Projective test findings for boys with gender disturbance: Draw-A-Person Test, IT scale, and Make-A-Picture Story Test.

With 66 boys, aged 3 yr. to 17 yr. who were referred for potential gender-identity disorder, this study examined intrapsychic manifestations as reflected in their projections to the Draw-A-Person Test, the Brown IT Scale for Children, and the Shneidman Make-A-Picture Story Test. Without access to these projective test findings, an independent clinical psychologist provided a diagnostic rating on the severity of gender disturbance on a five-point diagnostic rating scale, based on clinical interviews of the child and his parents and a systematic behavioral assessment based on previously published normative standardization data. For each of the three projective measures, significant correlations were found between the clinician ratings on severity of gender disturbance and the test findings in the feminine direction (D-A-P, r = .44; IT Scale, r = .64; M-A-P-S, r = .35). These results validated the use of intrapsychic phenomena of fantasy and self-perception as measured by these projective tests for the diagnosis of gender disturbance in male children and adolescents.

The relationship of measures of sex-typed play with clinician ratings on degree of gender disturbance.

Forty-nine boys, aged 3 to 11 years, who were referred for an evaluation of a potential gender identity disorder of childhood, were assessed with a standardized in vivo behavioral observation of sex-typed play in an alone condition and with the parent-report Bates-Bentler Games Inventory. Without access to these measures of sex-typed play, an independent clinical psychologist rated each of the subjects on a 9-point scale that indicated the degree of severity of a gender disturbance, based upon child and parent interviews and a complete psychological test battery. The percentage of feminine play in the behavioral observation procedure was found to be correlated significantly with the clinician rating of degree of gender disturbance (r = .55). The Games Inventory was found to differentiate significantly the gender-disturbed boys from the nonclinical reference group on its feminine/preschool games, masculine nonathletic games, and athletic games subscales and on its composite index of feminine play preference; however, only the composite index (and none of the 3 subscales) was correlated significantly (r = .34) with degree of severity of gender disturbance.

The association of gender identity disorder with parental separation.

56 boys diagnosed with gender disturbance, ages 3 to 18 yr. (mean age 8.4 yr.), were classified according to family structure. The proportion of gender-disturbed subjects separated from one or both parents (66%) was significantly higher than the 35% to 48% separated from one or both parents in comparable US general population statistics.

Relationship of maternal report of feminine behaviors and extraversion to clinician's rating of gender disturbance.

50 boys, aged 3 to 16 yr., referred for psychotherapy for a gender-identity disorder were assessed by two parent-report instruments completed by their mothers--The Gender Behavior Inventory for Boys for preadolescent subjects and a modified form of the Parents' Evaluation of Child Behavior. Without access to these data, an independent clinical psychologist provided a diagnosis of the severity of a gender disturbance on a 5-point rating scale, based on clinical interviews and a psychological test battery. The gender-disturbed boys scored significantly above the mean of the standardized normal boys on the Gender Behavior Inventory for Boys Feminine Behavior subscale and significantly below the mean on the Extraversion subscale of the Gender Behavior Inventory. The ratings of severity of gender disturbance were significantly correlated .34 with Feminine Behavior subscale scores and -.50 with the Extraversion subscale scores. On the Parents' Evaluation the number of observed feminine behaviors listed was significantly correlated .57 with rated severity of gender disturbance but not with the Feminine Behavior subscale scores on the Gender Behavior Inventory.

Differentiation of adolescent activity participation.

The sex typing or lack of it among 133 adolescent activities was investigated. Twenty-seven percent (32) of the activities on an Adolescent Activity Questionnaire showed very clear participation differences for male and female adolescents (11 to 18 years old). The initial two factors extracted in a principal components factor analysis were easily interpreted as feminine and masculine activities. Discriminant function analysis of 15 items from the first three factors yielded an 8-item function on the basis of which every sample member was correctly classified as male or female. Masculine activities included more sports-related activities and activities dealing with mechanics and building, whereas feminine activities were domestic in nature and included more sedentary activities (e.g., reading, writing in diaries).

Family correlates of male childhood gender disturbance.

In the context of a review of adult cases of gender disturbance, a clinical study was pursued on the status of fathers, father-substitutes, and older male siblings for 46 boys with deviations in male role development. Significantly fewer male role models were found in the family backgrounds of the severely gender-disturbed boys as compared to the mild-to-moderately gender-disturbed boys. Male childhood gender disturbance was also found to be correlated with a high incidence of psychiatric problems in both the mothers and fathers and with atypical patterns of the boys' involvement with their mothers and fathers, as measured by the Bene-Anthony Family Relations Test and the Rekers Behavior Checklist for Childhood Gender Problems.

Contingency management in the treatment of adolescent alcohol drinking problems.

Three case studies demonstrated that social and monetary reinforcement for abstinence reduced the rate of excessive alcohol drinking in adolescents. The self-monitoring and extrinsic reinforcement procedures (ABA reversal design) resulted in complete abstinence in a 15-year-old boy with a 10-year history of excessive alcohol abuse and hospitalization for an alcohol-induced psychosis. In the cases of the 13-year-old and 15-year-old girls with extensive alcohol abuse histories, the behavioral interventions decreased the rate of alcohol consumption during treatment phases, but alcohol abuse increased markedly with the removal of the intervention procedures.

Early intervention for female sexual identity disturbance: self-monitoring of play behavior.

This study is the first experimental demonstration of sex-typed play behavior change in a young girl with sexual identity disturbance. The 8-year-old child was treated with a self-monitoring procedure combined with a behavioral prompting technique that was gradually faded out. Self-monitoring in the clinic resulted in a high, stable rate of appropriate sex-typed play, and this effect generalized to a different set of sex-typed toys over time. The treatment effects did not generalize to the home environment. The self-regulation intervention was subsequently adapted to the home setting, resulting in a replication of the treatment effects across settings. After the removal of the self-monitoring interventions, a high level of feminine sex-typed play persisted. Pretreatment, posttreatment, and follow-up psychological testing demonstrated a reversal of a pronounced cross-gender identity to a normal female sexual identity.

Sex-role behavior change: intrasubject studies of boyhood gender disturbance.

Sex-role behaviors were modified in a seven-year-old boy who had been evaluated by an independent psychiatrist as manifesting cross-gender identification. The child's developmental history paralleled the retrospective reports of adult transsexuals. In Experiment 1, the boy was treated in the clinic by a nonprofessional female "therapist" who reinforced "masculine" sex-typed play behaviors and extinguished "feminine" behaviors. The treatment effects generalized to the boy's play with a different set of toys in the presence of male and female strangers, but did not generalize to the boy's play in the alone condition. An intrasubject reversal design was used to replicate the treatment effects. Concurrently, Experiment 2 was conducted to shape the child's athletic skills to a level that would enable him to compete with his peers. The treatment effect for "sockball" was replicated for "kickball" in a multiple-baseline intrasubject design. Future research is suggested to explore variables that would maximize both generalization of treatment effects and parental cooperation over time.

Congruence of childhood sex-role identity and behaviour disturbances.

Thirty-eight children who were aged between 4 and 12 1/2 years were referred for potential gender disturbances and received independent assessments of sex-role behaviour and identity. Ratings of sex-role behaviour were based on psychodynamic, behavioural and psychometric procedures, with the behavioural and psychodynamic ratings most highly correlated. Two ratings of sex-role identity disturbance, derived from psychodynamic and behavioural orientations, yielded a strong interrelated agreement. The mean ratings of sex-role identity and behaviour disturbance were moderately correlated and provided a high degree of internal consistency. An overall diagnosis was derived for each subject by combining the behaviour and identity mean ratings. The findings are discussed in terms of the limitations of present knowledge on normal and deviant sex-role developmental processes.

Genetic and physical studies of male children with psychological gender disturbances.

Twelve male children were diagnosed with psychological gender disturbances by 3 independent clinical psychologists using independent data sources focusing on behavioural deviance from normal comparison groups, on conventional psychological testing, and on parent report instruments which had been validated on normal comparison samples. These children received a paediatric evaluation consisting of a medical history, complete physical examination, chromosome analysis including 2 cells karyotyped and 15 counted, and sex chromatin studies. All gender disturbed boys were found to be normal genetically and physically with the exception of one subject with one undescended testicle.

Differentiation of childhood body gestures.

9 expressive body gestures were recorded while 180 boys and girls of three age groups (4--5 yr., 7--8 yr., and 10--11 yr.) individually performed a standardized play task. Analysis of variance showed a significant overall difference in gestures between the sexes, and 5 of the gestures ("limp wrist," "arm flutters," "flexed elbow," "hand clasp," and "palming") occurred significantly more frequently in girls than boys. There was an interaction between sex and age for the "hands-on-hips with fingers forward" gesture. No differences associated with sex of experimenter were found.

Sex-typed play in feminoid boys versus normal boys and girls.

Procedures for assessing children's sex-typed play were developed which (a) examined children's continuous play in four sessions totaling 20 minutes rather than measuring only initial choice of a sex-typed toy, and (b) did not impose the stimulus-specific condition of requiring an adult experimenter to be present to administer the task. Play with "masculine" and "feminine" toys was observed for 120 normal children (60 boys, 60 girls) aged 3 yr.-8 yr., and 15 similarly aged boys diagnosed as having childhood gender disturbance. Significant differences were found in the sex-typed play of the two normal groups, but no age differences were observed. The amount of feminine play by the feminoid boys was found to be significantly greater than that of normal boys, but not significantly different from the predominantly feminine play patterns of the normal girls. The usefulness of such a measure for the clinical assessment of deviant sex-role development in young children is discussed.