The Hot Questions of Prepubertal Gender Dysphoria in Girls

Modified from Baldaro Verde and Graziottin [2]

Satisfaction with the gender identity outcome depends on a number of variables that deserve the highest multidisciplinary consideration [2–6].

The most accurate evaluation of physical, emotional, psychoaffective, relational, and contextual difficulties should be taken into account to evaluate the best options. The goal is to offer the girl/patient (and her family) real expectations about the potential outcomes prior to starting a long treatment path. The chapter will briefly consider the most important issues in prepubertal GD girls, with a focus on the biological/medical sexological perspective, integrated with psychosexual implications.

25.2 The “Body-Ego”

As Freud stated back in 1923 [1], the sense of personal identity and gender identity are rooted first in the physical appearance: this is why the body issue of gender appearance is so vital for each of us in the lifespan, and, even more so, for children/adolescents with gender dysphoria. Early on, in 1912, he wrote “anatomy is destiny” [8]: the aspect of the external genitalia at birth is the first social cornerstone of gender identity leading to the attribution of the “anagraphic sex.” The description as “male” or “female” usually triggers comprehensive and pervasive family and social interactions oriented first to appreciate and reinforce the self-perception of the child as either a boy or a girl and, second, his/her adherence to the gender norms of that family and cultural belonging [2, 9]. In girls, a rewarding identification with the mother (or another affectively persistent/constant significant female caregiver, such as the grandmother in many families) and a satisfying complementation with the father (or another affectively persistent/constant respectful male figure) further contribute to developing a solid and consistent female gender identity [2]. This positive self-perception is well expressed in the statement “I’m happy to be a girl”: feminine, active, pretty, joyful, tender, vital, energetic, and smiling to life.

25.2.1 The Biological Priming of Brain and Body

The female genital organs (and the brain) differentiate in the feminine phenotype during the embryonic period without particular hormonal influences. Indeed, the “female” is the “default” program [10] exemplified in XO subjects (Turner syndrome): they are infertile, but the external genitalia are female and behavior is female. Not one case of gender dysphoria in Turner syndrome women is reported in the literature, in this author’s knowledge. Indeed, internal and external genitalia can be differentiated into the “male” organs and functions only in presence of androgens at male physiologic levels for the gestational age [10].

This biological asymmetry is key for the reading of the biological contributors of gender dysphoria. In boys, a reduced androgenic priming of the brain may lead to the emergence of the original basic female brain, with coherent feelings and behaviors. Inadequate androgen priming may contribute to inadequate development of the external genitalia to frank intersex ambiguous appearance.

The key directors of male gonad differentiation are substantially three:

The sex-determining region Y protein (SRY) also known as testis-determining factor (TDF) [11]. It is a protein that in humans is encoded by the SRY gene located in the Y chromosome. Its expression causes the development of primary sex cords, which later develop to seminiferous tubules. These cords form in the central part of the yet-undifferentiated gonad, turning it into a testis. The now induced Leydig cells of the testis then start secreting testosterone, while the Sertoli cells produce anti-Mullerian hormone.

Androgens, secreted by the Leydig cells, further “force” the basic program into the progressively male phenotype.

Anti-Mullerian hormone (AMH) produced by Sertoli cells in men, by the granulosa cells of the ovary in women.

In summary, the gonadal differentiation takes place in the second month of the fetal life: the female phenotype depends therefore on the absence of sexual SRY protein, androgens, and anti-Mullerian hormone (AMH), leading to gonads composed of an inner medulla (ovarian stroma) and an outer cortex (parenchyma).

The biological asymmetry in the process of gender differentiation may explain why gender identity disorders are more prevalent in the male gender, although reliable epidemiological data are still lacking [12]. In terms of probability, in chromosomic XY boys, it is more likely that a biologically complex process (the androgenization of the basic female body and brain) undergoes mistakes and inadequacies leading to a self-perception and “hardwired” inner body image more adherent to the basic female gender program than vice versa. In a chromosomic girl, androgens are necessary to partially masculinize the brain, body, and genitals. Androgens can be of fetal origin, such as in the adrenogenital syndrome, maternal, or, rarely, exogenous. In girls, this author’s working hypothesis is that psychodynamic, affective, and contextual factors may contribute to a mild GD of “defensive” motivational origin, while more severe GD up to a frank “expressive” transexualism requires an androgenic priming at least of the brain, if not of the genitals.

25.3 “I Want To Be a Boy”

In children and adolescent girls, this sentence is the alerting “tip of the iceberg” of a very heterogeneous set of psychodynamic and biological conditions that require the highest empathic clinical attention [13–16].

Indeed gender identity disorders encompass a spectrum of very different motivations, perceived first at the emotional level and then progressively at the cognitive one (Table 25.2).

Table 25.2

“I wanted to wear only trousers”: motivations to behave as male in prepubertal girls

Defensive against a female condition perceived as submissive, limiting, and restrictive

Expressive of desire, interests, talents, and vocations typical of male children

25.3.1 The Defensive Motivation

At one extreme, clinicians recognize girls in flight from femininity: when the female gender is perceived as “the losing one.” This is the defensive motivation against a female condition recognized as submissive, limiting, restrictive, and abused in all the cultures and family contexts that still stress women’s inferiority. Predisposing, precipitating, and maintaining factors can be considered.

25.3.1.1 Predisposing Factors

Four leading, and often overlapping, factors can interact:

The disappointment/delusion at perceiving continuously restrictive messages killing the personal talents (“stereotypically” considered appropriate for boys) and thirst for life with an obsessive refrain “girls must not behave as such” even when a simple extroverted joyful personality is in play or when the girl expresses a talent for autonomy and vital curiosity of the outer world: “Why boys can do what they want and I can do nothing?”
The early recruitment in all kinds of homework while boys can still play: caring of younger sibling, cleaning the house and dresses, ironing, cooking, and in many cultures still serving the family men. The oppression of being a girl, humiliated and crushed by all-day pervading gender role female duties, may lead to sadness and depression. It is well exemplified in the photo of boys and girl of the Italian countryside (in 1952) at the end of 5 years of primary school, where sadness and joy show a dramatic gender polarization (Fig. 25.1). Girls who do not surrender to this kind of female role identity may gradually shift to desire a male gender role if not a full male gender identity. The full shift in a frank gender dysphoria may progress with the contribution of: (1) not yet detected endocrine factors acting on the brain, during pregnancy – such as high level of maternal stress with increase of adrenal androgens – (2) subclinical level of adrenal congenital hyperplasia both in fetal life and early childhood, and (3) iatrogenic drugs administered in pregnancy [2].

Fig. 25.1

Photo of boys and girls of the Italian countryside (in 1952) at the end of 5 years of primary school. The picture highlights the contrast between the sad (except one), concerned, and serious expression of girls and the happy, vital, energetic, and confident expression of boys. It clearly shows how gender differences in breeding styles and behavioral codes may prime the attitudes not only toward life but toward one’s gender identity as well. In the 1950s, in the Italian countryside, the gender identity issue was nonexistent. Dissatisfied girls could just have thought that being a girl was a reason for sadness as it was a lesser gender. It is very likely that – were those girls living today – at least one or two would have expressed concerns and uneasiness with their gender of birth (Photo: Courtesy of Mrs Elena Bordin, Rist. Bosco del Falco, Treviso (Italy))
Inadequate identification with the mother and lack of a meaningful female significant other. A mother perceived as neglecting, refusing, and abusing may be a cofactor in a girl’s progressive refusal of the female gender identity. A parallel, stronger identification with the father, or a significant other positive male in the family, including a loved brother or grandfather, may facilitate the desire/choice of becoming a boy. In girls, when the process of identifying with the same gender parent (the mother) and complementing with the parent of the opposite gender (the father) is disrupted, a psychodynamic contributor to a gender dysphoria is in play. A detached, rigid mother, emotionally distant or frankly dismissing, who does not encourage a positive identification with her, contributes to redirect the identification process on the father. “Too much father, too little mother” well describes the parental scenario contributing to a stronger identification with the father or his stable male surrogate. An androgenic priming during the fetal life may predispose to and potentiate such a shift.
Having being sexually harassed or abused, within and/or outside the family: for this unfortunate children, being a girl equals being a prey. The escalation may move from “I want to wear only trousers” (still a symbol of male gender role in many cultures) perceived as an armor, a defense, and a key for freedom [17] to “I want myself to become a boy.”

25.3.1.2 Precipitating Factors

Four other key events may precipitate a kind of “collapse of awareness” of GD.

The defensive motivations may lead to a diagnosis of gender dysphoria: this label should be kept on hold (or expressed as a very mild disorder). Colette Chiland [18], a psychiatrist with an extensive experience with children and adolescents gender disorders, warns against an early use of “diagnostic etiquettes” as such, given the high plasticity of gender identity in the lifespan and maximum at adolescence. Indeed she warns about a “mediagenic transexualism” induced by the media attitude to oversimplify the extremely demanding path of changing/reassigning sex. Such an etiquette, given to children with more simple gender dysphorias, could become a “self-fulfilling prophecy” in children with a weak sexual identity, or with nontransexual gender dysphorias, when they are desperately looking for a clearer, more solid identity, whatever it could be. Instead of following a surgical, behavioral, and social change, she suggests that psychotherapeutic support should be offered to the child/girl and to the family, to improve the psychological well-being within the gender of birth. An empathic, skilled, and experienced female psychotherapist may do a good job for and with the child. She could work for a good mediation for a well-perceived male gender role, when desired, preventing a likely self-damaging acting out in the search of a male gender identity. Clinical wisdom suggests as well to avoid a premature jump on a label of frank transexualism (sometimes “diagnosed” as such by unexperienced health-care providers). A premature diagnosis of transexualism would be harmful per se as it may be perceived as a life buoy in a sea of unhappiness by the confused child and her helpless family. Changing sex is not the magic end of a cultivated dream, but a very difficult and painful process, of uncertain outcome. In prepubertal girl, temporal suppression of puberty (see the paragraph XYZ) may offer a therapeutic critical window to appreciate with the child all the unbiased pros and cons of changing sex in the real life. Concrete alternatives of physical satisfactions should be offered in sport, music, and dance to experience joy from and with the body she has. The enormous psychoplasticity of young brains may ease the goal of a satisfactory mediation in a loving and respectful female therapeutic setting.

Precipitating factors include [2]:

The onset of puberty, with the appearance of breast and periods, forcing the girl to move from a “totipotent, partially undifferentiated identity” to a definite female gender: a shocking discovery for many GD girls [19]
The loss of a very significant relative, often the father or a surrogate male parent (usually the grandfather)
The perception of an unaccepted homosexual drive
An escape from an unacceptable masturbatory activity, as pleasure derives from the stimulation of the “hated” and somehow “untouchable” female genitalia

Maintaining factors include on one side the unaddressed persistence of predisposing and precipitating factors and on the other the lack of professional support with a careful evaluation of defensive vs expressive GD conscious and unconscious motivations.

25.3.2 The Expressive Motivation

At the opposite end of the spectrum of gender dysphoria (with all the mixed motivations in between), clinicians recognize “a boy really trapped in a girl’s body.” The want to become a boy expresses lifelong desire, vocation, interests, and talents, more typical of a male child (Table 25.3). It is not a denial of or a flight from femininity, but the real feeling of belonging to the male gender, with a male “body image” hardwired in the brain [20]. Dreams and goals of girls with severe gender dysphoria are summarized in Table 25.3. Usually these girls are recognized as “boys” from age-mate companions since the first 2–3 years of life. Motivations and emotions to become a boy can be variably enhanced and supported by biological contributors. One of the most powerful biological contributor is brain-derived neurotrophic factors (BDNF) (with current more evidence, however, in male to female GD) [21, 22].

Table 25.3

Desires and goals of a girl with severe gender dysphoria up to transexualism

To live (and be accepted) in roles typical of the male sex

To have a male body

To become a member of the male gender

To acquire the social and anagraphic status coherent with the former goals

25.3.3 Emotions, Neurovegetative Pathways, and Motor and Hormonal Correlates

Physical appearance is shaped by the emotions that live and express themselves in the neurovegetative physical domain. Four basic emotions command systems: desire, anger, fear and panic with separation distress dominate the emotional life [23]. They pervade the body, in terms of neurovegetative correlates that activate pertinent behaviours. Emotions are the first experience we all have of our being alive, loved, disregarded/neglected or hated.

Emotions are not a cloud of feelings over the head. They have very solid somatic correlates, mediated by the neurovegetative system (that appears to be upregulated in persons with GD). They have an immediate motor expression: moving toward for desire; fight, or flight for fear; moving against for anger; and looking for a comforting presence/attachment/hug for panic with separation distress [23]. Emotions indeed reshape continuously the perception of human body image, further modulated by affective dynamics and mood (so critical to set the emotional “color” of self-perception, as we all know also in our personal life). Cognitive issues further contribute to the inner self perception of gender identity. Emotions are continuously modulated by hormones and by sexual hormones in the fetus and then from puberty onward. This is why endocrine medical issues are critical in this field. To reach and maintain a new, positive F to M identity requires more than a number of successful operations (but the quality of surgical outcome is certainly a powerful prerequisite though).

Only gold members can continue reading. Log In or Register to continue