CLINICAL PERSPECTIVES
Children With Gender Identity Issues and
Their Parents in Individual and Group Treatment
MIRIAM ROSENBERG, M.D., PH.D.
Recommended treatment for children who fit DSM-IV crite-
ria for gender identity disorder has involved attempting to dis-
courage cross-gender behavior and stimulate same-sex identification
(Bradley and Zucker, 1997; Zucker and Bradley, 1995), with a
goal of changing gender identity. For example, boys’ parents are
encouraged to have them spend more time with their father,
arrange play dates with boys, and join male groups such as Cub
Scouts (Meyer-Bahlburg, 1993). Failing this approach, adoles-
cents may be referred for sex reassignment treatment (Cohen-
Kettenis and van Goozen, 1997; Smith et al., 2001).
Since 1974, I have specialized in working with gay and les-
bian patients of all ages. Children with gender identity issues
are often sent to me, and in recent years I have run an indi-
vidual and group treatment program specifically for children
with gender identity issues and their families. All the children
fit DSM-IV criteria for gender identity disorder. Their ages
ranged from 5 to 17 years. My experience indicates that direct
attempts to “help” these children accept their biological gen-
der leads to exacerbated gender dysphoria and associated symp-
toms. In contrast is treatment consisting of acceptance and
support for the children just they are, self-esteem enhance-
ment, and education of children and parents. This approach
has led to clinical improvement of objective signs and symp-
toms of disturbances of mood, thought, school performance,
and behavior. As the children improved clinically, they also
came to identify with their biological genders, and abandoned
wishes to become the opposite gender, without abandoning
interests stereotypical of the opposite gender. The emergence
of happiness and psychological health was accompanied by
adaptation to the reality of biological destiny, but retention of
divergent interests. For example, a biologically male child who
had severe anxiety symptoms and wanted to become a balle-
rina retained his aspirations as he recovered from his anxiety
disorder, but came to want to be a male dancer.
Accepted October 31, 2001.
Child and Adolescent Psychiatrist, Director of Gay and Lesbian Program,
Harvard Vanguard Medical Associates, Wellesley, MA.
Reprint requests to Dr. Rosenberg, Harvard Vanguard Medical Associates, Wellesley
Center, 230 Worcester Street, Wellesley, MA 02481; e-mail: Miriam_Rosenberg@
vmed.org.
0890-8567/02/4105–0619!2002 by the American Academy of Child and
Adolescent Psychiatry.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 5 , M AY 2 0 0 2
Associate Editor: Michael S. Jellinek, M.D.
Patient Referral and Diagnosis
The most frequent referral source has been pediatricians,
and next has been mental health professionals. Families are
informed at the outset that treatment will consist of support,
self-esteem enhancement, and education and will not attempt
to change gender identity. No families left treatment for that
reason, but families intent on changing their child’s gender
identity may be avoiding my practice. Several children had pre-
viously been in treatment with child and adolescent psychia-
trists or therapists who had attempted, per conventional
treatment, to change the child’s gender identity, and this treat-
ment had been associated with increasing dysphoria, school
failure, and behavior problems. Prior treatment included advis-
ing the same-sex parents to spend more time with the child,
and opposite-sex parents less time; to enroll the child in gen-
der role activities such as team sports and scouting; to prohibit
cross-dressing or cross-gender play, etc. Predominant present-
ing symptoms included anxiety, attentional and behavior prob-
lems, and depression, in that order of frequency. Psychotherapy,
selective serotonin reuptake inhibitors, and stimulants had pro-
duced no apparent benefit when used in the context of treat-
ment aimed at changing gender identity.
My program currently includes 12 children and adolescents
from 5 to 17 years old (mean age 11 years) and their parents.
Two of the children, aged 6 and 15 years, are girls. Two fami-
lies have divorced parents with maternal sole custody, and the
remainder are nuclear. Between 1974 and the present I have
treated 14 other children with similar issues. All of the children
described here fit the DSM-IV definition of gender identity dis-
order and were genetically and phenotypically consistent with
their biological gender. All had primary gender identity issues
evident by 21⁄ 2 to 4 years of age. This is in contrast to two other
patients who appeared to have gender identity issues secondary
to primary psychiatric disorders: one became psychotic at age
9 and with the psychosis came feminine identity; the second
boy assumed a feminine identity when he was separated from
a beloved sister. He resumed his formerly masculine identity
when reunited with the sister. Most of the patients have been
boys, similar to other authors’ (Bradley and Zucker, 1997), prob-
ably reflecting the greater freedom our culture allows to girls to
exhibit cross-gender behavior. Upon initiation of treatment, all
the children but one suffered from additional psychiatric symp-
toms, primarily anxiety, academic attentional problems, and
619
ROSENBERG
social isolation. All experienced derogation by peers, neighbors,
and/or a teacher. One had anorexia nervosa. Significantly, the
sole child who had no comorbid psychiatric issues on initiation
of treatment has parents who are accepting of his gender issues.
All of the parents in my sample have had a clinical psychiatric
examination as well as individual and group treatment. Unlike
Zucker and Bradley (1995), I did not find parental psychopa-
thology at a rate exceeding the norm. One parent is an alco-
holic in recovery for 15 years; one had been in treatment for
nonpsychotic depressive disorder, another for anxiety disorder.
The others have been without significant psychiatric pathology
or history.
Treatment
Individual and group treatment for children consists of accep-
tance, support, self-esteem enhancement, and education. Using
language appropriate to their ages, I tell all children early in
their individual treatment that I have known many children
with similar issues and that it is possible for them to find hap-
piness. This single intervention has consistently had a dramatic
effect. The children express great interest in the fact that there
are others like themselves, asking many curious questions. The
intervention probably reduces anxiety and shame associated
with isolation. With younger children, I allow and support
cross-gender play in my office and respond in a manner intended
to enhance self-esteem: for example, complimenting little boys
on their Polly Pocket house arrangements or clothing designs
(both favorite activities). With adolescents I support their inter-
ests, when harmless, just as I would any adolescent, though the
interest may be cross-gender. I give adolescents information
on resources such as local clubs and Web sites for transgen-
dered teenagers, relevant book lists, and lists of eminent gay,
lesbian, and transgendered persons. I do not give references to
resources preparing for hormonal and surgical reassignment
procedures, although my patients have certainly discovered
such Web sites on their own.
For birthdays and the winter holidays, I give subtly cross-
gender gifts, for example rings and oriental fans for little boys and
conservative necklaces for adolescent boys. These gifts are always
received with delight, I believe because they affirm identity.
For group treatment, the children are divided into two groups
by age. They express great interest in one another. I believe that
knowing that others like themselves exist is self-esteem enhanc-
ing, probably by breaking through isolation.
Individual and group treatment for parents includes sup-
port and education. This usually involves helping parents with
their disappointment in having a child who is the object of
derision. One of my families had dirt thrown at their house
by neighbors; others have had teachers and adult neighbors
humiliate their children in public; all have witnessed peers
taunting their children in public. I advise parents that approx-
imately 80% of children with gender identity issues become
620
gay or lesbian adults (Green, 1987), and we explore parents’
feelings about homosexuality. Education involves referrals to
resources such as PFLAG, a support group for parents of gay,
lesbian, and transgendered persons. I give parents lists of emi-
nent lesbian, gay, and transgendered people and literature about
how to deal with the schools.
Another task is helping fathers and (less often) mothers with
their disappointment at not having a masculine son or femi-
nine daughter. Parents need support and education about work-
ing with teachers, neighbors, and extended families to create
a more benign environment for their children. This involves
coaching parents to talk directly with teachers, principals, rel-
atives, and neighbors. Prior to working with me, all the fami-
lies had attempted to keep their children’s gender identity issues
secret from everyone outside the immediate family, despite the
fact that these children’s cross-gender behaviors were obvious
to even the most casual observer.
Work with families includes group meetings at which they
share experiences, fears, and strategies. Parents express relief at
these meetings, since most had never before talked openly about
their children. Most parents have feared a transsexual outcome
but have been able to accept a homosexual outcome. Parents fear
that their children will be harmed physically and emotionally by
prejudice; some fear their children will contract AIDS.
I lend the families the video Ma Vie en Rose, about a young
boy with gender identity issues. Even though this is a subtitled
film, all of the patients in my program, even as young as 5 years
old, have expressed great enjoyment in it. In group treatment
for younger children, two boys, 7 and 8 years old, discussed
the movie enthusiastically. I believe their interest in this eso-
teric film probably reflects their isolation.
Outcome
The children have responded with improvement in comor-
bid symptoms such as anxiety and school and behavior prob-
lems. In some cases, the response was dramatic. For example,
an adolescent boy who wore long dresses to school and main-
tained the magical thought or delusion that he was married to
a male movie star began to change when I told him that boys
could be in love with other boys or men. He expressed intense
interest in this idea, and 2 months later, without medication,
this boy’s thinking was firmly rooted in reality and remained
so for 6 years of follow-up. He began to wear meticulously
arranged masculine clothing and to express a gay identity. In
an equally dramatic outcome, an adolescent boy with anorexia
nervosa began to recover from his eating disorder soon after
we talked about my program for children with gender issues.
He has remained in remission for more than 1 year.
With reduced comorbidity has come more consistent gen-
der role behavior. Two young boys who had preferred to design
girls’ and women’s clothing in my office began to design boys’
and men’s clothing as well. Boys who preferred to play with
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Barbie dolls and Polly Pocket started to play with cars. None
of these children abandoned their stereotypically cross-gender
interests, but they added gender-syntonic interests. All of the
children in treatment for several months or more begin to
express acceptance of their biological gender. As these chil-
dren’s comorbidity and cross-gender role behavior have become
less extreme, they have been more accepted by peers. Some
who had formerly been tormented by peers have reported reduc-
tion or absence of teasing and in some cases even acceptance;
this has included students in public middle and high schools,
settings notoriously intolerant of gender deviation (Governor’s
Commission on Gay and Lesbian Youth, 1993). Nevertheless,
all continue to prefer opposite-gender peers as friends.
DISCUSSION
Isolation and shame stemming from gender issues may con-
tribute to comorbid symptoms. It seems easy to understand
that small children, finding themselves profoundly and essen-
tially different from anyone they know or see or have ever heard
of, might develop anxiety and behavior and concentration
symptoms, especially if they feel that their essential nature is
rejected by family, peers, and even therapists. Others have pos-
tulated the opposite: that comorbidity is evidence of general-
ized psychopathology inherent to gender identity disorder
(Cohen-Kettenis, 2001).
In my experience, acceptance of these children’s essential
nature, and breaking through isolation using groups and edu-
cation, produced clinical improvement. Reduced comorbid-
ity was accompanied by reduced extreme cross-gender behavior.
Clinical work often involves helping patients to find a rea-
sonably happy and comfortable adaptation to reality, while retain-
ing their hopes and fantasies, and to find a way to accept and
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 1 : 5 , M AY 2 0 0 2
CLINICAL PERSPECTIVES
express formerly secret inner selves. Only in this area of gender
dysphoria do we attempt to help patients by pretending to change
reality. It is, after all, pretense because genetic gender is not changed.
This is a politically charged topic. A recent spate of popular
movies and books has called attention to the plight of trans-
gendered individuals: Boys Don’t Cry, Midnight in the Garden of
Good and Evil, The Crying Game, and more. Highly publicized
lawsuits have involved boys who wanted to wear dresses to school.
It is easy to see how adolescents in the midst of identity crises
might be attracted to this extreme identity solution, fraught with
peril and pain, which is unlikely to find approval from any par-
ent, however liberal. The fact that some adolescents continue to
request sex reassignment need not be taken as a mandate.
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