When Biological Sex and Gender Identity Don't Align in Children
The extent to which the alignment between biological sex and gender identity is reinforced in psychological theory and counseling practices is dramatically illustrated in the treatment strategies employed by medicine and psychiatry with children.
We explore the ways in which the psychiatric and medical professions have treated children who either defy our assumptions about the relationship between biological sex and gender identity or have gender dysphoria (defined as psychological discomfort with one’s biological sex), often diagnosed as gender identity disorder (GID). Beginning in the 1960s, researchers explored gender variance in children, mostly boys. The leading researchers in this area—Richard Green, John Money, Robert Stoller, and Bernard Zuger—argued that gender-variant children were at greater risk of becoming homosexuals, transvestites, or transsexuals (Bryant, 1996).
A treatment approach used in GID cases to help children accept their biological sex and associated gender identity is termed rehabilitative treatment (Hill, Rozanski, Carfagnini, & Willoughby, 2005; Raj, 2002). George Rekers, Susan Coates, and Kenneth Zucker are considered leading proponents of rehabilitative treatment of GID. Supporters of this reparative therapy argue that ultimately it helps defend against the negative effects of the social ostracism that gender-nonconforming children typically experience. Reparative treatment incorporates behavioral techniques (e.g., Rekers, 1995; Zucker & Bradley, 1995). One behavioral strategy known as play reconditioning (Rekers & Lovass, 1974) requires children to wear wrist counters when playing with same-sex-typed toys. While playing, they earn points they can exchange for rewards or privileges. “Bug-in-ear” devices are also used to communicate and guide the play of children diagnosed with GID. In this “treatment,” professionals who are observing communicate via a transmission device in the child’s ear: e.g., “No, Charlie, put down that doll. Pick up the truck.” Rekers describes the use of these techniques in Handbook of Child and Adolescent Sexual Problems (1995), which was used in the 1990s to assist pediatricians with the diagnosis and treatment of gender identity disorder in children (Burke, 1996).
The diagnosis of GID and the subsequent rehabilitative treatment approaches are certainly not without critics. Interestingly, Burke’s fascinating text Gender Shock (1996) provides an alternative perspective on the work of Rekers and those who practice aversive approaches to treatment. In her follow-up of Rekers’s treatment of “Kraig,” the subject of his 1974 article, Burke noted that several years after his treatment, Kraig attempted suicide by ingesting pills. He reportedly attributed his depression and suicidal attempt to the shame and embarrassment he felt over the childhood diagnosis and treatment he received.
In the excerpt below, Scholinski describes her rehabilitative-style treatment during her hospitalization in a psychiatric facility in the early 1980s. Scholinski’s autobiography, The Last Time I Wore a Dress (1997), chronicles her treatment regimen over a three-year period, including wearing make-up and swinging her hips. Scholinski’s words echo those of other gender minority clients who are angered and disillusioned as a result of their treatment in the mental health system.
[Dr. Browning] rolled his pen between his fingers for a moment. He said the other diagnosis was something called Gender Identity Disorder which he said I’d had since Grade 3, according to my records. He said what this means is you are not an appropriate female, you don’t act the way a female is supposed to act. I looked at him. I didn’t mind being called a delinquent, a truant, a hard kidwho smoked and drank and ran around with a knife in her sock. But Ididn’t want to be called something I wasn’t. Gender screw-up or whatever wasn’t cool. My foot started to jiggle, I couldn’t stop it. He was calling me a freak, not normal. He was like the boys in Little League calling out tomboy, tomboy, and Michelle who pinned me down for the red lipstick treatment. He was like the boys who yelled, “let me see your titties” when I rode shirtless on my bike in the wind. (Scholinski, 1997, pp. 15–16)
Critics of reparative treatment approaches argue that there is little research to support the idea that such therapy is effective. Further, they claim that such approaches “disrespect the youth’s subjective sense of gender” and cast parents and therapists into therole of “gender police” (Hill et al., 2005, p. 26). Protection against peer ostracism is typically used as a rationale in support of reparative treatment. However, Lev (2005) points out that in most instances in which children are bullied on the basis of race, ethnicity, and physical disabilities, any interventions are directed at the system level and “not on changing children to better fit in to oppressive circumstances” (p. 49).
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