A mother, concerned for some time about her 4-year-old son's effeminate mannerisms, lack of male playmates, and interest in Barbie dolls, finally decides to ask the pediatrician if these are signs of a problem. She is particularly worried that her husband has become increasingly upset and alienated from their son.

The pediatrician is reassuring: "This is just a phase nothing to worry about. He will grow out of it." Unfortunately, the pediatrician is probably wrong. Gender identity problems, including cross-dressing, exclusive cross-gender play, and a lack of same-sex friends should be treated as a symptom that something may be very wrong. Boys who exhibit such symptoms before they enter school are more likely: to be unhappy, lonely and isolated in elementary school; to suffer from separation anxiety, depression, and behavior problems; to be victimized by bullies and targeted by pedophiles; and to experience same-sex attraction in adolescence. If they engage in homosexual activity as adolescents, they are more likely than boys who do not: to be involved in drug and alcohol abuse or prostitution; to attempt suicide; or to contract a sexually transmitted disease, such as HIV/AIDS; or to develop a serious psychological problem as an adult. A small number of these boys will become transvestites or transsexuals.

The good news is that if the gender identity problems are identified and addressed and if both parents cooperate in the solution, especially fathers, many of the negative outcomes can be prevented. According to Dr. Kenneth Zucker and Susan Bradley, experts in the treatment of gender identity problems in children, treatment should begin as soon as possible.

        ...In general we concur with those who believe that the earlier treatment begins, the better. [1]...It has been our experience that a sizable number of children and their families can achieve a great deal of change. In these cases, the gender identity disorder resolves fully, and nothing in the children's behavior or fantasy suggest that gender identity issues remain problematic.... All things considered, however, we take the position that in such cases clinicians should be optimistic, not nihilistic, about the possibility of helping the children to become more secure in their gender identity[2].

The effeminacy in some boys is so pronounced that parents may assume the problem is genetic or hormonal, but no such factors have been scientifically proven. Experts report that children assumed to have a biological problem responded positively to therapeutic intervention: According to Rekers, Lovaas, and Low:

When we first saw him, the extent of his feminine identification was so profound (his mannerisms, gestures, fantasies, flirtations, etc., as shown in his "swishing" around the home and the clinic, fully dressed as a woman with a long dress, wig, nail polish, high screechy voice, slatternly, seductive eyes) that it suggested irreversible neurological and biochemical determinants. After 26 months follow-up, he looked and acted like any other boy. People who viewed the video taped recordings of him before and after treatment talk of him as "two different boys."[3] 

Healthy psychological development requires that a little boy be able to feel acceptance by and identify with his father, experience acceptance by male peers, recognize that there are two sexes and that he is male and will grow up to be a man and possibly a father, not a woman and a mother. Additionally he needs to feel good about his body and about being a boy and becoming a man. He needs to believe that his mother and father are happy that he is a boy and expect him to become a man and he needs to feel accepted as a boy by other boys.

If a boy feels inadequate in his masculine identity due to peer or father rejection or a poor body image, identifies with his mother instead of his father, feels that he would like to be a girl, those around him should not pass this off as non-stereotypical behavior. There is a reason why this boy is not developing a healthy masculine identity and that reason should be discovered and addressed.

One often hears boys with gender identity problems called "girlish", but if one observes their behavior carefully, one sees that they do not resemble healthy little girls of the same age, but imitate adult women. For example, while doll play for healthy girls includes mother/baby play and fashion/dress up play, boys with gender identity problems focus almost exclusively on fashion/dress up. While healthy girls combine outdoor physical activities with more sedate play, boys with gender identity problems are often unreasonably afraid of injury, avoid rough and tumble play, and dislike group sports.  Cross-dressing and cross-gender fantasy in boys is often passed off by the family as a sign that the boy is a "great actor" or has a "wonderful imagination." Family members fail to understand that a boy who never takes the part of male character, but identifies with either a benevolent, idealized female, such as a princess or Snow White, or  a domineering, angry female is revealing a deep ambivalence toward his own masculinity and toward women. Therapy can help the boy and his family understand why he feels more confident, comfortable, and accepted when he is fantasizing that he is a female.

Today many adults try very hard not to impose rigid gender stereotypes on young children, but this push for gender openness can lead parents to ignore the symptoms of gender identity conflict. Children with gender identity problems don't inhabit a gender neutral world where boys and girls play with the same toys. These troubled children reject certain types of play and clothing precisely because it is associated with their own gender or adopt activities because they are associated in their mind with the opposite sex. Boys with serious gender identity problems may use female clothing to gain acceptance or soothe anxiety become angry and upset  when deprived of these objects.

Some parents may ask "What is wrong with a boy playing with dolls?" The answer is that the problem is as much what he is not doing -- learning how to be a boy among boys -- as it is what he is doing -- escaping into a female world.

Parents need to be concerned when a child openly expresses a dissatisfaction with his or her sex. such as when a boy says "I want to be a girl" or when a girl insist she is a boy. One extremely effeminate boy when asked, "Do you want to be like your daddy when grown up?" responded "I don't want to grown up." Such statements should be taken as symptoms that something is very wrong. Although the boy may feel or even express the desire to grow up to be a woman, he is male and will grow up to be a man.

Children are born with a drive to seek love and acceptance by each parent, siblings and peers. If this need is met, children develop an acceptance of their masculinity or femininity. When this developmental  task is successfully completed, the child is free to choose gender atypical activities. Boys and girls with gender identity problems are not freely experimenting with gender atypical activities. They constrained by deep insecurities and fears and are reacting against the reality of their own sexual identity, usually as a result of failing to experience love and acceptance from the parent of the same sex or same sex peers. Therapy is not directed toward forcing a sensitive or artistic boy to become a macho-sports fanatic, but helping a boy to grow in confidence and be happy he is a boy.

Effeminacy, cross-gender play, and cross dressing are not the only signs that there may be a  problem. Some boys suffer from a chronic sense of being inadequate in their masculinity , but do not imitate female behavior. These boys may exhibit an almost phobic reaction to rough and tumble play and an intense dislike of team sports because of poor eye-hand coordination. This inability to bond with other boys through sports boys leads to isolation, profound loneliness, a weak sense of masculinity, deep resentment and often depression.

Gender identity problems also occur among girls, although the problem is less common. In some cases a father may be pleased with his daughter's success in athletics and ignore her phobic reaction to dresses or anything feminine. Girls with gender identity problems may believe that being a boy will make them safe from abuse. Other girls, like the majority of boys with GID, have struggled with low self-esteem and a poor body image and have never appreciated their God-given female gifts and beauty.

What should a parent do if they think that there might be a problem. First, they should take any repeated problematic behaviors as a cry for help. If their pediatrician ignores their concerns, they should find a therapist who is trained in the treatment of gender identity problems. Parents can read up on the subject. in Zucker and Bradley's book Gender Identity and Psychosexual Problems in Children and Adolescence, which offers a complete review of the problem.

Consistent cross-gender behaviors are a sign that the child believes he or she would be better off' as the opposite sex. According to Bradley and Zucker, "This fantasy solution' provides relief but at a cost." These are unhappy children who are using these behaviors defensively to deal with their distress.[4]

Parents sometimes try on their own to stop the overt behavior, but forcing a frightened child to engage in behaviors in which he feels inadequate or fearful is not the solution. The therapist can work with the child and the parents to uncover the root cause of the emotional conflicts, so that the problem can be addressed and resolved.

In our experience a challenging aspect of treatment is helping the father realize how crucial his role is in the healing process and then engaging him to become more involved with strengthening his son’s masculine identity.  This difficuly is often the result of the father’s modeling after a father (the boy’s grandfather) who did not communicate praise and love regularly to the father.

It is true that without treatment certain manifestations of gender identity conflicts, such as fantasy fashion doll play in boys or open cross-dressing may disappear by the time the child is 8 or 9, but these coping mechanisms are often replaced by other less overt expressions of an underlying gender identity problem. Once the problem goes "underground" it will be more difficult to treat.

Some people may avoid treatment because they believe that gender identity problems are a sign that the child was born "homosexual" and that the parents should simply accept this outcome as inevitable and encourage the child to accept a homosexual identity. Given the positive results of early intervention, the profound unhappiness of these children during elementary school, and the massive problems which accompany same-sex attraction in adolescence, parents should do everything possible to help their child resolve even minor gender identity problems.

Catholic parents need to be particularly concerned. The Church's teaching on homosexual activity is clearly stated in the Catechism of the Catholic Church, "homosexuals acts are intrinciscally disordered... Under no circumstances can they be approved" (CCC 2357). For a Catholic trying to be obedient to God, temptations to same-sex activity are a source of deep pain. Treatment of adolescents or adults is possible, but difficult and the outcome is not assured. It is far better to prevent the problem or treat it in early childhood. Those who would like to understand more about same-sex attractions can find information on the website of the Catholic Medical Association (www.cathmed.org) in a report entitled Homosexuality and Hope.

If a boy grows up at ease and confident about his masculine identity as a result of a close loving relationship with his father, with same-sex friends in childhood, with a mother who supports his manly development and is protected from vicious bullying and sexual predators, the chances are minimal that he will experience same-sex attraction in adolescence. Even if one or two items on the above list are missing, the chances are still small that the boy will become homosexually involved as an adult. Generally, the histories of men engaging in same-sex behaviors reveal a history of cumulative problems: significant peer rejection, a distant father, a poor body image, low self-esteem, an overprotective or controlling mother, victimization by bullies, or sexual abuse. Fortunately these conflicts can be resolved, and the masculine identity can be strengthened and then embraced.

* This article originally appeared in: Lay Witness, June 2001. Used with permission of the author.