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Intervention with preschool boys with gender identity issues
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Neuropsychiatrie de l’enfance et de l’adolescence 56 (2008) 392–397
Original article
Intervention with preschool boys with gender identity issues Intervention pour des garc¸ons d’âge préscolaire ayant un trouble de l’identité de genre S.W. Coates Psychiatry College of Physicians and Surgeons, Columbia University, Teaching Faculty, Columbia Center for Psychoanalytic Training and Research, Columbia, United States
Abstract This paper reviews the origins of gender identity issues in preschool boys and presents an overview of treatment strategies for working with parents of boys and with the boy. The goals of treatment are to reestablish a secure attachment relationship with both of his parents, to develop a range of coping mechanisms for handling separation anxiety and aggression, to help the child to understand and enjoy his temperament, to help the child to be able to have same sex friendships, to develop gender flexibility and most importantly, restore his self esteem and his sense of authenticity. Specific treatment interventions are reviewed. © 2008 Published by Elsevier Masson SAS. Keywords: Gender identity disorder (GID); Family dysfunction; Separation anxiety; Unresolved intergenerational trauma; Gender flexibility; Self-esteem; Authentic sense of self
Gender is shaped by societal norms and is deeply rooted in the child’s attachment experience. The child’s awareness and understanding of gender as an attribute of self and others evolve through the lens of developmental stages in the context of the specific meanings of gender to his or her parents. Ordinarily, integrating gender into one’s sense of self is experienced with positive affect in the child. Ideally, gender becomes a flexible and valued aspect of the self while receding in importance as an organizing schema as development proceeds into the school age. In a gender identity disorder (GID), the construct of gender becomes co-opted as a means of managing anxiety that is related to attachment security and is taken on in a rigid, inflexible and stereotypic form. Fantasies of boys with GID differ from the passing crossgender fantasies and enactments commonly encountered in most children by virtue of their persistence, intensity and duration. Further, GID is associated with significant suffering in the child and with impairment in flexible, adaptive functioning overall. In all these respects, it can be contrasted with a typical degree of
DOI of original article:10.1016/j.neurenf.2008.03.011. E-mail address: [email protected]. 0222-9617/$ – see front matter © 2008 Published by Elsevier Masson SAS. doi:10.1016/j.neurenf.2008.06.004
cross-gender interests and behavior that occurs in nearly all children and with behavior that constitutes gender non-conformity, which involves flexible same- and cross-gender behavior that is not driven or compulsive in character. Understood from this perspective, extreme and rigid hyper-masculinity in boys and extreme and rigid hyper-femininity in girls are also disorders even if they are not classified as such. Research has repeatedly shown that GID is associated with a high degree of psychopathology in the child and with significant parental psychopathology and with familial dysfunction [1–3]). The focal disturbance in the child’s sense of gender must be understood in relation to this multiplicity of factors that are responsible for bringing it into existence and perpetuating it. Clinically, what one observes is that: the cross-gender behaviors are most often used to help reestablish an attachment relationship that has been put in jeopardy. The child’s dysphoria with regard to his or her gender almost invariably bespeaks an inner unhappiness with the self. This is often experienced as not being what mommy really wanted, accompanied by the belief that she would be happier if he were a girl. This unhappiness frequently goes unobserved by others, because the overt cross-gender behaviors are often viewed as cute or charming. Yet in our experience many children readily express their suf-
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fering quite directly – even during the intake process. One little boy said: “I hate myself. I don’t want to be me. I want to be a girl”. Many others in various forms say I know my mom really wanted a girl. Many children experience this even when the wish is directly denied by the mother. To be successful, treatment must address itself to the sources of the child’s distress, demystify these in terms of their relation to gender constructs and enable the child to develop alternative means of managing anxiety while strengthening the child’s sense of self within the context of his or her particular temperament. Moreover, parents unresolved internal conflicts that are impinging on the child’s psyche must be addressed.
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1.3. Parental psychopathology Significant parental psychopathology occurs in nearly every case. In mothers, depression and anxiety are typical; in fathers, difficulties in regulating affect and problems with substance abuse are predominant [5,8]. In many instances, parental difficulties stem from unresolved mourning and/or unresolved trauma dating back to their own childhoods that have become coded – consciously or unconsciously – in gender constructions. These issues often have been dormant until reactivated in the process of parenting their child. 1.4. Severe family stress
1. Etiology of GID in boys GID typically emerges in the context of multiple predisposing factors that are simultaneously present during a sensitive period of cognitive and emotional development between the ages of one and a half to three years, before stable representations of self and other and gender constancy are established. During this developmental epoch, moreover, procedural and enactive modes of thought predominate. The clinician should be attentive both to non-specific factors predisposing the child to anxiety and to difficulties regulating affect in general (see below) and to specific factors, in the child and in his environment, which have inadvertently encouraged the development of this particular disorder rather than of some other. Non-specific and specific factors known to be associated with a gender identity disorder include the following. 1.1. Constitutional factors Boys with GID are most often sensitive, shy and behaviorally inhibited children. Unlike most other boys, they are avoidant of rough-and-tumble play and have heightened sensory sensitivities especially to colors and odors [4]). 1.2. Concurrent psychopathology Boys with GID have overall levels of psychopathology comparable to other clinic-referred children. Separation anxiety, symptoms of depression and difficulties in managing aggression are prominent [1,3]. The varying symptoms of disparate collateral psychopathology can coexist in the same child. Not infrequently, for example, a boy who will be timid and fearful, even panicked, in some situations will be capable of escalating into sudden rages in others. The cross-gender symptoms are often used to help contain the child’s distress in these multiple different contexts. Thus one little boy, when asked what he did when he felt angry feelings, replied: “I put on my red, ruby shoes” (girls high heeled shoes). The same boy at the end of therapy sessions, when told it would soon be time to stop, would promptly begin combing and recombing a Barbie doll’s hair. In most individual histories, it is possible to document the existence of significant stress around the time of the onset of GID. Once the GID is developed social ostracism becomes an additional, major source of distress for these children.
Traumatic experiences during the first three years of the child’s life have been documented in a very high percentage of families. Chronic, severe marital conflict is also very common. These stressors, besides compounding existing parental difficulties, often lead directly to a derailment of the child’s relationship to his primary attachment figure(s) and, in many cases, can be directly implicated in the onset of the GID. 1.5. Parental encouragement of the cross-gender behaviours This specific factor, which is the sine qua non for a GID to develop, can reflect a diversity of different dynamics in the parents. For a GID to become established, the child’s enactment of the cross-gender role must serve some regulatory function within the family system (such as providing the mother with momentary relief from depression or reassuring her about her fears of aggressive men). 1.6. Isolation from peers Boys with GID, for a variety of reasons including temperament, maternal attitudes and lack of opportunity, often have not developed relationships with male peers. 2. How these factors can interact? For a GID to become established a number of risk factors must come together during a sensitive period of cognitive development, when the child is first learning to categorize self and other by gender, but before he has achieved gender constancy, gender stability, or the domain-specific knowledge that the genitals are the defining attribute of gender (Gender stability refers to the knowledge that gender does not change during development; gender constancy refers to the knowledge that gender does not change with a change in activity or dress). Children with GID have greater difficulty establishing a cognitive understanding of gender and often believe that they can change their gender through changes in their clothing or activity. Beyond being a period of cognitive vulnerability in the domain of gender, the period for the onset of GID overlaps with the stage in the separation–individuation process in which the child’s attachment to primary caretakers undergoes a major
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reorganization to accommodate the child’s increased maturational push toward autonomy and exploration. This is a period when children are particularly vulnerable to the loss of emotional accessibility of their primary caretakers because they still lack the ability to symbolically hold the caretakers in mind in a way that is affectively sustaining when the caretakers are absent. This sensitive period of development provides a fertile ground for the child to use primitive mechanisms such as imitation of the emotionally inaccessible or absent mother as a means of coping with either her physical or emotional loss. Imitation can also be used as a means of attempting to understand otherwise incomprehensible behavior such as when the mother becomes inexplicably angry, enraged and chronically irritable, as often occurs in maternal depression. Then, too, the child can exploit the highly stereotypic conception of gender that is normative at this age in the service of magically disowning his own aggressive feelings, which he identifies as masculine, by pretending to be a girl. The child’s motives for imitating feminine behavior, however, must find a response in the family milieu for it to become stabilized as an enduring part of the child’s behavior. For example, if in an emotionally overburdened family context where the father is disengaged from child-care and a mother reinforces the child’s cross-gender imitation by becoming less angry or less depressed, the boy’s continued enactment will become, progressively, internalized as a psychic structure as the child develops. The depth and complexity of the family interactions, fuelling the cross-gender behavior in the child, are poorly captured by a simple reinforcement model, because they involve conscious and unconscious mechanisms. In our clinical experience, there can be multiple different pathways to the disorder, several of which may coexist simultaneously in any given case. 3. Goals of treatment Treatment should always be undertaken within the context of a contract to work with the family as a unit following an intensive assessment. We stress to the child that the whole family has been in difficulty and that we will be working not just with him but with his parents as well. Only such an arrangement, in our view, provides the child with sufficient security (some one other than me is taking care of my mommy and daddy) to allow him to experiment with alternative modes of coping with anxiety. Moreover, without significant parental involvement in the treatment, the factors that brought the GID into existence and are perpetuating it will undermine whatever progress the child is making. Within this general context, several goals of treatment can be stated: • to restore (or sometimes to create for the first time) an attachment relationship between the child and the mother and separately with the father, that is sensitively attuned to the child’s developmental needs including recognizing and respecting the child’s own unique temperament. This typically entails reparative work on the attachment relationships in general, but it also entails sorting out parental projections
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•
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so that the child’s specific strengths can be understood and appreciated outside of gender and cross-gender, categories; to enable the child to develop an authentic, narrative sense of self. This entails helping the child achieve a sense of stable continuity over time (something he may not have consistently experienced before) and then, as treatment proceeds, helping him to integrate his feelings, including most especially his conflictual feelings, with his self-experience. An authentic, narrative sense of self can only be achieved when his parents can reliably hold the child’s mind in mind thus enable the child to experience a mind of his own [6,7]; to help the child develop a range of coping mechanisms for handling anxiety, most especially separation anxiety and anxiety about the management of aggression. Beyond helping the child to resolve conflicts and develop particular skills, this entails helping the child to develop his symbolic and creative capacities so that he has a range of options not only for managing anxiety but also for self-expression. The move to a symbolic level would free up the child’s creativity; to help the child to value and enjoy his own temperament and in so doing to restore his self-esteem. Where treatment is successful, these children come to appreciate themselves in their gender non-conformity, while becoming less preoccupied with gender and cross-gender stereotypes; to help the child to resolve the difficulties that have been interfering with his capacity to make age-appropriate friendships, most especially with other boys.
4. Treatment Part of the treatment contract is for the family to be seen once a week while the child is generally seen at least twice a week. This structure should be used flexibly; sometimes it may need to be expanded to include a sibling, a nanny or a grandparent or another caretaker. During some stages of treatment it can be very useful to have a parent join a child’s session, for example, to foster the development of an empathic understanding of the child’s inner experience or to help a child to work through a current trauma or an old unresolved trauma that has left great confusion. 4.1. Strategies of intervention with parents For the most benefit to the child to accrue, it is essential for the work with the parents to remain directly focused on the needs of the child. In our experience this does not occur when parents are simply referred out for their own therapy but works best when the child’s therapist sees the child’s parents regularly. Issues of unresolved trauma in the parents often surfaces in the treatment with the parents, often requiring additional sessions. The working through of issues of unresolved trauma in the parents usually results in the child becoming less burdened by these issues. Parallel child–parent work, thus offers a rare window of opportunity for helping the parents rework old unresolved issues that are impinging on the child. Accordingly, therapy with the parents moves back and forth from working on issues in the present to working on issues from the past that have been unme-
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tabolized and are asserting an intrusive influence on their child that are getting in the way of their appropriately meeting their child’s needs. We have found it most effective to intervene directly and actively with parents. We begin by: • using a psycho-educational approach; • working on developing effective parenting skills; • addressing psychodynamic issues as they emerge in reaction to and often as a resistance against, following through on agreed-upon recommendations (such as, notably, scheduling play-dates for the child with same sex peers). Due to their own unresolved emotional difficulties, most of the parents that we work with have significant limitations in their understanding of their child’s developmental needs and the child’s mind and thus a major focus of treatment is to help parents to understand the child’s inner experience. Such issues usually include recognizing the child’s temperament understanding the nature of separation anxiety and developing sensitive ways of helping the child to cope with their disappointed and angry feelings. We help parents to notice special interests in the child such as their enjoyment of music or acting and help them to support these interests. Where to begin, in any individual case will vary depending on what is impinging most seriously on the child’s functioning and on what the parents are able to address. However, at the very top of the list are: current severe psychopathology in the parents and, most especially, severe depression in the mother. Depression, in its more severe forms, can lead not only to maternal inaccessibility, but also to highly negative reactions to the child that can even include physical abuse. Until serious depression in the mother is treated most other therapeutic work with the family is futile. A medication referral for the mother is often needed as an initial step, in order to make family work possible; in a number of cases we have seen, this has obviated the need to make a medication referral for the child, because his anxiety or depression lifted substantially once the mother started to receive treatment. Chronic substance abuse on the part of the father also needs to be actively addressed right from the beginning; its serious, negative impact on the family and on the identified patient should be brought to light as quickly as possible and appropriate referral made for its treatment. In all the families that we have worked with, a collaborative and effective parenting subsystem has not been in place at the time of the referral. In order for parents to carry out the work that they will need to do to help their child, first and foremost they need enough time away from their children to be able to talk and reflect upon what is going on in their family. We try to help parents to find time each week away from the children to reflect upon what is happening with their child and in their family. We also encourage parents to set aside time for them for a pleasurable activity that does not involve the children. In the majority of the families that we see, the care of children has crowded out the parents’ personal lives alone and with each other to such an extent that they no longer have a personal relationship separate from the children. In this parents have suffered a major
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loss, for example, the support of one another that needs to be rectified as soon as it is possible. Next we begin to try to help the parents identify the behavior in the child that is most troubling to them. The issues that come up most readily are the management of the child’s crossdressing and cross-gender interests, severe separation anxiety, bedtime and sleep problems, temper tantrums and the child’s difficulty with peers. The parents choose which problems they wish to work on first and as we proceed we move back and forth from the present to how things were done in the parents’ family of origin and consider the effect this has had and is continuing to have on them. This both begins to develop an effective parenting system with shared goals and child-rearing approaches while simultaneously creating an opportunity to begin to address unresolved problems from the parents’ own childhood that may be interfering with their current parenting abilities. We have found that many parents are massively anxious about the child’s cross-gender behavior and interests by the time they come for evaluation. Frequently, they ask if they should throw out all the child’s Barbie Dolls or dress-up clothes or jewelry, etc. We suggest that they throw out nothing. Instead, we request that they begin to think about specific times when the crossgender behaviors becomes particularly intensified and to reflect on what else was going on in the family at this point. In short, we wish to redirect their attention to the real sources of the child’s anxieties and away from the resulting symptomatic behaviors. Simultaneously, we work with the parents to help the child to expand his interests and repertoire of behaviors by encouraging them to find areas where they can honestly enjoy themselves in joining their son in a given activity. In addition, we try to help parents to redirect the child’s proclivities in creative ways. One father, for example, came home to find his four-year-old son dressed up in his big sister’s tutu. The father suggested that perhaps the boy might want some “extra-fancy” clothes of his own – and off they went to a boy’s store to buy dress clothes. His son was thrilled with this idea. In this way, the father helped the child expand his notion of how gender categories could be stretched to accommodate his own preexisting love of bright colors and fancy textures. Another important issue that should be addressed as soon as possible is the parents’ (most particularly, though not exclusively the mother’s) difficulty in differentiating normal rough-andtumble play from aggressive and destructive play. This is essential to explore so that fewer covert restrictions will be placed on their son in this regard. Moreover, work on this issue often directly leads back to unresolved abusive experiences in the mother’s own childhood. Yet another critical issue that comes up at the very beginning of the treatment is how to help the father to develop a satisfactory connection to his son. Most fathers have experienced their sons as actively rejecting and they have in turn actively withdrawn from their sons. This withdrawal by the father propels the son into greater dyadic dependence on the mother. Most of the parents that we have worked with, come from families where dyadic relationships were strong and triadic relationships weak; few of the parents have a working model for how a triad might function effectively and indeed their experiences work-
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ing with the therapists often provides valuable live experience in this regard. Beyond this, we help mothers to empower and vitalize the relationship between the boy and his father while continuing to repair and strengthen her own relationship to her son. This is an extremely important aspect of parent therapy. If a mother remains unable or unwilling to actively facilitate the child’s relationship to his father, this will remain a formidable obstacle to bringing about a viable relationship between the child and his dad. A critical mistake that many therapists make is to ask the mother to move into the background and have dad take over the relationship with the child. This almost always increases the child’s separation anxiety and sets things back. It is essential that one continue to strengthen the child’s relationship to his mother by helping her to become more sensitively attuned to his developmentally appropriate needs while simultaneously strengthening his bond with his father. Fathers often need concrete help in learning to engage their shy, sensitive sons. We educate the fathers about the child’s temperament and his need to adapt gradually to new situations and new activities. We encourage the fathers to think of activities that: both he and his son enjoy, they might be able to share, perhaps taking a walk or going swimming or helping in the flower garden. Similarly, we help fathers to understand that making a shift from mom to dad is not easy for most children and that he must be persistent and not overly sensitive to rejection. During this phase, it is extremely important for the therapist to carry the dad in mind for the child until the mother becomes able to take over this role. This can be done by asking about things that the child did with dad and being able to remind the child about the fun things that they did with dad when these can come up in an appropriate context. In the meantime, the therapist must actively help the mother to be able to find pleasure in and take credit for her role in fostering the child’s development of a tie to the father while simultaneously working on issues that make her fearful that she will lose the child. This is a critical piece of the treatment and should be done with great care and thought. In all cases we have worked with where a father still lives in the home with the child or has active regular visitation with the child, we have been able to foster a very satisfactory father–son relationship. When given adequate support and coaching on how to make contact with their sons, these fathers, despite having been previously withdrawn, are often remarkable in their willingness and ability to help their sons. As parents begin to feel more effective, as they strengthen their own bond as a parenting couple and begin to untangle their own projections onto the child from who the child really is, an increased sense of security often ushers in increased awareness of their own unresolved losses and unresolved early traumatic experiences. 4.2. Strategies of intervention with the child The core of individual work with the child is psychodynamically oriented play therapy that takes into account the child’s cognitive and emotional developmental level. The primary goal is to help the child develop a cohesive, authentic and integrated sense of self while also helping the child to broaden
his range of coping mechanisms. In this respect, treatment of the child with GID does not differ from the psychodynamic treatment of other pre-school and early school-age children. The cross-gender behaviors per se are not the focus of treatment, though they do present a number of issues that constitute a complex challenge to the therapist to sort out what is most helpful to each individual child. The therapist has to decide how to respond to the cross-gender behaviors, for this will have an enormous impact on the child’s ability to go beyond the limitations imposed by a compulsive use of cross-gender defenses. In younger children, simply helping the child identify the feelings or fantasies that initiate the behaviors is helpful. Only in somewhat older children do, we attempt to build on this kind of recognition and help the child to identify for himself some of the underlying connection with anxiety. Thus, for example, toward the end of the session when the therapist announces that it will soon be time to stop, a child who has begun to enjoy making male figures out of clay may abruptly squish them up and quickly make a female figure before leaving. This is an opportunity to explore the child’s anxieties about separations. Or, if a child begins to stroke Barbie’s hair every time anger or aggressive fantasies come up these feelings can begin to be addressed. Once these reactions have occurred over and over again and the therapist and the child have acquired a mutual context of shared experience of this pattern, the child can begin to understand the function that his behavior has served in alleviating anxiety whether its causes be separation, anger or a belief that mommy only likes girls or only people that are exactly like her. One little boy remembered that his mother was so angry about everything that he decided to imitate her and to do only what she did in the hope of winning her approval. It is essential while helping the child to understand the meaning of his behavior to, simultaneously, help the child develop new ways of handling separation anxiety and new ways of channeling aggressive impulses and expressing anger. In a variety of domains, the therapist will need to intervene actively to help the child gradually build new psychic structures. For example, with a child who is separation anxious, the therapist might help him to begin anticipating separations and developing means of keeping the soon-to-be-absent family member, or therapist, vividly in mind. Strategies such as having a picture of the child with family members put on the wall next to the child’s bed or keeping a video tape available of a parent reading the child his favorite story is often helpful if parents are going to be away from the child for a weekend. Similarly, the therapist can help the child develop acceptable ways of expressing anger by actively thinking out ways with the family that anger can be expressed in physical and/or verbal ways without anyone getting hurt (for example, by hitting a punching bag or by telling the parent directly how angry the child is?). Such interventions can be usefully integrated in work with the parents. For example, one of the strategies that we have used to help a child develop a narrative sense of self has been to write down in a child’s language at the end of a session what the activities of the hour were and draw an accompanying picture (with the child’s help if he can directly participate). The child is then given a copy of the drawing to take home with him. The
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strategy is relatively simple, but it has a number of additional advantages that begin to accrue over the course of treatment. The pictures constitute a cumulative record of the child–therapist relationship, thus helping the child to begin to develop a sense of continuity and a narrative sense of self. Moreover, when the child shows the picture to his mother and/or father and has her or him read the words aloud describing his activities of the day, he gets the parent, at least momentarily, to recognize his independence as an autonomous initiator of activity. He also thereby includes the mother and/or father in the treatment and this is useful in helping both child and parent begin to learn how to enjoy triadic relationships. Similarly, with some children, it can be helpful to make lists of “Things to do feel better when you are angry” that the child can take home with him. For the child, the list can become a stimulus for reactivating at home the procedural experience of calmly reflecting with his therapist on ways of coping with anxietyprovoking situations. This reactivation helps the child to create more internal space for reflection upon rather than just anxious reactions to threatening impulses or external provocations. As treatment progresses, the task of helping the child to develop new coping mechanisms evolves toward both practical as well as symbolic solutions. Many of these practical solutions evolve out of the child’s therapy and then become incorporated by the parents as part of the routines at home. Psycho-education for the child about his own temperament and when appropriate about peer responses to cross-gender behaviors (so as to minimize scape-goating) is often therapeutic. With regard to temperament, boys with GID can profit enormously from learning to think of themselves as sensitive tuned in boys and to learn to appreciate the strengths inherent in their own temperament. Once their sense of security is enhanced, remarkable capacities for empathy and for creative expression often become apparent and these can help the child considerably in developing a sense of self-esteem. Further, once the child can recognize strengths in regard to their own temperament, one can help them devise coping strategies that allow him to anticipate and manage situations in which he may have previously had difficulty. By the end of the first year of treatment, the child, ordinarily, has made considerable gains both in terms of becoming more
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accepting of himself and in terms of developing the capacity for personally meaningful symbolic play. In general, it has been our experience that the therapist’s sensitivity to the child’s feelings, when coupled with helping the child to develop coping and expressive strategies for managing his affect, in the context of a recognition of his unique capacities, leads spontaneously to a marked diminution in the cross-gender enactments. Also partly responsible for this diminution, we believe, is the child’s dawning awareness that steps are being taken to take care of his parents and that he does not have to bear the burden of trying to restore the attachment relationship on his own. Thereafter, the therapy can focus primarily on unresolved issues within the child involving separation, aggression and the working through of unresolved trauma. Ultimately the goal of treatment is to help the child to develop a mind of his own with an authentic sense of self. References [1] Coates S, Person E. Extreme boyhood femininity: isolated finding or pervasive disorder? J Am Acad Child Psychiatr 1985;24(6):702–9. [2] Marantz S, Coates S. Mothers of boys with gender identity disorder: a comparison to normal controls. J Am Acad Child Adolesc Psychiatr 1991;30(2):136–43. [3] Zucker KJ, Bradley SJ. Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press; 1995. [4] Coates, S. W., Hahn-Burke, S., Wolfe, S.M., Shindledecker, R., & Nierenberg, O.I. Sensory sensitivities in boys with gender identity disorder: a comparison with matched controls. Presentation at the American Academy of Child and Adolescent Psychiatry, New York 1994. [5] Cook, C. Paternal contributions to the etiology of gender identity disorder: a study of attachment, affect regulation and gender conflict. A dissertation submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy, The City University of New York 1999. [6] Coates SW, Moore MS. The complexity of early trauma: representation and transformation. Psychoanal Inq 1997;17:286–311. [7] Coates SW. Having a mind of one’s own and holding the other in mind: discussion of “Mentalization and the changing aims of child psychoanalysis” by Peter Fonagy and Mary Target. Psychoanal Dialogue 1998;8: 115–48. [8] Wolfe, S. Psychopathology and psychodynamics of parents of boys with a gender identity disorder. A dissertation submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy, The City University of New York 1990.
Neuropsychiatrie de l’enfance et de l’adolescence 56 (2008) 392–397
Original article
Intervention with preschool boys with gender identity issues Intervention pour des garc¸ons d’âge préscolaire ayant un trouble de l’identité de genre S.W. Coates Psychiatry College of Physicians and Surgeons, Columbia University, Teaching Faculty, Columbia Center for Psychoanalytic Training and Research, Columbia, United States
Abstract This paper reviews the origins of gender identity issues in preschool boys and presents an overview of treatment strategies for working with parents of boys and with the boy. The goals of treatment are to reestablish a secure attachment relationship with both of his parents, to develop a range of coping mechanisms for handling separation anxiety and aggression, to help the child to understand and enjoy his temperament, to help the child to be able to have same sex friendships, to develop gender flexibility and most importantly, restore his self esteem and his sense of authenticity. Specific treatment interventions are reviewed. © 2008 Published by Elsevier Masson SAS. Keywords: Gender identity disorder (GID); Family dysfunction; Separation anxiety; Unresolved intergenerational trauma; Gender flexibility; Self-esteem; Authentic sense of self
Gender is shaped by societal norms and is deeply rooted in the child’s attachment experience. The child’s awareness and understanding of gender as an attribute of self and others evolve through the lens of developmental stages in the context of the specific meanings of gender to his or her parents. Ordinarily, integrating gender into one’s sense of self is experienced with positive affect in the child. Ideally, gender becomes a flexible and valued aspect of the self while receding in importance as an organizing schema as development proceeds into the school age. In a gender identity disorder (GID), the construct of gender becomes co-opted as a means of managing anxiety that is related to attachment security and is taken on in a rigid, inflexible and stereotypic form. Fantasies of boys with GID differ from the passing crossgender fantasies and enactments commonly encountered in most children by virtue of their persistence, intensity and duration. Further, GID is associated with significant suffering in the child and with impairment in flexible, adaptive functioning overall. In all these respects, it can be contrasted with a typical degree of
DOI of original article:10.1016/j.neurenf.2008.03.011. E-mail address: [email protected]. 0222-9617/$ – see front matter © 2008 Published by Elsevier Masson SAS. doi:10.1016/j.neurenf.2008.06.004
cross-gender interests and behavior that occurs in nearly all children and with behavior that constitutes gender non-conformity, which involves flexible same- and cross-gender behavior that is not driven or compulsive in character. Understood from this perspective, extreme and rigid hyper-masculinity in boys and extreme and rigid hyper-femininity in girls are also disorders even if they are not classified as such. Research has repeatedly shown that GID is associated with a high degree of psychopathology in the child and with significant parental psychopathology and with familial dysfunction [1–3]). The focal disturbance in the child’s sense of gender must be understood in relation to this multiplicity of factors that are responsible for bringing it into existence and perpetuating it. Clinically, what one observes is that: the cross-gender behaviors are most often used to help reestablish an attachment relationship that has been put in jeopardy. The child’s dysphoria with regard to his or her gender almost invariably bespeaks an inner unhappiness with the self. This is often experienced as not being what mommy really wanted, accompanied by the belief that she would be happier if he were a girl. This unhappiness frequently goes unobserved by others, because the overt cross-gender behaviors are often viewed as cute or charming. Yet in our experience many children readily express their suf-
S.W. Coates / Neuropsychiatrie de l’enfance et de l’adolescence 56 (2008) 392–397
fering quite directly – even during the intake process. One little boy said: “I hate myself. I don’t want to be me. I want to be a girl”. Many others in various forms say I know my mom really wanted a girl. Many children experience this even when the wish is directly denied by the mother. To be successful, treatment must address itself to the sources of the child’s distress, demystify these in terms of their relation to gender constructs and enable the child to develop alternative means of managing anxiety while strengthening the child’s sense of self within the context of his or her particular temperament. Moreover, parents unresolved internal conflicts that are impinging on the child’s psyche must be addressed.
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1.3. Parental psychopathology Significant parental psychopathology occurs in nearly every case. In mothers, depression and anxiety are typical; in fathers, difficulties in regulating affect and problems with substance abuse are predominant [5,8]. In many instances, parental difficulties stem from unresolved mourning and/or unresolved trauma dating back to their own childhoods that have become coded – consciously or unconsciously – in gender constructions. These issues often have been dormant until reactivated in the process of parenting their child. 1.4. Severe family stress
1. Etiology of GID in boys GID typically emerges in the context of multiple predisposing factors that are simultaneously present during a sensitive period of cognitive and emotional development between the ages of one and a half to three years, before stable representations of self and other and gender constancy are established. During this developmental epoch, moreover, procedural and enactive modes of thought predominate. The clinician should be attentive both to non-specific factors predisposing the child to anxiety and to difficulties regulating affect in general (see below) and to specific factors, in the child and in his environment, which have inadvertently encouraged the development of this particular disorder rather than of some other. Non-specific and specific factors known to be associated with a gender identity disorder include the following. 1.1. Constitutional factors Boys with GID are most often sensitive, shy and behaviorally inhibited children. Unlike most other boys, they are avoidant of rough-and-tumble play and have heightened sensory sensitivities especially to colors and odors [4]). 1.2. Concurrent psychopathology Boys with GID have overall levels of psychopathology comparable to other clinic-referred children. Separation anxiety, symptoms of depression and difficulties in managing aggression are prominent [1,3]. The varying symptoms of disparate collateral psychopathology can coexist in the same child. Not infrequently, for example, a boy who will be timid and fearful, even panicked, in some situations will be capable of escalating into sudden rages in others. The cross-gender symptoms are often used to help contain the child’s distress in these multiple different contexts. Thus one little boy, when asked what he did when he felt angry feelings, replied: “I put on my red, ruby shoes” (girls high heeled shoes). The same boy at the end of therapy sessions, when told it would soon be time to stop, would promptly begin combing and recombing a Barbie doll’s hair. In most individual histories, it is possible to document the existence of significant stress around the time of the onset of GID. Once the GID is developed social ostracism becomes an additional, major source of distress for these children.
Traumatic experiences during the first three years of the child’s life have been documented in a very high percentage of families. Chronic, severe marital conflict is also very common. These stressors, besides compounding existing parental difficulties, often lead directly to a derailment of the child’s relationship to his primary attachment figure(s) and, in many cases, can be directly implicated in the onset of the GID. 1.5. Parental encouragement of the cross-gender behaviours This specific factor, which is the sine qua non for a GID to develop, can reflect a diversity of different dynamics in the parents. For a GID to become established, the child’s enactment of the cross-gender role must serve some regulatory function within the family system (such as providing the mother with momentary relief from depression or reassuring her about her fears of aggressive men). 1.6. Isolation from peers Boys with GID, for a variety of reasons including temperament, maternal attitudes and lack of opportunity, often have not developed relationships with male peers. 2. How these factors can interact? For a GID to become established a number of risk factors must come together during a sensitive period of cognitive development, when the child is first learning to categorize self and other by gender, but before he has achieved gender constancy, gender stability, or the domain-specific knowledge that the genitals are the defining attribute of gender (Gender stability refers to the knowledge that gender does not change during development; gender constancy refers to the knowledge that gender does not change with a change in activity or dress). Children with GID have greater difficulty establishing a cognitive understanding of gender and often believe that they can change their gender through changes in their clothing or activity. Beyond being a period of cognitive vulnerability in the domain of gender, the period for the onset of GID overlaps with the stage in the separation–individuation process in which the child’s attachment to primary caretakers undergoes a major
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reorganization to accommodate the child’s increased maturational push toward autonomy and exploration. This is a period when children are particularly vulnerable to the loss of emotional accessibility of their primary caretakers because they still lack the ability to symbolically hold the caretakers in mind in a way that is affectively sustaining when the caretakers are absent. This sensitive period of development provides a fertile ground for the child to use primitive mechanisms such as imitation of the emotionally inaccessible or absent mother as a means of coping with either her physical or emotional loss. Imitation can also be used as a means of attempting to understand otherwise incomprehensible behavior such as when the mother becomes inexplicably angry, enraged and chronically irritable, as often occurs in maternal depression. Then, too, the child can exploit the highly stereotypic conception of gender that is normative at this age in the service of magically disowning his own aggressive feelings, which he identifies as masculine, by pretending to be a girl. The child’s motives for imitating feminine behavior, however, must find a response in the family milieu for it to become stabilized as an enduring part of the child’s behavior. For example, if in an emotionally overburdened family context where the father is disengaged from child-care and a mother reinforces the child’s cross-gender imitation by becoming less angry or less depressed, the boy’s continued enactment will become, progressively, internalized as a psychic structure as the child develops. The depth and complexity of the family interactions, fuelling the cross-gender behavior in the child, are poorly captured by a simple reinforcement model, because they involve conscious and unconscious mechanisms. In our clinical experience, there can be multiple different pathways to the disorder, several of which may coexist simultaneously in any given case. 3. Goals of treatment Treatment should always be undertaken within the context of a contract to work with the family as a unit following an intensive assessment. We stress to the child that the whole family has been in difficulty and that we will be working not just with him but with his parents as well. Only such an arrangement, in our view, provides the child with sufficient security (some one other than me is taking care of my mommy and daddy) to allow him to experiment with alternative modes of coping with anxiety. Moreover, without significant parental involvement in the treatment, the factors that brought the GID into existence and are perpetuating it will undermine whatever progress the child is making. Within this general context, several goals of treatment can be stated: • to restore (or sometimes to create for the first time) an attachment relationship between the child and the mother and separately with the father, that is sensitively attuned to the child’s developmental needs including recognizing and respecting the child’s own unique temperament. This typically entails reparative work on the attachment relationships in general, but it also entails sorting out parental projections
•
•
•
•
so that the child’s specific strengths can be understood and appreciated outside of gender and cross-gender, categories; to enable the child to develop an authentic, narrative sense of self. This entails helping the child achieve a sense of stable continuity over time (something he may not have consistently experienced before) and then, as treatment proceeds, helping him to integrate his feelings, including most especially his conflictual feelings, with his self-experience. An authentic, narrative sense of self can only be achieved when his parents can reliably hold the child’s mind in mind thus enable the child to experience a mind of his own [6,7]; to help the child develop a range of coping mechanisms for handling anxiety, most especially separation anxiety and anxiety about the management of aggression. Beyond helping the child to resolve conflicts and develop particular skills, this entails helping the child to develop his symbolic and creative capacities so that he has a range of options not only for managing anxiety but also for self-expression. The move to a symbolic level would free up the child’s creativity; to help the child to value and enjoy his own temperament and in so doing to restore his self-esteem. Where treatment is successful, these children come to appreciate themselves in their gender non-conformity, while becoming less preoccupied with gender and cross-gender stereotypes; to help the child to resolve the difficulties that have been interfering with his capacity to make age-appropriate friendships, most especially with other boys.
4. Treatment Part of the treatment contract is for the family to be seen once a week while the child is generally seen at least twice a week. This structure should be used flexibly; sometimes it may need to be expanded to include a sibling, a nanny or a grandparent or another caretaker. During some stages of treatment it can be very useful to have a parent join a child’s session, for example, to foster the development of an empathic understanding of the child’s inner experience or to help a child to work through a current trauma or an old unresolved trauma that has left great confusion. 4.1. Strategies of intervention with parents For the most benefit to the child to accrue, it is essential for the work with the parents to remain directly focused on the needs of the child. In our experience this does not occur when parents are simply referred out for their own therapy but works best when the child’s therapist sees the child’s parents regularly. Issues of unresolved trauma in the parents often surfaces in the treatment with the parents, often requiring additional sessions. The working through of issues of unresolved trauma in the parents usually results in the child becoming less burdened by these issues. Parallel child–parent work, thus offers a rare window of opportunity for helping the parents rework old unresolved issues that are impinging on the child. Accordingly, therapy with the parents moves back and forth from working on issues in the present to working on issues from the past that have been unme-
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tabolized and are asserting an intrusive influence on their child that are getting in the way of their appropriately meeting their child’s needs. We have found it most effective to intervene directly and actively with parents. We begin by: • using a psycho-educational approach; • working on developing effective parenting skills; • addressing psychodynamic issues as they emerge in reaction to and often as a resistance against, following through on agreed-upon recommendations (such as, notably, scheduling play-dates for the child with same sex peers). Due to their own unresolved emotional difficulties, most of the parents that we work with have significant limitations in their understanding of their child’s developmental needs and the child’s mind and thus a major focus of treatment is to help parents to understand the child’s inner experience. Such issues usually include recognizing the child’s temperament understanding the nature of separation anxiety and developing sensitive ways of helping the child to cope with their disappointed and angry feelings. We help parents to notice special interests in the child such as their enjoyment of music or acting and help them to support these interests. Where to begin, in any individual case will vary depending on what is impinging most seriously on the child’s functioning and on what the parents are able to address. However, at the very top of the list are: current severe psychopathology in the parents and, most especially, severe depression in the mother. Depression, in its more severe forms, can lead not only to maternal inaccessibility, but also to highly negative reactions to the child that can even include physical abuse. Until serious depression in the mother is treated most other therapeutic work with the family is futile. A medication referral for the mother is often needed as an initial step, in order to make family work possible; in a number of cases we have seen, this has obviated the need to make a medication referral for the child, because his anxiety or depression lifted substantially once the mother started to receive treatment. Chronic substance abuse on the part of the father also needs to be actively addressed right from the beginning; its serious, negative impact on the family and on the identified patient should be brought to light as quickly as possible and appropriate referral made for its treatment. In all the families that we have worked with, a collaborative and effective parenting subsystem has not been in place at the time of the referral. In order for parents to carry out the work that they will need to do to help their child, first and foremost they need enough time away from their children to be able to talk and reflect upon what is going on in their family. We try to help parents to find time each week away from the children to reflect upon what is happening with their child and in their family. We also encourage parents to set aside time for them for a pleasurable activity that does not involve the children. In the majority of the families that we see, the care of children has crowded out the parents’ personal lives alone and with each other to such an extent that they no longer have a personal relationship separate from the children. In this parents have suffered a major
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loss, for example, the support of one another that needs to be rectified as soon as it is possible. Next we begin to try to help the parents identify the behavior in the child that is most troubling to them. The issues that come up most readily are the management of the child’s crossdressing and cross-gender interests, severe separation anxiety, bedtime and sleep problems, temper tantrums and the child’s difficulty with peers. The parents choose which problems they wish to work on first and as we proceed we move back and forth from the present to how things were done in the parents’ family of origin and consider the effect this has had and is continuing to have on them. This both begins to develop an effective parenting system with shared goals and child-rearing approaches while simultaneously creating an opportunity to begin to address unresolved problems from the parents’ own childhood that may be interfering with their current parenting abilities. We have found that many parents are massively anxious about the child’s cross-gender behavior and interests by the time they come for evaluation. Frequently, they ask if they should throw out all the child’s Barbie Dolls or dress-up clothes or jewelry, etc. We suggest that they throw out nothing. Instead, we request that they begin to think about specific times when the crossgender behaviors becomes particularly intensified and to reflect on what else was going on in the family at this point. In short, we wish to redirect their attention to the real sources of the child’s anxieties and away from the resulting symptomatic behaviors. Simultaneously, we work with the parents to help the child to expand his interests and repertoire of behaviors by encouraging them to find areas where they can honestly enjoy themselves in joining their son in a given activity. In addition, we try to help parents to redirect the child’s proclivities in creative ways. One father, for example, came home to find his four-year-old son dressed up in his big sister’s tutu. The father suggested that perhaps the boy might want some “extra-fancy” clothes of his own – and off they went to a boy’s store to buy dress clothes. His son was thrilled with this idea. In this way, the father helped the child expand his notion of how gender categories could be stretched to accommodate his own preexisting love of bright colors and fancy textures. Another important issue that should be addressed as soon as possible is the parents’ (most particularly, though not exclusively the mother’s) difficulty in differentiating normal rough-andtumble play from aggressive and destructive play. This is essential to explore so that fewer covert restrictions will be placed on their son in this regard. Moreover, work on this issue often directly leads back to unresolved abusive experiences in the mother’s own childhood. Yet another critical issue that comes up at the very beginning of the treatment is how to help the father to develop a satisfactory connection to his son. Most fathers have experienced their sons as actively rejecting and they have in turn actively withdrawn from their sons. This withdrawal by the father propels the son into greater dyadic dependence on the mother. Most of the parents that we have worked with, come from families where dyadic relationships were strong and triadic relationships weak; few of the parents have a working model for how a triad might function effectively and indeed their experiences work-
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ing with the therapists often provides valuable live experience in this regard. Beyond this, we help mothers to empower and vitalize the relationship between the boy and his father while continuing to repair and strengthen her own relationship to her son. This is an extremely important aspect of parent therapy. If a mother remains unable or unwilling to actively facilitate the child’s relationship to his father, this will remain a formidable obstacle to bringing about a viable relationship between the child and his dad. A critical mistake that many therapists make is to ask the mother to move into the background and have dad take over the relationship with the child. This almost always increases the child’s separation anxiety and sets things back. It is essential that one continue to strengthen the child’s relationship to his mother by helping her to become more sensitively attuned to his developmentally appropriate needs while simultaneously strengthening his bond with his father. Fathers often need concrete help in learning to engage their shy, sensitive sons. We educate the fathers about the child’s temperament and his need to adapt gradually to new situations and new activities. We encourage the fathers to think of activities that: both he and his son enjoy, they might be able to share, perhaps taking a walk or going swimming or helping in the flower garden. Similarly, we help fathers to understand that making a shift from mom to dad is not easy for most children and that he must be persistent and not overly sensitive to rejection. During this phase, it is extremely important for the therapist to carry the dad in mind for the child until the mother becomes able to take over this role. This can be done by asking about things that the child did with dad and being able to remind the child about the fun things that they did with dad when these can come up in an appropriate context. In the meantime, the therapist must actively help the mother to be able to find pleasure in and take credit for her role in fostering the child’s development of a tie to the father while simultaneously working on issues that make her fearful that she will lose the child. This is a critical piece of the treatment and should be done with great care and thought. In all cases we have worked with where a father still lives in the home with the child or has active regular visitation with the child, we have been able to foster a very satisfactory father–son relationship. When given adequate support and coaching on how to make contact with their sons, these fathers, despite having been previously withdrawn, are often remarkable in their willingness and ability to help their sons. As parents begin to feel more effective, as they strengthen their own bond as a parenting couple and begin to untangle their own projections onto the child from who the child really is, an increased sense of security often ushers in increased awareness of their own unresolved losses and unresolved early traumatic experiences. 4.2. Strategies of intervention with the child The core of individual work with the child is psychodynamically oriented play therapy that takes into account the child’s cognitive and emotional developmental level. The primary goal is to help the child develop a cohesive, authentic and integrated sense of self while also helping the child to broaden
his range of coping mechanisms. In this respect, treatment of the child with GID does not differ from the psychodynamic treatment of other pre-school and early school-age children. The cross-gender behaviors per se are not the focus of treatment, though they do present a number of issues that constitute a complex challenge to the therapist to sort out what is most helpful to each individual child. The therapist has to decide how to respond to the cross-gender behaviors, for this will have an enormous impact on the child’s ability to go beyond the limitations imposed by a compulsive use of cross-gender defenses. In younger children, simply helping the child identify the feelings or fantasies that initiate the behaviors is helpful. Only in somewhat older children do, we attempt to build on this kind of recognition and help the child to identify for himself some of the underlying connection with anxiety. Thus, for example, toward the end of the session when the therapist announces that it will soon be time to stop, a child who has begun to enjoy making male figures out of clay may abruptly squish them up and quickly make a female figure before leaving. This is an opportunity to explore the child’s anxieties about separations. Or, if a child begins to stroke Barbie’s hair every time anger or aggressive fantasies come up these feelings can begin to be addressed. Once these reactions have occurred over and over again and the therapist and the child have acquired a mutual context of shared experience of this pattern, the child can begin to understand the function that his behavior has served in alleviating anxiety whether its causes be separation, anger or a belief that mommy only likes girls or only people that are exactly like her. One little boy remembered that his mother was so angry about everything that he decided to imitate her and to do only what she did in the hope of winning her approval. It is essential while helping the child to understand the meaning of his behavior to, simultaneously, help the child develop new ways of handling separation anxiety and new ways of channeling aggressive impulses and expressing anger. In a variety of domains, the therapist will need to intervene actively to help the child gradually build new psychic structures. For example, with a child who is separation anxious, the therapist might help him to begin anticipating separations and developing means of keeping the soon-to-be-absent family member, or therapist, vividly in mind. Strategies such as having a picture of the child with family members put on the wall next to the child’s bed or keeping a video tape available of a parent reading the child his favorite story is often helpful if parents are going to be away from the child for a weekend. Similarly, the therapist can help the child develop acceptable ways of expressing anger by actively thinking out ways with the family that anger can be expressed in physical and/or verbal ways without anyone getting hurt (for example, by hitting a punching bag or by telling the parent directly how angry the child is?). Such interventions can be usefully integrated in work with the parents. For example, one of the strategies that we have used to help a child develop a narrative sense of self has been to write down in a child’s language at the end of a session what the activities of the hour were and draw an accompanying picture (with the child’s help if he can directly participate). The child is then given a copy of the drawing to take home with him. The
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strategy is relatively simple, but it has a number of additional advantages that begin to accrue over the course of treatment. The pictures constitute a cumulative record of the child–therapist relationship, thus helping the child to begin to develop a sense of continuity and a narrative sense of self. Moreover, when the child shows the picture to his mother and/or father and has her or him read the words aloud describing his activities of the day, he gets the parent, at least momentarily, to recognize his independence as an autonomous initiator of activity. He also thereby includes the mother and/or father in the treatment and this is useful in helping both child and parent begin to learn how to enjoy triadic relationships. Similarly, with some children, it can be helpful to make lists of “Things to do feel better when you are angry” that the child can take home with him. For the child, the list can become a stimulus for reactivating at home the procedural experience of calmly reflecting with his therapist on ways of coping with anxietyprovoking situations. This reactivation helps the child to create more internal space for reflection upon rather than just anxious reactions to threatening impulses or external provocations. As treatment progresses, the task of helping the child to develop new coping mechanisms evolves toward both practical as well as symbolic solutions. Many of these practical solutions evolve out of the child’s therapy and then become incorporated by the parents as part of the routines at home. Psycho-education for the child about his own temperament and when appropriate about peer responses to cross-gender behaviors (so as to minimize scape-goating) is often therapeutic. With regard to temperament, boys with GID can profit enormously from learning to think of themselves as sensitive tuned in boys and to learn to appreciate the strengths inherent in their own temperament. Once their sense of security is enhanced, remarkable capacities for empathy and for creative expression often become apparent and these can help the child considerably in developing a sense of self-esteem. Further, once the child can recognize strengths in regard to their own temperament, one can help them devise coping strategies that allow him to anticipate and manage situations in which he may have previously had difficulty. By the end of the first year of treatment, the child, ordinarily, has made considerable gains both in terms of becoming more
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accepting of himself and in terms of developing the capacity for personally meaningful symbolic play. In general, it has been our experience that the therapist’s sensitivity to the child’s feelings, when coupled with helping the child to develop coping and expressive strategies for managing his affect, in the context of a recognition of his unique capacities, leads spontaneously to a marked diminution in the cross-gender enactments. Also partly responsible for this diminution, we believe, is the child’s dawning awareness that steps are being taken to take care of his parents and that he does not have to bear the burden of trying to restore the attachment relationship on his own. Thereafter, the therapy can focus primarily on unresolved issues within the child involving separation, aggression and the working through of unresolved trauma. Ultimately the goal of treatment is to help the child to develop a mind of his own with an authentic sense of self. References [1] Coates S, Person E. Extreme boyhood femininity: isolated finding or pervasive disorder? J Am Acad Child Psychiatr 1985;24(6):702–9. [2] Marantz S, Coates S. Mothers of boys with gender identity disorder: a comparison to normal controls. J Am Acad Child Adolesc Psychiatr 1991;30(2):136–43. [3] Zucker KJ, Bradley SJ. Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press; 1995. [4] Coates, S. W., Hahn-Burke, S., Wolfe, S.M., Shindledecker, R., & Nierenberg, O.I. Sensory sensitivities in boys with gender identity disorder: a comparison with matched controls. Presentation at the American Academy of Child and Adolescent Psychiatry, New York 1994. [5] Cook, C. Paternal contributions to the etiology of gender identity disorder: a study of attachment, affect regulation and gender conflict. A dissertation submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy, The City University of New York 1999. [6] Coates SW, Moore MS. The complexity of early trauma: representation and transformation. Psychoanal Inq 1997;17:286–311. [7] Coates SW. Having a mind of one’s own and holding the other in mind: discussion of “Mentalization and the changing aims of child psychoanalysis” by Peter Fonagy and Mary Target. Psychoanal Dialogue 1998;8: 115–48. [8] Wolfe, S. Psychopathology and psychodynamics of parents of boys with a gender identity disorder. A dissertation submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy, The City University of New York 1990.