gender identity disorder in boys: the interface of constitution and early experience

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Gender identity disorderin boys: The interfaceof constitution and earlyexperienceSusan W. Coates Ph.D. a & Sabrina M. Wolfe Ph.D. ba Director of the Childhood Gender Identity Centerin the Department of Psychiatry , St. Luke's/Roosevelt Hospital Center , 1090 Amsterdam Ave.New York, New York City, NY, 10025b Associate Director of the Childhood GenderIdentity Center in the Department of Psychiatry ,St. Luke's/Roosevelt Hospital Center , 1090Amsterdam Ave. New York, New York City, NY,10025Published online: 20 Oct 2009.

To cite this article: Susan W. Coates Ph.D. & Sabrina M. Wolfe Ph.D. (1995) Genderidentity disorder in boys: The interface of constitution and early experience,Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 15:1, 6-38,DOI: 10.1080/07351699509534015

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Gender Identity Disorder in Boys:The Interface of Constitution andEarly Experience

S U S A N W. C O A T E S , Ph.D.S A B R I N A M. W O L F E , Ph.D.

GENDER IDENTITY DISORDER (GID) OF CHILDHOOD is a very rare syn-drome, first classified in DSM-III, characterized by a persistent

and determined wish to be the opposite gender coupled with anintense dislike of one's own gender. Boys with the syndrome arereferred for clinical evaluation far more frequently than girls by a ratioof approximately 5 to 1 (Zucker and Green, 1992). The onset of thedisorder almost invariably occurs during the ages of 2 to 4, and onceestablished, it is surprisingly stable and usually proves refractory to allbut the most intensive psychodynamic and family interventions.Extensive biomédical research has failed to document any chromoso-mal or hormonal abnormalities associated with the disorder.

Typical is the case of Colin, a 3-year-old boy reported in detailelsewhere (Coates, Friedman, and Wolfe, 1991). Colin had frequentlydressed in his mother's clothes since the age of 2. He was intenselyinterested in jewelry and makeup and would spend long periods oftime cross-dressed in front of a mirror. He had a strong preference forstereotypical feminine activities, such as playing with dolls, and he

Susan Coates, Ph.D. is Director of the Childhood Gender Identity Center in the Departmentof Psychiatry of St. Luke's/Roosevelt Hospital in New York City; Sabrina Wolfe, Ph.D. is Asso-ciate Director.

We would like to express our appreciation to John Kerr, whose many probing questions ledus to refine our thinking and sharpen our formulations, and to Larry Friedman and WilliamByne for their suggestions on an earlier draft of this paper.

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GENDER IDENTITY DISORDER AND CONSTITUTION 7

favored girls as playmates. His favorite childhood stories all involvedfemale heroines, such as Snow White, Alice in Wonderland, andRapunzel. Colin stated that he was lonely, that no one liked him, thathe hated being a boy and that he wished he was a girl.

Several features of the syndrome as it occurs in boys have beennoted repeatedly since the inception of the diagnosis. It usuallyemerges during a limited time frame in development in families withchronic problems in affect regulation (Bradley, 1985; Wolfe, 1990;Marantz and Coates, 1991). It typically occurs in sensitive, highlyreactive boys (Stoller, 1968; Coates, 1992; Coates, Hahn-Burke, andWolfe, 1994; Coates et al., 1994) who avoid rough-and-tumble play(Bates, Bentler, and Thompson, 1979; Green, Neuberg, and Finch,1983) and who are described by their mothers as beautiful (Stoller,1968; Green, 1974; Zucker et al., 1992). The symptoms of the disorderare almost always encouraged by parents, frequently in very subtleways that the parent is not aware of. Indeed, R. Green (1974) believedthat the factor that came closest to being a necessary etiological vari-able was the absence of discouragement by parents of the child'scross-gender behavior. Finally, all observers continue to agree thatthere appears to be a constitutional diathesis for the development ofthe disorder, though in the complete absence of any positive findingsregarding chromosomal or hormonal abnormalities, it has proveddifficult to conceptualize what that diathesis might be. The primarypurpose of this paper is to provide clarification regarding the role ofconstitutional factors in the etiology of childhood gender identitydisorder. Secondarily, we briefly consider what light, if any, such aclarification sheds on the normal development of gender identity.

Phenomenologically, the manifestations of gender identity disorderare quite striking and include both intrapsychic and behavioral mani-festations. Boys with gender identity disorder display the followingcharacteristics: they express a persistent and intense wish to be a girl;some claim that they will be a girl when they grow up; and they have amarked preference for stereotypically feminine activities, such asplaying with Barbie dolls. In fantasy play they have a marked prefer-ence for the roles of girls; they repeatedly dress up in girls' clothes;they show an intense interest in cosmetics, jewelry, and high-heeledshoes; and they prefer girls as playmates. Many, but not all, of theseboys also display anatomical dysphoria in the form of an intense

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8 SUSAN COATES AND SABRINA WOLFE

dislike of their penis, a wish to be rid of it, or both. The disorder isdefined by the persistence, pervasiveness, and duration of the cross-gender identification. The disorder is distinguishable both from time-limited cross-gender interests, which are not uncommon in normaldevelopment, and from gender nonconformity, which in boys involvesartistic interests, solitary activities such as reading or music, and theavoidance of rough-and-tumble play.

In boys with GID inner psychological suffering is often expressedin very poignant ways that reveal self-loathing and self-hatred. Forexample, one 3-year-old boy said during his evaluation: "I hatemyself. I don't want to be me. I want to be someone else. I want to bea girl." Another boy volunteered: "I hate myself. I hate being a boy. Iwant to die. I wish I was a girl. Why do I have to be a boy even in mydreams?"

Clinically, the syndrome presents as a pervasive disorder and isempirically associated with high levels of collateral psychopathologyin the child (Bradley et al., 1980), most especially separation anxiety(Coates and Person, 1985; Lowry and Zucker, 1991), and symptoms ofdepression (Coates and Person, 1985), as well as with high levels ofparental psychopathology including most notably: depression andanxiety in the mother (Wolfe, 1990; Marantz and Coates, 1991); sub-stance abuse, depression, and anxiety disorders in the father (Wolfe,1990); and family dysfunction and collateral experiences of traumatato child, parents, or all. As well, mothers of boys with GID have child-rearing attitudes and practices that make it difficult for the child todevelop a sense of separate identity (Marantz and Coates, 1991).

Research and extended clinical experience over the past fifteenyears at the Childhood Gender Identity Center at St. Luke's/RooseveltHospital in New York has gradually yielded a complex etiologicalmodel for the development of the disorder: psychodynamic andfamilial variables interact during a sensitive period in development ina child temperamentally at risk. In a majority of cases, we find that thedevelopment of the disorder in the child is initiated by an event that isexperienced by the mother as traumatic. The event may have occurredto the mother herself, or to the child, the father, or some other signifi-cant attachment figure. The events are often quite severe, such as alife-threatening illness or the death of a child, and would be experi-enced as traumatic by almost anyone. In some cases, however, the

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event may be traumatic because of the meaning it has for the mother;examples include events such as a miscarriage or an abortion or thedeath of a parent. In addition, cumulative trauma occurring in thecontext of severe marital difficulties, often accompanied by threats ofphysical violence, have been observed in many cases. Regardless ofcontent, the traumatic experience invariably has the effect of derailingthe attachment bond between the mother and the child. Massive sepa-ration anxiety in the child is then defended against by a restitutiveself-fusion fantasy with the mother. In essence, the child substitutes anidentification for a relationship and comes to confuse being mommywith being with mommy, this during a period when he lacks stableinternal representations of self and other and when his cognitiveunderstanding of the permanence of gender classification is stillimmature. Once established, the cross-gender identification becomesentrenched in part because it helps the child in various ways to restorea more satisfactory relation to the mother in reality, but also because itenables the child to function more autonomously. The contribution thecross-gender identification makes to the child's management of anxi-ety is such that the child experiences it as a "solution." As develop-ment proceeds, however, the child's creativity and spontaneitybecome increasingly consumed in the repetitive, stereotyped, andjoyless false-self enactments of the cross-gender identification whilehis social adjustment becomes increasingly precarious in the face ofcontinued peer rejection.

In some respects, the symptoms of the disorder seem analogous tothose associated with the adult condition of transsexualism, wherein aperson protests that he is a man trapped in a woman's body, or viceversa. In fact, research into childhood gender identity disorder wasinitially spurred by the search for childhood analogues to the adultcondition on the basis that adult transsexuals typically report severeanatomical and gender dysphoria for as long as they can remember.But it has since emerged clearly that the childhood condition is neitheran exact analogue nor, except in very rare cases, a precursor to theadult one. (The differential developmental pattern that leads to adulttranssexualism thus remains an area of open inquiry.) Nor is its phe-nomenology truly equivalent. A child aged three and a half cannot anddoes not represent his condition in terms of feeling like one gender"trapped" inside the body of another. Moreover, examined closely, the

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boy does not truly behave like girls his age; rather, he acts like hishighly stereotyped idea of what being a girl is like. Still, the possibil-ity that a very young boy can insist he hates being a boy and wishes hewere a girl and can maintain this posture despite adverse social andpsychological consequences raises important questions about howgender identity ordinarily gets established in development. In turn, thepossibility that a constitutional diathesis may be required for thedisorder raises important questions about the psychobiological rootsof femininity and masculinity. As we shall argue, an understanding ofthe constitutional diathesis for the development of gender identitydisorder does indeed shed light on the ordinary processes wherebyyoung children come to feel that they are boys and girls. But, the lightshed on the issue of the psychobiological roots of masculinity andfemininity is indirect at best. To anticipate our conclusion, the studyof constitution leads paradoxically to a greater appreciation both ofthe role of environmental and experiential factors and of the complex-ity of the nature-nurture interaction—even in an area so seeminglybiological as sex and gender.

Terminological Background

Before we can begin to sort out the constitutional factors that may beinvolved in gender identity disorder, a terminological excursus is inorder. In the world of contemporary research, an essential distinctionis made between sex and gender. Sex refers to the chromosomal statusat birth (46XX for girls, 46XY for boys). Except in certain rare physi-cal disorders, this status will be further reflected in the neonate'sexternal genitalia, which for parents and physicians alike are the hall-mark of sex. Gender, by contrast, is a social-psychological construct;it designates how persons are categorized by others and how theycategorize themselves. Within the category of gender, three furtherdistinctions are typically made. Gender role (Money, Hampson, andHampson, 1955a,b) describes the outwardly observable activities,proclivities, and attitudes that are associated with cultural roles asso-ciated with masculinity and femininity. Gender identity (Money,1965) is the complementary intrapsychic sense of oneself as beingeither male or female. Clearly, both gender role and gender identityare subject to a certain degree of variation in typical gender develop-

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ment. Equally clearly, however, many such variations occur within anormal range and bode nothing whatsoever vis-à-vis the overallmental well being of the individual.

Disturbances in core gender identity are another matter. Coregender identity, a term first proposed by Stoller (1968), refers to theaffectively laden sense that one is the "right" sex. If you ask smallchildren aged two and a half to three whether they are a boy or a girl,they will respond with something like indignation. "Of course I am aboy," the child will answer. Moreover, even though boys and girls atdifferent times feel disadvantaged in terms of the options that they seeas readily available to them, children of both sexes come up withreasons why it is "better" to be the sex that they are. This affectivelycolored sense of one's gender becomes consolidated in almost allchildren by the age of 5 or 6.

In boyhood gender identity disorder (GID), something is askewwith the experience of core gender identity. The child knows he is aboy but does not feel good about it. He does not like himself the wayhe is. On the basis of clinical experience but also on the basis of theresearch literature then available, Stoller (1968) supposed that amongthe factors contributing to core gender identity is a basic biologicalcontribution. He proposed that in cases of so-called "extreme femi-ninity" in boys, an initial, innate "feminine" tendency had been rein-forced during a critical period in development. One of the hallmarksof this constitutional factor in his view was special beauty in the boy(Stoller, 1968, 1975). Empirical studies (R. Green, 1974; Zucker et al.,1992) have since demonstrated that such children are in fact judged asunusually pretty by their mothers, also by independent observers,though the interpretation of these findings remains a matter of debate.The child's beauty, in Stoller's view, triggered response patterns in thefamily that had hitherto been latent. Relying on the reports of themothers, Stoller theorized that gender identity disorder resulted from aprolonged "blissful symbiosis" between a constitutionally predisposedchild and a basically bisexual mother lasting for several years. Theconsequence of this prolonged symbiosis was that the developingchild did not make the switch to a masculine identification. (Hehypothesized that all children begin life with an innately feminineorientation and along with Greenson [1968] believed that boys have todis-identify with their mothers to develop a masculine identification.)

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Something akin to "imprinting" was at stake in Stoller's theory, suchthat the inborn constitutional factor became fixed through prolongedcontact with the mother. In his view, the resulting feminine identifica-tion, though problematic socially, was otherwise nonconflictual forthe child. The identification was held responsible for other features ofthe disorder noted by Stoller, notably sensory sensitivities and unusualartistic capacity.

Many of Stoller's original observations of "extremely feminineboys"—their sensory sensitivities, their unusual artistic capacities,and their unusual beauty—as well as his observations of maternaldepression and paternal inaccessibility as collateral features of thesyndrome have withstood the test of further observation and research.Moreover, his basic belief that the disorder could come about onlywhen many factors converged in a single time frame, with some formof identificatory process serving as the central transformative factor(Stoller, 1985), is shared by nearly all long-term, systematic observersof the disorder. To be sure, the deficiencies of the "blissful symbiosis"aspect of his etiological hypothesis are now well known (see Coates,1992), thanks in large part to research efforts spurred by his importantconceptualization of core gender identity and by his challengingpsychodynamic formulations. Then, too, almost all observers of thecondition share Stoller's conviction that eventually some biologicalcontribution to the disorder will be identified, but consensus has beenlacking as to what the nature of that contribution will entail. Moreimportantly, it has not been clear whether such a biological factormight be sex-linked. It is easy to think of some of the traits enumer-ated by Stoller (beauty, special sensory sensitivities) as somehow"feminine," but is that characterization reflective of a truly innatebiological difference that is in fact sex-linked, or is it only a by-prod-uct of our particular culture with its particular stereotypes?

Gender and the Search for Meaningful Sex Differences

Interest in gender differences has become enlivened in recent years bya great deal of social, cultural, and political concern and most partic-ularly by the critiques and reappraisals of feminist psychoanalyticscholars (e.g., Mitchell, 1975; Dinnerstein, 1976; Chodorow, 1978;Person, 1980; Dimen, 1986; Benjamin, 1988; Goldner, 1991; Harris,

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GENDER IDENTITY DISORDER AND CONSTITUTION 1 3

1991). Contemporary social concern over gender roles has beenaccompanied by the spawning of important research efforts in anattempt to disentangle, if possible, what is indeed the biologicallygiven contribution of sex to gender versus what to the contrary is theresult of cultural influences. Additionally fueling interest in the biol-ogy of "sex differences" is another current debate over the relation-ship of homosexuality to sex-dimorphic neural structures (Byne andParsons, 1993; Friedman and Downey, 1993). In regard to sex andgender, no sophisticated researcher supposes nowadays that a purenature versus nurture dichotomy applies, and all researchers nowagree that progress can be made only through the study of the interac-tion of the two (in biological terms, the study of the necessary role ofexperience and environment in shaping the phenotypal expression ofthe genotype). Nonetheless, the search for identifiable sex differenceshas been deemed so important in our society that even weak oruncertain statistical findings that seem to bear on this topic commandgreat public and scientific interest.

If one looks at the outcome of years of psychological research onsex differences, however, one comes to a truly remarkable fact.Despite all the contemporary research into sex differences—inborn,psycho-biological differences that can be understood to be conceptu-ally independent of child-rearing practices—the fact is that only a fewpositive results have held up over time. As infants boys are more irri-table and difficult to soothe (Moss, 1967; Osofsky and O'Connell,1977) and are more reactive and show a greater vulnerability to theimpact of maternal depression (Weinberg and Tronick, 1992; Murrayet al., 1993). As toddlers, boys are somewhat bolder and more aggres-sive, and they are more active explorers of their environment. Inparticular they show a preference for rough-and-tumble play(DiPietro, 1981). On tests of visual-spatial abilities boys outperformgirls (Maccoby, 1990). In adulthood, men are more likely to be agentsof aggression (Maccoby, 1990). And that is about the extent of it.

The paucity of findings, and the relative nature of the findings,rather violates our initial expectations. Boys and girls, and men andwomen, are different, we tell ourselves. Yet, research findings thatcurrently exist suggest that these differences are only a matter ofdegree, and that the degree is not all that striking. That there are onlytwo genders could lead us to suppose that sooner or later, on some

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measure yet to be devised, we would see two essentially distinct pop-ulations. But what has been observed is two largely overlappingpopulations, with the degree of variance within each group more orless equaling the mean difference between them (Lewis, 1975). Thequestion thus arises whether the distinction between the two genders,so clearly in our mind, is essentially the result of cultural experiences.The innate differences between boys and girls, as we currently knowthem, are simply not sufficient to account for the observed culturaldisparities in gender.

History of Clinical Research into Gender

Quite apart from the search for sex differences, there exists an exten-sive contemporary clinical literature concerned with typical andatypical gender development. The first clear, concise descriptions ofgender identity disorder (GID) in childhood were elicited by thepioneer sexology researcher Krafft-Ebing (1902). His descriptions,however, were uniformly retrospective accounts elicited from adulthomosexuals on the basis of a complex etiological scheme that cannotbe described further here. Regrettably, some clinicians even todaycontinue to conflate GID and homosexual development, arguing thatcross-gender behavior in childhood is the first manifestation of homo-sexuality (Zuger, 1988). To be sure, there is some statistical supportfor this as a prospective correlation; current research has producedestimates that 66% to 75% of gender-referred children grow up to behomosexual (Zucker and Green, 1992). As a retrospective correlation,however, the conflation of the two conditions does not hold up. Inretrospective studies of clinically unreferred adult homosexuals, aboutthree-fourths have described themselves as gender-nonconforming inchildhood. Yet, this self-characterization includes, in the majority, apreference for solitary activities or artistic activities, as well as theavoidance of rough-and-tumble play (Saghir and Robins, 1973; Bell,Weinberg, and Hammersmith, 1981; Friedman, 1988). A significantminority of adult homosexuals recall some cross-gender interests infemale stereotypical activities yet without the intensity, pervasiveness,and duration that would meet the criteria for a GID of childhood. Theupper-level estimate based on current research of adult homosexualswho may have had a GID of childhood is about 15%, and the true

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percentage is probably much lower than that. In our view, the suppo-sition that boyhood gender identity disorder and adult homosexualityare manifestations of a unitary developmental pattern is both empiri-cally unwarranted and conceptually unsound and such a suppositiondoes not contribute to our understanding of the specific nature of thechildhood disorder. As long ago as 1907, Albert Moll, as part of amethodological criticism of Krafft-Ebing's (1902) use of retrospectivedata to infer childhood patterns, presented a clear case of genderidentity disorder in which the child did not grow up to be homosexual.Today we are still unable to predict sexual orientation in any individ-ual child. The origins of both homosexuality and heterosexuality aresimply not yet understood.

The preliminary descriptions of childhood gender identity duringthe first era of sexology research by Krafft-Ebing, Moll, and others atthe turn of the last century did not lead to a conceptualization ofgender as a distinct developmental line, nor did they spawn furtherresearch. In part this was due to a functional conceptualization ofsexual development and of sexual behavior as leading to and beingconsummated in procreation and the perpetuation of the species. Insuch a unified functional conception, it was difficult to distinguishgender, an aspect of the self, as independent of sexual orientation,which concerns the gender of one's preferred sexual object (Money,1973; Tyson, 1982).

It was the essence of the psychoanalytic redefinition of sexualitythat libido was composed of multiple, and functionally independent,component drives (see Davidson, 1987), each of which might have itsown developmental history and each of which might be conjoinedwith the others in adult sexual behavior only very poorly or not at all.Yet, the lacuna with regard to gender persisted. Psychoanalysis sub-stituted the vicissitudes of desire and defense for the functional con-ception of its predecessors as the basis for understanding psychosexu-ality. But it did not create a prominent place for gender as pertainingto one's own status independent of desire. Indeed, "gender" is notlisted as a category in the index of the Standard Edition. To be sure,the issue of sexual dimorphism, really anatomical dimorphism, didbecome important in analytic theory to the extent that it could betranslated into the language of desire and defense. The little girl wassaid to bring an additional motive, penis envy, and the little boy an

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additional fear, castration anxiety, into the oedipal drama, consideredin both its positive and negative dimensions. The important psycho-logical task of consolidating a psychological identification asbelonging to one or the other gender, in turn, was understood chieflyin terms of the resolution of the oedipal stage. Issues of gender confu-sion, in their place, principally became meaningful insofar as theymight reflect the negative Oedipus in one or another of its possiblevariations. But as we will see, contemporary research places the stageof gender identity formation well prior to the oedipal stage. In largemeasure, it was the work of Stoller that led psychoanalysis to begin toconsider gender as a theoretically distinct area of inquiry. In contem-porary psychoanalytic theory, gender identity is conceived of as anaspect of ego development, specifically of the development of self-and object representations.

The modern era of research on gender began with the work of JohnMoney and his associates at Johns Hopkins University in the 1950s onhermaphroditic children. These children typically have ambiguousgenitalia at birth, with both male and female organs present in variouscombinations. Money and the Hampsons (1955a,b) discovered thatsuch children nonetheless grow up thinking of themselves as unam-biguously boys or girls, provided they were assigned to one or anothergender at birth and raised that way thereafter. To put the matter intocontemporary terminology, core gender identity could be establishedand maintained even though biological sex was ambiguous. Thisremarkable and unanticipated finding paved the way for the conceptu-alization of gender identity as an issue distinct from biological sexand, perhaps not so obviously, from sexual orientation (Money andEhrhardt, 1972).

Money was the first to define the term gender role (Money, Hamp-son, and Hampson, 1955a) and the first to differentiate it from genderidentity (Money, 1973). His researches led not only to Stoller's psy-choanalytic investigations, but also to empirical studies of a host ofdisorders less extreme than true hermaphroditism. Moreover, with thework of Money and Ehrhardt (1972), it now became possible to con-ceptualize a "critical" or "sensitive" developmental period in thedevelopment of gender identity. Stoller's "imprinting" hypothesis isan example of such a hypothesis but the concept is more general still.A critical period is a window of time, often quite short in animal

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species, during which a genotypal capacity either will or will not findits typical phenotypic expression depending on environmental stimuli.The classic demonstration of a critical period is Konrad Lorenz's dis-covery of "imprinting" in baby ducks. At birth, the ducklings willfollow the first large moving object that they see and they will con-tinue to follow that particular object until they reach adulthood. Innature, this mechanism, entirely inborn, more or less efficiently guar-antees that baby ducks will follow their mother, a situation of obvioussurvival value.

Critical periods in neural-behavioral organization occur most strik-ingly during prenatal development. As one moves up the evolutionaryladder, such exceedingly brief critical periods are increasingly diffi-cult to find, even prenatally; in humans they are entirely unknown.This has led to the postulation of a less restrictive concept, that of a"sensitive" period in development, that is, a duration of some lengthduring which the genotypal potential flexibly takes its typical pheno-typal shape. If there is a sensitive period for the development of agiven trait or capacity, then the expectation is that once the sensitiveperiod passes, the trait or capacity in question either will fail todevelop or will develop in an atypical form. In this context, the ques-tion raised by Money's research was whether there was a sensitiveperiod postnatally for the development of gender identity.

Indeed there was. Money and Ehrhardt (1972) found that the crucialperiod was between 18 and 36 months. When sex assignment had tobe changed for medical reasons after this age, psychological difficul-ties invariably ensued. Money argued that during this period genderidentity was still flexible. After this time, gender identity was fixed.Money and Ehrhardt believed that the sensitive period was linked tothe acquisition of language.

The suggestion that the establishment of gender identity might becorrelated with the achievement of language in the developing childhas received independent confirmation from an entirely different lineof research. Beginning with Kohlberg (1966), cognitive-developmen-tal researchers have been able to describe a regular developmentalsequence in the child's growing ability to classify self and others bygender. By age 2 months children are able to discriminate male andfemale voices, by 9 months they can make categorical discriminations

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of male and female faces (Fagot and Leinbach, 1993). By age 2 theycan verbally label men and women. By age T>h they can verbally labelthemselves and peers. Moreover, as Bern (1989) has documented, thisclassification at first proceeds independently, and often in ignorance,of the knowledge of the anatomical distinction between the sexes.Indeed, it appears that the binomial distinction between boy and girl,and between man and woman, may be the second categorizationachieved by the child (Kohlberg, 1966), preceded only by thedistinction big-small. Moreover, as Fast (1984) has described andelaborated on in considerable detail, no sooner is this capacityachieved than it becomes affectively significant for the child. Oncethe boy can categorize by gender, he begins to show a preference forsame-gender peers and for stereotypically masculine activities. Boyswho do not have gender labels spend about as much time with dollsand other female-typical toys as girls. In boys who do have genderlabels for self and peers this interest in dolls is almost non-existent(Fagot and Leinbach, 1993). Though this has only recently beensubject to systematic study, it further appears that the emergentpreference for stereotypically masculine activities in the boy who hasgender labels, and its corollary expression in an increased interest inspending play time with same-gender peers, ordinarily meets withconsiderable reinforcement from other boys. Interestingly, however,the majority of children at this early age (2'/z to 7>Vï) have notachieved the further cognitive capacity to understand that gender doesnot change over the course of life (gender stability) and that it like-wise does not change even if one adopts the clothes and activities ofthe opposite gender (gender constancy). The consolidation of a cogni-tive understanding of gender requires the integration of the domainspecific knowledge that genitals take priority over cultural cues indefining gender (Bern, 1989). In short, from a cognitive-developmen-tal standpoint, this is a vulnerable period, and it should not surprise usthat the onset of gender identity disorder typically occurs during it.Considered from a cognitive standpoint, gender identity disorder ofchildhood entails defensively employing the ability to classify bygender in cross-gender fantasy in a way that seems to exploit thecognitive immaturity of not having achieved gender constancy andgender stability.

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Hormones and Temperament

The discovery of a sensitive period clinically and of a vulnerableperiod cognitively in the development of gender provides a more pre-cise context for considering how innate biological factors may affectself-categorization. One avenue of inquiry, which initially seemedquite promising, was to suppose that the operative biological factorsmight be hormonal in nature. That is to say, it has been hypothesizedthat some combination of hormonal influences, operating prenatallyor postnatally, might be affecting the formation of gender identitydirectly.

The relationship of hormones to sexually dimorphic behaviors hasbeen well studied in animal models. Prenatally, hormones typicallyserve to organize the sex-dimorphic structures of the brain. Postna-tally, hormones then usually serve an activating role (Phoenix, Goy,and Gerall, 1959). In some animal species there exist prenatal criticalperiods when even brief interruptions in the availability of hormonescan lead to striking differences in behavior later in development. Forexample, if a female rat is stressed during a specific period during herpregnancy, the resulting neurophysiological reaction blocks the"androgen bath" to the brain of the fetus (Ward, 1984). The interrup-tion in the "androgen bath" then alters the prenatal structuralization ofthe male brain. Startlingly, and somewhat misleadingly in terms of itsimplications, it has been discovered that this leads to decreasedstereotypical male reproductive behavior; male rats so affected pro-duce the female lordosis response, allowing themselves to be mountedby unaffected male rats. (For a discussion of the implications for ourunderstanding of the human brain, see Byne and Parsons, 1993 andFriedman and Downey, 1993.)

In the rat the presence or absence of androgens prenatally leadsdirectly to sex-dimorphic structuralization of the brain and to subse-quent differences in adult sexual behavior. The question thus ariseswhether an analogously direct role for hormones might be found inregard to the formation of gender identity. Here the work of Moneyand Ehrhardt, though it continues to be called into question on somepoints, would seem to offer a definitive answer. Among the manyconditions they have studied, one condition in particular deserves

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2 0 SUSAN COATES AND SABRINA WOLFE

mention in regard to the hormonal hypothesis: congenital adrenalhyperplasia (Ehrhardt and Baker, 1974). This rare autosomal inheriteddisorder involves a genetic defect in cortisone production, and thus inadrenal steroidogenesis. The consequence in a genetic female isexcessive levels of adrenal androgens prenatally, and ambiguous orelse fully masculinized external genitals at birth despite normalfemale internal reproductive organs. Though at one point in time suchchildren might have been raised as males, in recent decades all areraised as females (which is what their chromosomal inheritancedictates) with surgical correction and cortisone-replacement therapyas needed. The importance of this syndrome theoretically is thatowing to the genetic defect, itself not sex-linked, such girls areexposed to excessive levels of the male hormone androgen both pre-natally and in early childhood prior to the institution of cortisone-replacement therapy. Thus, in addition to the masculinized genitals atbirth, these girls are potentially exposed to androgen-related changesin the structure of their brains. If hormones played a crucial role ingender identity disorder, we should expect that a high proportion ofthese girls would develop it. Research into girls with congenitaladrenal hyperplasia suggests that they are indeed more masculine/lessfeminine than controls in their gender role behavior; that is, they aremore active and more involved in rough-and-tumble activities(Ehrhardt and Baker, 1974; Ehrhardt and Meyer-Bahlburg, 1981).They also exhibit somewhat higher levels of gender dysphoria thanwould be expected in the normal population. Their core sense of beingfemale is largely unaffected, however, and very few of them showsigns of formal gender identity disorder, either in early childhood or inadolescence.

But there do appear to be intermediate routes whereby the relativestatus of male and female hormones can indirectly influence one'score experience of gender in the interaction with significant others.Recall that one of the few sex differences found to date is the relativepreference of boys for active exploration and rough-and-tumble play.Interestingly, it has been found that such proclivities can be influ-enced by prenatal male hormones. Girls with congenital adrenalhyperplasia, for example, show a positive preference for rough-and-tumble play. Similarly, animal experiments have repeatedly shownthat a decrease in prenatal male hormones leads to a diminishment in

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those active behaviors that in children tend to lead to rough-housingand play-fighting with peers. The same bio-psychological relationbetween prenatal hormones and rough-and-tumble play appears tooperate in children, though the specific mechanisms governing it areunknown. These findings have led to repeated attempts to documenthormonal differences in male children with GID—all without success.

In summary, it strongly appears that while as yet undocumentedvariations in prenatal hormones likely have an effect on gender rolebehavior through their impact on temperament, they are not directlycausal in producing a full-blown gender identity disorder. Moreover,their impact on gender role behavior must be socially mediated in spe-cific ways before it can lead, even indirectly, to the development ofGID. Here let us consider how temperament might influence thechild's nascent ability to classify by gender.

Children appear to be programmed from the start to categorize inbinary dichotomies, for example, big/little, male/female, bad/good,pretty/ugly. Kohlberg (1966) has suggested that the first concept thatchildren learn is big/little and the second is male/female. Childrencreate concepts by abstracting from multiple instances of perceptuallysalient characteristics. At this early stage of categorization, conceptsare grossly overgeneralized and Stereotypie. When you ask a 2-year-old how to tell the difference between boys and girls, you typicallyhear variations of the following: girls wear dresses or have long hair,and boys fight (Kuhn, Nash, and Brücken, 1978). For young children,outward appearance (haircut and clothes) and aggression (fighting) arethe principal subcategories subsumed under the boy/girl categoricaldistinction. "Boys fight" is a stereotype that children learn early on.Indeed, as Fagot and Leinbach (1993) have indicated, in girls thedevelopment of the ability to classify according to gender leads to amarked decrease in their levels of aggression.

For a boy with a shy, inhibited temperament, a nonfighting boy, itmust be more difficult at this early age to feel that he really belongs tothe category of "boy" even if he knows how to place himself in it cor-rectly. Our impression is that many boys compare themselves to otherboys and feel that they don't quite fit in, particularly if their peers arevery rough and tumble and if they do not have other male peers with atemperament similar to their own. Contributing to the problem is thefact that the affiliation patterns of preschoolers are influenced by pref-

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erences for children with similar temperaments. This has been specifi-cally demonstrated around differences in aggression, social compe-tence, and social sensitivity (Moller, Gulko, and Serbin, 1988-89). Webelieve that temperamental similarity, particularly in regard to anaversion to rough-and-tumble play, leads boys with GID to prefer toplay with girls. This pattern of peer affiliation in turn makes them feelless like a boy.

In fact, clinical experience indicates that both of these routes (tem-peramental similarity, peer affiliation) whereby temperament affectsself-categorization are factors which help perpetuate the disorder onceit becomes established. We regularly address both issues in our treat-ment of the child. However, lest there be misunderstanding, neitherfactor is sufficient by itself to cause the disorder. GID comesinto being only under the impact of far more massively pressingpsychodynamics.

Constitution in Boys with GID

A different route to understanding the constitutional diathesis for GIDis through the application of concepts derived from other clinical syn-dromes. Thus, Bradley (1985) has made the important suggestion thatthese boys may share some of the genetic predisposition for affectivedisorder. Certainly, there is a great deal of supportive evidence forsuch a proposition. The high rate of depression and anxiety found inthe mothers of these boys (Wolfe, 1990; Marantz and Coates, 1991;Zucker, personal communication), and the presence of alcohol abuse,depression, and anxiety disorders in a significant percentage of thefathers (Wolfe, 1990) point to a strong familial loading for an affectivediathesis. The extremely high rate of separation anxiety disorder(55%-60%) in these children, as well as evidence of depressivesymptoms, lends support to Bradley's thesis. If one assumes such aconstitutional diathesis at work in these children, then one's attentionis drawn to the issues of separation and loss as potentially potenttraumas that may have a considerable role in instigating the disorder;this is exactly what one observes clinically in a great many cases.

Further support for Bradley's view comes from research into tem-perament in early development. Boys with GID are typicallydescribed as avoidant of rough-and-tumble play, more anxious andfearful in new situations, and more prone to separation anxiety. As

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Bates, Bentler, and Thompson (1979) have independently reported,boys who are cross-gender identified are inhibited and fearful at thetime of their clinic evaluations. In these respects boys with GIDstrongly resemble Kagan's (1989) "inhibited" type of child. InKagan's paradigm, inhibition refers to the degree of fearfulness anduncertainty that a child will manifest in a challenge situation, whichconsists of the presentation of unfamiliar stimuli in the absence of aprimary caretaker. Even at very young ages, children can be placedreliably along a continuum ranging from extremely inhibited (and thusfearful and timid in the challenge situation) to extremely uninhibited,or bold. Here, as with other variables such as curiosity and activitylevel, one would expect that during the course of development, thechild's degree of inhibition would shift according to environmentalvariation and, even more importantly, according to the quality andstability of the interaction with primary caregivers; initial scoreswould not by themselves be predictive of later ones. Indeed, this is sofor the great midrange of children (moderately inhibited to moderatelyuninhibited.)

What Kagan (1989) has discovered, however, is that the extremesof the continuum, i.e., the 15% of children who are extremely inhib-ited and the other 15% of children who are extremely uninhibited,prove to be remarkably stable over the course of the early years ofdevelopment. Kagan thus proposes that a qualitative distinctionapplies to these children, or in other words that we are here dealingwith constitutional types. Kagan (1989) further reports that the inhib-ited shy child shows a heightened degree of initial physiologicalarousal in the challenge situation. The phenomenon of behavioralinhibition can be seen as a strategy for coping with a more highlyreactive central nervous system. Put in common-sense terms, it takesfar less to send an inhibited child's pulse racing; accordingly, such achild is far less adventurous in spontaneously exposing himself to newthings in situations of uncertainty. The observed degree of inhibitionis the outward behavioral compensation for the inward condition ofbeing readily and highly aroused. Biederman and colleagues(Biederman et al., 1993) have found that shy children are at high riskfor developing childhood onset anxiety disorders.

The portrait of the boy who is susceptible to develop a gender iden-tity disorder shares some notable similarities with Kagan's inhibited

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type. Our clinical impression is that boys with GID often are markedlyanxious and fearful in new situations (a trait that can be observed wellbefore the onset of the disorder proper) and are very slow to maketransitions to these new situations. Compared to other children, boyswith GID typically need the safe base of their parents for longer peri-ods of time when making these transitions; in clinic situations theywill hang at the door, holding mother's hand, and wait for a timebefore going in on their own. These boys typically tend to rely onsignificant others for clues about novel situations.

In a recent pilot study, we were able to put our clinical impressionson a firmer empirical footing (Coates, Hahn-Burke, and Wolfe, 1994).Using a brief parent questionnaire developed by Kagan, we found that69% of our sample warranted the classification of inhibited. The rateof inhibited types was fully four times what would be expected in thegeneral population. The observed overall frequency corresponds withour general clinical experience; more than a majority of boys pre-senting with GID fit the description of Kagan's inhibited type. (Theissues raised by the minority of boys who do not fit this type are com-plex. Suffice it here to say that we believe that the combination ofparental psychodynamics and intercurrent trauma must be even moreextreme and more unsettling to the child in these cases where theordinary temperamental diathesis is not present.)

Kagan (1989) reports that shy adults have lower thresholds forolfactory stimulation. Stoller (1968) first described boys with GID ashaving unusual sensory sensitivities involving sight, sound, touch, andolfaction. These same sensory sensitivities, as well as a sensitivity totaste, have been striking in many of the boys we have evaluated at theSt. Luke's/Roosevelt Hospital Childhood Gender Identity Center.These sensitivities are reflected both in an increased capacity toderive sensory pleasure, such as pleasure from colors, music, textures,taste, and odors, and in a heightened vulnerability to the dysphoricaspects of sensory experience. A mother may report, for example, thather child will spontaneously remark on good odors, such as cookiesbaking in the oven, but that he will gag when a garbage truck passes.Similarly, these boys are frequently drawn to bright vivid colors butwill sometimes have strong aversions to dark colors to the pointwhere, for example, some will refuse to wear black. Another child willbe described as enjoying music and will demonstrate musical talent

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but also will cry at unexpected loud sounds such as the doorbell ring-ing, or a vacuum cleaner being turned on, or raised voices. Many boyswith GID refuse to wear a new shirt unless the tag is cut out, but bythe same token they will derive obvious enjoyment from the feeling ofsoft textures next to their skin.

Recently, we conducted a pilot study to document the presence ofspecial sensory sensitivities in boys with GID vis-à-vis a demographi-cally comparable control group. Significant and large differences werefound for reactivity to colors and odors, with suggestive trends notedfor reactivity to sounds and textures. Depending on the particular sen-sory modality, the percentage of boys with GID showing sensoryreactivity ranged from approximately 50% to 75%. On the basis ofthis data, we suspect that not only do a majority of boys with GIDcome from the inhibited type, but that they further come from theinhibited subtype, as described by Kagan, who manifest specialsensory reactivity.

In summary, the link between inhibited temperament and the devel-opment of GID is very striking. An inhibited temperament seems to bean important prédisposer to the development of GID. That is to say, asensitive, inhibited temperament serves to lower the threshold for thedevelopment of the disorder though by itself temperament is neither anecessary nor sufficient condition for the disorder to come about. Yetother environmental and experiential factors must come into play for aGID to originate.

The last point needs both emphasis and qualification. On the issueof temperament, Kagan (1989) raises the important question ofwhether temperament is determined by biology alone or in interactionwith the child's early environment.

We suggest, albeit speculatively, that most of the children wecall inhibited belong to a qualitatively distinct category of infantswho were born with a lower threshold for limbic-hypothalamicarousal to unexpected changes in the environment or novelevents that cannot be assimilated easily However, we believethat the actualization of shy, quiet, timid behavior at two years ofage requires some form of chronic environmental stress actingupon the original temperamental disposition present at birth.Some possible Stressors include prolonged hospitalization, death

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of a parent, marital quarreling, or mental illness in a familymember [pp. 161-162].

Although we agree with Kagan that a reactive temperament can bemade more reactive by stress, we also share the view of Sroufe (1985)that temperament is codetermined by constitution and the attachmentexperience from the beginning of life. That is to say, once one movesbeyond the neurological and behavioral status of the neonate asobserved immediately after birth, one is necessarily viewing featuresthat have evolved in the context of the continuing mother-child inter-action. In this context, one should note the recent finding of Kochan-ska (1991) that a pronounced inhibited temperament in childrenappeared as one of the significant sequellae of severe unipolar depres-sion in their mothers.

Constitution and Attachment in the Onset ofGID

Findings from primate research on the role of temperament, earlyexperience of separation, and attachment on the development ofdepression can help us to illuminate ways that temperament, stress,and attachment relationships interact. The relevance of primate mod-els to the psychobiology of human depression, first proposed byBowlby (1969), is no longer in doubt. The infants of many primatespecies show a distinct pattern of protest followed by resignationwhen they are separated from their mothers. When the separation per-sists, the infant monkeys typically develop both neurochemical andbehavioral sequellae. These sequellae in turn predispose the individ-ual monkey to develop reactions in later adulthood that appear analo-gous to human depression or, at the very least, to those aspects ofhuman depression that are anaclitic in nature.

What is not often appreciated by psychodynamic clinicians is thatthere is a considerable intraspecies variation in the degree to whichindividual monkeys are prone to develop separation reactions in earlylife and depressive equivalents later on. Indeed, it is possible throughselective breeding to develop strains within a given monkey species inwhich vulnerability to separation reactions is either unusually high orunusually low, as in the remarkable experiments of Suomi (1991a, b)with the Rhesus monkey. The Rhesus is a good species to study

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because these monkeys live in complex social groups in which thereare many long-term relationships between individuals. Moreover, theyshare over 90% of nonreplicated DNA material with Homo sapienswhich may be responsible for the fact that many of their social rela-tionships strongly resemble those seen in most human societies. WhatSuomi (1991a) did was breed one group of Rhesus monkeys in whichvulnerability to early separation and subsequent "depression" wasquite high, and one group of physiologically less reactive monkeys inwhich vulnerability to separation was low. In addition to depression,these high reactive monkeys displayed extreme behavioral and physi-ological reactions in the face of novelty. They would hover in the cor-ner of a new playroom while the low reactives would explore the newenvironment without inhibition. Like Kagan, he conceptualized thesetemperamental types as reflecting differences in neurophysiologicalreactivity, and he, too, found that at the extremes of the continuum,approximately the highest and lowest 20% were stable over longdevelopmental periods. That is, the high reactives were sensitive toseparations and tended to remain so over their life course.

Suomi (1991b) then conducted a remarkable additional experimenton the interaction of temperament and early attachment experience.He bred lines of high and low reactives that were then each dividedand raised by two different kinds of mothers. Half of each group wasraised by ordinary, competent foster-mothers while the other half wasraised by foster-mothers who were particularly nurturant: that is, theywere less punitive and rejecting during weaning and were more pro-tective and supportive when their infants began to experiment withseparating and exploring the environment on their own.

As they grew older the monkeys were placed in a large single groupwherein adolescent Rhesus monkeys normally form dominance hier-archies. Status in dominance hierarchies is determined by complexsocial skills and is a critical measure of adaptive competence inprimates. Placed in the group was a pair of "foster grandparents,"older monkeys whose presence was designed to keep control overlevels of aggression. As it happened, only the shy, high reactive mon-keys who had enjoyed unusually nurturant foster-mothering made useof these "grandparents," establishing a close social relationship withthem. To Suomi's surprise, the shy, high reactive monkeys raised bythe nurturant mothers (and who made use of the "grandparents") sub-

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2 8 SUSAN COATES AND SABRINA WOLFE

sequently ended up and remained at the top of the dominance hierar-chy. The shy ones raised by ordinary foster-mothers, by contrast, allended up at the bottom. And the low reactive, bold monkeys ended upin the middle of the hierarchy, with their status appearing to be unaf-fected by parenting style. High reactives appear to be more influencedby maternal style of caretaking than low reactives, and the influencehas long-term consequences.

These findings are in keeping with contemporary psychoanalyticdevelopmental researches (Stern, 1985; Emde, 1988a, b; Zeanah et al.,1989; Lachman and Beebe, 1992; Slade and Aber, 1992) that havefound that continuities in development grow out of the child-caretakerinteraction unit and not out of separate continuities within either thechild or the parent. In order to make even moderately successful pre-dictions of later childhood on the basis of observations at earlier ages,it is necessary to look at the mother-child interaction unit. Thesignificance of Suomi's work in this context is that he has demon-strated that a given temperamental trait (in this case high reactivity)can take variable phenotypal expression depending on the quality ofthe infant's early attachment relationship. Monkeys that are bred to besensitive to separation and later to depression, but that are given theadvantage early of unusually nurturant foster mothers and later of theavailability of foster "grandparents," proved to be unusually robust asadolescents, surpassing not only monkeys endowed with a similartemperament, but also monkeys bred to be bolder and less sensitive toseparation.

Constitution and Attachment in the Onset ofGID

The foregoing considerations allow us, we contend, to look at thetypical etiological constellation leading to the development of GID ina new light. Insofar as children prone to GID are comparable toKagan's inhibited type, one would expect them to be strongly affectedby their primary attachment relationship and to be unusually respon-sive to disruptions in that bond. This, in fact, is what is reported andobserved with many children who develop GID. Often the mothersreport that the early period of attachment was quite uneventful, andthat there only began to be significant difficulties at a later age. More-over, when one begins to chart the impact of intercurrent familial

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Stressors, whether experienced as traumatic by the child or by themother or by both, on the development of the disorder, one invariablyfinds that in the wake of the traumatic events, the attachment systembetween mother and child became derailed. The GID, in turn, arose inthe context of the derailment of the attachment system.

If we take matters from the child's point of view, the loss of mater-nal emotional availability (Emde, 1980) is a catastrophe. There isgrowing evidence that boys in general are more dependent upon theirprimary care-takers for help in regulating affect than are girls(Osofsky and O'Connell, 1977; Weinberg and Tronick, 1992; Murrayet al., 1993). Boys with a shy, inhibited, and highly reactive tempera-ment are to that extent still more dependent upon their primary care-takers to help modulate their levels of arousal, most especially duringtransitions and in new situations. Consistent, attuned, and attentivemothering will help the boy to reduce his anxiety in strange situationsand develop autonomy. A boy so predisposed will be far more vulner-able to inconsistent parenting, however, and the disruption of theattachment relationship will be far more destabilizing to him than to aboy of lower reactivity. Put in other terms, these children depend onthe intersubjective world between self and other in order to keep theiraffective balance; when they lose intersubjective connectedness, asfor example with a mother who is overcome by a depression, thesechildren lose more than their object. They potentially lose the abilityto mentalize their self (Fonagy, 1991) and to experience their affectivecore (Emde, 1983) and thus they lose themselves—or at least that isthe threat. The restoration of the object in the enactment of a fantasyfusion of self with mother becomes an important mode for attemptingto restabilize the self.

We believe that the imitative identification with the mother as adefense against loss and maternal emotional unavailability draws onthe boy's innate capacity for sensory sensitivities and reactivity. Sim-ilarly, we also believe that the same sensory sensitivities foster thehigh degree of empathie connectness that is so often prominent inboys with GID. Although empathy involves complex perceptual, cog-nitive, and affective processes, the first stage, resonance of feeling(Stern, 1985) or perceptual affective resonance (Ghent, 1994), isalmost certainly informed by special sensory sensitivities when theyare present. Ghent has proposed that affective resonance is employed

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not only in empathy, but may well be intrinsic to the very nature ofperception itself. He further suggests that perceptual affective reso-nance is involved at more complex cognitive-affective levels in pro-cesses of identification and mimicry that can be used as active vehi-cles for perceiving the other. With regard to identification andmimicry, Ghent's position draws on the earlier work of Emch (1944)who believed that in some children astonishing acts of mimicry cameabout in response to otherwise unassimilated events: "When the . . .experience is one which cannot yet be assimilated by the child, thenext best tool at its command is the attempt to know through an atten-uated repetition of the disturbing stimulus-experience, especially as itrelates to the mediator of the experience" (p. 14). Emch postulatedthat "knowing by acting out the likeness of a situation," which shetermed "identification-knowing," could take place in very young chil-dren. Ghent believes that this process is especially likely to beemployed in situations where the child encounters aggression that isincomprehensible and unmetabolizable; the process is said to be inte-gral to the higher level defense of identification with the aggressor(Ghent, 1990).

We find these observations compelling and useful in informing ourunderstanding of boys with GID. Our belief is that sensory sensitivi-ties heighten the basic capacity for affective resonance in the child,and thereby affect the development of both empathie connectednessand imitation. The case of Colin, a 3 Vi-year-old boy reported else-where (Coates, Friedman, and Wolfe, 1991), demonstrates how anunderstanding of the contribution of constitutional factors illuminatesfacets of the clinical presentation. During the intake, Colin's motherdescribed him as unusually loving as an infant and as being speciallytuned into her feelings. During his own initial interview, Colin com-mented to the two female interviewers that they were both wearing thesame shade of blue. Shortly thereafter in the interview, he began tovoice his fears of "ladies with angry eyes," and proceeded to act outwhat he had in mind. It emerged during further evaluation that athome he often cross-dressed with make-up in front of a mirror andmade angry faces. In the course of prolonged treatment, his mothercame to realize that during the height of her own trauma, she hadrepeatedly shaken Colin by the shoulders, while staring at him full-face, with a ferocity that scared both of them.

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In Colin's case, special sensitivity to sights and colors informed notonly his ability to make an empathie connection to his mother, butalso his imitation of her during her rages. In our experience, suchredeployment of the sensory sensitivities in the child's defensiveoperations is typical. Sensory affective resonance, we argue, helpsinform the notable acting ability and talent for mimicry that has beendescribed by many observers as typical of boys with GID (Green andMoney, 1966). Likewise, these sensitivities also inform the capacityfor empathie connection, another typical feature that is regularlycommented upon spontaneously by mothers of the boys. We haveobserved the same capacity for empathy become readily redirectedtoward peers, once treatment has reduced the child's anxiety. In manyways, the focal symptoms of these children represent their attempts toemploy their sensory affective resonance to find, reach, and connectwith a mother that has become emotionally inaccessible as well as tometabolize the incomprehensible experience of her emotional with-drawal and irritability.

The child's constitutional proclivities, then, help inform the defen-sive choices that lead to cross-gender behavior. To become stabilized,however, the cross-gender behavior must succeed not only in stabi-lizing the self but also in revitalizing the emotionally "dead" mother(see Green, 1986) in a way that repairs and stabilizes the derailedattachment relationship. For it to succeed in revitalizing the mother itmust be fueled by forces within her. Invariably, the child's attempt torepair the mother-child bond and thereby mitigate his anxiety, withinthe parameters set by his temperament, interlocks with powerfulmaternal psychodynamics in a way that makes the cross-gender identi-fication an improvement on the previous state of traumatic disrup-tion in attachment. It is this interlocking of the boy's and themother's solutions that sets the disorder in motion and contributes toits perpetuation.

Another aspect of the disorder that should be mentioned in connec-tion with constitution is poor peer relations, ordinarily one of the mostdestructive consequences of the disorder for the child once it is estab-lished. A sensitive, inhibited boy naturally will be aversive to the verysort of rough-and-tumble play that other boys prefer. On the basis oftheir temperament alone, one might expect these children to seek outthe company of girls because they are less drawn to rough-and-tumble

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pursuits. When a disturbance in gender identity is added to this,resulting in behaviors that are destined to provoke severe ostracismfrom other boys, the child's predicament vis-à-vis his male peersbecomes untenable (Fagot, 1989).

The disruption of peer relationships with other boys has seriousconsequences. As Fagot (1993) has recently reported, for boys aged 3to 4 the peer group is the single most powerful influence in thesocialization of gender behavior, surpassing both teachers and parentsin this regard. (This is not the case for girls.) But boys at this age arefrankly intolerant of cross-gender behavior, and girls merely tolerateit. The result is social ostracism, and inevitably a delay in acquiringbasic social skills. When, as so often happens, the father is eitherabsent from the home or emotionally unavailable to his son, the deficitin learning gender role behavior is further compounded, for fathers areextremely important for boys in learning to modulate aggression(Herzog, 1982). These facts make it imperative that the clinician, inconjunction with parents and perhaps also teachers, help the boyexplore the available interpersonal world in search of male peerswhose temperaments and interests more closely match his own, or elsemale peers who are accepting of having a shy friend (as some"roughneck" boys are). Similarly, wherever possible, it is important totry to establish a positive close relationship between the boy and hisfather.

Summary and Conclusions

Gender identity disorder of childhood is brought about by complexand multiple factors—biological, interpersonal, and intrapsychic—that interact during a vulnerable stage of development in a tempera-mentally predisposed child. In any given individual the relative weightof one of these factors over another may vary; the clinician and theresearcher must allow for multiple pathways leading to the develop-ment of the disorder.

A shy, inhibited, highly reactive constitution can best be conceptu-alized as a predisposing factor that lowers the threshold for thederailment of the attachment system. As well, it increases the child'ssensitivity to parental wishes. Chronic pathology in the parents leavesthe sensitive, reactive child with an insecure, anxious attachment.

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When trauma or severe marital stress are added, causing maternaldepression, a traumatic derailment of the mother-child attachmentbond occurs inducing severe separation anxiety in the child. When thechild's attempts to repair the derailed attachment involve gender con-tent and he succeeds in revitalizing the mother to some degree all thefactors necessary for the onset and development of GID are in place.Factors that then come to play a role in perpetuating the symptomsinvolve internal mechanisms, interpersonal mechanisms in theattachment relationship, and the experiences of the child with hispeers.

In this paper we have been concerned principally with two sub-sidiary questions arising out of research into this multiply determineddisorder of childhood. The first is the role of constitutional factors inlowering the threshold for the development of the disorder. Bradley'ssuggestion that these children may have an inherited predispositionfor affective disorder, clinically manifest in early childhood in aproneness to anxiety states, is valuable and consonant with our clini-cal experience. Support for this view comes from our finding that boyswith GID are a subset of Kagan's inhibited, high reactive tempera-ment type. On the basis of Kagan's observations, ethological parallels,and clinical experience, we have been emphasizing that reactive,sensitive boys have a higher than average need for a protective attach-ment relationship. Both we and Bradley are in agreement that a con-stitutional predisposition is operative in a majority of cases of thedisorder and that an understanding of this predisposition clarifies inimportant ways the impact of such psychodynamic, parental, andfamilial risk factors as have otherwise been identified. Rather thanconstitute an alternative mode of explanation, understanding the roleof constitution deepens our understanding of the psychodynamicetiology and clinical presentation of this disorder. To repeat what wassaid earlier, the study of the phenotypal expression of any set ofgenotypal factors necessarily must take into account the environmentand the individual's experience ofthat environment during the courseof development. Gender identity disorder, like other stable con-figurations in childhood, inexorably reflects the interaction betweenthe temperament of the child and his experience with significantcaretakers.

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The second subsidiary question with which we have been con-cerned is whether or not an understanding of the constitutional predis-position to this disorder sheds any light on the psychobiological rootsof masculinity and femininity. What we have found is that boys withGID are more like girls in that they typically avoid rough-and-tumbleplay. (It should be noted that there is a much smaller differencebetween boys and girls in levels of rough-and-tumble play prior to theachievement of gender categorization as compared to afterward [Fagotand Leinbach, 1993].) Our tentative guess, based upon animal modelsand research into neuroendocrine disorders, is that the aversion torough-and-tumble play likely reflects a hormonal influence operativein prenatal development, though such a hormonal influence has notbeen documented to date. Quite conceivably, a degree of normal vari-ation in prenatal hormonal levels may have evolved as an evolutionarymechanism for generating an adaptive degree of inter-individualbehavioral diversity. In any event, it is important to note that in theiraversion to rough-and-tumble play, boys with GID also resemble othershy, inhibited boys. These other boys typically construct gender iden-tities that are unconflicted. Accordingly, the inference to be drawn isthat the constitutional predisposition that lowers the threshold for adisturbance in gender identity in boys is not directly sex-linked.Rather, the constitutional factor, such as it is, becomes associated witha disturbance in gender through an indirect route, specifically bycausing the child to be especially vulnerable to disruptions in hisprimary attachment relationships.

If there is a lesson to be drawn from this research with regard to thegeneral topic of gender it is that masculinity and femininity, probablyover the course of the life cycle but most certainly during early child-hood, reflect the impact of and are embedded in the individual's expe-rience with significant others. Moreover, as regards early childhood,our research indicates that cross-gender fantasies can be used defen-sively to cope with massive anxiety such as occurs when the affectivebond between the male child and his mother is disrupted.

In short, becoming a boy or a girl is not biologically prepro-grammed in any simple sense. One learns to be a boy or a girl, and totake pleasure in that aspect of the self, only to the extent that the envi-ronment rewards, supports, and enjoys that aspect in the context of a

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more general recognition of one's right to be, including one's right tobe different.

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gender identity disorder in boys: the interface of constitution and early experience

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