Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices

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Peggy T. Cohen-Kettenis & Friedemann Pfäfflin

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  • Developmental Clinical Psychology and Psychiatry Series

    Series Editor: Alan E. Kazdin, Yale University

    Recent volumes in this series …

    • LIFE EVENTS AS STRESSORS IN CHILDHOOD AND ADOLESCENCE by James H. Johnson
    • CONDUCT DISORDERS IN CHILDHOOD AND ADOLESCENCE, 2nd Ed. by Alan E. Kazdin
    • CHILD ABUSE, 2nd. Ed. by David A. Wolfe
    • PREVENTING MALADJUSTMENT FROM INFANCY THROUGH ADOLESCENCE by Annette U. Rickel and LaRue Allen
    • TEMPERAMENT AND CHILD PSYCHOPATHOLOGY by William T. Garrison and Felton J. Earls
    • EMPIRICALLY BASED ASSESSMENT OF CHILD AND ADOLESCENT PSYCHOPATHOLOGY, 2nd Ed. by Thomas M. Achenbach and Stephanie H. McConaughy
    • MARRIAGE, DIVORCE, AND CHILDREN'S ADJUSTMENT, 2nd Ed. by Robert E. Emery
    • AUTISM by Laura Schreibman
    • DELINQUENCY IN ADOLESCENCE by Scott W. Henggeler
    • CHRONIC ILLNESS DURING CHILDHOOD AND ADOLESCENCE by William T. Garrison and Susan McQuiston
    • ANXIETY DISORDERS IN CHILDREN by Rachel G. Klein and Cynthia G. Last
    • CHILDREN OF BATTERED WOMEN by Peter G. Jaffe, David A. Wolfe, and Susan Kaye Wilson
    • SUBSTANCE ABUSE IN CHILDREN AND ADOLESCENTS by Steven P. Schinke, Gilbert J. Botvin, and Mario A. Orlandi
    • CHILD PSYCHIATRIC EPIDEMIOLOGY by Frank C. Verhulst and Hans M. Koot
    • EATING AND GROWTH DISORDERS IN INFANTS AND CHILDREN by Joseph L. Woolston
    • NEUROLOGICAL BASIS OF CHILDHOOD PSYCHOPATHOLOGY by George W. Hynd and Stephen R. Hooper
    • ADOLESCENT SEXUAL BEHAVIOR AND CHILDBEARING by Laurie Schwab Zabin and Sarah C. Hayward
    • EFFECTS OF PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS by John R. Weisz and Bahr Weiss
    • BEHAVIOR AND DEVELOPMENT IN FRAGILE X SYNDROME by Elisabeth M. Dykens, Robert M. Hodapp, and James F. Leckman
    • ATTENTION DEFICITS AND HYPERACTIVITY IN CHILDREN by Stephen P. Hinshaw
    • LEARNING DISABILITIES by Byron P. Rourke and Jerel E. Del Dotto
    • PEDIATRIC TRAUMATIC BRAIN INJURY by Jeffrey H. Snow and Stephen R. Hooper
    • FAMILIES, CHILDREN, AND THE DEVELOPMENT OF DYSFUNCTION by Mark R. Dadds
    • ADOLESCENTS AND THE MEDIA by Victor C. Strasburger
    • SCHOOL-BASED PREVENTION PROGRAMS FOR CHILDREN AND ADOLESCENTS by Joseph A. Durlak
    • CHILDHOOD OBSESSIVE COMPULSIVE DISORDER by Greta Francis and Rod A. Gragg
    • TREATING CHILDREN AND ADOLESCENTS IN RESIDENTIAL AND INPATIENT SETTINGS by Robert D. Lyman and Nancy R. Campbell
    • THE IMPACT OF FAMILY VIOLENCE ON CHILDREN AND ADOLESCENTS by Javad H. Kashani and Wesley D. Allan
    • CHILDREN'S ADJUSTMENT TO ADOPTION by David M. Brodzinsky, Daniel W. Smith, and Anne B. Brodzinsky
    • MOTOR COORDINATION DISORDERS IN CHILDREN by David A. Sugden and Helen Wright
    • CHILDHOOD SEXUAL ABUSE by David M. Fergusson and Paul E. Mullen
    • POVERTY AND CHILDREN'S ADJUSTMENT by Suniya S. Luthar
    • ALCOHOL USE AMONG ADOLESCENTS by Michael Windle
    • CREATING HEALTH BEHAVIOR CHANGE by Cheryl L. Perry
    • PSYCHOTIC DISORDERS IN CHILDREN AND ADOLESCENTS by Robert L. Findling, S. Charles Schulz, Javad H. Kashani, and Elena Harlan
    • LANGUAGE IMPAIRMENT AND PSYCHOPATHOLOGY IN INFANTS, CHILDREN, AND ADOLESCENTS by Nancy J. Cohen
    • TRANSGENDERISM AND INTERSEXUALITY IN CHILDHOOD AND ADOLESCENCE by Peggy T. Cohen-Kettenis and Friedemann Pfäfflin

    Copyright

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    Series Editor's Introduction

    Interest in child development and adjustment is by no means new. Yet, only recently has the study of children benefited from advances in both clinical and scientific research. Advances in the social and neurobiological sciences; the emergence of disciplines and subdisciplines that focus exclusively on childhood and adolescence; and greater appreciation of the impact of such influences as the family, peers, and school have helped accelerate research on developmental psychopathology. Apart from interest in the study of child development and adjustment for its own sake, the need to address clinical problems of adulthood naturally draws one to investigate precursors in childhood and adolescence.

    Within a few decades, the study of psychopathology among children and adolescents has proliferated considerably. Several different professional journals, annual book series, and handbooks devoted entirely to the study of children and adolescents and their adjustment document the proliferation of work in the field. Nevertheless, there is a paucity of resource materials that present information in an authoritative, systematic, and disseminable fashion. There is a need within the field to convey the latest developments and to represent different disciplines, approaches, and conceptual views to the topics of childhood and adolescent adjustment and maladjustment.

    The Sage Series on Developmental Clinical Psychology and Psychiatry is designed to serve uniquely several needs of the field. The Series encompasses individual monographs prepared by experts in the fields of clinical child psychology, child psychiatry, child development, and related disciplines. The primary focus is on developmental psychopathology, which refers broadly here to the diagnosis, assessment, treatment, and prevention of problems that arise in the period from infancy through adolescence. A working assumption of the Series is that understanding, identifying, and treating problems of youth must draw on multiple disciplines and diverse views within a given discipline.

    The task for individual contributors is to present the latest theory and research on various topics, including specific types of dysfunction, diagnostic and treatment approaches, and special problem areas that affect adjustment. Core topics within clinical work are addressed by the Series. Authors are asked to bridge potential theory, research, and clinical practice and to outline the current status and future directions. The goals of the Series and the tasks presented to individual contributors are demanding. We have been extremely fortunate in recruiting leaders in the fields who have been able to translate their recognized scholarship and expertise into highly readable works on contemporary topics.

    In this book, Drs. Peggy Cohen-Kettenis and Friedemann Pfäfflin examine Transgenderism and Intersexuality in Childhood and Adolescence. The book is broad in its scope, delineating the range of the issues of sexual development, identity, and roles. Biological underpinnings and features of sexual differentiation; cultural and contextual issues; and ethical, legal, and policy issues are carefully described and integrated. Gender identity raises issues for the individual but also for society at large. For example, the book considers whether, for whom, and how to intervene and the many treatment options available over the course of infancy through adulthood. There are major dilemmas for clinical practice and society at large on which this book elaborates. Whether atypical forms of gender identity qualify or ought to be considered as a disorder and strong views of the public about gender identity reflect key contextual issues in which both research and clinical work are conducted. It is rare that a book elaborates a set of developmental paths or disorders and places these in the broader context of society at large. We are very fortunate to have such an enlightened, engaging, and authoritative statement on the topic.

    — Alan E. Kazdin, Ph.D., Yale University School of Medicine

    Preface

    Most adults do not question the fact that they are male or female. However, a very small minority face a discrepancy between their subjective experience of being a man or a woman and their biological sex. They are individuals with gender identity problems. In others, discrepancies exist between their genetic, gonadal, hormonal, or genital sex. These individuals suffer from so-called intersex conditions. Many have great difficulties in classifying members of these groups as males or females. Others do not even want to classify at all and insist on allowing for more than two sexes. They argue that the mere existence of only two social categories, men and women, creates intolerance.

    Western cultures tend to reject certain deviations from the gender norm, making life hard for those who physically and/or psychologically have not differentiated completely in the male or female direction. If certain deviations from the gender norm are substantial enough they are regarded as psychiatric disorders (as defined in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), American Psychiatric Association, 1994). A significant amount of research and clinical attention have been given to children who belong to this group. Though many enigmas remain, the study of these children has increased our understanding of their situation. But studying these children as if they have a psychiatric disorder has also met with resistance. Some claim that the “Gender Identity Disorders” are not disorders at all, only behaviors that are not tolerated by our homophobic society. In their view, these behaviors have been called “disorders” to achieve gender conformity at all costs or even to “prevent” homosexuality. The suffering of the child is not seen as suffering from a condition, but from a stigmatizing society.

    When cross-gendered children enter puberty, new dilemmas emerge: Boys begin to grow beards and their voices become deeper, whereas girls develop breasts. When they come to gender clinics they have often already lived in the opposite gender role for an extended period of time. They very much want to take hormones to delay their puberty or even to start the development of physical characteristics of the opposite sex (e.g., breasts in boys and a beard in girls). To the despair of these youngsters, most clinicians are reluctant to prescribe hormones for this purpose to adolescents. Should one wait until adulthood before prescribing hormones when it is clear that they have a gender identity disorder and will never live in the role of their sex of birth?

    In the field of sexual differentiation disorders, an intense dispute is taking place along similar lines. However, in this field doctors are often accused of intervening all too readily. If a child is born with genitals that are not clearly male or female, surgeons tend to “adjust” the child to the sex of assignment as early as possible. Since the early 1990s, adults with intersex conditions have heavily criticized this policy. Many of these adults are very unhappy with the result of their own treatment. They insist on letting children make their own decisions regarding the type and timing of their genital surgery in due time.

    There are clinicians who do (e.g., “adjusting” babies with intersex conditions) and do not want (e.g., prescribing sex hormones to adolescents with gender identity disorders) to intervene medically. Though they seem to behave in opposite ways, they may act out of a similar motive: the fear of bringing or leaving children in a situation between that of “male” and “female.” This, in their view, is not in the best interest of the child.

    Another question concerns to which sex a child with ambiguous sex characteristics should be assigned. We do not yet know much about the factors determining gender identity development in children with intersex conditions. To make a perfect prediction in any individual case, whether the child will be happier as a girl or as a boy, is impossible. Some argue that one should refrain altogether from assigning children to one of the sexes. By doing so we would force society to accept and get used to more gender variance. This would ultimately make life easier for gender variant individuals. Whether children in our society will actually be happier when growing up as a member of a “third sex” is, however, questionable.

    Whichever side one takes in these debates, all discussants agree that large numbers of children with gender problems and with an atypical sexual differentiation suffer psychologically and existentially. These children are seen in clinics on a daily basis. Clinicians cannot sit and wait until more research has been done or consensus is reached. They are continuously faced with dilemmas and have to make choices even without a substantial empirical knowledge base. The choices they make have far-reaching consequences for their patients. The discussion on gender problems in adults touches sensitive strings. When it comes to children and adolescents the issues are sometimes beyond a rational discussion.

    In this volume, we give an overview of the research, clinical insights, and ethical dilemmas for those confronted with these patients.

    Acknowledgments

    We gratefully acknowledge the contributions of the many children and their parents who came to us for help and support. In doing so they helped us in better understanding nonstandard gender development. They shared their distress, but also their problem-solving capacities and their creativity. It has always been a challenge and at the same time inspiring and pleasurable to work with these youngsters and their families.

    We also thank the members of the Gender Team at the Child and Adolescent Psychiatry Department of the University Medical Center Utrecht (UMCU): Karin Tobias-Dillen, Jan Duyx, Tineke Mooibroek, Ciska van der Laan, Winkie Sandberg, and Dr. Hanna Swaab-Barneveld; and the members of the Sexual Differentiation Disorders team of the Wilhelmina Kinder Ziekenhuis/UMCU: Dr. Monique de Vroede, Dr. Maarten Jansen, Dr. Tom de Jong, Pieter Dik, Aart Klijn, Dr. Jacques Giltay, and Ineke van Seumeren. The many patient discussions enormously increased my (P. C.-K.) knowledge and understanding of atypical sexual differentiation and gender development. Maarten Jansen and Tom de Jong were so kind as to allow us to use photographs of their patients.

    We thank Professor Dr. jur. Michael R. Will and Professor Dr. jur. Heinz-Peter Mansel for their juridical advice; Dr. Luk Gijs and Professor Dr. Louis Gooren for their valuable comments on earlier drafts; Margreet van Eck, Irene de Jonge, and Elke Kunert for lots of help in finding references; Russell Deighton and Liesbeth Klein for polishing our nonnative English; and Margreet van Eck, Joke van Katwijk, and Eleonore Cohen for their administrative assistance and Max Cohen for his technical assistance when preparing the book.

    List of Abbreviations

    17ß-HSD17ß-hydroxysteroid dehydrogenase deficiency
    5α-RD5α-reductase deficiency
    AISandrogen insensitivity syndrome
    BSTccentral part of the bed nucleus of the stria teminalis
    CAHcongenital adrenal hyperplasia
    CBCLchild behavior checklist (a parent questionnaire listing emotional and behavioral problems of the child)
    CVAHcongenital virilizing adrenal hyperplasia
    DESdiethylstilbestrol
    DHTdehydrotestosterone
    DSMDiagnostic and Statistic Manual (of mental disorders)
    FMfemale-to-male transsexual
    GIDgender identity disorder
    HBIGDAHarry Benjamin International Gender Dysphoria Association
    ICDInternational Classification of Diseases
    KSKlinefelter Syndrome
    LHlutinizing hormone
    MFmale-to-female transsexual
    MISMüller Inhibiting Substance
    MMPIMinnesota Multiphasic Personality Inventory
    PAISpartial androgen insensitivity syndrome
    PIQperformance IQ
    SOCStandards of Care
    SRsex reassignment
    SRSsex reassignment surgery
    SRYa gene located on the Y chromosome
    TRFteacher report form (of the CBCL)
    VIQverbal IQ
    WISC-RWechsler Intelligence Scale for Children—Revised
    WAISWechsler Adult Intelligence Scale

    Dedication

    To our children Eleonore and Max Cohen Vincent and Tycho Pfäfflin

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    Name Index

    About the Authors

    Peggy T. Cohen-Kettenis, Ph.D., is Professor of Medical Psychology at the Vrÿe Universiteit Medical Center, Amsterdam, and Head of a gender clinic for children, adolescents, and adults. She was a pre- and postgraduate student in developmental and clinical psychology at the University of Utrecht, The Netherlands. She was trained to become a registered clinical psychologist and psychotherapist at the Utrecht Institute for Multidisciplinary Psychotherapy. After completing her Ph.D. thesis Cohen-Kettenis worked at the Department of Clinical Psychology of the Utrecht University. There she conducted a study evaluating sex reassignment, which was prompted by the advice of a committee of the Health Council, the medical advisory board of the Ministry of Public Health. The outcome of this study would also be the grounds for a new law allowing transsexuals to adjust their birth certificates. In 1987 she started the first outpatient clinic for children and adolescents with gender problems and intersex conditions in Europe at the Department of Child and Adolescent Psychiatry of the University Medical Center Utrecht. Her main areas of research are gender identity problems and gender-related psychopathology.

    Friedemann Pfäfflin, M.D., Ph.D., is Professor of Psychotherapy and head of the Forensic Psychotherapy Unit at Ulm University, Ulm, Germany. Trained as psychiatrist at Hamburg University, he first engaged in transgender clinical work in the mid-1970s, when he visited the Psychohormonal Research Unit and the Gender Identity Clinic at Johns Hopkins University Clinic in Baltimore, Maryland. From 1978 to 1992 he worked at the Institute of Sex Research at Hamburg University, Hamburg, Germany, and continued his work with transsexuals after moving to Ulm University in 1992. His main areas of research are transsexualism, transgenderism, psychotherapy process research, forensic psychiatry and psychotherapy, and the history of psychiatry. From 1995 to1997 he was president of the Harry Benjamin International Gender Dysphoria Association, Inc. In 1997, together with Eli Coleman, he founded The International Journal of Transgenderism.


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