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Clinical Child Psychology and
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DOI: 10.1177/1359104502007003013
2002 7: 487Clin Child Psychol Psychiatry
Domenico di Ceglie
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Tavistock Clinic, London, UK
AN OPPORTUNITY TO pause and reflect on how one got to a particular point in the
development of one’s own interests should not be missed. In this case, it is the creation
of a service for children and adolescents facing gender identity problems. This remains
a mystery to me and it is still surprising how apparently unpredictable sets of events
determine shifts in interests and professional activities.
In my case, it was an encounter with a teenager in the early 1980s who had been
referred by a colleague, Dr Jill Vites, to the Adolescent Department of the Tavistock
Clinic and who was claiming that she was a boy but in a female body. I knew little about
this subject but I decided to take this case out of curiosity and perhaps to expand my
training experience. I thought I would also learn more about what it meant to be male
or female and the differences between the two. After an initial assessment, I offered this
girl, or should I say boy, psychotherapy that was accepted. The impact of this relation-
ship was an unexpected one. I learned very little about sexuality as a good deal of the
sessions were spent in silence. My patient would say a few sentences and I would make
a few interpretations. The end result was that I could record very accurately what
happened verbally in the session. What went on non-verbally – is another story. I got the
impression that there was something very profound about her sense of identity of being
a boy which could not be easily explained and that was fundamental to her being.
Colleagues were saying that she was confused about her gender. I discovered instead
that Iwould become at times confused during the sessions about her identity, whereas
she seemed to be very clear that she was a boy and that there was nothing more to find
out about this. I was at times made to feel extremely curious in the sessions, only to find
out that my curiosity would be frustrated and that it was pointless to pursue my enquiries.
I started to read the work of Robert Stoller (1968, 1975) and other literature on trans-
sexualism. These articles concern mainly work with adults. I found, however, that this
Clinical Child Psychology and Psychiatry 1359–1045 (200207)7:3 Copyright © 2002
SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 7(3): 487–491; 024042
DOMENICO DI CEGLIE is a Consultant Child and Adolescent Psychiatrist in the
Adolescent Department at the Tavistock Clinic, Director of the Gender Identity Develop-
ment Unit at the Portman Clinic, Honorary Senior Lecturer at The Royal Free and University
College Medical School, and Psychoanalytic Psychotherapist at the Lincoln Centre. For many
years he has had an interest in adolescence and has worked in in-patient units for young
people. He has been widely involved in consultative work to organizations and to professional
networks about complex cases.
CONTACT: Domenico Di Ceglie, Gender Identity Development Unit, Portman Clinic, 8
Fitzjohn’s Avenue, London NW3 5NA, UK. [E-mail:].
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reading didn’t help as much as I’d hoped in understanding the complexity of the
condition. This patient had to move to another town and so her exploratory therapy with
me had to come to an end. In one of her last sessions she said that perhaps this form of
help had come too late and that her parents should have been aware of how she was
feeling by the way she behaved. She wondered why they had not sought help for her
when she was a child. Her thoughts made me wonder why there was no service for
children with these rare and unusual experiences. This planted in me the seed for the
creation of such a service.
Soon after the end of this experience I became a consultant in child psychiatry in
Croydon and started a workshop there with two or three members of staff who were
interested in this area. We tried to see all the cases in the London Borough of Croydon,
with a population of about 300,000, who presented with gender identity problems and
we ended up with 3 or 4 cases. Some were seen in family therapy and I took one case
into individual therapy. This child had some of the features that Stoller had described.
However, in the clinical sessions I could find no evidence of a ‘blissful’ relationship with
the mother. Stoller writes: ‘When extremely feminine boys are studied in childhood, I
find that their mothers try to maintain indefinitely a blissfully intimate symbiosis with
their son . . .’ (Stoller, 1992).
I used to see this 7-year-old boy after school as my last case. He made few demands
of me as his therapist. This seemed to be the perfect patient to have at the end of a hard
day. As soon as he walked in the room he would start to play with the dolls’ house,
placing all the dolls, which I had provided, in the little rooms apparently totally ignoring
me and tidying up everything near the end of the session. The problem started when I
asked him what he was playing. He came up with very elaborate fantasies on how all the
children in the house were going to be killed by various means, including the use of poiso-
nous gas released by a cylinder. I was shocked to find out that so much was going on in
his mind in spite of the mild appearances of his behaviour. Within a Kleinian perspec-
tive (Klein, 1975), if the dolls’ house represented the body of the mother or his relation-
ship with the mother there was very little of a benevolent nature going on there. So much
for the ‘blissful’ relationship! By now, I had become convinced of a need for a service
for children with gender identity disorders.
In 1987 at the international conference of the European Society of Child & Adolescent
Psychiatry I had the opportunity to meet Robert Stoller in person. During a coffee break
I mentioned to him my project to start a service for children and adolescents. He was
very encouraging. He thought that there was a real need for such a service and predicted
that there would be many referrals and a lot of interesting work. He suggested that I read
and made contact with Richard Green who had been doing clinical work and original
research on children (Green, 1968, 1971, 1974).
Some time after I met for lunch with Peter Hill, at the time Professor of Child and
Adolescent Psychiatry at St George’s Hospital Medical School. He enthusiastically
agreed to support the establishment of a gender identity service for children and adoles-
cents within the Department of Child Psychiatry at St George’s. I decided to call it
Gender Identity Development Clinic as the emphasis would be in promoting the
development, particularly that of gender identity, in the children/adolescents coming to
the service. So in September 1989 the service started. The staff included a social worker
Mary Lightfoot, a psychotherapist Barbara Gaffney and a senior registrar Martin
McCall. The clinic was held one afternoon fortnightly and then weekly. Later an eminent
paediatric endocrinologist from Great Ormond Street, David Grant, offered to run a
paediatric liaison clinic once a term in the Paediatric Department at St George’s, during
which the child/adolescent key worker from our service would join him in seeing the
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child and the family. I referred to these two settings as the ‘theatre of the mind’ and the
‘theatre of the body’ to use Joyce McDougall’s fitting metaphors (McDougall, 1985,
1989). These two spaces need to be first integrated in our minds as professionals and,
hopefully, they will then become integrated in the minds of our clients. However, they
needed to be seen as clearly definable and visible to meet the psychological needs of the
children, in particular, teenagers coming to our service. I also conceptualized some
aspects of the paediatric intervention as offering a transitional space, which allowed the
engagement of some teenagers who wouldn’t otherwise have engaged working with us.
This mind/body integration visibly represented by the working together of a paediatri-
cian with professionals involved in psychosocial interventions, became one of the
primary aims of our therapeutic model.
In 1992 our service, in association with the conference unit at St George’s, organized
the first international conference on gender identity problems in children and adoles-
cents. John Money presented a paper on the history of the concept of gender identity
and gender identity disorder, which was published in 1994 (Money, 1994). The
conference allowed a creative sharing of experiences with colleagues who had devel-
oped similar services in other parts of the world, particularly Peggy Cohen-Kettenis in
Utrecht and Ken Zucker in Toronto. I presented a paper on our model of working in
which altering the gender identity disorder per se was not a primary therapeutic objec-
tive. Our primary therapeutic objectives were instead the developmental processes,
which, on clinical and research experience, seemed to have been negatively affected in
the child. Particularly useful was the work of Susan Coates (Coates & Spector Person,
1985; Coates et al., 1991) on attachment patterns in children with gender identity
problems. This therapeutic approach was obviously a paradox for a service for children
with gender identity disorders in whom the primary aim was not the psychological treat-
ment of the disorder, which meant the necessity of adapting the mind to the body. Our
stance was to maintain an open mind as to what solution an individual would find to the
mind/body conflict. Our task was to assist the child/adolescent and the family in the
gender identity development and in the search to the best possible solution to the
identity conflict. Addressing developmental processes, however, might secondarily
affect the gender identity development. I remember vividly the controversy that this
approach provoked during the discussion, which followed my paper. Some pro-
fessionals seemed shocked that our energy was not devoted to treating the disorder,
whereas other members of the audience, particularly representatives of the self-help
organizations, appeared relieved that we were not trying intrusively to change these
children at all costs.
The method of achieving these aims relies on a range of therapeutic interventions
ranging from family work, individual work, group work, support and educational groups
for parents to professional network meetings involving teachers, health visitors, social
workers, general practitioners and other mental health professionals involved with the
child. In some cases only one therapeutic intervention for a short period is appropriate.
In other cases a combination of these interventions is necessary over a longer period.
A regular review of the needs of the child/adolescent and the family within a multi-
disciplinary team is necessary to determine which intervention would be the most appro-
priate and effective at a particular stage of development (Di Ceglie, 1998).
Over the years we have not had reason to radically change this model and the number
of children and teenagers referred to the service has gradually increased. However, the
model has been refined over the years, particularly with reference to physical inter-
ventions in adolescents with a transsexual outcome. A committee set up by the Child
and Adolescent Faculty of the Royal College of Psychiatrists produced a Guidance for
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Management for Gender Identity Disorders in Children and Adolescents in January
1998. I now refer to this model as the staged approach (Di Ceglie, 2000).
Since the start of the service other areas of needs have emerged, such as the gender
identity and psychosocial difficulties of some children with intersex disorders and the
management issues raised by children of transsexual parents, particularly in relation to
residence and contact disputes.
In 1996, the clinic transferred from St George’s to the Tavistock and Portman Trust,
based at the Portman Clinic. It organized two further international conferences in 1996
and in 2000. Some of the papers presented at the conference in 1996 were published in
a book A Stranger in My Own Body (Di Ceglie, 1998), which also contained a chapter
on children of transsexual parents. In the 2000 conference therapeutic models of
management of children and adolescents with gender identity problems were reviewed
and debated but a special feature of this conference was the psychosocial management
of children with intersex conditions. Milton Diamond presented a paper summarizing his
lifetime’s work in this area and giving his views on the management of this condition
(Diamond & Sigmundson, 1997). His presentation generated an interesting debate
involving a number of self-help organizations. By now it has become clear that there is
a need for a specialized service of this kind, covering three areas: (i) gender identity
disorder, (ii) some aspects of the psychosocial management of some intersex conditions,
and (iii) provision of specialized counselling to children and families with a transsexual
During the life of the service, staff and users have contributed creatively to its develop-
ment. For instance, a mother of a child with gender identity disorders involved in a
dispute over contact with her ex-partner, asked me during a court break if she could meet
other parents facing similar issues. This was the start of a new development – the running
of a group for parents of children with gender problems. This group became an import-
ant feature of our service and then led to the formation of a self-help organization called
‘Mermaids’. Mermaids had been the focus of discussion in one of the parents’ groups in
an attempt to understand the fascination that some children have for these mythical
creatures. ‘Mermaids’ is a complementary organization to our service, which offers the
kind of help and support that we, as professionals, cannot. Their social activities and
networks provide, in my view, a space within society in which children and teenagers
with unusual gender development can feel accepted. Their social isolation is reduced and
they can start to feel part of a community.
With the help of some families within Mermaids, the service became involved in a tele-
vision programme The Wrong Body in 1993. The programme featured some of the
dilemmas a 13-year-old with a gender identity problem had to face within the family and
social network. Should this teenager be addressed as he or she and in which gender be
accepted in the school? Another dilemma was the timing for the start of physical inter-
ventions. This was a courageous teenager who, with the support of his family, wanted to
share his experiences with society in an attempt to reduce the isolation and stigma which
experiencing this condition attracted. The process involved in the making of this docu-
mentary was a very interesting experience for the whole service. At a crucial point during
the filming a child protection conference was organized by social services involving a
number of lawyers. Two main issues were at the centre of the debate: first, can a teenager
of 13 give informed consent to a programme describing his unusual condition? And
second, are the parents really protecting their child by supporting his wish to make public
his unusual experiences? In this case, after a lengthy debate a clear decision was made
that the programme could go ahead if after seeing the documentary the adolescent
and the family agreed to its being broadcast. The programme was shown in 1995. It
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highlighted clearly the intensity of feelings and convictions experienced by this teenager.
It had a strong emotional impact on those watching it and was thought-provoking.
People were made aware of the seriousness and deep-rooted nature of the identity issues
involved. Some teenagers wishing to be open about their atypical gender identity with
peers and teachers in school have used this video to promote some understanding of their
But what about outcome? What has happened to children and teenagers, some of
whom have attended our service for years? What kind of life do they have? What
memories do they have of their contact with our service? We know little about this,
except in an anecdotal way. It is now time that we start to find out.
Coates, S., Friedman, R., & Wolfe, S. (1991). The aetiology of boyhood gender identity
disorder: A model for integrating temperament, development and psychodynamics.
Psychoanalytic Dialogues, 1, 481–523.
Coates, S., & Spector Person, E. (1985). Extreme boyhood femininity: Isolated behaviour or
pervasive disorder? Journal of the American Academy of Child and Adolescent Psychiatry,
24, 702–709.
Cohen-Kettenis, P.T., & van Goozen, S.H.M. (1997). Sex reassignment of adolescent
transsexuals: A follow up study. Journal of the American Academy of Child and
Adolescent Psychiatry, 36, 263–271.
Diamond, M., & Sigmundson, H.K. (1997). Management of intersexuality. Archives of
Paediatric & Adolescent Medicine, 151, 1046–1050.
Di Ceglie, D. (1998). Management and therapeutic aims with children and adolescents with
gender identity disorders and their families. In D. Di Ceglie & D. Freedman (Eds.), A
stranger in my own body: Atypical gender identity development and mental health (pp.
185–197). London: Karnac Books.
Di Ceglie, D. (2000). Gender Identity Disorder in young people. Advances in Psychiatric
Treatment, 6, 458-466.
Green, R. (1968). Childhood cross-gender identification. Journal of Nervous and Mental
Diseases, 147, 500–509.
Green, R. (1971). Diagnosis and treatment of gender identity disorders during childhood.
Archives of Sexual Behavior, 1, 167–174
Green, R. (1974). Sexual identity conflict in children and adults. New York: Basic Books.
Klein, M. (1975). The psychoanalysis of children. The writings of Melanie Klein – Vol. 2.
London: Hogarth Press
McDougall, J. (1985). Theaters of the mind: Illusion and truth on the psychoanalytic stage.
New York: Basic Books.
McDougall, J. (1989). Theaters of the body. New York: Norton
Money, J. (1994). The concept of gender identity disorder in childhood and adolescence
after 39 years. Journal of Sex and Marital Therapy, 20, 163–177.
Royal College of Psychiatrists. (1998). Gender identity disorders in children and adolescents –
Guidance for management. Council report CR63. London: Royal College of Psychiatrists.
Stoller, R.J. (1968). Sex and gender (Vol. 1). New York: Science House.
Stoller, R.J. (1975). Presentations of gender. New Haven, CT: Yale University Press.
Stoller, R.J. (1992). Gender identity development and prognosis: A summary. In C. Chiland
& J.G. Young (Eds.), New approaches to mental health from birth to adolescence
(pp. 78–87). New Haven, CT: Yale University Press.
Zucker, K.J., & Bradley, S.J. (1995). Gender identity disorder and psychosexual problems in
children and adolescents. New York: Plenum Press.
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Full-text available
Over the years I have found a number of metaphors which have helped me to deal with particular dynamics in therapeutic work or with group and institutional conflicts involving the Gender Identity Development Service at the Tavistock Centre. This nationwide service, which is for young people with atypical gender identity development and their families, was established in 1989. In this paper I describe some of these metaphors in relation to the particular problems or conflicts which had stimulated their appearance in my mind. The emergence of these metaphors links the vicissitudes of atypical gender identity development to issues regarding symbolisation or symbolic thinking. Metaphors such as ‘working at the edge’ or ‘navigating between Scylla and Charybdis’ allow the professional to hold on to multiple perspectives and to maintain a certain degree of ambiguity in situations in which the interpersonal dynamics can be experienced as rigid and deterministic. The emergence of metaphors can then be perceived by the professional with a sense of relief and freedom of thinking. In this paper, metaphors are linked to: the model of care developed; the therapeutic stance; and the aims, risks and pressures experienced by the professional in this area of work. The association between gender dysphoria in some young people and autistic spectrum features is explored. The paper emphasises the importance of responding flexibly to individual differences and of recognising complexity.
This paper is drawn from doctoral research which analysed clinical data from the once weekly psychotherapy of a young person who experienced both gender identity dysphoria and an eating disorder and whose depression had proved resistant to other interventions. Based on the psychoanalytic thinking of Klein, Segal, Bion and others regarding the role of symbolisation in development, the links between symbol formation, the depressive position and the negotiation of the Oedipus complex are outlined. Special attention is given to current thinking about the nature and genesis of gender identity dysphoria in the light of these concepts. The association with autistic features for a number of cases is briefly explored. In the light of these theoretical links, findings from the study are used to investigate and illustrate the movement this patient made within her therapy from an emotionally turbulent position where concrete thinking was manifest, to a more symbolic way of thinking that allowed emotional change, and less concrete acting out. Clinical narrative excerpts as well as findings from the study are used to discuss the progress made by the patient and to evaluate how her journey may inform future practice.
Gender Identity Disorder (GID) is classified as a mental illness and included in the DSM-IV and ICD-10. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds (pragmatic, rather than epistemological) may justify the inclusion of gender variance amongst mental illnesses.
To describe the relationship between parents with gender identity disorder (GID) and their child(ren) as described by the parent and to understand how being a parent affects transitioning from one gender to the other. Fourteen parents with GID underwent a semi-structured interview and completed the Index of Parental Attitudes (IPA). An IPA score of greater than 30 indicates parent-child relationship difficulties (range 0-100). The authors also conducted the SCID-I to establish other Axis I disorders. We assessed 12 male to female and two female to male parents with GID residing in Ireland. In total, 14 GID parents had 28 children. Three children had no relationship with their GID parent. The other 25 children, as reported by the parent, had good relationships with their children. In addition, these 25 children average score IPA score was 6.4 (range 0-25). Twelve GID parents (86 %) believed that being a parent had no effect on their desired level of transitioning, while two were influenced not to transition. Eleven GID parents (79 %) reported that being a parent had increased the time taken to commence transitioning, two have stopped transitioning altogether, while one cited no effect on time. Parents with GID report positive relationships or no relationship with their children and the IPA revealed no clinical problems. Being a parent can prolong transitioning time in people with GID and can affect overall achieved level of transitioning.
Full-text available
The recent film Boys Don't Cry illustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.
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In this paper, we present a model for conceptualizing the etiology of boyhood gender identity disorder. We illustrate the model with a specific case of a three‐year‐old boy who developed a gender identity disorder in reaction to his mother's depression after she had an abortion. We describe how the temperament of the child, his reaction to a psychic trauma during a sensitive period of mental representational development, and multigenerational transmission of psychodynamics lead to a gender identity disorder. We view the cross‐gender fantasy as a compromise formation for the management of separation anxiety and aggression, and we view its enactment in behavior, in part, as a defensive attempt to understand an unmetabolizable experience of aggression. This case offers an unusual window into understanding how interpersonal experience, particularly in the face of severe anxiety, becomes transformed into intrapsychic phenomena and how pathological beliefs both encode experience and construct psychic reality.
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This article provides a selected overview of the literature on gender identity disorder and psychosexual problems in children and adolescents, with a focus on diagnosis, clinical course, etiology, and treatment.
Following the publication of our article about a classic case of sex reassignment,1 the media attention was rapid and widespread,2-4 as was the reaction of many clinicians. Some wanted to comment or ask questions, but many contacted us directly or indirectly, asking for specific guidelines on how to manage cases of traumatized or ambiguous genitalia.5 Below we offer our suggestions. We first, however, add this caveat: these recommendations are based on our experiences, the input of some trusted colleagues, the comments of intersexed persons of various origins, and the best interpretation of our reading of the literature. Some of these suggestions are contrary to today's common management procedures. We believe, however, that many of those procedures should be modified. These guidelines are not offered lightly. We anticipate that time and experience will dictate that some aspects be changed and such revisions will improve the next set of
Twenty-five extremely feminine boys with DSM-III diagnosis of gender identity disorder of childhood were evaluated for the presence of behavioral disturbances, social competence and separation anxiety. Using the Child Behavior Checklist created by Achenbach and Edelbrock in 1983, 84% of feminine boys were reported to display behavioral disturbances usually seen in clinic-referred children. Sixty-four percent of the sample had difficulties with peers that were comparable to those of psychiatric-referred boys. Sixty percent of the sample met the criteria for diagnosis of DSM-III separation anxiety disorder. Only one child in sample fell within the normal range on all three of these parameters. Results suggest extreme boyhood femininity is not an isolated finding, but part of a more pervasive psychological disturbance. Additional clinical findings support this contentione.