Stranger in My Own Body

Atypical Gender Identity Development and Mental Health

Domenico Di Ceglie

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429919497
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book brings together the thinking of an international group of clinicians, researchers, and professionals from different disciplines and is based primarily on a selection of papers presented at a conference on the same topic held at the Tavistock Centre, London, in November 1996, but with additional original contributions. It presents a dialogue amongst the various perspectives that can be taken about atypical gender identity development and their relevance to mental health in children and adolescents. The book isfor multidisciplinary professional readership and interested lay people.

CHAPTER ONE
Development and mental health: the issue of difference in atypical gender identity development

Peter Wilson

People who are different—who appear, behave, or think in ways that are not congruent with the majority with whom they live—raise questions about the nature of normality or of health. By virtue of their difference, they represent a threat to others. For the most part they are required to conform; rarely are they adequately understood.

There is, of course, nothing exceptional in this state of affairs: groups and societies are forever tussling in one way or another to deal with the differences within them and hold on to their own essential equilibrium and identity. There are different levels of tolerance for different kinds of differences—and, by and large, the more complex a group or society is, the greater the range of tolerances found. However, there are some differences that present particular challenges. Some may be political or religious in nature, but invariably it is those that have a sexual quality about them that raise the largest concern. In our society, we struggle, for example, with issues about homosexuality, teenage sexuality, extra-marital casual sex, and so forth—against an underlying pressure towards adult heterosexual monogamy. When it comes to responding to individuals whose view of their gender role and identity is manifestly discrepant with the evidence of their physical bodies and appearances, most groups or societies are at a loss. So fundamental is the need for clarity about who is male and who is female that those who demonstrate apparent unclarity (or indeed express a perplexing certainty) are viewed with alarm.

Children and young people who present with unusual gender identities set a major challenge to the groups and societies in which they grow up. By virtue of their unique and peculiar self-convictioris, they stand out as odd, beyond conventional understanding. Their plight is perilous, testing the patience of those around them. Yet it is in the nature of their gender convictions that they persist in believing or behaving in the way that they do—and demand that the group or society in which they live pays respect and attention to who and what they are.

The developmental influences in gender organization are complex; clearly more research is needed to understand the interplay of genetic, biological, familial, psychological, and social factors in the developmental process of atypical gender identity organization. Through the combined forces of these various factors, children with particular and unusual gender identities produce for themselves and for others a situation of extraordinary and distinctive difference. They are unquestionably at variance with other people and within themselves; inevitably they enter a social world in which they are perceived as unfamiliar, out of step—a species apart to be mocked or bullied. This, of course, can do little to assist them in their development, but—whatever the response—these children raise difficult questions for themselves and others about how best to respond to their gender identity and how to deal with it. Is their difference to be seen as abnormal, as pathological, as something to be changed, eradicated, or "treated" in some way? Or should it be viewed as a manifestation of a unique developmental process, to be understood, fostered, protected, and adapted to? These questions can readily lead to polarized positions, and clearly there are no straightforward answers—but they do create problems, especially when, for example, a teenager's convictions demand physical interventions to change sex in a way that is irreversible.

The DSM-IV diagnostic criteria for Gender Identity Disorder (APA, 1994) are quite clear: a strong and persistent cross-gender identification; a persistent discomfort with one's sex or sense of inappropriateness in the gender role of that sex; a disturbance that is not concurrent with a physical intersex condition; a disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is enough here to describe and define a genuine state of disorder, and to justify an intervention of some sort to reduce discomfort and distress, improve functioning, and facilitate development (in the sense of restoring some degree of fluidity).

The task of intervention is formidable, involving a wide range of psychological, social, and physical responses, dependent on a full assessment of the individual child and the family. Much can be done to improve the child's environment and to gain greater understanding of associated and emotional difficulties, and the possibilities exist in some cases to alter the characteristics of the body. All such therapeutic activity is designed to reduce the anguish, confusion, and isolation of the child and his or her family—and, in effect, to mitigate the harmful effects of the child's essential state and experience of difference. In so far as it is the predicament of the child's state of difference that is problematic— that it is the child's extraordinariness that arouses such negative social responses—these therapeutic endeavours are clearly necessary. However, it is important, in carrying out any kind of intervention, to hold in mind two key considerations: firstly, the developmental context and, secondly, the mental health context in relation to the paradox of such difference.

The developmental context

The essential questions that need to be answered during the course of assessment and treatment of a child or adolescent with a gender identity developmental problem are (1) how different is he or she from other children and adolescents, and (2) how open to further development is he or she? We know, for example, that such children and adolescents, despite (and perhaps because of) their difference are but part of the wide generality of young people, all of whom are absorbed in one way or another in the mysteries of their own identities and sexualities. They may have unusually strong beliefs, all the more striking because of the discordance with the evidence of their bodies, but in many respects they share in the unease and uncertainty of all young people in the course of growing up. It is in the process of child and adolescent development that there is an ongoing fascination with the questions that arise about their bodies, their genders, and their selves. There is no adolescent who does not worry about the size or shape of his or her body, who does not compare it with others, and who does not wonder what he or she should do with it by themselves or with others. There is no child or adolescent who is not learning about the nature of masculinity and femininity and building some inner sense of himself or herself as male or female. At the core of this enquiry is a basic narcissistic preoccupation with the essence of oneself. This is difficult and complicated, for it embraces all the thoughts and memories that young people have about their natures and relationships with others: Who am I? How coherent am I (how well do I hold together)? How valued am I (by myself and by others)? How well do I stand up in relationship to other people? How like or unlike am I to them (and how likeable and unlikeable am I)? These are key questions about the nature of self and the issue of distinctiveness—how separate, individual, and, above all, different am I? The word "differ" derives from the Latin word differe, which means "to bear" or "to carry apart". The young person asks, how can I bear myself apart from others? It is through answering this question that children and adolescents build a sense of themselves and mark out their identities—different from their mothers, their fathers, their grandparents, their siblings, their peers, and so forth—and, in so doing, they seek their own difference, their own personal integrity, their sense of themselves that makes sense to themselves.

Development, then, involves the discovery of mind and body, which is fundamentally concerned with the emergence of differences. Whether at an intellectual, cognitive, physical, social, or emotional level, development consists of varying processes of differentiation—between different parts or elements within the individual and between the individual and others. Erikson (1963) emphasizes the epigenetic course of development, underlining its sequential nature, a series of rising steps, each state building on the developmental achievements of those that went before. As he sees it, the adequacy of development at one developmental state fortifies movement onto the next; inadequacy may not stop development from proceeding, but it may leave areas for future developmental vulnerability. Throughout his writing, Erikson stresses the uniqueness of individual development—the timing and intensity of development varying considerably from one person to an other—and the importance of mutual regulation between the individual's internal developmental momentum and the surrounding environment. He writes that society, in principle, tends to be so constituted as to meet and invite this succession of potentialities for interaction and attempts to safeguard and encourage the proper rate and the proper sequence of their enfolding.

Development is thus clearly a highly complex phenomenon—a gradual process of differentiation, an unfolding of abilities and potentialities—always in a social context and driven by the imperatives of maturation and by the assertion of the individual's self. It is not, by its very nature, an easy or comfortable process. It contains inevitable dilemmas and unpredictabilities. It also carries with it at any given point of time a particular contradiction. The individual in the midst of the movement and fluidity of development needs at the same time to mark out moments of achievement of new integration. The contradiction resides in the coincidence of fluidity and fixity. The growing individual needs, for example, to be able to say, in effect: "Today I have discovered something new about myself that is real and significant, but at the same time it is changing and disappearing and making way for something new." A great deal depends on the capacity of the individual to tolerate and cope with this tension, to build a sense of identity and yet to keep the processes of development open and not foreclose on further possibility through defensive fixation.

It is in this context of developmental preoccupation and the general capacity for growth and differentiation that children and adolescents with gender identity problems need to be considered. Their differences can be set alongside a continuum of variation in adolescent sexual development and their convictions and assertions understood and assessed in the midst of the process of change that is characteristic of child and adolescent development.

The mental health context: the paradox of difference

Mental health is a notoriously difficult concept to define. All too often it is confused with its opposite, mental illness. Alternatively, it becomes a vehicle for idealistic and moralistic notions of virtue and beauty. The mentally healthy individual comes to be seen, almost in statuesque form, as the epitome of perfection. At one level, mental health can be defined simply in terms of the soundness and the well functioning of the mind. Difficulties arise, of course, as to what it is that constitutes such soundness. In recent attempts to reach a definition (NHS Health Advisory Service, 1995), the mental health of children and adolescents has been understood in terms of a series of capacities: first and foremost, a capacity to develop (psychologically, emotionally, intellectually, and spiritually) and then to initiate, develop, and sustain mutually satisfying personal relationships; to become aware of others and be empathetic; and to use psychological distress as a developmental process so that it does not hinder further development. Implicit in all of this is a sense of movement and openness—to develop, initiate, become aware, and so forth. Mental health, like physical health, is not static: it ebbs and flows, functions well and not so well, and carries at any given time its own imperfections and sticking points.

There is clearly a close link between the concepts of mental health and development, not least in the capacity to be receptive to new experiences, to learn, and to seek integrity. It is in this respect that a paradox needs to be held in mind, a paradox that resides at the centre of the meaning of mental health itself: for in the midst of a mental illness or mental health problem, there may be a mentally healthy process in operation. There is, in short, health in illness. If we take this through to the fundamental problem of the difference of the child and adolescent with a gender identity problem, we can gain some fuller understanding of the function of that difference; that is to say that, in being so different, the child exposes him/ herself to mental health problems, yet safeguards his or her mental health, through maintaining his or her difference (and his or her integrity).

What is clear and unequivocal in the children and adolescents who have gender identity problems is the strength of their assertions and beliefs about themselves. Out of the diverse developmental processes that have produced their gender identity, they create their own certainties about themselves. Most definitions (e.g. Stoller, 1968a) of gender identity emphasize the sustaining and persisting quality that characterizes young people's perceptions of themselves as male or female. Such persistence, of course, can be problematic, unrelenting, and distressing. Equally, however, it can maintain a self-conviction that represents, in effect, the only meaningful conclusion for the individual in making sense of the many developed mental processes that have occurred throughout his/her life. There may be no other way, for example, that a boy with a significant hormonal imbalance who has been raised as a girl by his grandmother and subsequently traumatized by her death can experience himself at a certain point in his development other than as a girl. Such a conviction stands at the core of his mental health; he is holding on to a belief that is integral to his developmental experience and is not to be relinquished, whatever social advantages there may be.

In many respects, this is not dissimilar to the beliefs, assertions, and behaviours that many children (not only those with gender identity disorders) hold on to, often against the convenience of others, in order to keep faith with their own experience and to hold open possibilities for their "true self" to be developed (Winnicott, 1960). The obdurate disobedience of a child in school, the determined refusal of the anorectic to eat, the unrelenting self-destructiveness of the drug-taking adolescent—all can be seen as representing a vital position, standing up for something important for themselves that is consistent with their experience of what has happened to them. Their development may temporarily be stuck, but it can be said that their mental health resides in their capacity to be true to themselves and to the reality of their own developmerit—and not simply in terms of superficial happiness or conformity.

This is, then, a conception of mental health that allows us to see the possible strength and soundness of the nature of gender identity differences that in many other respects may be problematic and give rise to problems. Such a conception may, of course, be seen as fanciful, denying the desperateness of the distress of many young people and ignoring the anxieties that surround them. It may also be seen as anti-therapeutic, resistant to the demands from young people and professionals for immediate and dramatic intervention. It is, however, a conception that is founded on an understanding of the complexity of development and of an understanding of the nature of mental health. The primary therapeutic aims outlined by Domenico Di Ceglie in chapter twelve (see also Di Ceglie, 1995) clearly reflect this understanding—notably in fostering recognition and non-judgemental acceptance of the gender identity problem, activating interest and curiosity, allowing mourning processes to occur, and, most importantly, enabling the child and the family to tolerate uncertainty in the area of gender identity development (in particular, in allowing for the possibility of change in the course of further development). Perhaps the essence of mental health and of development is the capacity to keep possibilities open, to refuse to foreclose on their development, and to maintain respect for self-integrity.

CHAPTER TWO
Reflections on the nature of the “atypical gender identity organization”

Domenico Di Ceglie

The recognition in the late 1950s that there is a facet of personal identity called gender identity has had widespread repercussions in our understanding and attitudes towards unusual developments in our relationship to the body. A new Weltanschauung about psychosexual development could be constructed, and it became possible to conceptualize atypical experiences in the areas of sexuality which had been poorly understood thus far. In this chapter, I review the history of the concepts of gender role, gender identity, and core-gender identity. I propose the term atypical gender identity organization (AGIO) to define an internal psychological configuration whose phenomenology is represented by the typical characteristics of a gender identity disorder. This phenomenology includes atypical variation in the following areas: gender identity statements, dressing, toy and role playing, peer relations, mannerisms and voice, anatomic dysphoria (i.e. intense dislike of their sexual bodies), and rough and tumble play, as described by Zucker and Bradley in their book Gender Identity Disorder and Psychosexual Problems in Children and Adolescents (1995).

I then outline an interactive approach in the formation of the atypical gender identity organization, within a psychodynamic framework of development, and finally discuss the implications for therapeutic strategies.

Historical notes

The concept of gender identity made its appearance in the early 1960s as a result of the clinical work of Robert Stoller. It was preceded by the term "gender role" described by John Money in an article in the Bulletin of the Johns Hopkins Hospital in 1955. Money wanted to differentiate a set of feelings, assertions, and behaviours that identified the person as being a boy or a girl, or a man or a woman, from the contrasting conclusions that one could have reached by considering only their gonads. In the vast majority of the cases described, gender role was consistent with the gender in which they had been reared. Stoller (1986) defined gender identity as: "A complex system of beliefs about oneself: a sense of one's masculinity and femininity. It implies nothing about the origins of that sense (e.g. whether the person is male or female). It has, then, psychological connotations only: one's subjective state."

The definition of gender identity made it possible to further the thinking about human conditions in which the external reality of the body and the inner subjective perception do not match. In some cases, a harmonious relationship between the internal representation of the body and the body itself has not been achieved, with a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• ACKNOWLEDGEMENTS
• Contents
• LIST OF CONTRIBUTORS
• FOREWORD
• PREFACE
• 1 Development and mental health: the issue of difference in atypical gender identity development
• 2 Reflections on the nature of the "atypical gender identity organization"
• 3 Associated psychopathology in children with gender identity disorder
• 4 The complexity of early trauma: representation and transformation
• 5 Biological contributions to atypical gender identity development
• 6 The contribution of social anthropology to the understanding of atypical gender identity in childhood
• 7 Some developmental trajectories towards homosexuality, transvestism, and transsexualism: mental health implications
• 8 Gender identity disorder, depression, and suicidal risk
• 9 Gender identity development and eating disorders
• 10 Child sexual abuse and gender identity development: some understanding from work with girls who have been sexually abused
• 11 Intersex disorder in childhood and adolescence: gender identity, gender role, sex assignment, and general mental health
• 12 Management and therapeutic aims in working with children and adolescents with gender identity disorders, and their families
• 13 Case illustrations
• 14 Children of transsexual parents
• GLOSSARY
• APPENDIX A Gender Identity Disorders in Children and Adolescents Guidance for Management. The Royal College of Psychiatrists
• APPENDIX B The Gender Identity Development Unit at the Portman Clinic, London
• APPENDIX C Mermaids
• REFERENCES
• INDEX