Susan J. Bradley

Demographic Characteristics, Social Competence, and Behavior Problems in Children with Gender Identity Disorder: A Cross-National, Cross-Clinic Comparative Analysis

This study examined demographic characteristics, social competence, and behavior problems in clinic-referred children with gender identity problems in Toronto, Canada (N = 358), and Utrecht, The Netherlands (N = 130). The Toronto sample was, on average, about a year younger than the Utrecht sample at referral, had a higher percentage of boys, had a higher mean IQ, and was less likely to be living with both parents. On the Child Behavior Checklist (CBCL), both groups showed, on average, clinical range scores in both social competence and behavior problems. A CBCL-derived measure of poor peer relations showed that boys in both clinics had worse ratings than did the girls. A multiple regression analysis showed that poor peer relations were the strongest predictor of behavior problems in both samples. This study—the first cross-national, cross-clinic comparative analysis of children with gender identity disorder—found far more similarities than differences in both social competence and behavior problems. The most salient demographic difference was age at referral. Cross-national differences in factors that might influence referral patterns are discussed.

Attachment in Mothers with Anxiety Disorders and Their Children

OBJECTIVE This study examined adult attachment in mothers diagnosed with anxiety disorders and child-mother attachment in their children. METHOD Eighteen mothers with Axis I anxiety disorders completed the Adult Attachment Interview and standardized questionnaires. These mothers and their preschool children (n = 20) then participated in the Strange Situation Procedure. RESULTS All mothers were classified as nonautonomous with respect to attachment, with 78% judged unresolved. When those judged unresolved were reassigned to their alternate categories, the proportion of nonautonomous mothers was 61%. Eighty percent of the children were classified as insecurely attached, with 65% judged disorganized. When those judged disorganized were reassigned to their alternate categories, the proportion of insecurely attached children was 55%. Sixty-five percent of the children matched their mothers attachment classification. Mothers of securely attached children reported fewer recent life events, fewer depressive symptoms, and a greater sense of parenting competence than mothers of insecurely attached children. CONCLUSIONS These results suggest that attachment measures can be applied to anxious populations. The high rate of insecurity among offspring of anxious mothers indicates a need for longitudinal studies of these children.

Behavioural inhibition, attachment and anxiety in children of mothers with anxiety disorders.

Objective This study examined the relationship between behavioural inhibition, insecure mother-child attachment and evidence of anxiety in the offspring of mothers with anxiety disorders. Method Twenty children aged 18 to 59 months who were born to 18 mothers with diagnosed anxiety disorders were examined for behavioural inhibition (Kagans measures) and mother-child attachment (Strange Situation Procedure). Child anxiety was assessed using DSM-III-R criteria and the Child Behavior Checklist (CBCL). Results Sixty-five percent of the children were behaviourally inhibited. They showed more somatic problems and fewer destructive behaviours than those who were not inhibited. Eighty percent of the children were insecurely attached. They had higher CBCL internalizing scores than secure children and three of them met diagnostic criteria for anxiety disorders. Conclusion Though preliminary, this work suggests a need to identify children of anxious mothers as being at risk for anxiety, especially in the presence of inhibited temperament or attachment difficulties.

Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reassignment at 7 Months, and a Psychosexual Follow-up in Young Adulthood

Guidelines of psychosexual management for infants born with physical intersex conditions are intended to assist physicians and parents in making decisions about sex of assignment and rearing including the following: 1) sex assignment should be to the gender that carries the best prognosis for good reproductive function, good sexual function, normal-looking external genitalia and physical appearance, and a stable gender identity; 2) the decision regarding sex assignment should be made as early as possible, preferably during the newborn period, with an upper age limit for reversal of an initial sex assignment no later than 18 to 24 months; and 3) there should be minimal uncertainty and ambiguity on the part of parents and professionals regarding the final decision about sex assignment and rearing. J. Money used these guidelines in a case of a biologically normal male infant (one of a pair of monozygotic twins) whose penis was accidentally ablated during a circumcision at the age of 7 months. The decision to reassign the infant boy to the female sex and to rear him as a girl was made at 17 months, with surgical castration and initial genital reconstruction occurring at 21 months. Money reported follow-up data on this child through the age of 9 years. Although the girl was described as having many “tomboyish” behavioral traits, a female gender identity had apparently differentiated. Thus, it was concluded that gender identity is sufficiently incompletely differentiated at birth as to permit successful assignment of a genetic male as a girl, in keeping with the experiences of rearing. Subsequent follow-up by other investigators reported that by early adolescence the patient had rejected the female identity and began to live as a male at the age of 14 years. In adulthood, the patient recalled that he had never felt comfortable as a girl, and his mother reported similar recollections. At age 25, the patient married a woman and adopted her children. The patient reported exclusive sexual attraction to females. The present case report is a long-term psychosexual follow-up on a second case of ablatio penis in a 46 XY male. During an electrocautery circumcision at the age of 2 months, the patient sustained a burn of the skin of the entire penile shaft, and the penis eventually sloughed off. At age 7 months, the remainder of the penis and the testes were removed. By age 7 months, if not earlier, the decision was made to reassign the patient as a female and to raise the infant as a girl. The patient was interviewed on two occasions: at 16 years and twice while in the hospital for additional surgery at 26 years of age. At ages 16 and 26, the patient was living socially as a woman and denied any uncertainty about being a female. During childhood, the patient recalled that she self-identified as a “tomboy” and enjoyed stereotypically masculine toys and games; however, the patient also recalled that her favorite playmates were usually girls and that her best friend was always a girl. When seen at age 16, the patient had been admitted to the hospital for vaginoplasty. At that time, she wished to proceed with the further repair of her genitalia to make them suitable for sexual intercourse with males. At age 26, the patient returned to the hospital for further vaginoplasty. Regarding the patients sexual orientation, she was attracted predominantly to women in fantasy, but had had sexual experiences with both women and men. At the time of the second surgery, she was in a relationship with a man and wished to be able to have intercourse. The patients self-described sexual identity was “bisexual.” After surgery at age 26 years, the patient developed a rectovaginal fistula. Within a few months of the surgery, the patient and her male partner separated for reasons other than the patients physical problems. The patient subsequently began living with a new partner, a woman, in a lesbian relationship. The psychosexual development of our patient was both similar to and different from the patient described earlier. Our patient differentiated a female gender identity; in contrast, the other patient had adopted a male gender identity after experiencing intense discomfort living as a female, apparently around the beginning of adolescence. At the time of interview at age 26, our patient was living with a man, but they subsequently separated and she began a new relationship with a woman; the other patient was married to a woman. Our patient had a “bisexual” sexual identity; the other patient had a “heterosexual” sexual identity. The patients were similar in that they had a childhood history of “tomboyism.” Our patient was predominantly sexually attracted to women; the other patient was exclusively sexually attracted to women. Our patient had sexual experiences with both women and men; the other patient had sexual experiences only with women. The most plausible explanation of our patients differentiation of a female gender identity is that sex of rearing as a female, beginning at around age 7 months, overrode any putative influences of a normal prenatal masculine sexual biology. Because cases of ablatio penis in infancy are so rare and long-term follow-up data are scant, it is obviously impossible to know whether our patient or the previous case would be more typical of the psychosexual outcome in a larger sample of such individuals. However, our case suggests that it is possible for a female gender identity to differentiate in a biologically “normal” genetic male. At present, however, the clinical literature is deeply divided on the best way to manage cases of traumatic loss of the penis during infancy. Further study is clearly required to decide on the optimal model of psychosocial and psychosexual management for affected individuals.

Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Sex differences in referral rates of children with gender identity disorder: some hypotheses.

From 1978 through 1995, a sex ratio of 6.6:1 of boys to girls (N = 275) was observed for children referred to a specialty clinic for gender identity disorder. This article attempts to evaluate several hypotheses regarding the marked sex disparity in referral rates. The sexes did not differ on four demographic variables (age at referral, IQ, and parents social class and marital status) and on five indices of general behavior problems on the Child Behavior Checklist; in addition, there was only equivocal evidence that boys with gender identity disorder had significantly poorer peer relations than girls with gender identity disorder. Although the percentage of boys and girls who met the complete DSM-III-R criteria for gender identity disorder was comparable, other measures of sex-typed behavior showed that the girls had more extreme cross-gender behavior than the boys. Coupled with external evidence that cross-gender behavior is less tolerated in boys than in girls by both peers and adults, it is concluded that social factors partly account for the sex difference in referral rates. Girls appear to require a higher threshold than boys for cross-gender behavior before they are referred for clinical assessment.

A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder

This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto. The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provide clinical examples of how the model is used in the treatment.

Birth Order and Sibling Sex Ratio in Homosexual Male Adolescents and Probably Prehomosexual Feminine Boys.

The purpose of this study was to extend the findings, previously limited to adults, that male homo sexuals have a greater than average proportion of male siblings and a later than average birth order. There were 2 matched groups of 156 probands. The homosexual-prehomosexual (MP) group in cluded boys referred to a specialty clinic because of persistent cross-gender behavior plus homosex ual adolescents with or without gender identity problems. The controls were male child and adoles cent patients referred for reasons other than gender identity disorder, homosexuality, or transvestism. Both predicted results were obtained in comparisons of the MP group with the controls and with expected values for the general population. Psychosocial and biological theories have been advanced to explain why male homosexuals have later births and more brothers, but none are well established

Brief Psychoeducational Parenting Program: An Evaluation and 1-Year Follow-up

OBJECTIVE Despite recognition of the need for parenting interventions to prevent childhood behavioral problems, few community programs have been evaluated. This report describes the randomized controlled evaluation of a four-session psychoeducational group for parents of preschoolers with behavior problems, delivered in community agencies. METHOD In 1998, 222 primary caregivers, recruited through community ads, filled out questionnaires on parenting practices and child behavior. Parents were randomly assigned to immediate intervention or a wait-list control. The intervention comprised three weekly group sessions and a 1-month booster, the focus being to support effective discipline (using the video 1-2-3 Magic) and to reduce parent-child conflict. RESULTS Using an intent-to-treat analysis, repeated-measures analyses of variance indicated that the parents who received the intervention reported significantly greater improvement in parenting practices and a significantly greater reduction in child problem behavior than the control group. The gains in positive parenting behaviors were maintained at 1-year follow-up in a subset of the experimental group. CONCLUSIONS This brief intervention program may be a useful first intervention for parents of young children with behavior problems, as it seems both acceptable and reasonably effective.

Gender Identity Disorders

The gender identity disorders (GID) are defined as disorders in which an individual exhibits marked and persistent identification with the opposite sex and persistent discomfort (dysphoria) with his or her own sex or sense of inappropriateness in the gender role of that sex. Other terms, such as transsexual, transgendered and transvestite, are explained, as are gender role, sexual orientation and sexual identity. Prevalence estimates of GID are between 110,000 to 1:30,000. Sex ratios in adults are roughly equal but in childhood are 6 (males) to 1 (female). A brief description of the historical background and recent political challenges to the diagnosis of GID are provided. Based on current theory and research there is some support for a biological predisposition, which may reflect a general vulnerability to psychopathology, and psychosocial factors which shape that predisposition. Management includes child and family interventions, psychotherapy, and surgical and hormonal interventions. Outcome is variable, with relinquishment of GID for those children seen early with cooperative parents, and greater stability of GID in children seen later in childhood or adolescence. Surgical and hormonal reassignment in adults who meet criteria is generally successful. Evaluation of the various interventions, especially in childhood, is needed.