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A Follow-Up Study of Boys with Gender Identity Disorder

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A Follow-Up Study of Boys with Gender Identity Disorder A FOLLOW-UP STUDY OF BOYS WITH GENDER IDENTITY DISORDER by Devita Singh A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Department of Human Development and Applied Psychology Ontario Institute for Studies in Education University of Toronto Copyright by Devita Singh (2012) A Follow-up Study of Boys with Gender Identity Disorder Devita Singh Doctor of Philosophy Department of Human Development and Applied Psychology University of Toronto 2012 Abstract This study provided information on the long term psychosexual and psychiatric outcomes of 139 boys with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 7.49 years; range, 3–12 years) and at follow-up (mean age, 20.58 years; range, 13–39 years) were used to evaluate gender identity and sexual orientation outcome. At follow-up, 17 participants (12.2%) were judged to have persistent gender dysphoria. Regarding sexual orientation, 82 (63.6%) participants were classified as bisexual/ homosexual in fantasy and 51 (47.2%) participants were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. With gender identity and sexual orientation combined, the most common long-term outcome was desistence of GID with a bisexual/homosexual sexual orientation followed by desistence of GID with a heterosexual sexual orientation. The rates of persistent gender dysphoria and bisexual/homosexual sexual orientation were substantially higher than the base rates in the general male population. Childhood assessment data were used to identify within-group predictors of variation in gender identity and sexual orientation outcome. Social class and severity of cross-gender behavior in childhood were significant predictors of gender identity outcome. Severity of childhood cross-gender behavior was a significant predictor of sexual ii orientation at follow-up. Regarding psychiatric functioning, the heterosexual desisters reported significantly less behavioral and psychiatric difficulties compared to the bisexual/homosexual persisters and, to a lesser extent, the bisexual/homosexual desisters. Clinical and theoretical implications of these follow-up data are discussed. iii Acknowledgements There are a number of individuals who have contributed instrumentally in the various stages of the dissertation project and to whom I would like to express my most sincere gratitude. First, to my supervisor, Dr. Ken Zucker, there are no words to express what your continued mentorship has meant to me. Thank you for graciously accepting me as a student seven years ago. Your impact in my life extends far beyond research and clinical training– you also helped me to develop as a person and I feel privileged to have worked with you. You have equally inspired, challenged, and, certainly, frustrated me. Looking back, however, it has been the most insightful and rewarding journey these past years. Your immense wisdom and insightfulness never ceased to amaze and inspire me, perhaps rivaled only by your astute attention to detail and editing skills. Thank you for allowing me to complete this fascinating project with you and for the endless hours discussing the meaning of it all. Perhaps most importantly, thank you for holding such high expectations of me. Your relentless ability to “push” me (and prevent me from “whining”) caused me endless grief, but alas helped to create this wonderful piece of work and fostered my growth in numerous ways. I sincerely thank my thesis committee members for their invaluable contributions and insightful feedback that not only shaped this project in interesting ways, but also enhanced my learning. Dr. Michele Peterson-Badali, you have been instrumental in my Ph.D. research, first as the second reader for my M.A. thesis and now as a committee member for my dissertation. Your insight, feedback, and encouragement have been undoubtedly helpful, especially as I weathered seemingly insurmountable obstacles. Dr. Katreena Scott, I thank you for not only your intellectual commitment to this endeavor, but your ability to help me iv always remember to see the forest for the trees. I greatly appreciate your selflessness in always making time for me and your incredible capacity to problem solve. Dr. Susan Bradley, I am most grateful for your clinical insights. The commitment, empathy, and skills you bring to clinical work with children and their families have inspired me and provided me with skills which have enabled me to grow as a clinician. Dr. Lana Stermac, thank you for coming on board and offering your insights. Finally, to my external examiner, Dr. Michael Bailey, it was indeed my pleasure to have your insights and reflections on this project. Since I first read your book, I recognized your passion for understanding the lives of gender dysphoric children and was immensely pleased that you agreed to take on this role. I express sincere gratitude and appreciation to the study participants, for without you this project could not come have come to fruition. Thank you for the hours spent sharing your stories–your candor made data collection enjoyable and added much depth and complexity to this project. Thank you to members of the Gender Identity Service who have been important supports and to the research assistants who tolerated my need for perfection as you entered the large volume of data needed for this project. I would also like to thank Dr. Ray Blanchard and Dr. James Cantor for your statistical support and clinical insights. Finally, I thank my family and friends. This arduous journey would not have been possible without your warmth, support, and patience with the inevitable stress associated with this project. To old and dear friends–Tomoko and Heidy–we have shared countless memories throughout the years and your support helped me complete this journey. Hamed, there are no words! You made so much possible and I am forever grateful for our friendship and for your kindness when I needed it most. Brian, thank you for being an amazing friend and the most patient person I have ever met. The many, many hours you spent listening to v my venting and offering technical support made this journey substantially easier. Navin, your unconditional support has not gone unnoticed. To my parents, words cannot express the gratitude I have for unique ways in which you have both supported and encouraged me. Dad, thank you for always understanding and challenging me, and mom, thank you for inspiring me to be better than I think I am capable of. Finally, but by no means least, I sincerely thank my sister, Wanita. You get me in ways no one else can and made the most difficult phases of this project bearable. vi Table of Contents List of Tables..................................................................................................................... xiv List of Figures.................................................................................................................... xvi List of Appendices............................................................................................................. xvii Chapter 1: Introduction...................................................................................................... 1 1.1 Rationale for the Study................................................................................... 1 1.2 Terminology................................................................................................... 3 1.2.1 Sex and Gender................................................................................. 3 1.2.2 Gender Role...................................................................................... 4 1.2.3 Gender Identity................................................................................. 4 1.2.4 Gender Dysphoria............................................................................. 5 1.2.5 Sexual Orientation............................................................................. 9 1.2.6 Sexual Identity.................................................................................. 10 1.2.7 Transgender and Transsexualism...................................................... 10 1.3 Phenomenology of Gender Identity Disorder................................................. 11 1.3.1 GID in Children................................................................................ 11 1.3.2 GID in Adolescents and Adults........................................................ 14 1.4 Prevalence of Gender Identity Disorder......................................................... 15 1.5 Treatment of Children with Gender Identity Disorder................................... 16 1.5.1 The Therapeutic Model..................................................................... 16 1.5.2 Accommodation Model..................................................................... 18 1.5.3 Early Transition Approach................................................................ 19 1.6 Diagnostic Controversies................................................................................ 22 1.6.1 Diagnostic Reform............................................................................ 22 1.6.2 Is GID a Mental Disorder? ............................................................... 24 1.7 Psychosexual Outcome of Boys with GID..................................................... 27 1.7.1 Gender Identity Outcome of Children with GID.............................. 27 vii 1.7.1.1 Methodological Issues.......................................................
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