George A. Rekers

The behavioral treatment of a “transsexual” preadolescent boy

Behavioral treatment procedures were developed to suppress feminine sex-typed behaviors and to increase masculine sex-typed behaviors in an 8-year-old boy with “childhood cross-gender identity.” The boys clinical history paralleled the retrospective reports of adult transsexuals, including (1) feminine voice inflection and predominantly feminine content in speech, (2) verbal self-reference as “sissy” and “fag” and statements about his preference to be a girl, (3) feminine hand and arm gestures and “swishy” gait, (4) an aversion to masculine play activities, (5) a strong preference for girl playmates and taking a feminine role in play and role-playing, and (6) improvised cross-dressing. With a multiple-baseline intrasubject design across stimulus environments and across behaviors, the subject was treated sequentially in the clinic, at home, and in the school. The boys mother was trained to administer a token economy program in the home, and the school teacher was taught to apply a response-cost procedure in the classroom. The initial treatment effects were found to be largely response specific and stimulus specific, necessitating treatment for a number of behaviors in the three major environments. Followup data 12 months after treatment termination suggest that the boys sex-typed behaviors have become essentially normalized. This treatment holds promise for correcting pathological gender identity development in boys and for relieving the associated emotional adjustment problems.

Sex-typed play in feminoid boys versus normal boys and girls

Procedures for assessing childrens sex-typed play were developed which (a) examined childrens continuous play in four sessions totaling 20 minutes rather than measuring only initial choice of a sex-typed toy, and (b) did not impose the stimulus-specific condition of requiring an adult experimenter to be present to administer the task. Play with “masculine” and “feminine” toys was observed for 120 normal children (60 boys, 60 girls) aged 3 yr.–8 yr., and 15 similarly aged boys diagnosed as having childhood gender disturbance. Significant differences were found in the sex-typed play of the two normal groups, but no age differences were observed. The amount of feminine play by the feminoid boys was found to be significantly greater than that of normal boys, but not significantly different from the predominantly feminine play patterns of the normal girls. The usefulness of such a measure for the clinical assessment of deviant sexrole development in young children is discussed.

Stimulus control over sex-typed play in cross-gender identified boys ☆

Abstract Discriminative stimulus control over masculine and feminine sex-typed play behaviors was investigated in five boys, aged 5–8 yr, with “childhood crossgender identification.” Reliable observational measures of play were obtained with two sets of toys: (a) “dress-up toys” (girls apparel vs boys apparel), and (b) “affect toys” (maternal-nurturance play vs masculine-aggression play). With an ABA reversal intrasubject design, certain stimulus conditions (e.g., presence of father, mother, male, or female stranger) were found to be discriminative for reliable changes in sex-typed play. Sex-typed play was found to vary as a function of the social stimulus situation and as a function of the type of play response required. All children played predominantly feminine while alone in the playroom. While no single environmental stimulus was consistently discriminative for masculine play across children, at least one stimulus condition was found for each subject under which he played predominantly masculine.

Theoretical and diagnostic issues in child gender disturbances

Abstract A distinction is made between two different but closely related syndromes—“cross gender identification” and “gender behavior disturbance”—in male children. Based on assessment data and systematic clinical observations of a group of 47 such children in a longitudinal research study, a set of factors are identified as relevant to the diagnostic task. Specific diagnostic procedures were developed for the clinical evaluation and psychological testing of male children referred for potential gender dysphoric problems, and these procedures are presented in detail with accompanying rationale.

Childhood gender identity change: Operant control over sex-typed play and mannerisms

Abstract To our knowledge this case is the first successful change of childhood gender identity that is documented by pre- and post-diagnostic assessment procedures. Deviant sex-typed behaviors were modified in a 5-yr-old boy judged by an independent clinician to be a high risk for adult transsexualism. In Study 1, the childs mother was trained to reinforce “masculine” play behaviors and to extinguish “feminine” play behaviors in the clinic. This intrasubject study introduced new procedures designed to maximize the generalization of the treatment effect to play in the alone condition. Study 2 was designed to modify the childs cross-gender mannerisms through the use of a response-cost and verbal prompt procedure. The cross-gender mannerism “flexed elbow” decreased as a function of the treatment. At the follow-up 25 months after treatment terminated, the evaluation by an independent clinician indicated the therapeutic change to a male gender identity.

Family Correlates of Male Childhood Gender Disturbance

In the context of a review of adult cases of gender disturbance, a clinical study was pursued on the status of fathers, father-substitutes, and older male siblings for 46 boys with deviations in male role development. Significantly fewer male role models were found in the family backgrounds of the severely gender-disturbed boys as compared to the mild-to-moderately gender-disturbed boys. Male childhood gender disturbance was also found to be correlated with a high incidence of psychiatric problems in both the mothers and fathers and with atypical patterns of the boys involvement with their mothers and fathers, as measured by the Bene-Anthony Family Relations Test and the Rekers Behavior Checklist for Childhood Gender Problems.

Contingency Management in the Treatment of Adolescent Alcohol Drinking Problems.

Three case studies demonstrated that social and monetary reinforcement for abstinence reduced the rate of excessive alcohol drinking in adolescents. The self-monitoring and extrinsic reinforcement procedures (ABA reversal design) resulted in complete abstinence in a 15-year-old boy with a 10-year history of excessive alcohol abuse and hospitalization for an alcohol-induced psychosis. In the cases of the 13-year-old and 15-year-old girls with extensive alcohol abuse histories, the behavioral interventions decreased the rate of alcohol consumption during treatment phases, but alcohol abuse increased markedly with the removal of the intervention procedures.

Genetic and physical studies of male children with psychological gender disturbances

Twelve male children were diagnosed with psychological gender disturbances by 3 independent clinical psychologists using independent data sources focusing on behavioural deviance from normal comparison groups, on conventional psychological testing, and on parent report instruments which had been validated on normal comparison samples. These children received a paediatric evaluation consisting of a medical history, complete physical examination, chromosome analysis including 2 cells karyotyped and 15 counted, and sex chromatin studies. All gender disturbed boys were found to be normal genetically and physically with the exception of one subject with one undescended testicle.

Early intervention for female sexual identity disturbance: self-monitoring of play behavior.

This study is the first experimental demonstration of sex-typed play behavior change in a young girl with sexual identity disturbance. The 8-year-old child was treated with a self-monitoring procedure combined with a behavioral prompting technique that was gradually faded out. Self-monitoring in the clinic resulted in a high, stable rate of appropriate sex-typed play, and this effect generalized to a different set of sex-typed toys over time. The treatment effects did not generalize to the home environment. The self-regulation intervention was subsequently adapted to the home setting, resulting in a replication of the treatment effects across settings. After the removal of the self-monitoring interventions, a high level of feminine sex-typed play persisted. Pretreatment, posttreatment, and follow-up psychological testing demonstrated a reversal of a pronounced cross-gender identity to a normal female sexual identity.