Gender identity disorder in childhood: inconclusive advice to parents.

For purposes of this essay, let's invent a contemporary American child named William Lee. William is five years old and, as far as anyone can tell, his body is that of a typical male. But William has long acted in a fashion more typical of girls: he likes to play with "girl" toys like Barbie dolls and My Little Pony; he strongly prefers playing with girls to playing with boys; and he likes to dress up like a conventionally pretty woman, in pumps and dresses, with jewelry and make-up. He increasingly insists he is really a girl and indicates a belief--or a desperate hope--that he will grow up to be a woman. He wants to be called "Julie" and to go to school as Julie. He exhibits what psychologists call gender dysphoria. This stresses out his parents; it is not easy to have a child who challenges social norms, especially norms about gender. If William's parents are not living in a media-free universe, they will know that there are two basic models of thought about what they should do. One, which I'll call the therapeutic model, maintains that William is showing all the signs of gender identity disorder (GID) and that he should be treated by a mental health professional. Or rather, his family should be treated by mental health professionals because, according to the typical contemporary therapeutic perspective, William needs--and lacks--a family that is functioning well psychologically and emotionally. If his mother is depressed or clingy, if his father is physically or emotionally absent, if his parents' marriage is a stressful mess, William is going to keep suffering from gender role confusion, and secondarily from the anger, shame, disappointment, anxiety, and guilt that his parents may exhibit in response. Although the therapeutic model does not point to a single cause of GID, it does see familial dysfunction as an aggravating factor in virtually all cases. Under the therapeutic model, mental health professionals will attend to the relevant family members--particularly William and his parents--and will try to help move William toward a less stressful, more sustainable family environment and gender identity. William will be given gender-neutral toys to replace his Barbie and My Little Pony and will, ideally, be led to develop friendships with other boys--not boys of the rough-and-tumble, army-toy-obsessed type, since William will never relate well to those boys, but boys of the calmer, gentler variety. William will implicitly learn that he can be a boy without having to be aggressive and competitive. As part of the new family discipline, William's mother and father will learn to act like a loving mother and father should, and William will not be allowed to go to school as a girl or to otherwise pretend he is a girl. Thus, the therapeutic approach assumes that William's desire to grow up as a woman represents a kind of problematic fantasy and that, with the right interventions, it can be made to dissipate. (1) Evidence that this approach makes GID dissipate is lacking. The second model of thought, which I'll call the accommodation model, presumes that there is nothing wrong with William--or rather, Julie--and nothing wrong with the Lee family, either, except perhaps the largely unnecessary suffering they experience from failing to understand that William really is Julie. According to this model--but not according to any strong scientific evidence--Julie was born with a female brain in a male body. The problem is not the child, nor the family, but the culture, and so the culture must learn to accommodate Julie as she grows to become a woman. The role of medicine, according to the accommodation model, is not to "resolve" Julie's "gender identity disorder," but to provide her, when the time comes, with the hormones and surgeries she will need to make her body into what it should have always been and with the psychological support to help cope with a hostile world. (2) Now, if the Lees were to ask me, "What should we do? …