Source: Tom McIntyre & Joel VonOrsteiner (2001).  Reclaiming Children and Youth, volume 9, issue 4, pages....

 What Do We Do With Alberto?
 Assessment and Intervention for
 Youngsters with Gender Identity Disorder

View a video overview of G.I.D. (To become "Gender Disphoria" in 2013 according to reports on the upcoming DSM-5)

Abstract - Students with gender identity disorder display behaviors more commonly associated with the opposite sex.  This behavioral pattern presents educational professionals and support staff with concerns that must be addressed promptly.  In order to provide appropriate services for these youngsters, school personnel must become knowledgeable in the condition and issues surrounding it.  This article uses a case study to provide information regarding assessment of, and intervention with, youngsters who have gender identity disorder.

     Alberto, a twelve year-old Hispanic boy, has spent the majority of his life in institutional settings for youngsters with emotional and behavioral disorders.  Now, in his first year as an outpatient, he attends public school and lives with his mother.  Alberto still causes his teachers much concern.  His defiant and violent actions result in his continued identification as being "emotionally disturbed".  In addition, during the last couple of years, manifestations of "feminine" behavior have increased.  This behavioral trend has resulted in a clinical diagnosis of gender identity disorder (G.I.D.).  To what extent each of Alberto's conditions has caused, affected, or resulted from the others is difficult to determine.  This article deals with gender identity problems in boys such as Alberto, and the often found emotional and behavioral reactions which accompany them.

     The American Psychological Association (1995) defines gender identity disorder as: "...a persistent or recurrent discomfort and sense of inappropriateness about one's gender; there may also be persistent or current cross-dressing and engagement in the role of the other sex, either in fantasy or actuality, but not for the purpose of sexual excitement; and for at least two years, there must be no persistent preoccupation with getting rid of one's primary and secondary sex characteristics; and or acquiring the biological sex characteristics of the other gender (as in transsexualism)."  Generally, there is a preoccupation with stereotypical female activities.  The criteria for diagnosis also include a persistent and intense distress about being a boy and an intense desire to be a girl.  More rarely, there is insistence that one actually is a girl; an assertion that one will grow up to become a woman (not merely in role), or; that one's penis or testicles are disgusting and/or will disappear.

     These beliefs may or may not surface later in Alberto's development, but thus far in his personal history, Alberto is well described by the APA definition.  He interacts poorly with male peers, preferring to spend social time by himself or with the only female student in the self-contained classroom.  There, he often play-acts being a girl.

     Alberto's tendencies also reveal themselves at other times.  For example, during the classroom's "show and tell" session, while the other male students displayed and described typical "masculine" items, Alberto lip-synched "I Enjoy Being A Girl" from the film and Broadway musical, The Flower Drum Song, an apparent extension of his effeminate role-taking.  The teacher had inadvertently provided a socially permissible opportunity for this role-taking that gave a certain degree of acceptability and respectability to Alberto's feminine yearnings.

     Alberto's other-gender behavior does not go unnoticed by others.  He is referred to by male classmates as "she", and some school teachers sarcastically refer to him as "Alberta".  Alberto responds to these demeaning references with disgusted reactions more typical of females.  Outside of the school setting, neighborhood children tease him, older youngsters threaten him with harm, and his mother is worried that her son might grow up to be a "drag queen".

Assessment for Gender Identity Disorder
 Alberto's preoccupation with stereotypical female activities, plus his rejection of traditional male toys, games, and pastimes, seems to indicate that he is experiencing gender confusion.  By twelve years of age, boys' masculine gender identity is typically defined more clearly due to developmental changes, role modeling, and social pressures.

 Upon noticing pronounced "feminine" behavior in a boy, schools should move quickly to determine if specialized services are needed.  Teachers, students, and parents should be queried to determine if others perceive the behaviors to be odd.  Repeated verbal and/or physical attacks upon the youngster would also serve as evidence that the behavior is viewed by others as being outside of common social boundaries.

 If the above conditions occur, a psychological evaluation of the student is indicated.  Through interviews and projective testing, the psychologist assesses whether the youngster meets the American Psychological Association's (1995) diagnostic criteria for gender identity disorder in males.  In Alberto's case, disordered perceptions were indeed evidenced in evaluation sessions.  When he and his class were asked by the school psychologist to "draw a person" on a blank sheet of white paper, he drew a female in a mini skirt with high heeled shoes that were half as tall as the figure. The rest of the class drew a person of their own gender.

 According to the interpretation guidelines of the Draw-a- person test (Machover, 1949), the drawn figure represents the artist.  The individual, directed to "draw a person", is believed to reflect his or her impulses, anxieties, conflicts and compensations in the product (Machover, 1949; Sidun & Rosenthal, 1987).  Additionally, the gender of the person drawn first is presumed to reflect the person's sexual identity (Machover, 1949).

Psychological Intervention
 The majority of staff at the public school attended by Alberto hope that he will "outgrow" this current "stage".  This could indeed happen: Zucker (1990), conducted a clinical longitudinal study that revealed that the majority of 94 adult males diagnosed with gender identity disorder in childhood, in retrospect, remember the disorder "spontaneously" disappearing by late adolescence.  Zucker questioned whether the majority of those diagnosed with G.I.D. grow out of this disorder regardless of treatment (or lack of it).

 Whatever happens in the future, right now Alberto's behavior and appearance incite negative reactions from others.  These cruel and rejecting actions could affect his capability and need for trust, acceptance, and intimacy.  Yet advocating treatment simply because others do not approve of someone's behavior can only be taken so far as a general principle (Zucker, 1990).  However, Alberto's extreme unhappiness and discontent (as evidenced by his verbal and physical aggression against his tormentors) due to rejection by school peers is reason enough to recommend treatment for his emotional concerns, if not his gender orientation.  Certainly, counseling will have to address the reasons why others condescend toward him.

 The question of gender identity also arises due to the physiological changes that take place in the course of sexual maturation.  While Alberto and other adolescents struggle with their identity, counseling typically attempts to assist them in becoming more comfortable with their biological sex, in hopes of alleviating internal concerns and facilitating interaction with others.  Sexual orientation may also be a topic of discussion as research and longitudinal studies (Duncan & Lee, 1984; Money & Russo, 1979; Money & Russo, 1981; Steiner, 1985; Zucker, 1990) suggest that adolescents with G.I.D. are more likely than non-affected peers to become homosexual adults.  They are also "at risk" for transsexualism or transvestitism.  In essence, for Alberto and other adolescents with this disorder, the central concern is "What kind of man or woman will I become?" (Cohen, 1991).

 Behavioral therapy is another of the more common treatments prescribed for G.I.D. males in response to concerns from caregivers who want visual changes in mannerisms and carriage.  Treatment is designed to eliminate feminine behavior and develop masculine traits via behaviorist reinforcement procedures.  A successful outcome results in a turning of the clients's social attention toward the display of masculine behavior (Wolfe, 1979).

 During behavioral therapy treatment sessions, adolescents such as Alberto are videotaped while walking, conversing, sitting, and socializing with male peers.  Afterwards, they would be shown the tape while the therapist points out feminine mannerisms.  They would then be instructed in how to replace their present actions with more traditional masculine behavior.  Later videotape viewing would point out progress in certain areas, and work would continue on changing resistant mannerisms.  Under the program, G.I.D. youngsters are also tutored in masculine athletics and given praise for their efforts by an athletic male role model.  In the classroom, they are seated next to a popular, athletic, and accepting male peer, so they can identify with and emulate a strong role model.

 Concerns have been expressed regarding behavioral interventions of this nature.  Rosen, Rekers & Bringham (1982) found no substantial support for the position that behavioral therapy yields "macho" results.  Their study examined the effects on 22 "gender confused/gender dysphoric" boys in behavioral programs.  They found no masculine enhancements after their behavioral treatment.  Many would also question whether we can or should attempt to "make a leopard change its spots".  This concern is heightened in modern day society wherein it is difficult to know whether different sexual orientations are "disorders", or merely "variations" (McIntyre, 1992).

 Punishing specific "feminine" behaviors and rewarding "masculine" ones also fails to consider the reasons why G.I.D. boys prefer traditionally "feminine" activities.  Many professionals feel that it is important to look at why the youngsters have chosen to play with dolls, but not trucks.  While we may be able to condition them to act differently, one has to ask: "To what extent has self-concept changed for the better?"  Perhaps being unable to compete well in rough and tumble aggressive play, they, with the logic of early childhood, chose the only alternative; being with girls and adopting their behavior.  Or, perhaps an inability to conform to a father's definition of masculinity caused them to view dad and his activities as negative, thereby drawing closer to mother and her activities (Green, 1987).  In other words, if we change the actions, do we also change the mind?

 As a result of psychological counseling, it is hoped that Alberto learns that being loved is the natural result of being a lovable and good person.  First, however, he will have to learn to love and respect himself.  Only then will he have the self-esteem necessary to love and respect others (Isay, 1989).  Via counseling, Alberto would be made to feel that his choice to be a boy or be a girl is one aspect of his personal development.  Optimally, he would grow up loving himself and others in spite of being "different" and in spite of the bigotry that surrounds him.    Suppose Alberto continues to display "gender wishes" to be a girl and desires to become a woman when he "grows up".  Once he has been evaluated by a psychologist, and his transsexual aspirations have been assessed, most experts suggest that the adolescent lead a complete life in his chosen gender role for a considerable length of time.  This period is referred to as the transition phase.  During this period of time, the adolescent is encouraged to seek a consistent and solidified personal, as well as sexual and gender identity.

 The G.I.D. adolescent is all too aware of the pain and torment that will follow this more fervent display of cross-gender behavior, but is reminded that this is an important real life experiment.  He comes to recognize that the transition phase is a time to investigate his yearning, resolve problems, and mature and stabilize emotionally.  Parallel to psychological therapy must be rehabilitative planning and career training so that the adolescent can plan for the future during the (approximately) five year cross-dressing tryout (Steiner, 1985).

 Alberto, and others like him, would, for the next few years, take reversible steps while attempting to establish their cross-gender identity.  They would wear the articles of clothing in which they feel comfortable in their new female gender role (Zucker, 1990).  Cosmetic treatment for male adolescents in transition starts with any necessary electrolysis to the face, arms and chest. This is an expensive and painful process, usually requiring four to five treatments for each hair follicle.  Ensuing hormonal treatments serve to make the face and body softer, add tissue weight to the hips and chest, and stop hairline recession.  Almost without exception, transition level individuals express a feeling of well being and contentment not experienced previously, and are generally delighted with the feminizing effects (Steiner, 1985).  Continued hormonal intake will be required throughout adulthood.
 The decision to treat with hormones or surgery is typically made after all alternative plans for reversing gender dysphoria are explored via psychotherapy, and permission has been obtained from the youth's parents.  It is only after years of transition that the individual might be considered for transsexual surgery.  Given a successful transition phase, an adolescent's dream of actually becoming a woman could conceivably be fulfilled as early as age eighteen.

The Role of the School and Educational Professionals
 It is often difficult for school personnel to deal compassionately with gender disordered youth.  Most educational professionals' personality traits, gender outlook, and mannerisms closely match those commonly promoted by society.  As teachers, administrators, social workers, and counselors, they are expected to pass on the standard behaviors, values, and beliefs of society at large.  When confronted by a pupil who falls outside of the cultural borders of sexuality and sex-typed behavior, many professionals become emotionally charged and strike out at the youngster.

 The enrollment of a gender disordered youth will undoubtedly require intervention on his behalf.  When it comes to G.I.D., educators are definitely in need of information and sensitivity training.  So are the students.  Ongoing training is necessary because condescending attitudes are not easily vanquished.  It is important to prepare others so that the G.I.D. youngster is accepted and valued.  With training, most educators can be expected to develop greater tolerance, and offer the G.I.D. student protection from the cruel behavior of others.  Even "oddballs" deserve tolerance and respect.
 Upon noticing a student who displays the traits mentioned previously, intervention options include designating a "point person" to befriend the youth (McIntyre, 1992).  This individual might later serve as a role model for traditional male ways of interacting, carrying oneself, handshaking, and even urinating.  The point person would also speak with the student's parents, teachers, and peers to answer questions and offer advice.

 Early referral for evaluation is essential to minimize the negative impact of ridicule from many sources.  Upon receiving parental permission to conduct an assessment, and arriving at a diagnosis of G.I.D., appointments would be made with pivotal figures to discuss and address the youth's developing gender identification/sexual orientation.

 Parents would also need to be contacted to obtain permission to intervene.  If youngsters could be diagnosed early enough, it might be possible to counsel the family so that rejection, injury to self-esteem, and negative self-images would be minimized or avoided altogether.  In general, parents should be advised of the possible outcomes of this disorder (e.g., homosexual orientation, cross-dressing, transvestitism) (Steiner, 1985).  If they desire, support systems and resources (e.g., counseling facilities, successful adults who experienced G.I.D. during their adolescence, and parental support groups) would be identified and contacts made.  Arrangements can be made for them and siblings to receive information and meet with support groups.  The family is encouraged to be supportive, but they often feel inadequate or alienated when faced with this condition which is probably oppositional to their dreams for the G.I.D. youngster's development.  This concern may be especially pronounced among culturally diverse families from groups that promote strong and traditional gender roles.

 The parent's role in contributing to the display of femininity might also be investigated by the counselor.  Although most parents seem to play no role, some do promote these behaviors.  Alberto's case is an unusually sensitive.  He has mentioned on occasion that he sleeps with his mother and has seen her vagina numerous times.  She could be counseled regarding her own conceptions, psychological needs, and societally incorrect actions, and told to arrange for Alberto to express more independence and spend more time with males.

 Last, schools must provide a safe haven for all who wish to learn.  Teachers and administrators must insure that the gender identity disordered youth receives the same psychological and physical protection offered to other students.  Peers should not be allowed to verbally or physically torment him.  The same restriction must also apply to the adults in the school setting.

 If, despite all attempts, the youngster is unable to function within a typical school setting, an "out-placement" may be necessary.  While large metropolitan areas may have special facilities like New York's Hetrick-Martin Institute or San Francisco's Project 10 that supply educational and support services for youngsters with alternative sexual/gender orientations, most school systems do not have such placements.  If alternative programs cannot be developed, private tutoring and counseling may be required for the remainder of the youngster's educational career.

 As educators, we are professionally and morally obligated to help these special needs students, for without the benefit of early intervention, the Albertos of the world will continue to be affected in a debilitating way by societal prejudice.  Educational personnel, as the passers-on of citizenship and society's values, must model tolerance and acceptance of differences (McIntyre, 1992).  It is long past time for the schoolhouse to recognize, accept, and accommodate for variations.  Differences are not necessarily deviancies, even if behaviors, lifestyles, and orientations fall outside society's generally accepted social boundaries.  Of what use is ridicule or chastisement?  Educational professionals must seek out and hold higher ground.  Our job is to assure that youngsters leave us with a good education, strong self- esteem, and a positive self concept.


 American Psychological Association. (1995). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

 Cohen, Y. (1991). Gender identity conflicts in adolescence as motivation for suicide. Adolescence, 26(101), 19-29
 Duncan, M.K. & Lee, P.A. (1984). Transsexualism in the adolescent girl. Journal of the American Academy of Child Psychiatry, 26(6), 654-661.

 Green, R. (1987). The sissy boy syndrome and the development of homosexuality. New Haven: Yale University Press.
 Isay, R. (1989). Being homosexual: Gay men and their development. New York: Avon Books.

 Machover, K. (1949). Personality projection in the drawing of a human figure. Springfield, MA: Charles C. Thomas.

 McIntyre, T. (1992). The invisible culture in our schools: Gay and lesbian youth. Beyond Behavior, 3(3), 6-12.

 Money, J. & Russo, A.J. (1979). Homosexual outcome of discordant gender identity role: Longitudinal follow up. Pediatric Psychology, 4, 29-41.

 Money, J. & Russo, A.J. (1981). Homosexual vs. transvestite outcome study in boys. International Journal of Pharmacological Psychiatry, 2, 139-145.

 Rosen, A.C., Rekers, G.A., & Bringham, S.L. (1982). Gender stereotypes in gender dysphoric young boys. Psychological   Reports, 51(2), 371-374.

 Sidun, N.M. & Rosenthal, R. H. (1987). Graphic indicators of sexual abuse in "Draw A Person" tests of psychiatrically hospitalized adolescents. Arts in Psychotherapy, 14, 25-33.

 Steiner, B.W. (1985). The management of patients with gender dysphoria. New York: Plenum Press.

 Wolfe, B. (1979). Behavioral treatment of childhood gender disorders. Behavior Modification, 3, 550-576.

 Zucker, K. J. (1990). Gender identity disorder and psychosexual problems of children and adolescents. Canadian Journal of Psychiatry, 35(6), 477-486.

Note: The authors wish to thank Don Braswell for his contributions to this manuscript.
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