Recurring Patterns in the Evaluation of Girls with Gender Identity Disorder

By Susan Bradley, MD

Susan Bradley is a Child Psychiatrist. She founded the Toronto Gender Identity Clinic at the Centre for Addiction and Mental Health in 1975 (now closed). She was previously Chief of Psychiatry at the Hospital for Sick Children and Head of the Division of Child Psychiatry at University of Toronto. She is the co-author with KJ Zucker of Gender Identity Disorder and Psychosexual Problems in Children and Youth, 1995, and author of Affect Regulation and the Development of Psychopathology, 2000. She is currently a consultant psychiatrist to Children’s Mental Health Agencies outside of Toronto.

Therapists who are new to seeing children or youth who declare that they are “trans” or exhibit gender dysphoria may not intuitively know what to look for in doing an assessment. It is my experience that there are recurring patterns that can assist in understanding why some children may express such wishes.

When I began the Toronto Clinic in 1975 for children with Gender Identity Disorder (now called gender dysphoria), my initial approach was to look carefully for some physical evidence of intersex or hormonal conditions. This approach yielded nothing and we began to see patterns in the children and families which we felt contributed to the child feeling uncertain or unvalued in their natal sex.

We continued to wonder about the cognitive style of these children, as their solution to their apparent distress was very concrete. After many years of working with these children and their families we began to realize that the concrete thinking was typical of children in the Autism Spectrum who would be considered high functioning. High functioning girls with ASD are often missed by clinicians and so most of these girls had not been identified prior to being seen for their gender dysphoria.

As we explored this more fully we came to the conclusion that many if not all of the children and youth coming to our clinic either had traits or met criteria for Autism Spectrum Disorder High Functioning. This realization made sense in terms of their concrete solution but also in the rigidity of their thinking when challenged about their feelings or solution. When past history was explored more fully, many had patterns of earlier repetitive/narrow interests and most had peer difficulties.

In the young children most of the girls could acknowledge, if asked, that they felt girls were weak and unable to protect themselves or others. They could frequently recall episodes of parental conflict interpreted by them as mother being in danger, this despite mother’s reassurance to us that she never felt threatened. When we explored these issues we realized that this child was prone to misinterpreting situations but genuinely feared for mother’s wellbeing and in some instances felt responsible to protect her. In other situations older male siblings had been aggressive to the girl herself and she felt very vulnerable.  Some other girls were, in fact, sexually abused and so traumatized by this and their sense of being weak and powerless as a female that they tried very hard to disguise any evidence of pubertal development in order to feel safe.

Many of these girls did not fit in well with peers and as they matured, especially if their social understanding issues were not identified and ameliorated. They felt rejected and often bullied and seldom had a close confiding same sex peer friend. Those youth who were approaching puberty inevitably had poor self-esteem. Many of these youth who did not self-identify as “trans” until that time longed for a close female friend but felt lost as to how to fit in to this rapidly changing culture. There was a tendency for the longing for a close female friend to be interpreted as being lesbian. This interpretation made this young woman feel “even more weird” and thus the search for a more acceptable solution. The acceptance by the “trans” community was like a powerful elixir, one that took away the pain of rejection and poor self-esteem. Parents were rightly confused at the sudden change but many also realized that their child was distressed and were aware of the social rejection and low self-esteem. Some knew that their child was often rigid when they thought they were right but felt that their solution did not make sense.

I believe that, with enough time to explore their feelings, some youth will understand that there may be better solutions than altering their bodies. However, given the cult-like culture that surrounds many youth who begin to think about being “trans” it can be very hard to imagine letting go of a solution that takes away distress so completely and provides an accepting community of friends.

This Post Has 7 Comments

  1. Thanks for this post. It’s very accessible, and I appreciate that it is drawn from the author’s extensive experience with gender dysphoric youth over several decades. It would appear that young women on the spectrum have been identifying as trans for longer than I thought.

    I was curious about the author’s assertion that rigid thinking left some of them to think they were lesbian. Is there a way of knowing that they were not in fact lesbian? I was wondering why it was de facto assumed that that was, in fact, not the case. Perhaps at least some of them were?

    The parents that call me almost all have academically gifted kids, many of whom are on the spectrum. This is true of boys as well as girls.

  2. I agree that it is very helpful to read that the presentations many of us are seeing in our practices are not as new a phenomenon as we thought. The issue seems to be the recent exponential increase in the number of teens presenting in this way. I wonder how much the rapid cultural and legislative changes that have occurred over the last decade have contributed. The current transgender discourse frames trans in a medicalized, concretized way: you are either trans or you are not and once you have decided you are, there is nothing more to think about. It is a diagnosis and an identity that then comes to define the person. I am thinking here about the way trans is now approached in schools, in the media, and in so-called gender-affirming treatment centers. I wonder how much this either feeds into the teen’s rigid way of thinking or even creates it.

  3. I have been working almost solely with gender for the past five years and am very familiar with young people who present like this. I am also interested to hear that these presentations are not new. I think what has probably changed, though, is the context in which clinicians are working. I think clinicians are being given less ‘permission’ to help these young people explore their feelings over time as you suggest. Many of my patients start therapy with me with a wish to be affirmed, many do not want to explore anything. Some are shocked when I encourage them to explore and some even tell me that exploring is in itself transphobic. Many young patients are told (usually online) that explorative therapy is an attempt by psychotherapists to ‘convert’ them to being non-trans. This new context certainly adds an interesting dynamic to therapeutic work and is providing us with new ethical and theoretical challenges I think.

  4. Thank you for this piece, Susan. I appreciate the notion that there is a sort of wisdom that would develop in a clinician from treating many cases like this. It seems clear that your work has helped you develop this intuition about what to look for, perhaps BECAUSE it began before the affirmation approach was pushed widely as the only ethical way. It seems in your work, the desired outcome of initial conversations/assessment goes well beyond finding quickest or most obvious way to alleviate symptoms. Instead, the focus of the assessment, must be, as you state, to carefully weed out auxiliary patterned issues (or even causal factors) and treat those first. It seems your work may be grounded in the philosophy that it’s objectively preferable not to assist kids in transitioning IF there are less invasive or disruptive ways to work with their cluster of symptoms. I’m curious, in your opinion, if you can hypothesize why that aim seems to have been discarded. Why is work like yours not being seen as a gold standard since it’s less invasive, less potential harm, less expensive, etc…

  5. There has been an exponential increase in the number of these children I see in my private practice. I have been working with them for years and they present as gifted, on the Spectrum and have rigid thinking processes, including social naivety, making them much more vulnerable than others to other groups influence. I identify with much of what you have said here Susan and thank you for your contribution.

    1. I’m not sure why the gifted advocacy community isn’t paying attention this. I think it’s important to note that we don’t have good evidence that transition for these kids produces good outcomes. Anecdotally, there is evidence that the outcomes are, in fact, quite poor. Does anyone know if there has been relevant research on this population? NB — I’m asserting here that medical transition for gifted, autistic teens and young adults may produce poor outcomes. I am not saying that all transitions result in poor outcomes.

  6. I appreciate the discussion and agree that it has become politically incorrect to question whether individuals who declare themselves as “trans” were “born that way”. There is little evidence for that assertion but we do know that some individuals may feel better after they have transitioned. What we don’t have is solid evidence as to how many of the group of ROGD teens will regret transition because of the rapidity of the process to transition and lack of reflection on other options that could help them feel stronger as who they are. I agree that anecdotally even a few of the dreadful outcomes that have been described to me should caution anyone who cares about helping vulnerable teens. I recently saw the Utube videos by CJ, a young woman with ASD very high functioning who talks about what she has learned about her own identity after de-transitioning and learning to accept herself for who she is regardless of gender. I wish that everyone who is thinking about transitioning could see this video as she clearly understands the complexity of feelings that propels individuals into considering this course of action.
    The issue of whether these women are lesbian is somewhat difficult to sort out. It is clear that many of the young persons from our study and from Green’s follow-up eventually came out as lesbian. My comments about thinking they were lesbian and not being sure comes from the fact that these young women seemed to come to that assumption when they had crushes on popular girls, something that is not uncommon in heterosexual women as well. I believe that defining oneself as lesbian can be a process particularly in women who may initially feel they are heterosexual and later come out as lesbian after dissatisfying relationships with men.

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