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George A. Rekers, Ph.D., is Professor of Neuropsychiatry and Behavioral Science, Research Director for Child and Adolescent Psychiatry, and Chairman of Faculty in Psychology at the University of South Carolina School of Medicine in Columbia, S.C. He has authored nine books, over 120 academic journal articles, and numerous book chapters. He is the editor of the Handbook of Child and Adolescent Sexual Problems (Lexington/Jossey-Bass/Simon & Schuster, 1995) which can be ordered by calling 1-800-956- 7739.
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The past three decades have witnessed a well-publicized trend for certain vocal elements in education and the media in American culture to sharply question the legitimacy of many, if not all, sex role distinctions in the socialization of children. Television programs and textbook revisions have been used by these social forces in the attempt to normalize father-absent families as well as household of various combinations of unmarried adults as simply alternate family forms with no inherent adverse social consequences.
Paradoxically, during these same recent decades, two developments emerged in the mental health and behavioral science disciplines. First, a mass of research data accumulated which led to a recognition of the often detrimental effects of father absence on several critical aspects of child development, including normal sex role development and sexual adjustment (see reviews by Biller, 1974; Hamilton, 1977; Hetherington, Cox & Cox, 1979; Lamb, 1976; Mead and Rekers, 1979; and Rekers, 1986b, 1992, for example). Secondly, clinical and research data accumulated to a sufficient degree to enable the mental health professions to officially identify a newly recognized form of psycopathology-"Gender Identity Disorder of Childhood" (American Psychiatric Association, 1980).
Recent years witnessed the swing of the pendulum of public attention to the social advocates of "eliminating all distinctions based on sex." However, an objective consideration of the whole scope of findings in human development research and clinical studies yields an appreciation and recognition of appropriate sex roles in the family and their critical importance to the normal gender identity development of children.
Normal Versus Abnormal Sex Role Development
As part of the process of normal gender identity in the family, young children will often try out a variety of sex role behaviors as they learn to make the fine distinctions between masculine and feminine roles. Some young boys occasionally perform behaviors that our culture traditionally has recognized as feminine, such as wearing a dress, using cosmetics or play acting the roles of bearing and nursing infants. Similarly, many young girls will occasionally assume a masculine role- pretending to be "daddy" while playing house, or temporarily adopting a cluster of masculine behaviors which leads to the social designation of "tomboy." This type of temporary and episodic exploration of cross-sex- typed behaviors is typical of many boys and girls and usually constitutes a learning experience in the process of normal sex role socialization (Maccoby & Jacklin, 1974, Mischel, 1970; Serbin, 1980).
In pathological cases, however, children deviate from the normal pattern of exploring masculine and feminine behaviors and develop an inflexible, compulsive, persistent and rigidly stereotyped pattern (Zucker, 1985). On one extreme is the distorted supermasculinity of boys who are belligerent, destructive, interpersonally violent, and uncontrolled and simultaneously lacking gentle and socially sensitive behaviors (Harrington, 1970). Professional intervention is required for these exaggeratedly "hypermasculine" boys who actually have adopted a maladaptive caricature of masculinity. The opposite extreme is observed in effeminate boys who reject their masculinity to the extent of rigidly insisting that they are a girl or that they want to become a mother and bear children (Rekers, 1981; Rekers & Milner, 1978; Rekers & Kilgus, 1997). Such a boy frequently avoids play with boys, dresses in girls' clothing, plays predominantly with girls, tries on cosmetics and wigs, and displays stereotypically feminine arm movements, gait, and body gestures. This boyhood femininity goes beyond normal transitory, curiosity induced exploration of feminine behavior to constitute a serious clinical problem (Rekers, 1985d, 1985e) Although little research exists on female childhood gender disorders, it is possible to identify the parallel conditions of maladaptive hyperfemininity and hypermasculinity in girls (Rekers & Mead, 1979, 1980).
One of the clinician's tasks is to differentiate normal adjustment phases in psychosexual development from gender disturbances that require specific treatment intervention (Rekers & Kilgus, 1995; Rekers, 1995a). To illustrate this task, let me describe a boy to you.
Carl (a pseudonym) was referred to me for treatment at the age of 8 years, 8 months (Rekers, Lovaas & Low, 1974). The referring physician had found Carl to be physically normal in terms of currently available methods of biomedical testing. Prior to referral to me, Carl had been evaluated by two separate psychiatric agencies as having a severe cross gender identity problem. In one clinic, Carl had been treated in family therapy for a period of 8 months in a largely unsuccessful attempt to alleviate his personal problems and his major difficulties in peer and family relationships.
He came from a broken family in which his mother had had four marriages in Carl's lifetime. Carl had a brother seven years old and a sister six years old.
Since the age of our years, Carl had pronounced feminine voice inflection and feminine speech content. He was extremely verbal, and his conversations were dominated by topics such as dresses, cosmetics, maternal roles, female impersonators, delivering babies, and female underclothing. He had several recurring exclamatory feminine sounding remarks, such as "goodness gracious," and "oh, dear me."
His feminine gestures were exaggerations of an effeminate, swishy gait and arm movements. He would typically sit with his legs crossed very effeminately and his arms folded like a female model. At home, he would frequently use towels after a bath to simulate female garments and long hair.
In his peer relationships, Carl passively allowed boys to lease him without asserting himself in return. He preferred girls in play, assuming the female role himself with great....played house with his sister frequently. Carl was ostracized by his male peers who labeled him "sissy" and "queer." He harbored a strong fear of "getting hurt" and feigned illnesses and injuries to avoid play with boys. Not only was Carl labeled by his peers as effeminate, but also he referred to himself as a "sissy" and "fag," and his speech regularly implied that he preferred to be considered a girl.
Carl's feminine behavior was increasingly leading him to social isolation, ridicule, and chronic unhappiness. His mother, who had found his feminine gestures to be amusing before he was age four, was very alarmed when they persisted to the age of eight years. She strongly wanted him to receive professional help, and she requested help herself to solve the related problems in her family.
Disorder Created by Incongruity Across Dimensions
Physically, Carl's physician had determined that his sexual status was normal prepubertal male with a normal 46XY male karyotype. His sex of assignment had been male, and his mother had raised him as a boy.
His gender identity was that of a girl. In other words, he had a cross gender identity. He called himself a "sissy" and a "fag," and this constituted an aspect of his sex role identity. His gender role behavior was predominantly feminine.
Because of his age, his sexual object orientation and genital interpersonal behavior were not assessed at the time of his initial evaluation. He was not involved in sexual behavior.
Carl's case illustrates how any incongruity across any two of these psychosexual dimensions can create psychological conflict and associated maladjustment problems (Rekers, 1981b; Rosen & Rekers, 1980). This brings us to a distinction between Gender Role Behavior Disturbance and Cross Gender Identification in boys.
Gender Role Behavior Disturbance
A Gender Role Behavior Disturbance may be present in a boy as young as three years old who has normal male physical sex status. Typically, the sex assignment has been male, although cases have been reported where family members have given incongruent or ambiguous messages to a young child regarding his physical sex status. Gender identity is typically male and not female, although sex role identity may range from male gender role, to self-labeling as "fag" or "queer" across settings. For this reason, our case of Carl is not a classic example of Gender Role Behavior Disturbance. In this developmental disorder, sexual orientation may be absent, unreported, or varied-including sexual arousal tom feminine clothing. At the sexual behavior level, the boy may or may not have a documented history of deviant sexual behavior or masturbation patterns associated with feminine clothing or articles.
The distinguishing features of Gender Role Behavior Disturbance exist at the interpersonal dimension where any of the following behavior are observed over an extended period of time; Cross dressing; play with cosmetic articles; "feminine" appearing gestures; avoidance of masculine sex-typed activities; avoidance of male peers; predominant ratio of play with female peers; high "feminine" like voice inflection; predominant ratio of feminine speech content over masculine; and taking predominately female roles in play.
Of course, Gender Role Behavior Disturbance may occur in either boys or girls, although it is detected more frequently in boys. And there are two major extremes that can be manifested in terms of role inflexibility in either the masculine or feminine direction, in either boys or girls. The two possible chromic patterns in boys are (1) excessive feminine behavioral rigidity, and (2) pathological hypermasculinity. The two possible chronic patterns in girls are (1) excessive masculine behavioral rigidity, and (2) pathological hyperfemininity.
Gender Identity Disorder of Childhood
In addition to the behavioral manifestations of a Gender Role Behavior Disturbance, a boy with a Gender Identity Disorder also manifests one or more of these features: (1) And expressed desire to be a girl or a woman, (2) expressed fantasies of bearing children and breast-feeding infants or assuming a female identity, or (3) a request to have his penis removed.
Carl illustrates the potentially more serious disorder of Cross Gender Identification. This condition in boys involves gender identification as a female, including requests to change one's physical sex status.
I have observed and reported in the literature (Rosen & Rekers, 1980) this distinction between the Gender Role Behavior Disturbance and the Cross Gender Identification Disturbance. Theoretically, Gender Role Behavior Disturbance in child development may parallel the adulthood conditions of transvestism, while the problem of Cross Gender Identification in children may parallel the adulthood condition of transsexualism. But this remains a question for empirical research into the life span development of these individuals.
Cross Gender Identification in boys is only one potential type of Gender Identity Disorder because a parallel condition can be found in some girls.
Prognosis for Child Gender Disorders
In terms of atypical gender development in children, the literature deals almost exclusively with the cases of deficit masculine development in boys, including cross gender identity disturbance, gender role behavior disturbance and homosexual behavior development. This state of the research literature is, in part, a function of the frequently replicated finding that problems of sexual dysphoria and deviation occur more frequently in males than females and may be a function of the relatively greater concern by American parents over feminine sex role behavior in their sons.
The feminine sex-typed behaviors which are used as the initial screening criteria for assessment of gender disturbed boys can exist in many different developmental contexts. Theoretically speaking, it is probable that the prognosis and treatment of gender role behavior disturbance and cross gender identity disturbance are not the same; but research on this question has not yet been conducted. The developmental histories of all these types of gender deviant boys parallels the retrospective reports of adult male transsexuals, transvestites, and some homosexuals; and the prospective longitudinal studies of children as they grow up to adolescence and adulthood indicate that most of these effeminate boys became homosexual in orientation and some are transvestite or transsexual (Green, 1982; Zucker, 1985; Zuger, 1966, 1978, 1984).
There are no base rate data on the occurrence of these various types of sex role disturbance.
Medical Examination for Research Subjects
Over the past 12 years, over 100 boys have been referred to my N.I.M.H. supported Gender Research Project for evaluation and potential treatment for a gender disturbance. My research team completed comprehensive psychological evaluations of approximately 70 of these children, and we required a complete physical examination and medical history report from the child's pediatrician. In addition, a pediatric geneticist joined us to conduct a more complete medical examination for a subset of consecutive referrals to our project. According to our geneticist, baseline endocrinological studies were considered unnecessary unless abnormalities were detected in the physical examination. The following medical examination was given to the subset of research subject referrals: Medical history; physical examination, including external genitalia; chromosome analysis, including two cells karyotyped and 15 counted; and sex chromatin studies.
All 70 of the gender disturbed boys were found to be normal physically and the more completely evaluated boys were found to be normal physically, with the single exception of one boy with one undescended testicle (Rekers, Crandall, Rosen & Bentler, 1979). No evidence was found for maternal hormone treatment during pregnancy nor were there any histories of hormonal imbalance in the mothers. Our findings were consistent with the literature on adulthood gender disturbances such as transsexualism and transvestism-namely, occur in individuals without detectable or measurable abnormalities in any of the five physical variables of sex.
The Importance of Family Variables
In these cases, therefore, the social environment of child-rearing is primarily implicated in the etiology of the psychosexual disturbance. I investigated the family variables correlated with the degree of gender disturbances in the sample of subjects that I have accumulated.
Why should the families of gender disturbed children be studied? I believe that much has been learned about normal life span development by investigations of deviant cases which shed light upon critical processes relevant to normal social development.
My first step in the analysis for the families of these boys was to focus upon the fathers, the father substitutes, and the male models available to these boys with inadequate masculine role development. The research literature of the psychosexual development of normal children has revealed that the father is the parent whose role behaviors are most likely to generate sex appropriate behaviors in the children in a family unit (Mead & Rekers, 1979). The characteristics that have been reported to foster the establishment of normal gender identity in children include the father's nurturance and dominance. In contrast, literature on the effects of paternal deprivation indicates that the sex role learning process is adversely affected when fathers are either physically or psychologically absent from the home (Biller, 1974; Hamilton, 1977).
The impact of paternal deprivation on psychosexual development is most conspicuous in the retrospective clinical studies of homosexual and transsexual men. But direct studies of the families of gender disturbed children have been few.
Family Problems Associated with Gender Disturbance
My own study of the family variables associated with childhood gender disturbance was based upon a subset of the boys we evaluated for gender disturbance, for whom we completed three independent psychological evaluations, each of which took into account these factors: Identity statements, cross dressing history and frequency, cross gender role play behavior, parent-child relationships, parental attitude toward gender behaviors, peer relationships, social and academic adjustment, emotional adjustment, and congruence of diagnoses by independent psychologists.
Two other clinical psychologists, in addition to myself, completed independent diagnostic evaluations of each subject, and rated each subject on two scales one scale for gender role behavior and another for gender identity. Each of these scales constituted a five-point continuum from "normal" to "profound" disturbance (Bentler, Rekers & Rosen, 1979; Rekers, 1988a; Rekers & Morey, 1989a, 1989b, 1989c, 1990).
One of the most striking findings in the families of these boys I studied was the incidence of psychiatric problems. Eighty percent of the mothers and 45% of the fathers had a history of mental health problems and/or psychiatric treatment. It may be possible that these figures are somewhat inflated compared to the larger population of gender disturbed boys in that parents who have sought treatment for themselves may be more likely to seek treatment for their children. However, these findings suggest that the parents of gender disturbed boys have an unusual degree of psychological maladjustment.
Our findings with regard to paternal deprivation in these boys parallels much of the literature on the detrimental effects of father absence on normal psychosexual development.
In the boys who were classified as the most profoundly disturbed, father absence was observed for all cases. In the remaining less disturbed cases, father absence was found in 54% of the cases. Using the nonparametric Fisher's exact probability test, this difference was found to be statistically significant.
For the entire group of 46 subjects, 37% had no adult male role model (either biological father or father substitute) present in the home. According to the 1977 U.S. Census figures (which are comparable to this sample) only 12% of all white children lived with their mother only, therefore without the benefit of a father or a father surrogate. Of the 36 boys in this study who received a diagnostic rating, 75% of the most severely disturbed boys and 21% of the less severely disturbed had neither the biological father nor a father substitute living in the home-a statistically significant difference (p = .01, Fishers).
Eighty percent of the boys whose fathers left their family were five years or under at the time of that separation-the mean age at separation from the father was 3.55 years. Figure 2 shows that the most common cause for father absence was marital separation or divorce.
For all the gender disturbed boys, if the biological father or a father substitute were present, he was described in 60% of the cases as being psychologically distant or remote by the other family members.
A consistent picture is beginning to emerge from these findings and from other small sample studies. The young males with the most pronounced gender disturbances tend to be less likely to have a male role model in the home, as compared to less severely gender disturbed boys (Rekers, Mead, Rosen & Brigham, 1983; Rekers & Swihart, 1989).
In general, the picture of the fathers of gender disturbed children found in these data is in sharp contrast to the image of the idealized father who promotes masculinity in his sons through his psychological and physical presence, his active involvement with his children and with the family decision making, his leadership, his dominance and his nurturance (Mead & Rekers, 1979).
In a large number of instances, no male role model existed during early childhood developmental years in the home, whether it be father, father substitute or older male sibling. This absence of male role models with whom to identify was even more characteristic of the most severely disturbed effeminate boys. In cases where the father or a father surrogate was present in the home, he was typically described as psychologically remote from the family.
These various sources of clinical evidence suggest that fathering variables are correlated with male sex role disturbance, even though the direction of causality between these variables is inferred, not established, by scientific observation. An ideal future study in this area would be a longitudinal investigation of a large enough sample of boys selected at random at birth that would contain a sufficient number of male role disturbed boys to provide definite causal evidence. Two comparison groups would be in order-a normal control group and a group of boys with other types of psychological disturbance.
Child and Family Treatment Interventions
There are numerous interrelated reasons for intervening in the life of a boy diagnosed with a gender disturbance. The first reason for treatment is the psychological maladjustment of gender disturbed children. The second reason for intervention is to prevent severe sexual problems of adulthood such as transsexualism and homosexuality (Rekers, 1985b; Rekers & Kilgus, 1995) that are highly resistant to treatment in later phases of development. The third reason is to prevent the serious emotional, social and economic maladjustments secondary to severe adulthood sexual problems. And the fourth main reason is to cooperate with appropriate parental concern over gender deviance. I have published several detailed articles developing this rationale with reference to the clinical data (Rekers, 1977, 1984; Rekers, Bentler, Rosen & Lovaas, 1977; Rekers & Mead, 1980; Rekers, Rosen, Lovaas & Bentler, 1978; Rosen, Rekers & Bentler, 1978).
I have developed and validated several child and family treatment interventions with intrasubject research studies on gender disturbed children (Rekers, 1995b). The mother-child and father-child interventions in the clinic have focused upon behavioral counseling and behavioral rehearsal with in vivo training sessions. The most effective therapeutic techniques for the therapist to use in the clinic pertain to instructions regarding the performance of feminine speech and gesture/mannerism behaviors, coupled with videotape feedback and behavior shaping sessions. Family interventions in the home and consultation with school personnel have involved social learning approaches. We have developed father-son interaction programs, including athletic skill training. We have provided male role models if fathers are not available to young boys, and we have insured that the child received appropriate sex education in either the home or in counseling sessions. I have also published some intrasubject studies on the efficacy of various self-monitoring and self-reinforcement interventions with the children. I have evaluated these approaches with intrasubject designs, and published long-term followup outcome studies (Rekers, Kilgus & Rosen, 1990; Rosen, Rekers & Brigham, 1982).
Let me illustrate this program of treatment strategies by returning to the case of the young boy, Carl, whom I described earlier. With a multiple baseline intrasubject design across stimulus environments and across behaviors, Carl was treated in one setting at a time in order to assess the generalization of behavioral treatment effects.
Both before and during the brief treatment in the clinic, Carl's gender role behaviors were recorded in the home by the mother and a research assistant using time sampling procedures. The major portion of Carl's treatment took place in the home and school settings because Carl felt overly self-conscious in the clinic with its one way mirrors; and because our previous investigations had found no stimulus generalization of treatment effects from the clinic to the home environment.
Because Carl enjoyed telling elaborate fantasized stories while drawing pictures on a chalkboard, the brief clinic intervention procedure was designed to demonstrate simple reinforcement control over the sex-typed verbal behavior during the boy's story telling.
You will recall that Carl's conversations at the initial evaluation were dominated by topics such as dresses, cosmetics, maternal roles, female impersonators and female underwear. After obtaining a baseline measure of masculine and feminine speech content, a psychology intern introduced a differential social reinforcement contingency in which Carl's questions regarding masculine or neutral topics were answered by giving short, nonleading, direct answers, expressing positive interest. When Carl referred to a feminine topic, the psychology intern immediately withdrew social attention by looking away and by reading a magazine. If Carl persisted with direct questions regarding feminine topics, the intern expressed disinterest.
An ABA reversal design demonstrated reinforcement control over sex-typed speech; the therapeutic contingency resulted in a sharp decrease in feminine speech and an increase in masculine content. The data suggested, but did not confirm, a generalized suppression effect to feminine voice inflection as well, even though that behavior was not specifically treated.
Then Carl's mother was trained to administer a token and point economy reinforcement procedure in the home which successively increased Carl's masculine play with brother and decreased his feminine gestures, feminine speech content, feminine voice inflection and predominant play with his sister.
Because Carl's treatment in the clinic had not generalized to the home or to the school setting, his teacher was trained to apply a response cost procedure to what she called his "brat behaviors" and to his feminine/gesture mannerisms. The "brat behaviors" included: Creating a class disturbance, bossing another child, behaving rudely to teacher and teasing another child.
When the contingency was applied to the brat behaviors, they decreased immediately. The contingency for feminine gestures resulted in a gradual suppression of both gestures and feminine speech. These effects were found to be stimulus-specific to the classroom setting, necessitating a reintroduction of the contingencies into Carl's new classroom when he was promoted to the next grade level the following fall.
After a 15 month period, this treatment program in the clinic, home and school setting was completed. The social learning interventions for the boy had been combined with individual counseling for the mother and her marital problems and family relationship difficulties.
Carl and his mother were then referred for an independent evaluation by two clinical psychologists who administered tests, interviews and unobtrusive observations of the boy at school. They found no evidence of any feminine behavior or cross-gender identification in the boy after treatment. His mother, school teachers, and neighbors all agreed that he had changed in a comprehensive way from a feminine appearing to a masculine boy. Major improvements were found by those psychologists in Carl's overall social and emotional adjustment. However, Carl retained his previous social reputation as a "sissy" and "queer." We, therefore, assisted the mother in obtaining a transfer of Carl to a new school where he developed a normal social reputation and was well accepted by his peers.
However, Carl remained inept at most games and sports played by his male peers at school and in his home neighborhood. We, therefore, provided an additional 15 month program of behavior shaping procedures to overcome his deficits in throwing the ball, socking a playground ball, and in playing kickball. This training was combined with what are called "companionship therapy" in which a relationship was established between Carl and a male psychology student who modeled appropriate masculine behaviors and took Carl on numerous trips to the park, beach, and for tumbling lessons.
Twelve months after this additional program, another clinical evaluation was made of Carl's adjustment. Once again, no evidence of feminine behavior or cross gender identification were found. He was found to be normal in emotional and social adjustment.
Six years after the completion of therapy, we arranged another followup evaluation by an independent clinical psychologist. Carl was then 16 years and ten months of age. A comprehensive set of interviews, personality tests and observations were completed. This independent psychologist concluded: "This young man appears to be a normal gender appropriate adolescent boy with no salient evidences of difficulty in gender role or gender identity. He has some difficulty in feeling unsure of himself in social interactions and is generally, however, emotionally within the normal adolescent range."
Similar positive outcomes have been obtained with the other previously treated gender-disturbed children in my group (Rekers, 1979; Rekers & Lovaas, 1974; Rekers et al, 1974; Rekers & Mead, 1979a; Rekers & Milner, 1979, 1981; Rekers & Varni, 1977a; Rekers, Willis, Yates, Rosen & Low, 1977; Rekers, Yates, Willis, Rosen & Taubman, 1976) which we are following up into late adolescence now (Rosen, Rekers & Brigham, 1982). It was in the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published in 1980 that the American Psychological Association included, for the first time, the diagnosis of "Gender Identity Disorder of Childhood" (pages 264-266). Reflecting on the results of longitudinal studies of untreated children with gender disorders (e.g., Green, 1982; Money & Russo, 1979; Zucker, 1985; Zuger, 1966, 1978, 1984), the Fourth Edition of DSM published in 1994 states, "By late adolescence or adulthood, about three-quarters of boys who had a childhood history of Gender Identity Disorder report a homosexual or bisexual orientation, but without concurrent Gender Identity Disorder. ... Some adolescents may develop a clearer cross-gender identification and request sex-reassignment surgery or may continue in a chronic course of gender confusion or dysphoria" (page 536). From the result of my research studies, it now appears that a preventive treatment for transvestism, transsexualism, and some forms of homosexuality may have been isolated in these techniques of early identification and early intervention in the childhood years (Rekers, 1978, 1980, 1981b, 1983, 1987).
If the psychopathology of "Gender Identity Disorder of Childhood" is one of the major etiological precursors to adulthood homosexual orientation disturbance (as the research indicates at present), it would now appear logical that homosexuality per se be re-examined as a mental disorder.
In the introduction to his political analysis of the psychiatric battle over homosexuality, Ronald Bayer described the subject of his book:
"In 1973, after several years of bitter dispute, the Board of Trustees of the American Psychiatric Association decided to remove homosexuality from the Diagnostic and Statistical Manual... Instead of being engaged in a sober consideration of data, psychiatrists were swept up in a political controversy. The American Psychiatric Association had fallen victim to the disorder of a tumultuous era, when disruptive conflicts threatened to politicize every aspect of American social life. A furious egalitarianism that challenged every instance of authority had compelled psychiatric experts to negotiate the pathological status of homosexuality with homosexuals themselves. The result was not a conclusion based on an approximation of the scientific truth as dictated by reason, but was instead an action demanded by the ideological temper of the times..." (Bayer, 1981, pages 3-4).
It remains to be seen if the mental health professions will be able to readdress the issue of homosexuality from a logical and scientific perspective in the near future (Lundy & Rekers, 1995b, 1995c). The use (or abuse) of research may continue to be influenced by ideological factors in American culture (Lundy & Rekers, 1995a).
Suggestions for Future Research Study
1) Prior to my own series of studies, no treatment procedures for Gender Identity Disorder in Childhood had been experimentally demonstrated to be effective. We, therefore, intervened with labor intensive, multiple methods to achieve a positive therapeutic outcome. Future clinical research should investigate the most efficient set of treatment variables, for economically feasible treatment applied on a larger scale in routine clinical practice.
2) Preliminary findings have been published in the literature which report on the positive therapeutic effects of religious conversion for curing transsexualism (Barlow, Abel & Blanchard, 1977) and on the positive therapeutic effect of a church ministry to repentant homosexuals (Pattison & Pattison, 1980). Further research should be addressed to the relationship of spiritual conversion and spiritual well-being upon sexual identity development and sexual adjustment. The anecdotal reports of the healing effects of the social support of a local church should be followed up with systematic empirical study.
3) Research is needed to further understand the etiology and treatment of the other type of inadequate male role development in boys namely, those boys who are interpersonally violent, destructive and sexually promiscuous with girls sometimes to the extent of aggressive rape (Harrington, 1970; Rekers & Jurich, 1983; Rekers, 1992, 1996). This pattern, too, has been associated with father absence; but the paternal deprivation typically occurs after the age of six years (Mead & Rekers, 1979).
It is possible that our society has not yet fully reaped the full consequences of widespread breakdown of family units caused by divorce. Too often divorce of the parents results in a divorce of the father from the children. If research on the effects of divorce and separation on children can be better communicated to the general population of our culture, perhaps the American public will make greater efforts to achieve stable marriage and family life and be more highly motivated to seek genuine problem solving solutions to marital conflict rather than so quickly considering divorce, as though it were the only alternative (Rekers, 1985a).
4) As a matter of public policy, it appears now to be necessary for federal and local governments to direct funding not only to the remediation of categorical problems associated with family dysfunction (such as gender identity disorder of childhood, run away youth, or teenage pregnancy) but also toward evaluation research of community level demonstration projects using preventative educational approaches to teach fathers the value and importance of their active, warm emotional involvement with their children. Baseline measures of paternal involvement with children might be recorded before and after an intensive educational effort. Data should be gathered regarding the maintenance of the hoped for increase in paternal involvement over time.
5) Finally, in a generation confused by radical ideologies on male and female roles, we need solid research on men and women who are well adjusted examples of a secure male identity and a secure female identity. Such research could demonstrate what adaptive masculinity and femininity bring about for family life and the larger culture (Rekers, 1986a, 1991). Children with poor parental models need substitute male role and female role models. Such research could serve this need.
Figure 2
Family Correlates to Male Gender Disturbance
Gender Distributed Boy Sample
46 boys with diagnoses by 3 independent clinicians aged 3 to 13 years, mean age 7 years.
Psychiatric History of Family Available on 30 of 46 Boys
80% of mothers with mental health problems/history
45% of fathers with mental health problems/history
Male Role Model Deprivation
67% of biological fathers physically absent from the home for all cases; 100%* fathers absent for most severely disturbed boys; 54%* fathers absent for less severely disturbed boys; *
Significant at .02 level (Fisher's Exact Test)
3.55 Years = Mean Age of Boys at Time of Father's Separation
(80% of boys were aged 5 years or under at separation)
Reason for Separation from Father
82% due to marital separation or divorce
10% due to death of the father
8% due to birth out of wedlock
Presence of Stepfather or Surrogate Father Figure in
25% of most severely disturbed boys
60% of less severely disturbed boys
Presence of Older Male Sibling in
25% of most severely disturbed boys
48% of less severely disturbed boys
[This paper was presented at the First Annual Meeting of the North American Social Science Network, Washington, D.C., on June 15, 1985. The author's research presented herein was supported by major research grants from the National Institute of Mental Health, by a post-doctoral fellowship at Harvard University from the Foundations' Fund for Research in Psychiatry, and a predoctoral fellowship at U.C.L.A. from the National Science Foundation. This article was taken from The Journal of Family and Culture, Vol. II, No. 3., 1986, The Free Congress Research and Education Foundation, and updated by the author. Used by permission.]
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Lundy, M., & Rekers, G.A. Homosexuality: Presentation, evaluation, and clinical decision-making. Chapter 15 in G.A. Rekers (Ed.), Handbook of Child and Adolescent Sexual Problems. New York, NY: Lexington Books of Macmillan/Simon & Schuster, 1995, pages 313-340. (b)
Lundy, M., & Rekers, G.A. Homosexuality in adolescence: Interventions. Chapter 16 in G.A. Rekers (Ed.), Handbook of Child and Adolescent Sexual Problems. New York, NY: Lexington Books of Macmillan/Simon & Schuster, 1995, pages 341-377. (c)
Maccoby, E.E. & Jacklin, C.N. The Psychology of Sex Differences. Stanford: Stanford University Press, 1974.
Mead, S.L. & Rekers, G.A. The role of the father in normal psycho-sexual development. Psychological Reports, 1979, 45, 923-931.
Mischel, W. Sex-typing and socialization. In P.H. Mussen (Ed.), Carmichael's Manual of Child Psychology, Third Edition, Vol. 11. New York: Wiley, 1970, pages 3-72.
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Pattison, E. M. & Pattison, M.L. Ex-Gays: Religiously mediated change in homosexuals. American Journal of Psychiatry, 1980, 137(12), 1553-62.
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Rekers, G.A. Stimulus control over sex-typed play in cross-gender identified boys. Journal of Experimental Child Psychology, 1975, 20, 136-148.
Rekers, G.A. Assessment and treatment of childhood gender problems. Chapter 7 in B.B. Lahey and A.E. Kazdin (Eds.), Advances in Clinical Child Psychology, Volume 1, New York: Plenum, 1977, pages 267- 306.
Rekers, G.A. Atypical gender development and psychosocial adjustment. Journal of Applied Behavior Analysis, 1977, 10, 559-571.
Rekers, G.A. Sexual problems: Behavior modification. Chapter 17 in B.B. Wolman (Ed.), Handbook of Treatment of Mental Disorders in Childhood and Adolescence. Englewood Cliffs, New Jersey: Prentice Hall, 1978, pages 268-296.
Rekers, G.A. Sex-role behavior change: Intrasubject studies of boyhood gender disturbance. Journal of Psychology, 1979, 103, 255- 269.
Rekers, G.A. Therapies dealing with the child's sexual difficulties. In Jean Marc-Samson (Ed.), Enfance et Sexualité / Childhood and Sexuality. Montreal & Paris: Les Editions Etudes Vivantes, Inc., 1980, pages 525-538.
Rekers, G. A. Childhood sexual identity disorders. Medical Aspects of Human Sexuality, 1981, 15(3), 141-142.
Rekers, G.A. Psychosexual and gender problems. In E.J. Mash & L.G. Terdal (Eds.), Behavioral Assessment of Childhood Disorders. New York: Guilford Press, 1981, pages 483-526.
Rekers, G.A. Play therapy with cross-gender identified children. Chapter 20 in Charles E.
Schaefer and Kevin J. O'Connor (Eds.), Handbook of Play Therapy. New York: John Wiley and Sons, 1983, pages 369- 385.
Rekers, G.A. Ethical issues in Child assessment. Chapter 12 in Thomas H. Ollendick and Michael Hersen (Eds.), Child Behavioral Assessment: Principles and Procedures. New York: Pergamon Press, 1984, pages 244-262.
Rekers, G.A. (Editor) Family Building: Six Qualities of a Strong Family. Ventura, CA: Regal Books, 1985. (a)
Rekers, G.A. Gender identity disorder of childhood. In David G. Benner (Ed.), Baker's Encyclopedia of Psychology. Grand Rapids, Michigan: Baker Book House, 1985, pages 446-448. (b)
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Rekers, G.A. Transvestism. In David G. Benner (Ed.), Baker's Encyclopedia of Psychology. Grand Rapids, Michigan: Baker Book House, 1985, pages 1179-1181. (d)
Rekers, G.A. Gender identity problems. In Philip H. Borstein & Alan E. Kazdin (Eds.), Handbook of Clinical Behavior Therapy with Children. Dorsey Press, 1985, pages 658-699. (e)
Rekers, G.A. Inadequate sex role differentiation in childhood: The family and gender identity disorders. Journal of Family and Culture. 1986, 2(3) 8-37. (a)
Rekers, G.A. Fathers at home: Why the intact family is important to children and the Nation. Persuasion at Work. C.V. Mosby Publishing Company, 1986, 9(4):1-7. (b)
Rekers, G.A. Cross-sex Behavior. In Sheridan Phillips, Chapter 26, "Behavioral and Developmental Problems in Childhood" in R.A. Hoekelman, S. Blatman, S.B. Friedman, N.M. Nelson & and H.M. Seidel (Eds.), Principles of Pediatrics: Health Care of the Young, Second Edition. C.V. Mosby Publishing Company, 1987, pages 719-721
Rekers, G.A. Psychosexual assessment of gender identity disorders. In R.J. Prinz (Ed.), Advances in Behavioral Assessment of Children and Families, Volume 4, Greenwich, CN: JAI Press, Inc., 1988, pages 33- 71. (a)
Rekers, G.A. The formation of homosexual orientation. In P.F. Fagan (Ed.), Homosexuality. Washington, D.C.: The Center for Child and Family Policy, 1988, pages 1-27. (b)
Rekers, G.A. Psychological foundations for rearing masculine boys and feminine girls. Chapter 17 in Piper and W. Grudem (Eds.), Recovering Biblical Manhood and Womanhood, Wheaton, IL: Crossway Books, 1991, pages 292-311, and endnotes pages 510-523.
Rekers, G.A. Development of problems in puberty and sex roles in adolescence. Invited chapter in C.E. Walker & M.C. Roberts (Eds.), Handbook of clinical child psychology: Second edition, New York: John Wiley and Sons, 1992, pages 606-622.
Rekers, G.A. Early detection and treatment of sexual problems: An introductory overview. Chapter 1 in G.A. Rekers (Ed.), Handbook of Child and Adolescent Sexual Problems. New York, NY: Lexington Books of Macmillan/Simon & Schuster, 1995, pages 3-13. (a)
Rekers, G.A. Assessment and treatment methods for gender identity disorder and transvestism. Chapter 13 in G.A. Rekers (Ed.), Handbook of Child and Adolescent Sexual Problems. New York, NY: Lexington Books of Macmillan/Simon & Schuster, 1995, pages 272-289. (b)
Rekers, G.A., Amaro-Plotkin, H., & Low, B.P. Sex-typed mannerisms in normal boys and girls as a function of sex and age. Child Development, 1977, 48, 275-278.
Rekers, G.A., Bentler, P.M., Rosen, A.C., & Lovaas, O.I. Child gender disturbances: A clinical rationale for intervention. Psychotherapy: Theory, Research and Practice, 1977, 14, 2-11.
Rekers, G.A., Crandall, B.F., Rosen, A.C. & Bentler, P.M. Genetic and physical studies of male children with psychological gender disturbances. Psychological Medicine, 1979, 9, 373-375.
Rekers, G.A., & Hohn, R. Sex education. In J. Sears & J. Carper (Eds.), Public Education and Religion: Conversations for Enlarging the Public Square. New York: Teachers College Press, 1996, in press.
Rekers, G.A. & Jurich, A.P. Development of problems of puberty and sex- roles in adolescence. Chapter 33 in C. Eugene Walker and Michael C. Roberts (Eds.), Handbook of Clinical Child Psychology. New York: John Wiley and Sons, 1983, pages 785-812.
Rekers, G.A., Kilgus, M. & Rosen, A.C. Long-term effects of treatment for childhood gender disturbance. Journal of Psychology and Human Sexuality, 1990, 3(2), 121-153.
Rekers, G.A., & Kilgus, M.D. Differential diagnosis and rationale for treatment of gender identity disorders and transvestism. Chapter 12 in G.A. Rekers (Ed.), Handbook of Child and Adolescent Sexual Problems. New York, NY: Lexington Books of Macmillan/Simon & Schuster, 1995, pages 255-271.
Rekers, G.A., & Kilgus, M.D. Cross-sex behavior problems. Chapter in R.A. Hoekelman, S. Blatman, S.B. Friedman, N.M. Nelson & H.M. Seidel (Eds.), Primary pediatric care: Third edition. St. Louis, MO: C.V. Mosby Publishing Company, 1997, in press.
Rekers, G.A., & Lovaas, O.I. Behavioral treatment of deviant sex-role behaviors in a male child. Journal of Applied Behavior Analysis, 1974, 7, 173-190.
Rekers, G.A., Lovaas, O.I., & Low, B.P. The behavioral treatment of a "transsexual" preadolescent boy. Journal of Abnormal Child Psychology, 1974, 2, 99-116.
Rekers, G.A. & Mead, S. Early intervention for female sexual identity disturbance: Self-monitoring of play behavior. Journal of Abnormal Child Psychology, 1979, 7(4), 405-423.
Rekers, G.A. & Mead, S. Human sex differences in carrying behaviors: A replication and extension. Perceptual and Motor Skills, 1979, 48, 625-626.
Rekers, G.A. & Mead, S. Female sex-role deviance: Early identification and developmental intervention. Journal of Clinical Child Psychology, 1980, 9(3), 199-203.
Rekers, G.A., Mead, S.L., Rosen A.C. & Brigham, S.L. Family correlates of male childhood gender disturbance. Journal of Genetic Psychology, 1983, 142, 31-42.
Rekers, G.A. & Milner, G.C. Sexual identity disorders in childhood and adolescence. Journal of the Florida Medical Association, 1978, 65, 962-964.
Rekers, G.A. & Milner, G.C. How to diagnose and manage childhood sexual disorders. Behavioral Medicine, 1979, 6(4), 18-21.
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Rekers, G.A. & Moray, S.M. Sex-typed body movements as a function of severity of gender disturbance in boys. Journal of Psychology and Human Sexuality, 1989, pages 183-196. (b)
Rekers, G.A. & Moray, S.M. Personality problems associated with childhood gender disturbance. Italian Journal of Clinical and Cultural Psychology, 1989, 1, 85-90. (c)
Rekers, G.A. & Moray, S.M. The relationship of sex-typed play with clinician ratings on degree of gender disturbance. Journal of Clinical Psychology, 1990, 46, 28-34.
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Rekers, G.A. & Rudy, J.P. Differentiation of childhood body gestures. Perceptual and Motor Skills, 1978, 46, 839-845.
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Organisation Intersex International
Gender Identity Disorder
by George A. Rekers, Ph.D.
