Counseling Gender Confusion
Describing different approaches to gender confusion and a list of resources to consider.
Photo by Vitaly Gariev on Unsplash
Counseling Gender-Dysphoric Children and Teenagers
Julie Hamilton, Ph.D., LMFT
When it comes to treating childhood gender dysphoria, there are generally three different approaches: Gender Affirming Care, Watchful Waiting, and an Active Psychotherapeutic Approach.
Gender Affirming Care involves several steps. First, the child is encouraged to socially transition beginning as early as 3 years old. Next, the child takes puberty suppressing hormones prior to puberty, and then in the teen years, he or she takes cross-sex hormones. For some, surgery follows in the late teen years or early adulthood. Many European countries have stopped Gender Affirming Care, citing the lack of evidence for its effectiveness. Additionally, this approach has been found to be potentially harmful in various ways. And many individuals have detransitioned, regretting the irreversible steps they have taken. (Cass, 2024). Further, hormones and surgery do not change chromosomes – people are still male or female at the cellular level.
Watchful Waiting refers to the therapist waiting to see if the child will outgrow the gender dysphoria. Researchers have found that 80-90% of children who are not encouraged to become the opposite sex will outgrow the desire to be the opposite sex by the time they reach adulthood (Singh, et al., 2021). Most of those children will instead be gay or lesbian (Green, 1987; Singh, et. al., 2021). Although Watchful Waiting may seem to be a safe approach, this approach fails to address or resolve underlying issues, which may be a disservice to the child.
The Active Psychotherapeutic Approach is when a professional helps the child by addressing the underlying issues associated with gender dysphoria. There are reasons that a child might reject being male or female, and it is important to deal with those reasons rather than leave them unaddressed. According to Zucker (personal communication, 2024), the Active Psychotherapeutic Approach makes the most sense whenever possible, because it helps a child become more comfortable in his or her own skin and is less invasive. The active psychotherapeutic approach is also the oldest approach in the clinical literature (K. Zucker, personal communication, 2024).
Sadly, the Active Psychotherapeutic Approach has often been mischaracterized as so-called “conversion therapy,” a term that has become synonymous with abusive practices. But in reality, it is simply talk therapy, like talk therapy for any other issue. The reason it is referred to as “conversion therapy” is due to the goal of therapy, not the methods. If the goal is to help a gender-dysphoric client become more comfortable with his or her biological sex or to decrease unwanted same-sex attractions, it is automatically classified by some as conversion therapy with implications of harm. Ironically, this characterization ends up harming clients by discouraging them from pursuing professional help for resolution of their internal conflicts. And yet, contrary to the mischaracterization, therapy can be quite effective in helping a child become comfortable in his or her own skin (Singh, et al., 2021; Zucker et al., 2012).
Contributing Factors
For many children, gender dysphoria has an early onset starting at or around 3 years of age, but for some it has a late onset, starting in adolescence or early adulthood. One late-onset type is called autogynephelia, in which cross-dressing is a sexual fetish. This type occurs mostly among males. (Autogynephelia is not the subject of this paper). Another late-onset type, found mostly among females and occurring culturally in the last two decades, is what some professionals have referred to as ROGD or Rapid Onset Gender Dysphoria (Littman, 2018; Sapir, 2024). This is more common for those who are on the autism spectrum, and they often have other mental health issues as well (de Vries, et al., 2010; Kaltiala-Heino, et al., 2015; Kaltiala-Heino, et al., 2018). Additionally, cultural and social influences might also play a significant role (Marchiano, 2017; Littman, 2018). While cultural, social, and mental health factors may contribute to ROGD, the following are factors that may contribute to early onset gender dysphoria.
1. Personality
The first category of contributing factors, or risk factors, is personality characteristics. Children with gender dysphoria or even gender confusion often have personality characteristics that contribute. Many of these children are temperamentally sensitive. They are usually smart, observant, deep feelers, analytical, taking everything in and sometimes taking in information inaccurately. For example, they may perceive rejection when rejection is not actually taking place. They tend to personalize and internalize their experiences. Boys with gender dysphoria may be highly anxious and may tend to avoid rough and tumble play, whereas girls may be more active than their female peers (Bradley & Zucker, 1990; Zucker & Bradley, 1995).
2. Perceptions
The next category is perceptions or misperceptions about gender (Zucker, personal communication, 2024). A child might misinterpret events that take place, and the misinterpretation might lead to a negative view of his or her gender. For example, a girl whose mother is a victim of domestic violence might perceive that women are weak or she might equate being female with being a victim. She might prefer to identify with masculinity to avoid feeling weak or helpless. A child might also perceive himself or herself to be inadequate in regards to gender, due to misperceptions of self or others. For example, a boy, who is not comfortable with rough and tumble play or who is not athletically inclined, might perceive himself to be inadequate as a male.
3. Parent-Child Relationships
The next category of factors has to do with the parent-child relationships, especially the relationship to the same-sex parent. Children first need to bond with their mother during infancy, and then from the ages of approximately 1 ½ through 3 a child needs to bond with the parent of the same sex, girls with their mothers and boys with their fathers (Nicolosi, 2016). Identifying with the same-sex parent is important for developing a secure gender identity. Lack of healthy attachment to the same-sex parent is one of many factors that can put a child at risk for developing gender dysphoria (Lung & Shu, 2007; Meyer-Bahlburg, 2002; Nicolosi, 2016; Bradley & Zucker, 1990; Zucker & Bradley, 1995; Zucker et al., 2012).
4. Peer Relationships
In addition to bonding with the same-sex parent, children need to relate well to same-sex peers. From about the age of 5 through puberty, children seek acceptance and inclusion from same-sex peers. This identification with members of the same sex helps to solidify a secure gender identity. After years of bonding with the same-sex and being secure in one’s own gender, adolescents go on to develop curiosity and interest in that which is different – the opposite sex. But first, same-sex bonding must take place, and a lack of same-sex peer bonding is another factor that can put a child at risk for developing gender dysphoria. (Meyer-Bahlburg, 2002; Nicolosi, 2016; Zucker, et al., 2012).
5. Psychodynamics of the Family
There are many types of family dynamics that can contribute to gender dysphoria. These may include marital conflict, a parent becoming emotionally dependent on a child, lack of nurture for the child, parents wanting a child of the opposite sex and not being able to accept the sex of their child, or adverse childhood experiences such as parental mental illness, domestic violence, or physical or sexual abuse (Giovanardi, et al., 2018; Mayer & McHugh, 2016; Bradley & Zucker, 1990; Zucker & Bradley, 1995; Zucker et al., 2012).
Counseling
When it comes to counseling, many experts have found that it is helpful to work with both the parents and the child or teen. (Bradley & Zucker, 1990; Zucker et al., 2012). Each situation is unique, so counselors can explore underlying factors and address whatever seems most relevant to each individual client.
1. Addressing Personality Characteristics and Perceptions
Personality issues can be addressed by helping both parent and child to understand the child’s personality, especially if the child has a more sensitive temperament. Counselors can help children identify their tendency to personalize their experiences, help them understand their experiences more accurately, and clear up any misperceptions about gender.
For children on the autism spectrum, parents might benefit from the many autism resources available. Additionally, these children may need help with emotion regulation and social interactions (S. Bradley, personal communication, 2024)
2. Assisting with the Parent-child Relationship
Professionals can also help parents to strengthen the parent-child relationship – especially with the same-sex parent. Counselors can help parents work on the A’s of parenting: attention, affirmation, approval, and affection. Therapists can teach parents how to listen more effectively, how to empathize and validate their child’s feelings, how to tune in, how to affirm and build up their child, and so forth.[HT1]
Counselors can also equip parents to gently redirect their child away from identifying as the opposite sex.
3. Advancing Peer Relationships
If same-sex peer relationships are lacking, parents and professionals can help children fill in any bonding gaps that may be present. Some of the ways parents and professionals can do this are: teaching social skills; arranging frequent play-dates with same-age, same-sex peers; helping the child find common ground with same-sex peers; and leading the child to join teams or other same-sex peer groups.
4. Attending to Family Psychodynamics
Therapists can also identify unhealthy family dynamics and work with parents to make whatever changes are needed. And of course, where there have been adverse childhood experiences, therapists can address these through trauma-based interventions.
In addition to any above-mentioned factors, when it comes to working with Rapid Onset Gender Dysphoria, it is similarly important to deal with underlying issues, including other mental health issues; to slow down the process of transitioning; and to remove negative influences and replace them with positive experiences and people. Parents can work to replace on-lineonline relationships with real- life experiences. In later onset cases, parents can work to strengthen family relationships and same-sex peer bonding.
Conclusion
It’s clear that there is a lot more going on underneath the surface for gender-dysphoric children and teenagers. It would seem the most helpful approach would be to deal with the underlying issues. In doing so, we can help them to live a life more comfortable and confident in their own skin.
For more information, go to www.genderidentity101.com.
References
Bradley, S.J., & Zucker K.J. (1990). Gender identity disorder and psychosexual problems in children and adolescents. Canadian Journal of Psychiatry 35(6):477-86.
Doi:10.1177/070674379003500603. PMID: 2207982.
Cass, H. (2024). Independent review of gender identity services for children and young people: Final report. https://cass.independent-review.uk/home/publications/final-report
de Vries, A.L.C., Noens, I.L.J., Cohen-Kettenis, P.T. et al. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40, 930–936. https://link.springer.com/article/10.1007/s10803-010-0935-9
Giovanardi, G., Vitelli, R., Maggiora Vergano, C., Fortunato, A., Chianura, L., Lingiardi, V., Speranza, A.M. (2018). Attachment patterns and complex trauma in a sample of adults diagnosed with gender dysphoria. Frontiers in Psychology. 9:60.
https://doi:10.3389/fpsyg.2018.00060
Green, R. (1987). The “sissy boy syndrome” and the development of homosexuality. Yale University Press.
Meyer-Bahlburg, H.F.L (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol Clinical Child Psychology and Psychiatry Vol. 7(3): 360–376.
Kaltiala-Heino R., Sumia M., Työläjärvi M., & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9:9. doi: 10.1186/s13034-015-0042-y.
Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisén, L. (2018). Gender dysphoria in adolescence: current perspectives. Adolescent health, medicine and therapeutics 9, 31–41.
Lung, F.W., & Shu, B.C. (2007). Father-son attachment and sexual partner orientation in Taiwan. Comprehensive Psychiatry, 48, 20-26.
Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLOS ONE 13(8): e0202330.
https://doi.org/10.1371/journal.pone.0202330
Marchiano, L. (2017). Outbreak: On transgender teens and psychic epidemics. Psychological Perspectives, 60 (3): 345-366.
Mayer, L. S., & McHugh, P. R. (2016). Sexuality and gender: Findings from the biological, psychological, and social sciences. The New Atlantis, 10-143.
Nicolosi, J.J. (2016). Shame and attachment loss: The practical work of reparative therapy. Liberal Mind Publishers.
Sapir, L., Littman, L. & Biggs, M. (2024). The U.S. transgender survey of 2015 supports Rapid-Onset Gender Dysphoria: Revisiting the “Age of realization and disclosure of gender identity among transgender adults”. Archives of Sexual Behavior, 53, 863-868.
https://doi.org/10.1007/s10508-023-02754-9
Singh, D., Bradley, S.J., Zucker, K. J. (2021). A follow-up study of boys with gender identity disorder. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.632784
Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. Guilford Press.
For more information or to watch the free video, go to:
www.genderidentity101.com
Two additional articles on treatment, including research on those approaches:
Zucker, K. J., Wood, H., Singh, D., Bradley, S.J. (2012). A developmental, biopsychosocial model for the treatment of children with gender identity disorder. Journal of Homosexuality. 59:369–97. 10.1080/00918369.2012.653309
Meyer-Bahlburg, H.F.L (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol Clinical Child Psychology and Psychiatry Vol. 7(3): 360–376.