Bernadette Wren

‘I Can Accept My Child is Transsexual but if I Ever See Him in a Dress I’ll Hit Him’: Dilemmas in Parenting a Transgendered Adolescent

In this article I describe the accounts of a group of parents with transgendered adolescents. I look specifically at how the parents try to build an intelligible story of the young people’s gender identity and how their story shapes their coping strategies. For the qualitative study on which this article is based, I interviewed adolescents with a well-established cross-gender identification and their parents from families referred to a specialist NHS service. The first-person reports were analysed using grounded theory methodology. There were a number of suggestive findings. First, communication about gender identity issues within the family and outside was handled with enormous care; second, it was clear that these parents are aware that their response to the gender problems is a deeply moral issue; third, there was an iterative relationship between the activities of making-meaning and accepting (or not) the child’s claims, and a similar interaction between the activity of meaning-making and the tasks of practical coping; fourth, a belief in biological causation of transgenderism was associated with a more benign view of the adolescent; and fifth, there were interesting differences between the accounts of mothers and fathers. The findings of the study hopefully illuminate clinical encounters, stimulate further research into how families cope with this unusual predicament and encourage reflexive thinking in practitioners in related fields.

Early physical intervention for young people with atypical gender identity development

This article describes the misery and frustration of young people for whom the external reality of the body is at odds with their gender identity. As hormonal and surgical treatments to alter the sexual body increase in sophistication, clinicians may be under pressure to provide this treatment to the under-18s – if only for the postponement of puberty. This pressure is especially powerful in the absence of evidence for the effectiveness of psychological treatment in reconciling cross- gendered youngsters to their bodies. Current practice is outlined and the legal context is described briefly. The clinician’s dilemmas are explored with particular reference to conflicting views of adolescent development, our limited understanding of the aetiology of gender dysphoria, the lack of empirical data on the impact of early physical intervention and changing cultural attitudes to transsexuality.

The validity of the diagnosis of Gender Identity Disorder (Child and Adolescent Criteria)

This article looks at the diagnosis of gender identity disorder (child and adolescent criteria) as used in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). It considers how gender identity disorder came to be in the fourth edition, and explores some of the problematic aspects of the DSM-IV criteria. The authors argue that research has focused on cross-gender behaviours and gender role, and consequently muddled issues of pathology. In particular, that this has served to pressurize boys to conform to traditional gender and heterosexual roles. The authors suggest that the pathology accompanying gender identity dysphoria should be the focus of the clinical work rather than treating gender role behaviour. It is proposed that the model of atypical gender identity organization, is able to account for the diverse factors that may be contributing to a discordant gender identity, without labelling what may be a normal developmental pathway as pathological.

The interaction between young people with atypical gender identity organization and their peers

This exploratory study involved the qualitative analysis of the responses of eight children with atypical gender identity organization to open-ended questions about their experiences of secondary school. The aim was to develop an understanding of these young people’s interaction with their peers. It became apparent that all but one of the participants had been bullied. In this context, participants reported difficulties in developing friendships, although each participant received support from at least one of their peers. Given the hostile school environment participants did not necessarily talk to these individuals about their experiences in relation to their gender identity. The clinical implications for working with young people on a developing gender identity, and the impact on their mental health, are considered.

Building bridges to observational perspectives: A grounded theory of therapy processes in psychosis

OBJECTIVES This study set out to explore therapy processes in psychosis with an initial focus on reflexivity and how this might be expressed in therapy conversations. DESIGN Leimans (2000) definition of reflexivity was used as a starting-point for an exploratory investigation of the use of language as reflective activity. Grounded theory was chosen as an appropriate methodology to distil an explanatory account across the qualitative data collected. METHOD Six psychologist-client pairs supplied three tapes of therapy sessions spread out across the course of therapy. Each participant was separately interviewed on two occasions to ascertain their views of therapy and of the emerging grounded theory. RESULTS A grounded theory was developed conceptualizing the processes and activities in psychological therapy in psychosis. CONCLUSIONS Building bridges to observational perspectives summarizes the core process in psychological therapy in psychosis. Therapy in psychosis is understood as intimately linking the social and internal world in a dialogical process aimed at enhancing the clients functioning in the social world rather than at specifically developing the private mental experience of reflexivity or mentalizing.

Thinking postmodern and practising in the enlightenment: Managing uncertainty in the treatment of children and adolescents

In this paper, I explore how postmodern ideas about gender may impact on clinicians working with gender variant children and adolescents. The postmodern turn has built on the feminist rejection of the idea of ‘essential’ gender, to further interrogate accepted conceptions of sex and gender and the stability of all identity categories. Some queer theorists have taken a further step, viewing all gender as fictional and artificial and celebrating the subversive potential of transgender identities. However, those working clinically with trans adolescents may experience a troubling tension between, on the one hand, a view of sex and gender categorisations as undecidable and fragmented (as postmodern theory suggests), and, on the other hand, the apparent need of many for a coherent and settled sense of self. In particular, how do we justify supporting trans youngsters to move towards treatment involving irreversible physical change, while ascribing to a highly tentative and provisional account of how we come to identify and live as gendered? I conclude that the meaning of trans rests on no demonstrable foundational truths but is constantly being shaped and re-shaped in our social world. Clinicians must be accountable in this process; far from succumbing to a paralysing relativism, the task for clinicians is to be highly attuned to our young clients’ complex narratives and to question our complex investments in the positions we adopt.

Editorial: Sexual Identity and Gender Identity: Understanding Difference

W H Y A S P E C I A L issue on gender identity and sexual identity in Clinical Child Psychology and Psychiatry? Although the numbers of clients with gender dysphoria or same-sex sexual interests are relatively small, articles discussing these issues are under-represented in the clinical and research literature, especially with regard to child and adolescent services. Lesbian, gay, bisexual and transgendered (lgbt) youth are identifying, and presenting at child and adolescent clinical services, at ever younger ages. They can experience a range of mental health problems as varied as those of heterosexual and non-transgendered youth and may encounter difficulties specifically related to the development of a lesbian, gay, bisexual or transgendered identity. We have also extended the special issue to examine issues relating to the children of lesbian, gay and transgendered parents. Among clinicians discussions of issues of sex, intersex, sexuality and transsexuality can still be bedevilled by a lack of consensus on the meanings conveyed by particular terms. In this special issue, most writers broadly go along with common usage, taking the term sexual identity to refer to an acknowledgement of one’s primary sexual attraction to people of one’s own sex, the other sex or both sexes. The self-consciousness inherent in the idea of ‘identifying as’ homosexual, heterosexual or bisexual, linked to the idea of ‘coming out’, is a relatively modern phenomenon. At an earlier time there might have been identifiable homosexual acts, but not identifiable homosexual people. The idea of a relatively fixed sexual identity seems to be part of a drive to self-definition, and we might ponder whether it is sometimes unhelpful in thinking about the experience of young people. On the one hand, finding an identity may be liberating; previous difficulties may dissolve with the recognition of a new sense of belonging to a community and a purpose to life. On the other hand, identifying inevitably means that other avenues of exploration peter out, possibly prematurely foreclosing, in the case of some young people. The term gender identity is widely used to refer to one’s sense of oneself as male or female, or neither, and this is the usage broadly kept to here. Many writers draw a distinction between gender identity and gender role, seeing the latter as the set of conventional expectations for masculine or feminine behaviour imposed on us in our social worlds. For most people, gender identity and the sexual body are in line. In transgendered people gender identity and the sexual body are at odds – although even this way of speaking is

In Defence of Eclecticism

In attempting to understand the aetiology and progress of childhood illness, where the presentation is a mixture of physical and emotional distress, an overarching systemic approach is required, combining a broad range of psychological and somatic factors in a comprehensive formulation. The clinician needs to shuttle between the comprehensive picture and the partial or linear views which constitute it. Treatment has to start with work on several different arcs of the circular chain of causality. Once some change is triggered, the task is to make sense of what is happening in the wider system if that change is to be accommodated and maintained. Any linear interventions may be built into the therapeutic conversation in which new meanings and behaviours are established. The eclectic clinician will introduce interventions from various schools of thought. The possible effectiveness of these manoeuvres, in different combinations, their timing and their acceptability, all need careful consideration.

Tenth Anniversary Editorial

W I T H T H I S I S S U E , we arrive at the tenth anniversary of Clinical Child Psychology and Psychiatry (CCPP). To mark this occasion each member of the Editorial Board was asked to write a short essay looking back over which topics and concerns have been strikingly present, and which strikingly absent, in the past 40 issues of CCPP, and then looking forward to what they hope to see in the next 10 years. They have taken up the offer in robustly different ways.

Editorial: Research reflexivity.

Q UA L I TAT I V E A P P R OAC H E S T O research are often believed to make a good fit for clinician/researchers as they are typically characterized by more open-ended and exploratory questions concerning meanings and processes. For the clinician, qualitative research papers often offer elaborations of rich and detailed empirical material that can extend our understanding of particular client predicaments, highlighting the quality and texture of people’s experience. Inherent contradictions and conflicts in the responses of participants are anticipated and welcomed, not sidestepped or minimized. Making sense of the kind of complex and often ambiguous responses typically generated by qualitative research involves active engagement with the data, in ways that can draw directly on clinical experience and sensitivity. A further ‘virtue’ of qualitative research is that it permits – or even requires – a degree of reflexivity that has been until recently antithetical to researchers in the quantitative mode. This valuing of reflexivity is largely due to the fact that the work of interpretation carried out on the research material is more open to view, more transparently a part of the research activity, than it typically is with quantitative studies. Qualitative researchers are aware of the extent to which they use their own judgement and creativity and skill with language to generate the categories that help to both systematize and elaborate the meaning of the material under scrutiny. The close re-reading of the texts, the collecting of small items of meaning into larger chunks, the handling of multi-layered or frankly contradictory accounts – all this calls for the active engagement of the researcher in ways that would be considered by many quantitative researchers to ‘contaminate’ the data. Centrally for this Editorial, it calls, too, for the qualitative researcher to show evidence of careful reflection on the professional and personal investments s/he may have in the research outcome. This kind of reflexive research has appeal for many clinicians because it mirrors to some extent the reflexivity inherent in good clinical work. Skilled clinicians consider the impact of their own professional and personal backgrounds – of a range of theoretical social and cultural assumptions – on their understanding of clients, on the development of a therapeutic relationship, and on their choice of intervention. They may try to understand the client’s communications at a number of levels. They need to consider what powerful assumptions and beliefs the client brings to the encounter and what sense the client is actively making of what the clinician says and does. Hopefully, the good practitioner also ponders on whether an alternative approach might not produce a desired outcome for the client more speedily or effectively. Good clinical work is a reflexive business. So the promise of qualitative research has been that the researchers will not too readily assume an unproblematic, unmediated relationship between their findings and the bit of social reality that they have explored, that they will demonstrate a particular self-awareness of the traditionally invisible but powerfully influential aspects of the research