Gender identity in young people

Abstract

The recent film Boys Don't Cry illustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.

Full text

APT (2000), vol. 6, p. 458 Di Ceglie
Advances in Psychiatric Treatment (2000), vol. 6, pp. 458–466
The recent film Boys Don’t Cry illustrates in a highly
dramatised form the problems that the phenomenon
of gender identity disorder can create in an extreme
situation. The film is based on the true story of a
young person, Brandon, with a female body who
perceived himself as a male. In the film we do not
know when the issue of his male gender identity
first appeared, but we see him living in a male role
as a teenager trying to conceal, to his peers, the reality
of his female body. (I refer to Brandon as ‘he’ because
this is how Brandon presents himself in the film.
The dilemma about using ‘he’ or ‘she’ typically
confronts professionals in the management of
teenagers like Brandon.) The struggles of these
concealments are well portrayed, as in the scene
when he steals tampons from a shop. He joins in
male activities and displays of physical strength as
a confirmation of his male role. He is well accepted
as a boy within a troubled and troublesome group
of young people. He falls passionately in love with
a girl, Lana, who accepts him as he is without much
questioning, and a close intimate relationship
develops, which the peer group seems to accept. The
reality of his body is eventually revealed. His
girlfriend can accept the new situation, but had she
really not known or had she turned a blind eye?
Unfortunately, two young men become more and
more disturbed by this realisation. It stirs a primitive
violence in them, which leads first to Brandon’s rape
and then to his murder.
How can we make sense of this complex tragedy?
Here I would like to suggest that a sense of
unbearable identity confusion in the two young
people is what leads to the violence. It is aimed at
changing Brandon and eventually destroying him
when their attempt to make him submit to their views
of order on gender and sexual matters fails. For them,
having a female body is inextricably connected with
having a female identity. Any digression from this
rule is a terrible threat to their flimsy sense of identity.
Obviously, other factors can be invoked in making
sense of their behaviour, but these are beyond the
scope of this paper.
The establishment and maintenance of secrecy
can have serious psychosocial consequences, as the
film shows when secrecy is suddenly broken. On
the other hand, people who are aware and come
into contact with a child or teenager with a gender
identity disorder often experience a sense of
confusion. Breaking a cycle of secrecy by promoting
openness and creating the conditions for the
tolerance of confusion and uncertainty are impor-
tant issues in the management of gender identity
disorders (see ‘Primary therapeutic aims’, Box 3).
Before the 1960s, secrecy and confusion dominated
the area of atypical gender identity development.
The first definition of the term ‘gender role’ was
given by John Money (1955). Money wanted to
differentiate a set of feelings, assertions and
behaviours that identified a person as being a boy
or a girl, or a man or a woman, from the contrasting
conclusion one could have reached by considering
only their gonads. In the vast majority of cases he
described, the gender role adopted by the individuals
was consistent with their rearing.
The term ‘gender identity’ appeared in the mid-
1960s in association with the establishment of a
gender identity study group at the University of
California. Stoller (1992: 78) defines it as:
“A complex system of beliefs about oneself: a sense
of one’s masculinity and femininity. It implies nothing
about the origins of that sense (e.g. whether the
person is male or female). It has, then, psychologic
connotations only: one’s subjective state.”
Gender identity disorder
in young people
Domenico Di Ceglie
Domenico Di Ceglie is a Consultant Child and Adolescent Psychiatrist at the Tavistock Clinic, and Director of the Gender
Identity Development Service, Portman Clinic (8 Fitzjohns Avenue, London NW3 5NA). He is also Honorary Senior Lecturer,
Royal Free & University College Medical School, London. He was the founder in 1989 of the Gender Identity Development
Clinic (for children and adolescents) at St George’s Hospital, London, now at the Portman Clinic.

Gender identity disorder
APT (2000), vol. 6, p. 459
The concept of gender identity and role having been
formulated, it became possible to make sense of, and
give order to, conditions that had until then been
ill-defined and poorly understood. Incongruity
between the biological sex and the psychological
behavioural manifestations of gender identity
indicated the presence of a gender identity disorder.
Classifications of gender
identity disorders of childhood
Over the past 20 years, four diagnostic models have
been proposed. The first is the Diagnostic and Statis-
tical Manual of Mental Disorders (4th edn) (DSM–IV;
American Psychiatric Association, 1994). This sets
criteria for children, adolescents and adults (Box 1)
and requires that four criteria be satisfied for the diag-
nosis to be made. Criteria A and B refer to two aspects
of gender identity disorder: A to evidence of cross-
gender identification; and B to the experience of
discomfort about one’s biological sex and the feeling
of inappropriateness in the gender role of that sex.
The second is the International Classification of
Diseases, Tenth Revision (ICD–10, F64.2; World Health
Organization, 1992). In this classification there is
no distinction between criteria A and B and “the
diagnosis requires a profound disturbance of the
normal gender identity; mere tomboyishness in girls
or girlish behaviour in boys is not sufficient”.
Third is Rosen et al’s (1977) distinction between
cross-gender identification and gender-behaviour
Box 1 Criteria for diagnosis of gender identity disorders from the Diagnostic and Statistical Manual
of Mental Disorders (4th edn) (DSM–IV; American Psychiatric Association, 1994)
A A strong and persistent cross-gender identification (not merely a desire for any perceived cultural
advantages of being the other sex)
In children the disturbance is manifested by four (or more) of the following:
••
••
• repeatedly stated desire to be, or insistence that he/she is, the other sex;
••
••
• in boys, preference for cross-dressing or simulating female attire; in girls, insistence on only
wearing stereotypical masculine clothing;
••
••
• strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies
of being the other sex;
••
••
• intense desire to participate in the stereotypical games and pastimes of the other sex;
••
••
• strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested in symptoms such as:
••
••
• stated desire to be the other sex
••
••
• frequent passing as the other sex
••
••
• desire to live and be treated as the other sex
••
••
• conviction that he/she has the typical feelings and reactions of the other sex
B Persistent discomfort with his/her sex or sense of inappropriateness in the gender role of the sex
In children, the disturbance is manifested by any of the following: in boys, the assertion that their
penis and testes are disgusting or will disappear, or assertion that it would be better not to have a
penis, or aversion towards rough and tumble play and rejection of male stereotypical toys, games
and activities; in girls, the rejection of urinating in a sitting position, assertion that they have or will
grow a penis, or assertion that they do not want to grow breasts or menstruate, or marked aversion
toward normative female clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation
with getting rid of primary and secondary sex characteristics (e.g. request for hormones, surgery
or other procedures to alter sexual characteristics physically to simulate the other sex) or belief
that they were born the wrong sex.
C The disturbance is not concurrent with a physical intersex condition
D The disturbance causes clinically significant distress or impairment in social, occupational or other
important areas of functioning

APT (2000), vol. 6, p. 460 Di Ceglie
disturbance. This classification has proved unsatis-
factory, as a large number of children (71%) present
both characteristics (Bentler et al, 1979).
Fourth is Stoller’s (1968) diagnosis of ‘male
childhood transsexualism’. This is based on the
presence in a boy of “a fixed belief that he is a
member of the opposite sex and will grow up to
develop the anatomical characteristics of the
opposite sex” (p. 195).
The following case study illustrates an initial
clinical presentation.
Case study 1: James
James was referred to the Gender Identity
Development Service at the age of 8 years.
At the assessment interviews, he said that since
the age of 4 or 5 years he had very much wished he
were a girl. He had been secretly dressing up in his
mother’s clothes. He liked to play with dolls and
cuddly toys and fantasised that he was a mother
feeding them. He played weddings and liked to be in
the role of the bride. At school he wanted to play
with girls and avoided rough-and-tumble play or
other activities with boys.
His maternal grandmother had looked after him
from age 6 months to 5 years, as his mother was
away often for her work. The grandmother involved
him in many activities, including cooking and tidying
up the house. After her sudden death in hospital,
James developed a gender identity disorder. He could
not talk about the loss of his grandmother or even
mention her, but he concretely identified with her
and persistently wished to continue with all the activ-
ities in exactly the same way as he had once with her.
Family therapy, focusing on a family tree constructed
over many sessions, enabled the narrative of his
experiences with his grandmother to be developed.
The clinical features of his gender identity disorder
gradually reduced in intensity and disappeared.
In this case the psychological work focused not
only on mourning processes, but it also removed the
secrecy about his gender problem, encouraged
curiosity about its origins and established a link
between his atypical gender development and the
way he had coped with the loss of his grandmother.
Symbol formation was stimulated, so that he could
have a mental picture of her and memories of the
past, rather than concretely identifying with and
becoming her. Increased contact with his father
seemed also to play an important role.
Epidemiology
The incidence of childhood cross-gender identification
in the general population and in the psychiatric
population has not yet been definitely established.
The studies that have been carried out have used
differing criteria, such as single behaviours or
identity statements. No large-scale investigation
with standardised criteria, such as those of DSM–
IV, has yet been conducted.
Zuger and Taylor (1969) interviewed the mothers
of boys aged about 7 years with regard to the
presence of six cross-gender behaviours. Table 1
shows the percentage of positive occurrences for
each behaviour. The mothers were not asked how
long the behaviours had been apparent nor when
they started. Zuger and Taylor also showed that
these behaviours were not frequently found in
children (73% never engaged in any of them).
Feinblatt and Gold (1976) found that of 193
children referred to a Connecticut child guidance
clinic, four boys and three girls (3.6% of the total)
were referred primarily because of ‘gender-role
inappropriate behaviour’.
Epidemiological data suggest that “extreme forms
of cross-gender behaviour are uncommon among
boys in the general population” (Zucker, 1985; see
also Zucker & Bradley, 1995). One could fairly
confidently say that cross-gender behaviour is not
“a common phase in boyhood behaviour” (Green,
1968). There is insufficient epidemiological research
regarding girls to be able to make a similar
statement.
Long-term follow-up studies
The most scientifically accurate follow-up study
was conducted by Green (1987). He reports that of
the 66 males in the original ‘feminine boy’ group,
two-thirds were re-interviewed in adolescence or
young adulthood, when three-quarters of them were
found to be homosexual or bisexual. Only one boy
in this study had a transsexual outcome.
Zucker (1985) collated all the long-term follow-
up studies of children identified as cross-gender
referred to mental health professionals (Table 2).
Table 1 Maternal report of cross-gender
behaviour in boys aged about 7 years (from
Zuger & Taylor, 1969)
Behaviour Number % positive
occurrence
Desire to be female 46 7
Feminine dressing 95 13
Wearing lipstick 94 7
Doll play 95 7
Preference for girl
playmates 41 15
Aversion to boys’ games 93 2

Gender identity disorder
APT (2000), vol. 6, p. 461
Money and Russo (1981), explaining the low
incidence of a transsexual outcome, suggest that the
“natural history of transsexualism is disrupted by
the child’s contact with the mental health profes-
sion” (Zucker, 1985).
Green et al (1987) examined five types of behaviour
in boys: role/doll play, cross-dressing, having female
peers, rough-and-tumble play and the wish to be a
girl. They found that doll play and role play as a girl
associated more strongly with a homosexual
outcome.
Comorbidity
Coates and Spector Person (1985) have shown that
children with gender identity disorders also present
with separation anxiety, depression and emotional
and behavioural difficulties. In a number of cases
referred to the Gender Identity Development Service
(GIDS) at the Portman Clinic, learning difficulties
and school refusal are also present. In a small
percentage of cases, child sexual abuse has been
associated with a gender identity disorder. Suicide
attempts in adolescence are frequent and in some
cases this is how adolescents with gender identity
disorders come to professional attention.
In a survey of the first 124 cases referred to the
GIDS at the Portman Clinic, we found that the most
common associated features were relationship
difficulties with parents or carers (57%), relationship
difficulties with peers (52%), depression/misery
(42%), family mental health problems (38%), family
physical health problems (38%), being the victim of
harassment or persecution (33%) and social sensitiv-
ity (31%). These data suggest that children with
gender identity problems may experience consider-
able isolation owing to difficulties in their relation-
ships with significant adults and peers. They can
also become the victims of persecution, which may
contribute to feelings of depression and misery. In
this sample, boys appear to experience more
harassment than girls and this may be due to the
fact that gender non-conformity in boys is less
socially acceptable than in girls. The high percen-
tages of mental and physical health problems in the
families of children and adolescents referred may
indicate that factors such as parental depression or
major physical illness may represent a traumatic
event for the child, possibly contributing to the
gender identity problem. This survey also showed
that associated difficulties and case complexity
increase during adolescence.
Aetiology
No single cause has yet been found with certainty
for the development of a gender identity disorder.
Hereditary factors (Bailey & Pillard, 1991) have
been suggested for male homosexuals. The contrib-
ution of such factors to the development of gender
identity disorders in children, however, is unclear
and further research is needed.
Hormonal influences on the brain during foetal
development have also been suggested, with
androgens masculinising the brain during a critical
period of foetal life.
In humans the third interstitial nucleus of the
anterior hypothalamus is usually larger in the male.
LeVay (1991) has shown that in the brain of
homosexual men this nucleus is similar in size to
that of women and about half the volume of that in
heterosexual men.
However, each of these factors alone may be
insufficient to produce a gender identity disorder.
Stoller (1968) has described particular family
constellations associated with gender identity
disorders in boys and girls. For boys, he suggests
there is an overclose relationship with the mother
and a distant father. For girls, he suggests a
depressed mother during the early months of the
child’s life and a father who is absent and does not
support the mother, but encourages the child to
assuage the mother’s depression.
Marantz and Coates (1991) have described very
early maternal influences that negatively affect the
early development of the child.
Bleiberg et al (1986) have linked the development
of gender identity disorders in some children to their
inability to mourn a parent or an important
attachment figure in early childhood.
A parent’s wish for a child of the other gender, or
direct parental pressure in rearing the child in the
gender role opposite to the biological sex, are not
sufficient on their own to produce a marked gender
identity disorder.
Table 2 Long-term follow-up studies of children
with gender identity disorders (from
Zucker, 1985)
Outcome Cases, n % of total
cases
Transsexual 5 5.3
Homosexual or bisexual 43 45.7
Transvestite 1 1.1
(heterosexual)
Heterosexual 21 22.3
Uncertain 24 25.5
Total 94 100

APT (2000), vol. 6, p. 462 Di Ceglie
A number of authors (e.g. Coates et al, 1991; Money,
1994) would agree that many of these factors need
to be present simultaneously and work together
during a critical period to produce a full-blown
gender identity disorder. This would also explain
the rarity of the condition.
Case study 2: Mark
Mark, aged 16 years, presented a gender identity
disorder of a transsexual type. He hated his male
body intensely. Socially isolated and in despair, he
had attempted suicide. Since the age of 3 or 4 years
he had felt that he was a girl. At the age of 7 years his
father sexually abused him and this experience
confirmed for him that he was a girl as, at that time,
he thought that men were sexually attracted only to
women. At the time of the referral he felt that his
body should be changed immediately, as he could
not bear living in a contradictory situation. There
was also a real possibility of further suicide attempts.
A structured therapeutic programme, including
individual and family sessions, and also consultation
with a paediatric endocrinologist, made him feel that
mind and body had been taken into consideration
and helped him to tolerate a transitional phase of
uncertainty by containing his feelings of despair. It
also supported his hope that the incongruence
between his mind and body would eventually be
overcome. It was important that network meetings
of the professionals involved with his care were held
at regular intervals.
Exploration of the patient’s expectations, gender
identity and roles, body image, self-perception and
other people’s perception of the individual is essential
preparation for the young person before referral to
a gender identity service for adults at the age of 18
years. No irreversible physical intervention should
be undertaken before this age.
Nature of atypical gender
identity organisation
In 1964 Stoller proposed the concept of core gender
identity. He saw this as:
“produced by the infant–parent relationship, the
child’s perception of its external genitalia, and a
biologic force, which results from the biologic
variables of sex (chromosomes, gonads, hormones,
internal accessory reproductive structures and
external genitalia)”.
Stoller believed that the core gender identity is
established before the fully developed phallic stage,
although gender identity continues to develop into
adolescence or beyond (1964: 453). He further stated
that the beliefs comprising the “mental structure”
of the core gender identity are the earliest part of
gender identity to develop and are relatively
permanent after the child reaches 4 or 5 years of age
(1992: 78).
Further research and clinical experience shows
that there may be more flexibility in gender identity
development than Stoller’s concept of core gender
identity would imply. Only in some children and
adolescents with an atypical development does the
core gender identity have the structural character-
istics described by Stoller. In 1998 I proposed the
concept of atypical gender identity organisation
(AGIO) as a clinical entity that can be examined
under a number of parameters relevant to clinical
management (Box 2; Di Ceglie, 1998a). These are as
follows.
Rigidity–flexibility. This refers to the capacity of
the organisation to remain unchangeable or, altern-
atively, to be amenable to evolution in the course of
development. Only in particular cases will it possess
the unchangeable structural qualities of Stoller’s
core gender identity.
Timing of the AGIO formation. Atypical organis-
ations that develop very early in the child’s life may
be more likely to become rigidly structured than
organisations that develop later.
Identifiable traumatic events in the child’s life in
relationship to the AGIO formation. In some cases
the AGIO is formed as a psychological coping
strategy in relation to a traumatic event in childhood.
The earlier the trauma occurs, the more likely it is
that the organisation will acquire rigid and
unchangeable qualities.
Where the formation of the AGIO can be located on the
continuum from the paranoid–schizoid to the depressive
position. The hypothesis here is that if the AGIO is
formed within a mental functioning dominated by
paranoid–schizoid processes in response to a
traumatic event, it is more likely to become very
structured and therefore not amenable to change.
Alternatively, if it is formed within a mental
functioning of the depressive position it is likely that
the organisation will be amenable to evolution.
Box 2 Clinical features of atypical gender
identity organisation (AGIO; from Di
Ceglie, 1998a)
Rigidity–flexibility
Timing of formation of the AGIO
Presence/absence of traumatic events in the
child’s life in relation to formation of the
AGIO
Position of the AGIO on continuum from the
paranoid–schizoid to the depressive
position

Gender identity disorder
APT (2000), vol. 6, p. 463
Therapeutic exploration over a long period of time
may be able to elucidate the characteristics of the
organisation and therefore guide management. The
following clinical example illustrates this point.
Case study 3: Jennifer
Jennifer was 17 when I saw her following three
suicide attempts. She was a female to male transsexual
who presented with depressive episodes and a
number of borderline features. Her mother, who had
died just before Jennifer came to see me, suffered
depression after Jennifer’s birth, and her father had
been physically violent towards his wife during
Jennifer’s childhood, until they separated. During her
psychotherapy sessions with me, she vividly
remembered episodes when her father in fits of
temper had kicked her mother, even in the stomach.
In one session she admitted, not without a sense of
embarrassment and shame, that she had identified
with him, an experience that she could not explain.
She loved her mother, and her main aim in life was to
do something extraordinary that would have made
her mother happy. There was no recollection that
Jennifer herself had been physically abused by her
father, but witnessing violence between her parents
had been a traumatic childhood experience.
One defensive manoeuvre she used to cope with
the fear of damage to her mother and possibly to
herself was to identify with a male possessing the
strength of a physical masculine body. This belief,
once established, allowed her an omnipotent sense
of survival and also of protecting her ‘damaged’
mother. A female representation of herself had to be
strongly avoided, as this was equated in her mind
with being weak and damaged.
Another important factor also seemed to play a
part. After the birth of two older sisters, her mother
had miscarried a baby boy. One year later, Jennifer
was born. Jennifer seemed to feel that her mother
had expected her to be a boy, and in one session she
alluded to her mother having “psychic qualities”, as
if she had been part of a magical experience in which
she and her mother could read each others’ minds.
She had probably received, and made her own, her
mother’s wish that she were a boy. This wish was
probably never consciously expressed by her mother,
but remained unconsciously active in the relationship
between them.
Two years’ psychotherapeutic exploration with this
patient allowed me to make this partial reconstruction
of her childhood relating to her atypical gender
identity development. However, my attempts to
explore this understanding with Jennifer led to
continuous interruptions to the therapeutic work,
which showed her extreme resistance and fears of
having the foundation of her gender identity revisited.
Even if she retained some of this understanding, it
certainly did not alter Jennifer’s gender identity
development – that is to say, the sense of who she
was – within the limitations of twice-a-week
psychotherapy. Her atypical gender identity
organisation (AGIO) was well established and not
amenable to evolution. It formed very early in her
life, and traumatic events had played a large part in
it. Its formation seemed to have occurred under the
dominance of the paranoid–schizoid position,
constituting a rigid nucleus of gender identity on
which her development had been based.
Other aspects of her life improved. She did not
attempt suicide again, she settled in a job and she
was more able to establish relationships with other
people. One might say that therapy had helped her
to reduce the hold of the AGIO on other aspects of
her development and of her life.
Management and therapy:
the staged approach
Behavioural therapy, individual psychotherapy,
family therapy and group therapy have been used
with these children and their families. Their efficacy
is unproven.
As the aetiology of gender identity disorder is
unclear and probably multi-factorial, at the GIDS
we have developed a model of management in which
altering the gender identity disorder per se is not a
primary therapeutic objective. Our primary thera-
peutic concern is the developmental processes that,
on clinical and research experience, seem to have
been negatively affected in the child (Box 3).
While changing the gender identity disorder itself
is not the primary aim, it is possible that by targeting
and improving the developmental processes that may
underpin gender development, it will be affected in
a secondary way and will not lead to establishment
of an atypical gender identity in adulthood. The aims
outlined in Box 3 could be achieved through various
psychotherapeutic interventions, ranging from
individual to family and group therapy. Social and
educational interventions are also useful. It is
important that these are well coordinated and
integrated in a comprehensive management plan.
These aims are more relevant in some cases than
in others. The three case studies above give a brief
illustration of how these therapeutic objectives could
be tackled in clinical work; for a more detailed
account see Di Ceglie (1998b).
The recognition and non-judgemental acceptance
of the gender identity problem, which is not the result
of the child’s conscious choice, is important. Without
this the child would experience feelings of rejection,
psychological splitting processes would increase to
cope with this and no further therapeutic work could
be undertaken. Group work for parents of children
with gender identity disorders can be very helpful
in this respect, as it helps the parents to realise that
their problem is not unique.

APT (2000), vol. 6, p. 464 Di Ceglie
Where an inability to mourn attachment figures
has interfered with gender identity development,
work enabling mourning to occur may secondarily
alter an atypical gender identity development, as
shown in case study 1.
The general approach to the management of
gender identity disorder can be best conceptualised
as a process involving four stages, in line with the
guidance for management issued by the Royal Col-
lege of Psychiatrists (1998), summarised in Box 4.
Stage 1 of the process for children and adolescents
is a therapeutic exploration, as described above. In
adolescents, if the AGIO persists and shows a high
level of rigidity and therefore evolution towards
transsexualism, then physical interventions could
be considered if they are requested by the adolescent
and his or her family. There is often pressure for
physical intervention because of the high level of
distress brought about by the reality of the changing
body at puberty. However, the move towards
physical intervention should be cautious.
Stage 2 includes wholly reversible intervention.
This involves the use of hypothalamic blockers,
which suppress the production of oestrogens or
testosterone and produce a state of biological
neutrality. In order that adolescents and parents may
make a properly informed decision, the Royal College
of Psychiatrists’ guidance recommends that young
people have some experience of themselves in the
post-pubertal state of their biological sex. When this
intervention has been properly assimilated, while
continuing psychological exploration, support and
physical monitoring by a paediatric endocrinologist,
stage 3 can be considered.
Stage 3 includes partially reversible interventions,
such as hormonal treatment that masculinises or
feminises the body.
Finally, stage 4 includes irreversible interventions,
such as surgical procedures. The College guidance
recommends that:
“surgical intervention should not be carried out prior
to adulthood, or prior to a real life experience for the
young person of living in the gender role of the sex
with which they identify for at least two years. The
threshold of 18 should be seen as an eligibility criterion
and not an indicator in itself for more active
intervention, as the needs of many adults may also
be best met by a cautious, evolving approach” (Royal
College of Psychiatrists, 1998: 6).
Children, particularly adolescents, and their
families often find the experience of a gender identity
Box 4 Summary of Royal College of Psychi-
atrists’ (1998) guidance for management
of gender identity disorders in children
and adolescents
Gender identity disorders in children and
adolescents:
••
••
• are rare
••
••
• are more common in boys
••
••
• are developmental
••
••
• involve psychological, biological, family
and social issues
••
••
• have an outcome that cannot be easily
predicted
••
••
• require early and careful assessment and
attention to emotional and developmental
needs
Consideration of physical interventions
should be cautious, involve extensive
psychological, family and social explor-
ation, take into account adverse effects on
physical growth and be undertaken only
by specialist teams
A large element of management is pro-
moting the young person’s tolerance of
uncertainty and resisting pressures for
quick solutions
Surgical intervention cannot be justified
until adulthood
Box 3 Primary therapeutic aims (from Di
Ceglie, 1998a)
To foster recognition and non-judgemental
acceptance of gender identity problems
To ameliorate associated behavioural,
emotional and relationship difficulties
(Coates & Spector Person, 1985)
To break the cycle of secrecy
To activate interest and curiosity by exploring
the impediments to them
To encourage exploration of the mind–body
relationship by promoting close collabor-
ation among professionals in different
specialities, including a paediatric
endocrinologist
To allow mourning processes to occur
(Bleiberg et al, 1986)
To enable symbol formation and symbolic
thinking (Segal, 1957)
To promote separation and differentiation
To enable the child or adolescent and the
family to tolerate uncertainty in gender
identity development
To sustain hope

Gender identity disorder
APT (2000), vol. 6, p. 465
disorder painful and unbearable, and adolescents
are at high risk of suicide attempts. This sense of
despair frequently leads to extreme pressure being
placed on clinicians to act and to provide immediate
solutions, through physical intervention, which may
not be clinically appropriate at the time of request.
In such cases, a detailed discussion with the
adolescent and the family of the treatment as a staged
process may be containing, by creating space for
thinking. This may allow time to explore the issues
involved in each stage, and this may gradually
reduce the pressure for immediate solutions that
have not been properly thought through.
A follow-up study of transsexual adolescents who,
after careful asssessment, started the process of sex
reassignment during adolescence (after the age of
16) shows that they had acheived a good level of
psychological and social adjustment at least 1 year
after surgical intervention (Cohen-Kettenis & van
Goozen, 1997).
Conclusions
Gender identity disorders remain complex con-
ditions to treat. However, clinical practice and
research in the past two decades have made it
possible to create models of care that benefit children
and adolescents. In Boys Don’t Cry, Brandon could
not avail himself of this type of help and support,
which includes an integrated programme of
psychological, social and physical interventions.
The tragedy portrayed in the film clearly shows the
need for making professional services available to
people with gender identity problems and for
educating society at large about these unusual life
experiences.
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APT (2000), vol. 6, p. 466 Di Ceglie
Multiple choice questions
1. Gender identity disorders in children and
adolescents are:
a frequent conditions
b a phase of ordinary development
c precursors of adult transsexualism in all cases
d uncommon conditions
e more prevalent in boys than in girls.
2. The outcome of gender identity disorders in
childhood is:
a transsexuality only
b transsexuality and homosexuality only
c transvestism and transsexuality only
d transsexuality, homosexuality, bisexuality,
transvestism and heterosexuality
e paraphilias in adulthood.
3. Gender identity disorders are:
a usually pure conditions
b often associated with behavioural and
relationship difficulties
c linked to a clear and well-defined aetiology
d commonly associated with sexual abuse
e caused by parental attitude and expectations
4. Atypical gender identity organisation is:
a present in all children who only cross-dress
b an alternative for the concept of core gender
identity
c a research instrument
d useful in clinical management
e a less intense presentation of gender identity
disorder.
MCQ answers
12345
aF aF aF aF aF
bF bF bT bT bF
cF cF cF cF cT
dT dT dF dT dF
eT eF eF eF eT
5. The clinical management of gender identity
disorders in children and adolescents involves:
a hormonal treatment only
b preparation for surgical intervention in all
cases
c a staged approach, including psychosocial
and physical interventions
d psychotherapy only
e the prevention of other symptoms and
behavioural difficulties.