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Gender Identity Disorder In Adolescence: Outcomes Of Psychotherapy

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).

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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.

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Gender Identity Disorder In Adolescence: Outcomes Of Psychotherapy

Adolescence, Summer, 1999

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