Recent years have seen a burgeoning interest in gender identity disorders (GID) in children. Boys and girls with GID are distressed about their gender, wish to be of the opposite gender, and manifest a predominant interest in behavior and activities that are typical of the opposite gen- der. Boys with GID prefer female stereotypical activities, such as dressing up in girls’ clothes, playing with dolls, and playing the role of a female in fantasy activities. Symptoms of GID in boys usually emerge between the ages of 2 to 4 in the form of an intense interest in dressing up in female clothes (Stoller, 1968; Green, 1974; Coates, 1985; Meyer and Dupkin, 1985). Although most homosexuals have not had a childhood history of GID (Saghir and Robins, 1973; Friedman, 1988), follow-up studies have found that at least three-quarters of boys with GID become homosexual as adults (Money and Russo, 1979; Zuger, 1984; Green, 1985). The role of biological influences on the development of GID is not understood to date. No differences have been found between boys with and without GID in either morphology of external genitalia or in karyotyping of sex chromosomes (Green, 1974; Rekers et al., 1979). Despite these results, there is indirect evidence from animal studies and from spontaneously occurring endocrinological disorders that suggests that prenatal hormones may influence certain as- pects of temperament, such as energy expenditure and rough and tumble play (Ehrhardt and Meyer-Bahlburg, 1981; Hines, 1982; Friedman, 1988). The authors’ clinical observations Accepted October 16, 1990. Dr. Marantz is Director of Clinical Services, Comprehensive Re- habilitation Consultants, New York City. Dr. Coates is Director, Childhood Gender Identity Unit, Department of Psychiatry. St. Lukes- Roosevelt Hospital Center, and Associate Clinical Professor of Med- ical Psychology, College of Physicians and Surgeons, Columbia Uni- versity . Reprint requests to Dr. Coates, Director, The Childhood Gender Identity Center, AfSiated with the Psychiatric ssociates of Manhat- tan, P.C., at St. LukeslRoosevelt Hospital Center, 1090 Amsterdam Avenue, New York, Ny 10025. 0890-856719113002-03 10$03.00/00 1991 by the American Academy of Child and Adolescent Psychiatry. of boys with GID as well as observations of others suggest that most have a temperament that involves avoidance of rough and tumble play (Coates and Zucker, 1988). Although GID is presumed to be a relatively rare disorder, epidemiological studies have not yet been carried out to identify the incidence and prevalence of GID in boys and girls. Boys, however, are more often referred to child psy- chiatry clinics for evaluation than are girls (Coates and Zucker, 1988). It is now fairly well established that GID usually occurs in a context of psychopathology other than cross-gender behavior (Bates et al., 1973, 1974, 1979; Bradley et al., 1980; Coates, 1985, 1988; Coates and Person, 1985; Tuber and Coates, 1989). For example, studies have found that extremely feminine boys have more psychopathology than normal controls on behavioral disturbance inventories, such as the Child Behavior Checklist (CBCL), scoring in the range of psychiatrically referred children (Bradley et al., 1980; Coates and Person, 1985). Coates and Person (1985) found that 60% of their sample of boys with GID met the DSM-ZZZ-R criteria for separation anxiety disorder and also scored in the clinical range on the depression scale of the CBCL. The finding of a relationship between GID and sep- aration anxiety disorder has recently been replicated by Lowry and Zucker (1990). On blind rated Rorschachs, boys with GID, when compared with normal controls, were found to have more evidence of boundary disturbances and a more frequent internal experience of others as overpowering and malevolent (Tuber and Coates, 1989). Boys with GID exhibit chronic suffering that is often expressed directly by them as self-hate. One boy at age three said: ‘‘I hate myself. I don’t want to be me. I want to be somebody else. I want to be a girl.” They often experience the anguish of feeling lonely and isolated. Be- cause most are shy and nondisruptive in school, their psy- chological pain and suffering often go unrecognized by oth- ers in their environment. Studies designed to elucidate the factors that contribute to the etiology of gender identity disorders are important.
MOTHERS OF BOYS WITH GENDER IDENTITY DISORDER for developing strategies for prevention, early intervention, and treatment planning.
While gender identity disorder is comparatively rare, an understanding of the genesis and dynamics of this syndrome promises to illuminate funda- mental mechanisms involved in the development of mas- culinity-femininity and the process of identity acquisition that underlies it. The clinical observations of mothers of boys with GID from several different research units suggest that the mothers have difficulty with affect regulation that manifests itself in psychiatric disorders, such as borderline personality and depression (Stoller, 1968; Bradley et al., 1980; Coates, 1985; Coates and Zucker, 1988; Meyer and Dupkin, 1985). Depression in mothers is a known risk factor in the devel- opment of depression, separation anxiety, and attention def- icit disorder in children (Weissman et al., 1984; Puckering, 1989). Borderline personality disorder in mothers is a known risk factor in the development of borderline personality dis- orders in adolescents (Masterson and Rinsley, 1975). One of the first steps involved in developing an understanding of the cause of childhood psychiatric disorders is to begin to identify parental predisposing factors. Elsewhere, Coates ( 1990) proposed a biopsychodevel- opmental model to explain the origins of GID in boys that involves a complex interplay of biological, psychological, and cognitive developmental predisposing factors. She has explored the contribution of temperament, massive trauma, cognitive representational level of the child, and parental psychopathology to the development of this disorder. She believes that a predisposition in the boy to anxiety, an un- usual capacity for positive emotional connection, an ability to imitate, and a variety of sensory sensitivities as well as parental difficulties in affect regulation interact during a critical period of mental representational ability in the boy’s life (before gender constancy is established) to bring about a GID (Coates, 1988, 1990). According to this model, fam- ilial psychopathology is only one of several significant pre- disposing factors in the development of GID in boys. This paper reports a pilot study that is the first systematic study of psychopathology in mothers of boys with GID. The authors chose to focus on disorders that had been clin- ically observed in the families of these boys by previous investigators. The research reported here represents the start of a series of ongoing family studies and is a preliminary step in the process of pinpointing familial factors that con- tribute to the development of GID. The aims of this pilot study were two-fold: First, to de- termine whether the symptoms of depression and borderline character pathology are significant features of the psycho- logical functioning of mothers of boys with GID; and sec- ond, to determine whether child-rearing attitudes and prac- tices involving interference in the development of autonomy are predisposers to the development of GID as well.
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