Castaway’s Corner

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Psychiatry
Clinical Child Psychology and
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DOI: 10.1177/1359104502007003013
2002 7: 487Clin Child Psychol Psychiatry
Domenico di Ceglie
Castaway's Corner
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CASTAWAY’S CORNER
DOMENICO DI CEGLIE
Tavistock Clinic, London, UK
AN OPPORTUNITY TO pause and reflect on how one got to a particular point in the
development of one’s own interests should not be missed. In this case, it is the creation
of a service for children and adolescents facing gender identity problems. This remains
a mystery to me and it is still surprising how apparently unpredictable sets of events
determine shifts in interests and professional activities.
In my case, it was an encounter with a teenager in the early 1980s who had been
referred by a colleague, Dr Jill Vites, to the Adolescent Department of the Tavistock
Clinic and who was claiming that she was a boy but in a female body. I knew little about
this subject but I decided to take this case out of curiosity and perhaps to expand my
training experience. I thought I would also learn more about what it meant to be male
or female and the differences between the two. After an initial assessment, I offered this
girl, or should I say boy, psychotherapy that was accepted. The impact of this relation-
ship was an unexpected one. I learned very little about sexuality as a good deal of the
sessions were spent in silence. My patient would say a few sentences and I would make
a few interpretations. The end result was that I could record very accurately what
happened verbally in the session. What went on non-verbally – is another story. I got the
impression that there was something very profound about her sense of identity of being
a boy which could not be easily explained and that was fundamental to her being.
Colleagues were saying that she was confused about her gender. I discovered instead
that Iwould become at times confused during the sessions about her identity, whereas
she seemed to be very clear that she was a boy and that there was nothing more to find
out about this. I was at times made to feel extremely curious in the sessions, only to find
out that my curiosity would be frustrated and that it was pointless to pursue my enquiries.
I started to read the work of Robert Stoller (1968, 1975) and other literature on trans-
sexualism. These articles concern mainly work with adults. I found, however, that this
Clinical Child Psychology and Psychiatry 1359–1045 (200207)7:3 Copyright © 2002
SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 7(3): 487–491; 024042
487
DOMENICO DI CEGLIE is a Consultant Child and Adolescent Psychiatrist in the
Adolescent Department at the Tavistock Clinic, Director of the Gender Identity Develop-
ment Unit at the Portman Clinic, Honorary Senior Lecturer at The Royal Free and University
College Medical School, and Psychoanalytic Psychotherapist at the Lincoln Centre. For many
years he has had an interest in adolescence and has worked in in-patient units for young
people. He has been widely involved in consultative work to organizations and to professional
networks about complex cases.
CONTACT: Domenico Di Ceglie, Gender Identity Development Unit, Portman Clinic, 8
Fitzjohn’s Avenue, London NW3 5NA, UK. [E-mail: GIDU@tavi-port.org].
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reading didn’t help as much as I’d hoped in understanding the complexity of the
condition. This patient had to move to another town and so her exploratory therapy with
me had to come to an end. In one of her last sessions she said that perhaps this form of
help had come too late and that her parents should have been aware of how she was
feeling by the way she behaved. She wondered why they had not sought help for her
when she was a child. Her thoughts made me wonder why there was no service for
children with these rare and unusual experiences. This planted in me the seed for the
creation of such a service.
Soon after the end of this experience I became a consultant in child psychiatry in
Croydon and started a workshop there with two or three members of staff who were
interested in this area. We tried to see all the cases in the London Borough of Croydon,
with a population of about 300,000, who presented with gender identity problems and
we ended up with 3 or 4 cases. Some were seen in family therapy and I took one case
into individual therapy. This child had some of the features that Stoller had described.
However, in the clinical sessions I could find no evidence of a ‘blissful’ relationship with
the mother. Stoller writes: ‘When extremely feminine boys are studied in childhood, I
find that their mothers try to maintain indefinitely a blissfully intimate symbiosis with
their son . . .’ (Stoller, 1992).
I used to see this 7-year-old boy after school as my last case. He made few demands
of me as his therapist. This seemed to be the perfect patient to have at the end of a hard
day. As soon as he walked in the room he would start to play with the dolls’ house,
placing all the dolls, which I had provided, in the little rooms apparently totally ignoring
me and tidying up everything near the end of the session. The problem started when I
asked him what he was playing. He came up with very elaborate fantasies on how all the
children in the house were going to be killed by various means, including the use of poiso-
nous gas released by a cylinder. I was shocked to find out that so much was going on in
his mind in spite of the mild appearances of his behaviour. Within a Kleinian perspec-
tive (Klein, 1975), if the dolls’ house represented the body of the mother or his relation-
ship with the mother there was very little of a benevolent nature going on there. So much
for the ‘blissful’ relationship! By now, I had become convinced of a need for a service
for children with gender identity disorders.
In 1987 at the international conference of the European Society of Child & Adolescent
Psychiatry I had the opportunity to meet Robert Stoller in person. During a coffee break
I mentioned to him my project to start a service for children and adolescents. He was
very encouraging. He thought that there was a real need for such a service and predicted
that there would be many referrals and a lot of interesting work. He suggested that I read
and made contact with Richard Green who had been doing clinical work and original
research on children (Green, 1968, 1971, 1974).
Some time after I met for lunch with Peter Hill, at the time Professor of Child and
Adolescent Psychiatry at St George’s Hospital Medical School. He enthusiastically
agreed to support the establishment of a gender identity service for children and adoles-
cents within the Department of Child Psychiatry at St George’s. I decided to call it
Gender Identity Development Clinic as the emphasis would be in promoting the
development, particularly that of gender identity, in the children/adolescents coming to
the service. So in September 1989 the service started. The staff included a social worker
Mary Lightfoot, a psychotherapist Barbara Gaffney and a senior registrar Martin
McCall. The clinic was held one afternoon fortnightly and then weekly. Later an eminent
paediatric endocrinologist from Great Ormond Street, David Grant, offered to run a
paediatric liaison clinic once a term in the Paediatric Department at St George’s, during
which the child/adolescent key worker from our service would join him in seeing the
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child and the family. I referred to these two settings as the ‘theatre of the mind’ and the
‘theatre of the body’ to use Joyce McDougall’s fitting metaphors (McDougall, 1985,
1989). These two spaces need to be first integrated in our minds as professionals and,
hopefully, they will then become integrated in the minds of our clients. However, they
needed to be seen as clearly definable and visible to meet the psychological needs of the
children, in particular, teenagers coming to our service. I also conceptualized some
aspects of the paediatric intervention as offering a transitional space, which allowed the
engagement of some teenagers who wouldn’t otherwise have engaged working with us.
This mind/body integration visibly represented by the working together of a paediatri-
cian with professionals involved in psychosocial interventions, became one of the
primary aims of our therapeutic model.
In 1992 our service, in association with the conference unit at St George’s, organized
the first international conference on gender identity problems in children and adoles-
cents. John Money presented a paper on the history of the concept of gender identity
and gender identity disorder, which was published in 1994 (Money, 1994). The
conference allowed a creative sharing of experiences with colleagues who had devel-
oped similar services in other parts of the world, particularly Peggy Cohen-Kettenis in
Utrecht and Ken Zucker in Toronto. I presented a paper on our model of working in
which altering the gender identity disorder per se was not a primary therapeutic objec-
tive. Our primary therapeutic objectives were instead the developmental processes,
which, on clinical and research experience, seemed to have been negatively affected in
the child. Particularly useful was the work of Susan Coates (Coates & Spector Person,
1985; Coates et al., 1991) on attachment patterns in children with gender identity
problems. This therapeutic approach was obviously a paradox for a service for children
with gender identity disorders in whom the primary aim was not the psychological treat-
ment of the disorder, which meant the necessity of adapting the mind to the body. Our
stance was to maintain an open mind as to what solution an individual would find to the
mind/body conflict. Our task was to assist the child/adolescent and the family in the
gender identity development and in the search to the best possible solution to the
identity conflict. Addressing developmental processes, however, might secondarily
affect the gender identity development. I remember vividly the controversy that this
approach provoked during the discussion, which followed my paper. Some pro-
fessionals seemed shocked that our energy was not devoted to treating the disorder,
whereas other members of the audience, particularly representatives of the self-help
organizations, appeared relieved that we were not trying intrusively to change these
children at all costs.
The method of achieving these aims relies on a range of therapeutic interventions
ranging from family work, individual work, group work, support and educational groups
for parents to professional network meetings involving teachers, health visitors, social
workers, general practitioners and other mental health professionals involved with the
child. In some cases only one therapeutic intervention for a short period is appropriate.
In other cases a combination of these interventions is necessary over a longer period.
A regular review of the needs of the child/adolescent and the family within a multi-
disciplinary team is necessary to determine which intervention would be the most appro-
priate and effective at a particular stage of development (Di Ceglie, 1998).
Over the years we have not had reason to radically change this model and the number
of children and teenagers referred to the service has gradually increased. However, the
model has been refined over the years, particularly with reference to physical inter-
ventions in adolescents with a transsexual outcome. A committee set up by the Child
and Adolescent Faculty of the Royal College of Psychiatrists produced a Guidance for
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Management for Gender Identity Disorders in Children and Adolescents in January
1998. I now refer to this model as the staged approach (Di Ceglie, 2000).
Since the start of the service other areas of needs have emerged, such as the gender
identity and psychosocial difficulties of some children with intersex disorders and the
management issues raised by children of transsexual parents, particularly in relation to
residence and contact disputes.
In 1996, the clinic transferred from St George’s to the Tavistock and Portman Trust,
based at the Portman Clinic. It organized two further international conferences in 1996
and in 2000. Some of the papers presented at the conference in 1996 were published in
a book A Stranger in My Own Body (Di Ceglie, 1998), which also contained a chapter
on children of transsexual parents. In the 2000 conference therapeutic models of
management of children and adolescents with gender identity problems were reviewed
and debated but a special feature of this conference was the psychosocial management
of children with intersex conditions. Milton Diamond presented a paper summarizing his
lifetime’s work in this area and giving his views on the management of this condition
(Diamond & Sigmundson, 1997). His presentation generated an interesting debate
involving a number of self-help organizations. By now it has become clear that there is
a need for a specialized service of this kind, covering three areas: (i) gender identity
disorder, (ii) some aspects of the psychosocial management of some intersex conditions,
and (iii) provision of specialized counselling to children and families with a transsexual
parent.
During the life of the service, staff and users have contributed creatively to its develop-
ment. For instance, a mother of a child with gender identity disorders involved in a
dispute over contact with her ex-partner, asked me during a court break if she could meet
other parents facing similar issues. This was the start of a new development – the running
of a group for parents of children with gender problems. This group became an import-
ant feature of our service and then led to the formation of a self-help organization called
‘Mermaids’. Mermaids had been the focus of discussion in one of the parents’ groups in
an attempt to understand the fascination that some children have for these mythical
creatures. ‘Mermaids’ is a complementary organization to our service, which offers the
kind of help and support that we, as professionals, cannot. Their social activities and
networks provide, in my view, a space within society in which children and teenagers
with unusual gender development can feel accepted. Their social isolation is reduced and
they can start to feel part of a community.
With the help of some families within Mermaids, the service became involved in a tele-
vision programme The Wrong Body in 1993. The programme featured some of the
dilemmas a 13-year-old with a gender identity problem had to face within the family and
social network. Should this teenager be addressed as he or she and in which gender be
accepted in the school? Another dilemma was the timing for the start of physical inter-
ventions. This was a courageous teenager who, with the support of his family, wanted to
share his experiences with society in an attempt to reduce the isolation and stigma which
experiencing this condition attracted. The process involved in the making of this docu-
mentary was a very interesting experience for the whole service. At a crucial point during
the filming a child protection conference was organized by social services involving a
number of lawyers. Two main issues were at the centre of the debate: first, can a teenager
of 13 give informed consent to a programme describing his unusual condition? And
second, are the parents really protecting their child by supporting his wish to make public
his unusual experiences? In this case, after a lengthy debate a clear decision was made
that the programme could go ahead if after seeing the documentary the adolescent
and the family agreed to its being broadcast. The programme was shown in 1995. It
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highlighted clearly the intensity of feelings and convictions experienced by this teenager.
It had a strong emotional impact on those watching it and was thought-provoking.
People were made aware of the seriousness and deep-rooted nature of the identity issues
involved. Some teenagers wishing to be open about their atypical gender identity with
peers and teachers in school have used this video to promote some understanding of their
condition.
But what about outcome? What has happened to children and teenagers, some of
whom have attended our service for years? What kind of life do they have? What
memories do they have of their contact with our service? We know little about this,
except in an anecdotal way. It is now time that we start to find out.
References
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disorder: A model for integrating temperament, development and psychodynamics.
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Coates, S., & Spector Person, E. (1985). Extreme boyhood femininity: Isolated behaviour or
pervasive disorder? Journal of the American Academy of Child and Adolescent Psychiatry,
24, 702–709.
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transsexuals: A follow up study. Journal of the American Academy of Child and
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