Some case reports of boys noted that an actual physical loss of the mother (or a mother surrogate) preceded the emergence of feminine behaviors (e.g., Gilpin et al. 1979; Wallach 1961). This loss was understood to create a vulnerability in the child that, at least in part, was dealt with defensively by resort to the use of behavioral enactments of gender representations (a “fetish” in the older analytic literature) to cope with the loss of the mother. In this view, the goal of therapy would be to help the child work through the loss of the attachment figure, which would presumably then alleviate the internal pressure to engage in cross-gender reenactments of the lost mother.

In some other case reports, a psychological loss or withdrawal of the mother was deemed important (e.g., Pruett and Dahl 1982). Coates (1985) reported a high rate of adverse life events experienced by the mothers of boys with GID during the putative sensitive period for gender identity formation. These events included physical and sexual assault, death of another child in the family, and husbands’ extramarital affairs. Among others, Coates et al. (1991), Schultz (1979), and Thacher (1985) all provided detailed accounts of this perspective. As noted earlier, the psychological sequelae - separation anxiety, feminine behavior, and so on - are then the same as those for boys who physically lose their mothers.

Other psychotherapists have explained feminine behavior in boys in precisely the opposite way: Feminine identification is caused by an excessive closeness to the mother, not by an excessive distance (e.g., Greenson 1966; Loeb and Shane 1982; Stoller 1966). In this view, the therapeutic task would be to help the boy individuate from his mother. Finally, other clinicians report fluctuations between a distant or unpredictably available mother and a mother who is periodically enmeshed with her son.

Case Example 9 Ricky was a 4-year-old boy with an IQ of 107. He lived with his middle-class parents. Ricky was described by his mother as having been feminine “since the day he was born.” She stated that he was always drawn to women, that he was attuned to their beauty, and that he had no men in his life. She described his father as ineffectual and that she had to do “everything.” Ricky’s mother had deeply ambivalent feelings about his cross-gender behavior. On the one hand, she was concerned that he was going to be teased and isolated; on the other hand, she did not think that there was anything “wrong” about his feminine behavior, even the fact that Ricky insisted that he was a girl: “As long as he’s happy…if he wants to become a woman, I’ll be there for him.” Her female friends expressed their concerns about Ricky’s feminine preoccupations, but his mother’s view was that it was their problem. Ricky’s father felt that his efforts to encourage his son to “act more like a boy” were viewed with disdain by his wife: “She thinks that I’m macho just because I think it is inappropriate to let him wear a dress when we go out.” Ricky’s mother said to his father that “You’re just upset that your son is, or will be, gay.” Ricky was unplanned and his mother reported that she was miserable during the pregnancy. She gained a lot of weight, was depressed, and chose not to fantasize about the baby: “I didn’t want it and I didn’t want to think about it.” During his infancy, she reported extreme fatigue and had symptoms of depression: “All I wanted to do was to sleep.” By the time Ricky was 2, his mother reported that they “could read each other’s mind…we’re like one person…I can finish his sentences and he can finish mine…when I look into his eyes, I see myself…we’re like twins.”