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.     

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.     

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.     

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.     

From gender identity disorder to gender identity creativity: true gender self child therapy

True gender self child therapy is based on the premise of gender as a web that weaves together nature, nurture, and culture and allows for a myriad of healthy gender outcomes. This article presents concepts of true gender self, false gender self, and gender creativity as they operationalize in clinical work with children who need therapeutic supports to establish an authentic gender self while developing strategies for negotiating an environment resistant to that self. Categories of gender nonconforming children are outlined and excerpts of a treatment of a young transgender child are presented to illustrate true gender self child therapy.     

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.     

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.     

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.     

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.     

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.     

Negotiating Identities in a Heteronormative Context

Society prescribes a set model of heterosexual development toward a gender and sexual identity. Individuals with gender and sexual identities that do not conform to the prescribed heterosexual identities must essentially develop their own way, that is, they must privately negotiate their path through identity development and identity adoption. However, while negotiating their private reality, they must rely on existing concepts of other. Using a social constructionist framework, we explore the private negotiation of an individual who does not conform to the socially prescribed gender and sexual identities—a transgender lesbian. Based on this interview, we suggest that the model of traditional heteronormative gender socialization to sexual identity would need to be revised.     

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.     

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.     

Interiorized Homophobia,Identity Dynamics and Gender Typization. Hypothesizing a Third Gender Role in Italian LGB Individuals

With this research, we explored the relation between (a) internalized homophobia, (b) lesbian, gay male, and bisexual (LGB) social identity statuses (along with the Marcia model), and (c) gender typization (along with Bem gender schema theory) of an Italian online LGB sample. Results show how the identity process of exploration is a risk factor in relation to internalized homophobia, whereas commitment is a protective factor. Against the authors' expectations, data indicate that androgynous, non-heterosexual individuals are mostly in a foreclosure identity status, while the typed ones are in an acquisition status and more protected against homophobia. This suggests that the androgynous social representation of homosexuality for non-heterosexual individuals is an alternative gender role more socially available to them.     

Complicating the Coming Out Narrative: Becoming Oneself in a Heterosexist and Cissexist World

Traditional stage models of LGBTQ identity development have conceptualized coming out as a linear process from “closeted” to “out” that all queer/trans individuals must follow if they are to be considered healthy and well adjusted. These stage models have been critiqued for their rigidity and absence of a dynamic understanding of the coming out process. In this article we explore the findings from a qualitative photovoice study with 15 LGBTQ youths in a small urban center in Ontario that supports these critiques. We explore the efficacy of the photovoice technique in investigating questions of sexual and gender identity. This article identifies some contextual factors that are important in understanding coming out as a social (rather than internal) process; it also identifies some of the ways in which these youths’ experiences challenge normative understandings of the “good, out queer.”     

Homosexual Experience,Desire and Identity Among Young Adults

ABSTRACT

Is young people's sexuality becoming more fluid and less tied to steady, stable identity patterns? Are we developing into a society where sexual relationships between individuals of the same sex are no longer reserved for the small minority of gay men and lesbian women? Adherents of so-called queer theory have promulgated such views. Using a population-based sample of young adults (aged 19 to 26, N 2753), we investigated homosexual experiences, desire and identity. We found that levels of prevalence of homosexuality were primarily a function of the criteria we used. Using the most restricted (“narrow”) definitions, we found that about one percent of both genders reported “exclusive” homosexual interest and identity. Using the most inclusive criteria, we found that one of ten young men and one of four young women reported having some homosexual experience, interest or identity. Still, the most striking finding involved the substantial gender-specific differences: homoerotic activity and interest are far more interwoven with heterosexual activity for women. There are strong indications that homosexuality is a lot more threatening and potentially in conflict with traditional male gender roles than we find to be the case for women. In other words, while there may be signs of more fluid sexual identity categories, this phenomenon primarily applies to women.     

Salience,Valence, Context,and Integration: Conceptualizing the Needs of Sexually and Gender Diverse Youth in P–12 Schools

A framework for conceptualizing the needs of lesbian, gay male, bisexual, transgender, questioning, and other sexually and gender diverse youth is essential for guiding service delivery throughout educational settings. Review and synthesis of the literature reveals that integrating assessment of the salience, valence, and context of issues related to sexual and gender diversity facilitates affirmative practice at the individual student, group, and school-wide levels. The authors describe the components of the salience, valence, context, and integration (SVCI) model with emphasis on practical application. The theoretical and empirical support for each component of the model is also discussed.     

Gender trouble in the workplace: applying Judith Butler’s theory of performativity to news organizations

Judith Butler’s theory of performativity, introduced in her 1990 book Gender Trouble, has significantly shaped individual and collective understandings of gender. This essay examines performativity as a framework for critically assessing gender performances in patriarchal workplace environments, including the institutional rules and norms that shape behaviors and interactions. Specifically, we suggest that performativity offers a valuable lens for critiquing women’s experiences in newsrooms, spaces where expectations for gender can significantly shape professional experiences and success. We provide an overview and evaluation of the development and existing applications of Butler’s performativity theory, including its use in organizational contexts. We also propose methodological and topical approaches through which performativity can be used to study newsrooms and the experiences of female journalists in particular.     

A multidimensional approach to homosexual identity

The existing developmental stage models of homosexual identity do not consider the diversity of human sexual experience. The stage models stem from an essentialist perspective, in which the process of homosexual identity formation is largely a matter of becoming aware of one's underlying, or real, sexual orientation. Once homosexual orientation is identified, the only legitimate outcome is to develop homosexual identity and eventually incorporate that identity as one aspect of the total self. In this paper, we are concerned with those people for whom the stage models are inadequate in describing their experience of sexual identity development. The social constructionist perspective holds that the process of identity formation is a continual, two-way interactive process between the individual and the social environment, and that the meanings the individual gives to these factors influence the development of self-constructs and identity. Sexual identity develops within this contextual framework and, because it is influenced by continual interaction, is fluid over time and experience, throughout one's life. Our model does not rely on the existing developmental models of homosexual identity; rather, our model looks at desire, behavior, and identity as three separate constructs related to sexual identity. We posit that from the social constructionist viewpoint, there is in fact no true endpoint to sexual identity development.