Two rationales have been offered for parental involvement in treatment. The first emphasizes the hypothesized role of parental dynamics and psychopathology in the genesis or maintenance of the disorder. From this perspective, individual therapy with the child will probably proceed more smoothly and quickly if the parents are able to gain some insight into their own contribution to their child’s difficulties. Many clinicians who have worked extensively with gender-disturbed children subscribe to this rationale (Coates and Wolfe 1997; Green et al. 1972; Newman 1976; Stoller 1978). In this context, it is important to note that a treatment plan requires as much an assessment of the parents as it does of the child, as is the case with many child psychiatric disorders. Assessment of psychopathology and the marital relationship in the parents of children with GID reveals great variability in adaptive functioning, which may well prove to be a prognostic factor.

The second rationale is that parents will benefit from regular, formalized contact with the therapist to discuss day-to-day management issues that arise in carrying out the overall therapeutic plan. Work with parents can focus on the setting of limits with regard to cross-gender behavior, such as cross-dressing, cross-gender role and fantasy play, and cross-gender toy play and, at the same time, attempting to provide alternative activities (e.g., encouragement of same-sex peer relations and involvement in more gender-typical and neutral activities). In addition, parents can work on conveying to their child that they are trying to help him or her feel better about being a boy or a girl and that they want their child to be happier in this regard. Some parents, especially the well-functioning and intellectually sophisticated ones, are able to carry out these recommendations relatively easily and without ambivalence. Many parents, however, require ongoing support in implementing the recommendations, perhaps because of their own ambivalence and reservations about gender identity issues.

Case Example 10
Harry was a 4-year-old boy with an IQ of 121. He had an older brother and lived with his parents, who were of a lower-middle-class background. At the time of assessment, his parents were about to separate. During Harry’s life, his parents’ relationship had deteriorated as a result of many issues, including an affair on his father’s part, multiple disagreements about lifestyle and parenting issues, and his mother’s deteriorating psychiatric state, which had required inpatient treatment after a suicide attempt when Harry was around 18 months old. Harry had displayed signs of cross-gender behavior since the age of 2 years, including compulsive and frantic cross-dressing and the verbalized desire to become a girl. His mother expressed marked ambivalence about treating Harry’s GID: “This is who he is…if I tell him not to, I will destroy his basic essence.” Exploration of the mother’s life history revealed many reasons for her ambivalence about men and masculinity. She had grown up in a family in which her father was largely absent, she had been gang-raped at the age of 13 years (following which she had developed a severe eating disorder), and, in her relationship with her husband, she had found sexual intimacy increasingly aversive. For Harry’s mother, fantasy aggression (e.g., sword play, squirt-gun play) was equated with real aggression, and she worried that if such behavior was encouraged in Harry that he would develop into a rapist. Apart from the mother’s ambivalence about masculinity, she also enjoyed Harry’s “feminine side”: he would often brush her hair and bring her tea when she was depressed and bedridden. Thus, there was suggestive evidence that Harry took care of his mother and that, in her mind, there was the risk of losing Harry if he became more autonomous from her, which was equated with him becoming more masculine.

Technical Aspects of Limit Setting
In my experience, there are some technical aspects of limit setting that are often misunderstood. Thus, the role of limit setting in treatment requires some consideration of conceptual and contextual issues. A common error committed by some clinicians is to simply recommend to parents that they impose limits on their child’s cross-gender behavior without attention to context. This kind of authoritarian approach is likely to fail, just like it will with regard to any behavior, because it does not take into account systemic factors, both in the parents and in the child, that fuel the symptom. At the very least, a psychoeducational approach is required, but, in many cases, limit setting needs to occur within the context of a more global treatment plan. From a psychoeducational point of view, one rationale for limit setting is that if parents allow their child to continue to engage in cross-gender behavior, the GID is, in effect, being tolerated, if not reinforced. Thus, such an approach would contribute to the perpetuation of the condition. Another rationale for limit setting is that it is, in effect, an effort to alter the GID from the “outside in,” while individual therapy for the child can explore the factors that have contributed to the GID from the “inside out.” At the same time that they attempt to set limits, parents also need to help their child with alternative activities that might help consolidate a more comfortable same-gender identification. As noted earlier, encouragement of same-sex peer group relations can be an important part of such alternatives. Some boys with GID develop an avoidance of male playmates because they are anxious about rough-and-tumble play and fantasy aggression. Such anxiety may be fueled by parent factors (e.g., where mothers conflate real aggression with fantasy aggression), but may also be fueled by temperamental characteristics of the child. Efforts on the part of parents to be more sensitive to their child’s temperamental characteristics may be quite helpful in planning peer group encounters that are not experienced by the child as threatening and overwhelming. It is not unusual to encounter boys with GID who have a genuine longing to interact with other boys but, because of their shy and avoidant temperament, do not know how to integrate themselves with other boys, particularly if they experience the contextual situation as threatening. Over time, with the appropriate therapeutic support, such boys are able to develop same-sex peer group relationships and begin to identify more with other boys as a result.

Another important contextual aspect of limit setting is to explore with parents their initial encouragement or tolerance of the cross-gender behavior. Some parents will tolerate the behavior initially because they have been told, or believe themselves, that the behavior is “only a phase” that their child will grow out of or that “all children” engage in such behavior. For such parents, they become concerned about their child once they begin to recognize that the behavior is not merely a phase. For other parents, the tolerance or encouragement of cross-gender behavior can be linked to some of the systemic and dynamic factors described earlier. In these more complex clinical situations, one must attend to the underlying issues and work them through. Otherwise, it is quite likely that parents will not be comfortable in shifting their position.

Case Example 11
Shawn was a 7-year-old boy with an IQ of 115. He lived with his middle-class parents and an older sibling. Since the age of 3, Shawn had engaged in all of the behaviors that comprise the GID diagnosis. Shawn’s mother spoke on a regular basis with her pediatrician, who reassured her that the behaviors were “normal” for a boy “until” the ages of 6 or 7 years. Prior to the referral, Shawn was cross-dressing; when his mother spoke to him about it, he became tearful and said “Mom, I just can’t let go of wanting to be a girl.” Apart from the GID, Shawn was emotionally labile and prone to temper tantrums when he did not get his own way. Shawn’s parents had a close marital relationship and generally functioned well. The one clear area of disagreement in their relationship concerned Shawn’s cross-gender behavior. In general, the father deferred to the mother with regard to parenting issues. Shawn’s mother did not know if limit setting was an appropriate approach to take with her son and the advice of the pediatrician reassured her that his behavior was “only a phase.” During the assessment, it became apparent that Shawn’s father had been “boiling” for many years with regard to his wife’s tolerance and encouragement of the cross-gender behavior. The parents were stalemated on this issue and the mother would covertly buy Shawn Barbie dolls. The increase in Shawn’s felt distress about being a boy and the recent increase in social ostracism led the mother to rethink her position. Clinical observation indicated that Shawn was very attuned to his mother’s position on various matters. Once she began to verbalize to Shawn that she wanted him to feel happier about being a boy, he rather easily stopped cross-dressing in her clothes, stopped playing with Barbie dolls, and, with parental support, began to develop close friendships with other boys. With the shift in the family system, Shawn and his father were able to develop mutual interests and began to spend much more shared time together, which they both immensely enjoyed.

Although many contemporary clinicians have stressed the important role of working with the parents of children with GID, one can ask if there is any empirical evidence that this is effective. Again, systematic information on the question is scanty. The most relevant study (Zucker et al. 1985) found some evidence that parental involvement in therapy was significantly correlated with a greater degree of behavioral change in the child at a 1-year follow-up, but this study did not make random assignment to different treatment protocols, so one has to interpret the findings with caution.