual with transvestitic traits and that Holger was a boy with fetishistic traits that were temporarily predominant. However, the case of Sandra demonstrates that, even with patients where there is no doubt about the diagnosis of GID, recommending sex reassignment measures would have been a wrong decision.

Lothstein (1980) also discussed a case where sex reassignment would have been an incorrect decision. Seen at the Case Western University Gender Identity Clinic in Cleveland, a young adult male patient was diagnosed as transsexual. He was treated for over two years with female hormones and lived during that time as a female. The patient then discontinued therapy, decided to live as a male, and planned to get married.

Since such cases do happen even in well-established gender identity centers with experienced specialists, it is even more important to proceed with great caution when treating young patients. For adolescents with GID, as compared with adults, gender role behavior may vary more widely, and premature decisions, especially those involving surgery, must be avoided. Before sex reassignment is considered, an attempt at psychotherapy for at least one year should be made, a real-life test of one-year duration should be successfully passed, and the patient should be at least eighteen years old. In some treatment centers, even higher age limits are set.

REFERENCES

Barlow, D. H., Abel, G. G., & Blanchard, E. B. (1979). Gender identity change in transsexuals: Follow-up replications. Archives of General Psychiatry, 36, 1001-1007.

Barlow, D. H., Reynolds, E. J., & Agras, W. S. (1973). Gender identity change in a transsexual. Archives of General Psychiatry, 28, 569-576.

Cohen-Kettenis, P. T. (1994). Die Behandlung von Kindern und Jugendlichen mit Geschlechtsidentitatsetorungen an der Universitat Utrecht. [Clinical management of children and adolescents with gender identity disorders at the University of Utrecht.] Zeitschrift fur Sexualforschung, 7, 231-239.

Davenport, C. W., & Harrison, S. I. (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6(4), 327-340.

Kirkpatrick, M., & Friedmann, C. T. H. (1976). Treatment of requests for sex-change surgery with psychotherapy. American Journal of Psychiatry, 133(10), 1194-1196.

Kronberg, J., Tyano, S., Apter, A., & Wijsenbeck, H. (1981). Treatment of transsexualism in adolescence. Journal of Adolescence, 4, 177-185.

Lothstein, L. M. (1980). The adolescent gender dysphoric patient: An approach to treatment and management. Journal of Pediatric Psychology, 5(1), 93-109.

Meyenburg, B. (1992). Aus der Psychotherapie eines transsexuellen Patienten. [Psychotherapy in a transsexual patient.] Zeitschrift fur Sexualforschung, 5(2), 95-110.

Newman, L. E. (1970). Transsexualism in adolescence: Problems of evaluation and treatment. Archives of General Psychiatry, 23, 112-121.

Philippopoulos, G. S. (1964). A case of transvestism in a 17-year-old girl. Acta Psychotherapeutica, 12, 29-37.

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