Gender Identity Disorder In Adolescence: Outcomes Of Psychotherapy

Adolescence,  Summer, 1999  

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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.