Thoughts on the nature of identity: how disorders of sex development inform clinical research about gender identity disorders

Disorders of sex development (DSD), like gender dysphoria, are conditions with major effects on child sexuality and identity, as well as sexual orientation. Each may in some cases lead to change of gender from that assigned neonatally. These similarities-and the conditions' differences-provide a context for reviewing the articles in this issue about clinical approaches to children with gender dysphoria, in relation to assessment, intervention, and ethics.     

A comprehensive program for children with gender variant behaviors and gender identity disorders

This article describes a clinical program designed to address broadly defined mental health needs of children who experience stress related to not fitting into normative gender types and argues for the need for integrated services that address the spectrum of gender variance. An array of services useful to children and their families is proposed. The article describes the clinical population served, common clinical and social problems, and a rationale for the interventions provided.     

The dynamic development of gender variability

We diagram and discuss theories of gender identity development espoused by the clinical groups represented in this special issue. We contend that theories of origin relate importantly to clinical practice, and argue that the existing clinical theories are under-developed. Therefore, we develop a dynamic systems framework for gender identity development. Specifically, we suggest that critical aspects of presymbolic gender embodiment occur during infancy as part of the synchronous interplay of caregiver-infant dyads. By 18 months, a transition to symbolic representation and the beginning of an internalization of a sense of gender can be detected and consolidation is quite evident by 3 years of age. We conclude by suggesting empirical studies that could expand and test this framework. With the belief that better, more explicit developmental theory can improve clinical practice, we urge that clinicians take a dynamic developmental view of gender identity formation into account.     

Listening to children imagining gender: observing the inflation of an idea

Using three of the clinical articles in this special issue of the Journal of Homosexuality as examples, the author attempts to show how their views of gender may influence clinicians' conceptualizations and treatment choices in response to children diagnosed with gender identity disorder (GID), or gender dysphoria. In particular the author argues that the belief that gender is a psychophysiological entity that is organismic and transhistorical, that is, the view known lately as essentialism, promotes more invasive interventions (e.g., endocrinological and surgical) and mistakenly deemphasizes psychological therapies as a clinical response to the suffering of trans children. He tries to show that the drawbacks of essentialism and its correlated treatment approaches are twofold, that a) they promote treatments with insufficient attention to our limited knowledge regarding their safety and efficacy, and b) they advance a reified differentiation of the genders that is politically problematic. The author suggests that a better response to trans children would be one that emphasizes the child's broadly subjective role in his or her construction of transgressive, gender-related psychological and interpersonal phenomena (both painful and not), thus, offering a deeper validation for trans children's challenges to our gender system.     

Commentary on the treatment of gender variant and gender dysphoric children and adolescents: common themes and ethical reflections

This commentary offers preliminary ethical reflections on the range of treatments for gender variant and gender dysphoric children, adolescents, and young adults described in the preceding five clinical articles. After clarifying the terminology used to discuss these issues, this commentary reviews several common themes of the clinical articles. Focusing on ethical values of informed consent, full disclosure, the minimization or avoidance of harm, and the maximization of life options, the commentary expresses concerns about various treatment options endorsed by some of the articles. In particular, this commentary focuses on how these practices problematically reproduce social prejudices and stereotypes and how they fail to acknowledge and embrace the multiple pathways for expressing one's gender. It also compares and contrasts the ethical issues related to gender variant and gender dysphoric youths and youths who identify as lesbian, gay, bisexual, or queer.     

Clinical management of gender dysphoria in children and adolescents: the Dutch approach

The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.     

Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn

The optimal approach to treating minors with gender dysphoria/gender variance (GD/GV) is much more controversial than treating these phenomena in adults. This is because children have limited capacity to participate in decision making regarding their own treatment, and even adolescents have no legal ability to provide informed consent. Minors must, therefore, depend on parents or other caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term. Presently, the highest level of evidence available for selecting among the various approaches to treatment is best characterized as "expert opinion." Yet, opinions vary widely among experts and are influenced by theoretical orientation and assumptions and beliefs regarding the origins of gender identity, as well as its perceived malleability at particular stages of development. This article outlines some of the more salient points raised by the clinicians who treat GD/GV and their discussants. This article summarizes what the editors believe is known and what has yet to be learned about minors with GD/GV, their families, their treatment, and their surrounding cultures.     

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.     

Supporting transgender children: new legal, social, and medical approaches

The author, a lawyer who advocates for transgender children and youth, explores how clinical approaches to transgender children and youth are keeping pace with social and legal changes affecting these young people and with recent evidence suggesting that children are harmed by family and societal rejection as well as by attempts to change their gender identity or gender expression. The author urges providers and legal advocates to work with policymakers and the families of transgender children and youth to create a future in which these young people can reach their full potential and be embraced as fully equal, respected, and participating members of society.     

Child gender and father involvement in fragile families

In this article, we use data from the first two waves of the Fragile Families and Child Wellbeing Study to examine the effects of child gender on father involvement and to determine if gender effects differ by parents' marital status. We examine several indicators of father involvement, including whether the father acknowledges "ownership" of the child, whether the parents live together when the child is one year old, and whether the father provides financial support when the child is one year old. We find some evidence that child gender is associated with unmarried father involvement around the time of the child's birth: sons born to unmarried parents are more likely than daughters to receive the father's surname, especially if the mother has no other children. However, one year after birth, we find very little evidence that child gender is related to parents' living arrangements or the amount of time or money fathers invest in their children. In contrast, and consistent with previous research, fathers who are married when their child is born are more likely to live with a son than with a daughter one year after birth. This pattern supports an interpretation of child gender effects based on parental beliefs about the importance of fathers for the long-term development of sons.     

Lay Theories of Gender Identity Disorder

This study examined lay theories regarding gender identity disorder (GID). Pilot interviews were completed with participants (n = 10) regarding their views on possible causes and treatments of GID. Participants (mainly young British people and students; n = 124) then completed a questionnaire that was based on the interviews and a review of the salient literature on lay theories. As hypothesized, participants believed most in biomedical causes and treatments of GID. Factor analysis (with varimax rotation) identified 4 factors in relation to causes of GID: upbringing and personal factors, pregnancy and brain abnormalities, environmental factors, and biomedical causes. Five factors that were identified in relation to the cure/treatment of GID were psychological assistance and personal factors, extreme medical and behavioral changes, alternative therapies, external factors, and medical treatments. The results indicated that participants neither agreed nor strongly disagreed about causes and cures regarding GID, but that these beliefs were logically related. Limitations, particularly of sampling, were considered.     

Coming Out as Transgender: Navigating the Social Implications of a Transgender Identity

ABSTRACT

This study examines transgender coming-out narratives. Most previous studies of coming out as transgender have relied on psychological stage models of identity development, with little empirical verification. This study uses identity theory to reframe transgender coming out as a primarily external, ongoing, and socially situated process. The data were collected from 20 transgender people residing in the Minneapolis-St. Paul, Minnesota metro area through interviews and focus groups. The analyses reveal that coming out as transgender requires navigating others’ gender expectations, others’ reactions, and the threat of violence. The results indicate that transgender individuals do not simply decide to “come out of the closet” and then stay out. Rather, they make strategic decisions regarding the enactment of gender and gender identity disclosure based on specific social contexts. Coming out as transgender is best conceptualized as an ongoing, socially embedded, skilled management of one’s gender identity.     

Mapping the diversity of gender preferences and sex imbalances in Indonesia in 2010

Indonesia is usually viewed as a country free of the acute forms of gender discrimination observed elsewhere in East or South Asia, a situation often ascribed to Indonesia's bilateral kinship system. I re-examine this hypothesis by focusing on ethnic and regional variations in sex differentials. New indicators of marriage practices and gender bias derived from 2010 census microdata highlight the presence of patrilocal patterns as well as a distinct presence of son preference in fertility behaviour in many parts of the archipelago. I also present evidence for excessive child sex ratios and excess mortality of females in some areas that appear to be related to son preference and patrilocal residence systems. The findings confirm the association between son preference, sex differentials in mortality, prenatal sex selection, and kinship systems. I conclude with a more regional perspective on demographic vulnerability of females, distinguishing bilateral South East Asia from more patrilineal Melanesia.     

Being Transgender: The Experience of Transgender Identity Development

This article is based on a grounded theory analysis of interviews with transgender-identified people from different regions of the United States. Participants held a variety of gender identities under the transgender rubric (e.g., crossdresser, transman, transwoman, butch lesbian). Interviews explored the participants’ experiences in arriving at their gender identity. This article presents three clusters of findings related to the common processes of transgender identity development. This process was made possible by accessibility of transgender narratives that injected hope into what was a childhood replete with criticism and scrutiny. Ultimately, participants came to their identities through balancing a desire for authenticity with demands of necessity—meaning that they weighed their internal gender experience with considerations about their available resources, coping skills, and the consequences of gender transitions. The implications of these findings are considered in terms of their contribution to gender theory, research, and clinical support for transgender clients.     

Narrations and practices of mobility and immobility in the maintenance of gender dualisms

This paper analyses the role of practices and representations of mobility in supporting particular kinds of gender orders. While scholarship has shown the various ways women are materially and symbolically ‘fixed’ in place, less attention has been paid to how discourses and practices of mobility interface with systems of gender differentiation more broadly. This work is based on a robust empirical base of 55 interviews, 90 h of participant observation and an analysis of museum displays in Kalgoorile, Western Australia, an iconic frontier mining town selected for this investigation as a site of strongly bifurcated gender discourses. Analysing our field data through the lens of feminist theory which problematizes gender binaries, we argue that while some narrations of gender mobilities serve to reinforce gender binaries, lived practices of movement can also destabilise (idealised) notions of gendered movement. This paper extends conceptual work by advancing understanding about the role of mobility within systems of gender differentiation, showing how lived practices of mobility are just as likely to challenge idealised patterns of gendered movement as they are to reinforce these patterns.     

Apples to committee consensus: the challenge of gender identity classification

The debate surrounding the inclusion of gender dysphoria/gender variant behavior (GD/GV) as a psychiatric diagnosis exposes many of the fundamental shortcomings and inconsistencies of our current diagnostic classification system. Proposals raised by the authors of this special issue, including basing diagnosis on cause rather than overt behavior, reclassifying GD/GV behavior as a physical rather than mental condition, and basing diagnosis on impairment or distress, offer some solutions but have limitations themselves given the available database. In contrast to most accepted psychiatric conditions where emphasis is placed on ultimately changing internal thoughts, feelings, and behaviors, consensus treatment for most GD/GV individuals, at least from adolescence onward, focuses on modifying the external body and external environment to maximize positive outcomes. This series of articles illustrating the diversity of opinions on when and if gender incongruence should be considered pathological reflects the relative lack of scientific indicators of disease in this area, similar to many other domains of mental functioning.     

Ethnic dimensions of gender differentials in mortality in Malaysia

Higher mortality rates among males are a common occurrence across different cultures and countries. The causes of this higher mortality can be biological as well as behavioural in nature. The biological evidence applies across all nations and communities, but the behavioural causes, arising from the decision processes and communication strategies of individuals, will necessarily have cultural and environmental dimensions that change with time. This study examines gender disparities in mortality across ethnicity and time in Malaysia. The study shows that there is a consistent gender differential across time but it has widened for the Malays and the Indians and narrowed for the Chinese. Most importantly, it has widened considerably for young adults. Analysis of the leading causes of death show that young adult males are more likely to engage in risk-taking behaviour, and that the related causes and the extent of such causes vary across the ethnic groups.     

Child gender and the transition to marriage

We estimate the effect of a child's gender on the mother's probability of marriage or remarriage using data from the PSID Marital History and Childbirth and Adoption History Files. We find that the birth of a son speeds the transition into marriage when the child is born before the mother's first marriage. A competing-risks analysis shows that the positive effect of a son is stronger for marriages to the child's biological father than for other marriages. We find no significant effect of child gender on the mother's remarriage probabilities when the children are born within a previous marriage. These results are consistent with a marital-search model in which sons, more than daughters, increase the value of marriage relative to single parenthood.     

A critical examination of visualized femininity: selective inheritance and intensification of gender posing from historical painting to contemporary advertising

This study investigates the visual correspondences of gender posing behaviors, specifically exhibited by female figures, between historical European painting and contemporary American photographic advertising. While utilizing Erving Goffman’s Gender Advertisements as an analytical framework, the study focuses on the visual legacy of gender ritualization that is salient in contemporary mass media, proposing five semiotic codes to concretely analyze it. Although Goffman’s gender posing is traditionally associated with female vulnerability and indolence, the study proposes that such qualities are exploited as indicators of luxury within Western visual culture and advertising specifically. It seeks to deconstruct and re-frame the interconnected connotations of luxury and gender display, both expanding Goffman’s framework and providing a unique interpretive resource for critical readers of media texts.