Case Study, "A Psychological Investigation of Seven Hermaphroditic Children" Doctorate of Philosophy Dissertation

Text document Case study on Children born intersexed and their family's sample group is from Oklahoma

Utah State University DigitalCommons@USU All Graduate Theses and Dissertations Graduate Studies 5-1969 A Psychological Investigation of Seven Hermaphroditic Children Peter Lewis Kranz Utah State University Follow this and additional works at: https://digitalcommons.usu.edu/etd Part of the Child Psychology Commons Recommended Citation Kranz, Peter Lewis, "A Psychological Investigation of Seven Hermaphroditic Children" (1969). All Graduate Theses and Dissertations. 5641. https://digitalcommons.usu.edu/etd/5641 This Dissertation is brought to you for free and open access by the Graduate Studies at DigitalCommons@USU. It has been accepted for inclusion in All Graduate Theses and Dissertations by an authorized administrator of DigitalCommons@USU. For more information, please contact [e-mail]. A PSYCHOLOG I CAL INVESTIGATION OF SEVEN HERMAPHRODITIC CHILDREN by Peter Lewis Kranz A dissertation submitted in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Psychology Approved: UTAH STATE UNIVERSITY Logan, Utah 1969 ii ACKNOWLEDGMENTS I wish to thank all those who have c ontributed their time, guidance, support, and suggestions to the formulation and completion of this study. Grateful appreciation is ex pressed to Dr . Glendon W. Casto, my major profess or, for th e direction, encouragement and free dom he gave to me throughout this study . My indebtedness is als o ex pressed to the other members of my graduate committee, who in various ways facilitat ed the developmen t of this study: Dr. David R. Stone, Dr. Heber C. Sharp , Dr . Jo hn R. Cragun and Dr. Kaye D. Owens . Ac knowledgment is also given to various staff members of the Oklahoma Medic al Center for thei r he lp, e nc ouragement and guidance with this project . I ex press special appreciation to all of the families who partic i pated for without them this study would not have been posib l e. Also to Renee Ostl e r for he lp and encouragement throughout he ~ n tire project. Peter Lewis Kranz iii TABLE OF CONTENTS Page ACKNOWLEDGMENTS ii LI ST OF TABLES v AB TRACT vi Chapter I. INTRODUCTION 1 Statement of Probl em II. REVIEW OF LITERATURE Sex Ass ig nment ; Neonatal Period Sex Ass ig nment : Post -neo nata l Period Parental Manag ement 1L METHODOLOGY Subjec ts Procedure Diganost ic Instruments V. RESULTS 3 5 5 12 20 27 27 27 29 50 Diagnostic Test Data Summary Cas e Histories First c ase report Second ca se r e po rt Third case r e por t Fourth ca s e r e por t Fift h case r e port Six th and seventh c ase report Therapy Inte rviews Cas e l =- 18 -year=o ld female Cas ~ 2=- 15 -ye ar - old f emal e 50 53 53 54 60 68 72 80 84 93 93 99 iv TABLE OF CONTENTS (Continued) Page Ca se 3-- 15 -year-o ld femal e Ca se 4 -- s even-ye ar-o l d female Cas e 5-- six - year - old female Ca s e 6- - 17-year - old female Cas e 7- - six - year - old female V. DISCUSSION 136 Diagnostic Test Mate rial I nte ll ectual functioning Family Histories . Therapy Interviews VI . 106 113 118 123 129 SUMMARY 136 136 147 150 154 Suggestions for Further Studies 156 BIBLIOGRAPHY 158 APPENDIXES 166 VlTA Appendix A. Struc tured Chi ld Interview 167 Appendix B. Bradley Sentence Compl etion Test 168 Appendix C. Bradley Self Conce pt Measure 170 173 v LIST OF TABLES Table 1. 2. 3. 4. Page Means and t-test scores for controls and experimentals on me asures of intellectual functioning 50 Means and t-test scores for controls and experimentals on selected Rorschach data 51 Mean and t-test scores for controls and experimentals on measures derived from the Family Relations Test 52 Means and t-test scores for controls and experimentals on remaining personality measures 53 vi ABSTRACT A Psychological Investigation of Seven Hermaphroditic Children by Peter Lewis Kranz, Doctor of Philosophy Utah State University, 1969 Major Professor : Glendon Casto De partment : Psychology An in - depth pe rsonality and intellectual evaluation of a group of he rmaphrod i tic children residing in the state of Oklahoma was und er taken in this study. The following techniques were utilized in order to ex t e nsive ly study the impact of this anomaly on the families o f th e se c hild re n : psychological tests, parental interviews by a socia l worker, and diagnostic play interviews conducted by the investiga tor . It was the purpose of this study to examine the psycho- l ogica l impact of sexual ambiguity on the child and his parents . There we re no significant differences between the two groups on any o f the tests given . This may be attributed to the small sample size . Certain tr e nds seemed apparent but they could also have been ffecte d by the limited sample . 1. These trends were: The play activities and interests of the children appeared to be age appropriate in relation to their socio-economic background. There was , however , a tendency on the part of the older children to prefe r a c tivities which were mor e masculine than feminine in nature. vii 2. Few close heterosexual relationships were mentioned by the subjec ts. 3. Four of the children stated that they would like to make nur sing a career. 4. The three older children seemed more aware of their medical c ondition than the younger subjects and were aware that they were diffe rent i n some ways from the normal population. 5. The thr e e older subjects seemed more affected by the anomaly than the younger ones and were more sensitive to it and to relationships with others. 6. As a group there seemed to be nothing unusual in their typical daily routine except for the medication which had to be taken r e gularly . 7. The children seemed to be self-conscious and reluctant in desc ribing themselves to the investigator particularly as it perta i ned to their medical anomaly. 8. An optimistic philosophy of life was expressed by the sub- jects i n which emphasi s was placed upon religious values, a desire t o he lp others, and an ambition to live the golden rule . 9. In the children ' s explanations of how they would like to be d i ff erent, reference was made to their medical condition. 10 . In no case did the birth of a hermaphroditic child into a family inhibit future conceptions and subsequent births. 11 . All families but one felt that they needed greater medical und e rstanding and guidance with regard to the anomaly as well as wi t h p r op e r management of the condition once it had been diagnosed. viii 12 " It was felt by four groups of parents that desirable sex c ha nge s hould occur in the child as early as possible, preferably be fo re th r ee years of age . 13 . All families tended to keep the sexual anomaly issue closed and limited to their immediate family. 14. It appeared that socio-economic factors made little dif- f e r e nce in the parents' general concern for their child and its adequate adjustment to the environment. 15 . Accessible and comprehensible medical information about hermaphrod i tism is almost unavailable to those desiring it because of th e cur re nt infre qu e ncy of incidence and variations in condition. (181 pages) CHAPTER I INTRODUCTION The term "hermaphroditism" is derived from the legendary appearance of the mythical child Hermaphroditus (born to Hermes and Aphrodite), who was said to possess genitalia of both sexes . In today's terminology a true hermaphrodite is an individual who possesses ovarian as well as testicular tissue. In order for the correct diagnosis of this intersexual state to be made, the presence of both types of gonadal tissue has to be proven histologically (Bartalos and Baramki, 1967) . Other variations of hermaphroditism include male ps eudohermaphroditism, a condition in which a person is genetica lly and gonadally masculine but whose body build and external genitalia have female features, and female pseudohermaphroditism, a condi tion in which a person is genetically and gonadally feminine but whose external genitalia and body build have male features. The major center for research in the study of hermaphroditism is the Johns Hopkins University Hospital in Baltimore, Maryland . Wilkins, Jones, J . L. Hampson, J. G. Hampson, Van Wyk, Grumbach, Judson, a nd Money have been major contributors from this institution . Money is by far the most active researcher in the area of psychologic al i mplications of this disorder and is the major source which this i nvestigator utilized in order to compile his review of literature . I n spite of the fact that some researchers feel that there are 2 · · 1 d ata wit · h regar d to inci · ·d ence no statistica found. 1 some meager d ata were It has been stated that true hermaphroditism is an extremely rare condition and that there have only been 40 cases reported whic h were adequately authenticated by microscopic examination of the gonads (Talbot et al., 1952). As of 1958, only 70 verified cases had appeared in the literature according to Lisser and Escamilla (1962). Danowski (1965) estimated that there are probably no more th a n 100 true hermaphrodites on record. Pseudohermaphroditism occurs far more frequently, about once in 1 , 000 persons, and approximately 75 percent of patients with pseudohermaphroditism are felt by Lisser and Escamilla (1962) to be males . It ca n be a result of the most common adrenal abnormality encountered in chi ldhood : congenital adrenal hyperplasia (Bartalos and Baramki, 1967) . Adrenal hyperplasia is an increase in the size of the adrenal glands as compared to normal. There is a resultant androgenic excess which may cause virilizing effects within the fetus, infant or child (Brainerd, Margen, and Chatton, 1967). If this condition appears wi thin a female, sexual ambiguity is often the result. The statis- tics relating to pseudohermaphroditism with regard to incidence of adrena l hyperplasia are meager, and they vary from researcher to res e arche r. Childs, Grumbach and Van Wyk (1956) report one case in eve ry 67,000 live births in the state of Maryland and Prader (1958) r e ports one case in every 8,000 births in Switzerland. 1 John Money, letter to the author, Peter L. Kranz, March, 1968 ; Darre l Smith, interview at the Oklahoma Medical Center, Oklahoma City, Oklahoma, March, 1968. 3 Statement of Problem There has been relatively little research relating to the psychologic al problems of the child with intersex difficulties and hormonal dysfunction. Most reports are of the case study variety and lack uti lization of objective measurement and effective controls. The use of objective measures appears particularly deficient since many studies offer conclusions regarding sex role identification, self conce pt, parental attitudes, expectancies, related child adjustment, achievemen t, etc. It was the purpose of this study to gather data re lating to these factors and to compare the psychological test data between an experimental group of hermaphroditic children and a control group. The psychological impact of sexual ambiguity on the c hild and his parents was also examined. Psychological tests, parental interviews by a social worker, and diagnostic play interviews were utilized as sources of data. It is felt that the major con tribution of this study was the acquisition of quantifiable data which past studies have not obtained. Focus on the family was also a c ontribution of this study . Sample size was restricted due to the number of available hermaphroditic school-age children in the state of Oklahoma . fact has limited the N to seven children. This Three of these children have been diagnosed as male pseudohermaphrodites with testicular feminizing syndrome, and four of the children as female pseudohermaphrodites with congenital adrenal hyperplasia. are common in related research. Small samples For example, in a study conducted by Money, Hampson,and Hampson (1955b) a sample size of 11 was used . 4 Another study by Dewhurst and Gordon (1963) utilized an N of 20, and Berg, Nixon, and MacMahon (1963) reported a case study which included only one subject. The objectives of this study were: (1) to compare the performance of an experimental and control group on various diagnostic ins truments, (2) to carry out an in-depth personality and intellectual evaluation of each hermaphroditic child, and (3) to study indepth the impact of this anomaly on the families of these children . 5 CHAPTER II REVIEW OF LITERATURE This review of literature is divided into three parts. The first part is concerned with sex assignment of the neonatal period , t he second part with sex assignment of the post-neonatal period, and the third part with parental management. Sex Assignment: Neonatal Period There is considerable evidence to indicate that much of a c hild's psychosexual inclinations and behavior are not predetermined by the chromosomal pattern, the morphology of the gonads, or the type of sex hormones, but instead are largely determined through the gender role assignment made early in life. This hypothesis was pro- posed initially by Money, Hampson, and Hampson (1955a, b) and later supported through the work of many other researchers (Hampson, 1955 ; Money, Hampson, and Hampson, 1957; Money, 1955, 1963, 1965a, b, c, d ; Bunge et al., 1959; Wilkins et al., 1955; Sturgis et al., 1962) . These researchers feel that the parent's attitude toward the child's sex role is the single most important factor in the determination of psychological maleness or femaleness. A finer discrimination is made in cases in which it is felt that the psychological maleness or fema leness of the child is not a result of any single one or combination of the following physical variables of sex: chromosomal sex, gonadal sex, hormonal sex, internal accessory reproductive structures 6 and ex ternal genital morphology. Rather, the psychosexual neutrality prese nt at birth becomes differentiated later on, primarily as a result of social interactions with those significant others in the envi ronment (Money, Hampson, and Hampson, 1957). The significanc e of gender role will be discussed more thoroughly under "Sex Assignment: Post-neonatal Period . " If the preceding assumptions concerning gender role hold true , several considerations should be taken into account . The obstetricia n and/or pediatrician should attempt to settle the sex of the newborn c hild as quickly as possible. Several researchers feel that this assignment should be instituted within the first few weeks of lif e before the child's gender role becomes too firmly established (Money, Hampson, and Hampson, 1955a, b, 1956; Wilkins et al., 1955; Gross and Meeker, 1955; Money, 196lc, 1968b; Wilkins, 1965; Melicow, 1967 ) . However, most writers also feel that it is preferable that there be a delay of a few days or, if need be, even a few weeks, during which time finality of sex is decided rather than to state a determination which is not clear and which might later need to be retracted (Gros s and Meeker, 1955; Hampson, Money, and Hampson, 1956; Bunge et al., 1959 ; Wilkins, 1965). Regarding the basis for determining the sex of a child, Wilkins (1965, p . 335) states: "It is most important that in earliest infancy, a firm and rational decision be made in regard to the gender in which the patient is best adapted to lead as normal a life as possible, devoid of psychosexual maladjustments." Others have expressed similar ideas (Hampson, 1955; Money, Hampson, and Hampson, 1955a, b, 1956; Wilkins et al . , 1955; Money, 1961c). 7 Therefore, before the physician in charge arrives at a particular sex determination, it is nece ssary that he carry out a thorough investigation. This should include comprehensive diagnostic studies, of which the buccal smear and the 17-ketosteroid test are espe cia lly important; familial history , including pregnancy data ; and a thorough physical examination of the infant with particular atte ntion being given to its genital morphology. In this way the diagnosis of the exact type and etiology of the disorder can be determined, giving assurance of a permanent d ec ision concerning the sex assignment made and thereby preventing a speculative pronouncement of sex which may later have to be reversed. However, there are some cases of hermaphroditic children in which the question of ambisex uality is not suspected at birth due to the apparent clarity regarding th e morphology of the external genitalia (Money, Hampson, and Hampson, 1956). In cases such as these, it is recommended that the infant be declared by the attending phys icia n either of the male or female sex. If the external organs of the child are so predominantly ma l e, or so predominantly female that no amount of surgical reconstruction will convert them to serviceably and erotically sensitive organs of the other sex, then the sex assignment should be directed toward maintaining the person in that sex. (Money, Hampson, and Hampson, 1955b, p . 288) Early uncertainty is aroused only whPn there is some amb iguity concerning the appearance of the external genitals (Money, Hampson, and Hampson, 1955b). When this is the case, researchers at the Johns Hopkins Hospital concluded (after a 3 1/2 year study of the psychological development of 65 hermaphroditic infants, children and adults) that the use of a simple c riterion like gonadal structure or chromosomal pattern in the assignment of a hermaphrodite child to 8 one sex or the other is extremely unwise. Instead they recommend that the attending physician give c onsideration not only to external genital morphology but also to the adequate functioning ability of the genitalia in his choice of sex assignment. In this regard cor- rective hormonal intervention can also be considered. The most frequently raised objection in giving primary consideration to the genital anatomy of the hermaphroditic infant is that this flagrantly disregards the issue of fertility. There are no reported cases in which a male pseudohermaphrodite or true hermaphrodite has become a parent (Money, Hampson, and Hampson, 1955b). With regard to male pseudohermaphrodites, it has been stated by Wilkins (1965) that those who possess external female genitalia should be reared as girls. Male pseudohermaphrodites regularly feminize at puberty if they remain untreated. Although they do not menstruate or bear children, they frequently marry and live normal sex lives . Since their testes secrete estrogens at puberty, gonadectomies are not performed until after adolescence so that the patients may be convinced of their feminity without hormonal therapy . The testes are usually removed shortly after the individual reaches the age of 20 years due to the possible risk of malignancy. Once the gonadectomy has been performed it is essential that substitution therapy with estrogens be administered. Plastic correction may be carried out in those cases in which the individual's vagina is too short for satisfactory coitus (Wilkins, 1965). One of the primary considerations in the selection of the appropriate sex for the male pseudohermaphrodite with ambiguous or 9 male external genitalia is the size of the phallus and the anatomy of the external genitals (Wilkins, 1965). Provided that the phallus is sufficiently well developed to f unc tion reasonably well as a penis, it is often felt to be wise to raise the child as a male and to surgically correct any c hord ee, hypospadias or scrotal cleft that might be present. Tubes and uterus are generally removed if th ey are present, and hormonal injections of testosterone are given if satisfactory masculinizat io n does not occur at puberty (Wilkins, 1965) . However, the phallus is so rudimentary and poorly developed in many male pseudohermaphrod ites t hat there is unfortunately no hope of constructing an adequate, functioning penis . Wilkins (1965 , p . 336) states that "if these patients are raised as males, the abnonnality of their external genitals c onstitutes an insuperabl e handicap to a satisfactory psychologic adjustment in their gender role . " He feels that these pat ients are ashamed to associate with other boys and tend to develop marked feelings of inferiority . It is also felt by Wilkins (1965) that as these individuals reach adult life they have a tendency to bec ome even more psychologically maladjusted in spite of testosterone therapy. Several of Wilkins' patient s who had been raised as males i nsisted on changing to the female role after they reached adulthood . Of te n this type of change is felt to carry connotations of homosexuality to the layman whereas it would not if such a change had be en implemented during infancy . Because of these difficultie s, Wilkins is co nvinced that it is preferable to raise patients of this type as females and to remove the test es, 10 which are invariably sterile, th e reby preventing the possibility of future virilization. To do th is properly, it is felt that the external genitalia should be alte red surgically to resemble the female and that the phallus needs to be removed only if it is conspicuous . Wilkins continues: Separation of labios crotal fusio n may externalize the vaginal orifice if there is a well deve loped mullerian tract with vagina and uterus . If no vagina or only a small pouch is present, a plastic procedur e to construct a vagina will have to be undertaken after adolesc e nce . Estrogens should be given at puberty to develop the breasts . (Wilkins, 1965, p . 336) It is felt that female pseudohermaphrodites should be raised as females since they have normal female organs and are capable of maturing as normal fertile women (Wilkins, 1965). Wilkins suggests that cortisone therapy should be started as soon as the diagnosis is established and continued throughout life in patients with viril izing adrenal hyperplasia . Also, there is the possibility that the patien t may have the salt losing type of adrenal hyperplasia during infancy which would require a sodium retaining hormone in addition to cortisone administration . Money, Hampson,and Hampson state: If the external genital anatomy of the infant is thoroughly ambiguous and the possib ilities of surgical reconstruction are equally promising in either direction, then gonadal and hormonal considerations may be more heavily weighted with regard to sex of assignment . On the basis of gonadal structure alone, however, it is frequently impossible to predict a virilizing or feminizing puberty. In the particular instance of hyperadrenocortical vir i lism in girls, it is possible to correct the hormonal incongruity by treatment with cortisone . (Money, Hampson,and Hampson, 1955b, p . 288) It is felt that this treatment should be started as soon as the diagnosis is established and be continued throughout the person's life . Similar conclusions were arrived at in other case studies (Gross and 11 Meeker, 1955; Wilkins et al. , 1955 ; Hampson, Money, and Hampson, 1956; Bunge et al . , 1959 · Money , 196lc ; Wilkins, 1965; Melicow , 196 7) . No hormonal therapy i s r equired of female pseudohermaphrodites of the non-adrenal type as they have no tendency of progre ssive virilization after birth (Wilkins, 1965). It appears that the indications for surgical correction are the same in both the salt losing and non-adrena l type of hyperplasia. In order to externalize the vagina, labioscrotal fusion requires surgical correction. This is a relatively simple operation and should be carried out within the first year or two of life. Wilkins (1965, p. 335) states, "If there is no labioscrotal fusion, the phallus may or may not be removed or recessed according to whether or not it is sufficiently enlarged as to be conspicuous or annoying." In conclusion, the attending physician should carefully consider the fact that in cases of c ongenital abnormalities it is relatively easy through surgery to cons truct a functional vagina and remove the gonads that serve a masculinization function (Sabbath, as cited in Sturgis et al . , 1962) . Sabbath states that: It is substantially impossible to construct a satisfactory functioning penis by plastic surgery. Therefore, it is usually wise to direct the rearing of such infants with ambiguous sex towards that of a female. In such cases, the grossly apparent anomaly of a clitoris if it is enlarged to the size of a small penis should be altered by amputation as early as practical in life and certainly before the age when children begin to make obs ervations of themselves, their siblings, associates, or parents. (Sabbath, as quoted in Sturgis et al., 1962, p. 135) Also estrogen hormones can be administered quite easily and effectively throughout the individual ' s life. In this regard, Masters and Johnson (1961) found that not only is successful intercourse 12 possible as an adult female with an entirely artificial vagina, but that, surprisingly enough, orgasm too is possible. Money adds that the artificial vagina in the female hermaphrodite not only can function efficiently in sexual intercourse, but . will also permit c onception, as contrasted with the sterility typical of male hermaphrodites. Fertility is common in effectively treated female hermaphrodites. The surgically reconstructed vagina may be inadequate for delivery, Caesarian sec tion being needed instead . (Money, 1965b, p. 185) Sex As s ignment: Post-neonatal Period Most researchers in the area of sexual ambiguity feel that all sex assignment problems should ideally be settled once and for all at the time of birth . met . Unfortunately this expectation is not always It is in the area of pos t poned sex assignme nt that the most perplexing and difficult probl ems arise. The so-called "safe time period" for reassignment of sex is short in duration because as the infant is growing and functioning within his environment he is simul taneously assimilating and ac c umulating a gender role (Money, 1968b) . In this regard, Money, Hampson, and Hampson define the term gender role as: All these things that a pers on says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It inc ludes, but is not restricted to sexuality in the sense of eroticism . Gender role is appraised in rela tion to the following: general mannerisms, deportment and demeanor; play preferences and recreational interests; spontaneous topics or talk in unprompted conversation and casual comment; content of dreams, daydreams and fantasies; replies to oblique inquiries and projective tests; evidence of erotic practices and, finally , the person's own replies to direct inquiry. (Money , Hampson, and Hampson, 1955a, p . 302) 13 Gender role establishment is not an inborn process but instead becomes established after b irt h i n ac cordance with the infant's s ex of assignment and rear ing . Mo ne y (196 l c ) has stated that the proces s of sex assignment and rearing is th e most influential variable in the establishment of ge nd er ro l e wi thin the child . This takes into c onsideration the five other variable s of sex, namely nuclear sex, gonadal structure, hormonal f unc t i on, internal reproductive organs and external genital morphology . The signific ance of gender role establishment in its relationship to assignment a nd rearing was originally introduced through a study by Money , Hampson , and Hampson (1955a). Their psychological study of 76 cases of hermaphroditism which manifested somatic ambi sexual anomalies showed that gender role more nearly followed the assigned sex than any other fa c tor ; there were only four exceptions . This conclusion was also substantiated by the same researchers in 1957 in a study based on a population of 105 hermaphroditic patients seen over a five year period at the Johns Hopkins University School of Medicine . Establishment of a c hi ld 's gender role is felt to begin around the time that the child is able to communicate verbally, or between 18 months and two years of age . I t is also within the latter part of this same time period that considerable impersonation of, and identification with, the parent of the same sex is observed. According to Money (196lc ) the gender role is established in most children by the time the c h ild is four years old. Money (1965b, c, d) feels that it is during t hi s period, especially through the acquisition and use of language, that the child becomes aware of himself 14 as being boy or girl. And , at about the fourth year of life, gender role becomes established within him so that sex reversal would be harmful to the child ' s self conce pt and subsequent personality development and would create more problems than it would alleviate. This conclusion was originally based on a study of 11 cases of hermaphrodites in which change of sex took place. Four of them were changed before nine months of age and subsequently assimilated th e ir new gender role without identifiable signs of psychologic maladaptiveness. The other seven were changed at or aft e r fifte e n months, the latest at sixteen years, voluntarily, and the other six before school age. All of these seven had assimilated their new gender role in varying degrees of pe rvasiveness, but all except one, who was changed at two years and thr e e months, subsequently evidenced at least one indisputable, chronic symptom of psychopathology. Severity of the symptom varied, though in no instance reached psychotic proportions. The incidence of psychologic maladaptiveness was conspicuously less frequent among cases with no history of change of sex . (Money, Hampson, and Hampson, 1955b, p. 289) There are, howeve r, some r e searchers (Dewhurst and Gordon, 1963; Berg, Nixon, and MacMahon, 1963) who feel that the sample size investigated by Money, Hampson, and Hampson was too small to justify their conclusions. These researche rs feel that sex reassignment after the age of approx imat e ly two and a half years does not necessarily have to be psychologically damaging to the person. However, their conclusions were also ba s ed on a small sample size. Dewhurst and Gordon's B was 20 ; Nixon and MacMahon's B was 1. Money, Hampson, and Hampson (1955b) point out that it is impossible to determine a fixed age at which gender awareness in all infants becomes permanently established. Instead they suggest that a general period up to 2 1/2 years can be approximated as a safe time period for sex reassignment. This is true in sex reassignment 15 as well as with other d ev e lopme ntal and maturational sequences within the infant due to the un i qu e natur e of e ach c hild's development. Money (1961c) furth e r states that just as it is possible for an individual to establish a di stinc t male or female gender role, there is also the possibility of an indiv i dual establishing an ambiguous gender role . He feels that th is ambiguity can occur through a de- fective or erroneous " i mprinting " proc e ss . The concept of imprin t ing is a new one in sexual theory and is defined as: . . . a kind of l e arning that requires a highly specific perceptua 1 stimulus, wi thout which it cannot take place and in the presence of which it cannot fail to take place, provided the nervous system i s intact and functional. The stimulus can be varied, but only within the boundaries of specifiable perceptual dimensions. Imprinting takes place readily at critical periods of the life history, which differ for species and types of imprint, aft e r which it will not take place at all or only imperfectly . Onc e an imprint takes place, it is indelible, if not for life then for a pa rt i cular epoch (period of time) in the life history. (Money, 1961c, p. 477) Fortunately enough, howeve r, the majority of human beings become imprinted with a gender rol e and orientation compatible with their reproductive capacities and ge n i tal equipment. The suggestion that the imprinting proc e sses may be r elated to the establishment of gender role was originally pres e nt ed by Money, Hampson, and Hampson (1955a), and was later substantiated by others (Hampson, 1955; Money, Hampson, and Hampson, 1956, 1957 ; Money, 196lc; Green and Money, 1961). The investigator's criticism of Money's concept of imprinting as it applies to the a c quisition of gend e r role revolves around Money's failure to d e f i ne and el a borate as to the meaning of specific 16 perceptual stimulus and the boundaries of specifiable perceptual dimensions , Imprinting is a form of learning very closely allied to the instinctive propensities of a particular kind of organ ism at a particular age (Hilgard and Bowe , 1966, p. 3). It is possible that this process is facilitat ed th r ough an externa l process such as reinforcement, but at th e present t i me there is no conclusive evidence to this effect. In this regard, Money's gender role acquisition seems to be more of an external proce ss than that of an internal one , and, if so, the process of imprint ing may not apply to gender acquisition as Money so suggests . It is felt by Green and Money (1961, p. 288) that deviations of an individual's gender role may represent "mixprinting" in which "a more or l e ss normal response, that of identifying with and impe rsonating a spec ific human being becomes associated with the wrong perc e ptual stimulus." These authors go on to feel that imprinters can be bred among animals and perhaps, therefore, disorders of gender - rol e within people might be related to the fault of the person's part icular env ironment in which their behavior bec omes attached to poor pe r c eptual stimulation (Green and Money, 1961). Green and Money , howeve r , fail to d efine what constitutes a good or poor imprinter as well as the imprinting process itself in both animals and human situations , In any case, when a later sexua l reassignment is necessary, due to a provisional or inadequate diagnosis made at birth, the all important consideration is the degree to which the gender role has become fixed and incapable of being changed (Money, 1961c). Because maturation rat s within individuals differ, there are no fixed 17 chronological boundaries in the establishment of gender role. In- stead, it is felt that there are time zones which should be evaluated in case to determine the extent to which gender role has been fixed (Money, 196lc). It is felt by Money, Hampson, and Hampson, and other researchers, that sex change should be carefully avoided in older children except in rare and carefully appraised instances. Two con- ditions warrant serious consideration of sexua 1 reassignment: children whose external genitals totally contradict their assigned sex, and older children whose gender role has been established contrary to the assigned sex and thus is desirous of the change (Money, 196lc). In both of these instances, Money feels that psychiatric supervision and follow-up should be available in order to assist the person in adjusting to his or her new sex assignment. Psychiatric supervision refers to some form of supportive therapy which hopefully helps to alleviate the client's anxiety and doubts with regard to his new gender. The chief objection to be raised against sex change in the older hermaphrodite is that it may disregard the possibility of depriving nonsterile hermaphrodites the chance of fertility in adult life (Money, 196lc; Money, Hampson, and Hampson, 1955b). The authors continue that: The answer to this objection is that actual child bearing as distinguished from potential biological fertility is not determined by chromosomal, hormonal, and gonadal sex alone. It is also determined by the social encounters and cultural transactions of mating and marrying, which are inextricably bound up with gender role and erotic orientation. Gender role may be established so thoroughly and irreversibly despite chromosomal, gonadal or hormonal contradictions, that it cannot be modified in accordance with a change of sex by edict. Thus a boy, changed to wear dresses once ovaries were discovered, may continue to think, act and dream as the boy he was brought 18 up to be, eventually falling in love as a boy, only to be considered homosexual and maladjusted by society. Alternatively, after the change, the gender ro l e may be partly modified, but only at the c ost of psychologic disorder and symptomatology sufficiently disabling to prevent marriage. In the seeds of its own defeat by ensuring that fertility never culminates in reproduction. (Money, Hampson, and Hampson, 1955b, p. 290) In summary, the consensus of researchers in the area of sexual ambiguity is that sexual r e assignment is best accomplished during infancy, and before 24 to 30 months of age. Under this condition, it is expected that the child will adapt readily to th e new change, and will be unable to remember that there had been a sex reassignrnent. After 24 to 30 months a sex reassignment involves the chance of creating difficulties within the life adjustment of the child. For the most part it is r ec ommended that change be avoided after 30 months (Money, Hampson, and Hampson, 1955b; Bunge et al., 1959; and Money, 1965a, b) . The i nvestigator feels it appropriate to reempha- size that sometimes calculated risks in sex reassignment are justified, such as in cases of c hildren whose assigned sex is totally contradicted by their external genitals. Hermaphroditic children who have a unitary psychosexual identity are less qualified candidates for sex reassignme nt than those who are psychosexually equivocal (Money, 1965a, b, c). In all cases, follow-up and psychiatric supervision is recommended. Another rare exception in which sex reassignment is felt to be justified is in an older child whose gender role has been es tabl is hed contrary to the assigned sex, with the child himself d esi r ing a cha nge. It is not felt to be a neces- sity that the assign d sex be in agreement with chromosomal or gonadal sex, but rath e r that the externa l genitals be surgically 19 correctible and functional (Money, 1965a, b, c). The research team at Johns Hopkins particularly feels it is too late to impose a change of sex after the transition from "infancy" to "childhood" which is felt to occur sometime between the ages of 3 1/2 to 4 1/2 years. Suc cessful negotiation of a change of sex assignment may be possibl e in the exceptional instance of a hermaphroditic child who has decided for himself that a sex assignment error has been made and desires reassignment. The Johns Hopkins group's experience, however, has led them to believe that voluntary requests by hermaphrodites for change of sex are more appropriate during adolescence and are more likely to be made by this age group than in younger hermaphroditic children . Although such requests from adoles- cents are rare, they are felt to deserve serious evaluation for they are presumed to be a culmination of years of doubt and perplexity (Money, Hampson, and Hampson, 1955b; Money, 1965a, b). This view- point is also supported by Bunge et al. (1959). Arbitrarily imposing a sex reassignment on older children has been argued for by some, based on the premise that these children may be fertile later in life, instead of being infertile in the sex of original assignment (Money, 1961c). Since congenital infertility is the rule in all other varieties of hermaphroditism, this fertility argument can only be applied to cases of female hermaphroditism. Even then the argument can break down, as being fertile is not the same as being reproductive. Patients who are arbitrarily forced into a reassignment of sex retain the gender role that was already established and henceforth act and feel like homosexuals and do not reproduce. Thus, a hyperadrenocortical female hermaphrodite who has been 20 reared for years as a boy retains the sexual inclinations and desires of a mal e , irres pec t ive of being forced into surgical feminization and the assumption of l i fe as a female. (Money, 196lc, p. 478 ) Therefor e, it is not fe l t to be sufficie nt to advocate a sex reassignment simply in order t o bring the sex of rearing into conformity with the chromosomal or gonadal sex (Money, 1965a, b, c). A sex reassignment, on the contrary, may purposefully contradict the chromosomal or gonadal sex a nd be based on the fact that only in the newly reassigned sex will the external genitals be functional and surgically correctable. An exampl e would be a male hermaphrodite who was misassigned as a boy with too small a phallus, and who ought to be changed in order to live as a girl. Paren tal Management Hampson (1959) states that a moth er usually asks two questions about her newborn c hild as s he wakes from her anesthetic. These questions are : (1) is my chi ld a ll right ? and (2) is it a boy or a girl? It is felt to be extreme l y important that the doctor in charge at the time of birth be frank and honest with the parents and tell them that at the pres en t time th ere is some doubt as to their child's sexuality and that various t es ts will have to be performed before the baby can be declared a boy or a girl. In this way the parents can curtail announc ements of the birth and avoid embarrassment associat ed with having to make a second contradictory announcement (Hampson, Mone y, and Hampson, 1956 ; Hampson, 1959; Money , 196lc, 1963, 1968b). Money states: 21 It is desirable for a speedy decision about the sex of assignment and rearing. Even more important than speed is thorough conclusiveness and finality. All debate should be disposed of so the subject need never be opened again. It is in the best interest of the child that henceforth everyone agree about his being a boy, or her being a girl. (Money, 196lc, p. 478) Hampson (1959, p. 15) feels that it is a grave error on the part of the attending physician to say, "'I think the chances are 99 out of 100 that it is a boy, so you can think of him as a boy until we finish the tests.' has to be undone." This may do psychological damage that later She further states that parents should not be left with the notion that their child is "half and half" or "two sexed"--which are often corrunon conclusions arrived at by parents who are not medically sophisticated. A great many parents of hermaphroditic children express apprehensions fostered by folk·-lore and myths that surround their child and his particular development (Hampson, Money, and Hampson, 1956). These stories reflect that such children are freaks, social outcasts and will become subjects of a great deal of ridicule and contempt. But the authors state: It is heartening beyond words for them to hear that the hermaphroditic child can grow up to be as thoroughly healthy, psychologically, as his anatomically normal sibling, and that he need by no means exclude marriage from his expectations of life. (Hampson, Money, and Hampson, 1956, p. 554) These authors feel that most parents welcome an opportunity to prepare themselves so that they will be able to answer their children's questions. This will mean the acquisition of an adequate vocabulary for discussion with their children. Many parents are themselves woefully ignorant of respectable terminology for genital structures, as well as of sexual anatomy and physiology! It may come as a surprise not only 22 to a child, but to the parents also, to learn that a large phallus is actually an unusua lly developed clitoris, and not a "male organ." (Hampson, Money , and Hampson, 1956, p . 554) It has been suggested that one show simplified embryologic diagrams of normal prenatal sex differentiation to the parents so as to relieve parental confusion by making it clear that their infant is genitally "unfinished" (Hampson, Money, and Hampson, 1956). The doctor can usually give some reassurance to the parents by telling them that their infant is in good condition and generally healthy and handsome (Hampson, as cited in Bunge et al . , 1959; Money, 1963) . The doctor, however, must make it very explicit that at the present time the child's genital development is incomplete and until further tests and studies have been conducted the sex will be in doubt. It is far more advantageous to leave the parents in doubt during the interval of indecision than to make a temporary declaration of sex creating the possibility of the parents having to go through the ordeal involved in changing the information about their child that has gotten around (Hampson, as cited in Bunge et al., 1959). The doctor in charge should have the courage to tell the parents that he does not know (Bunge et al., 1959). It is not an easy task for parents to have to face friends and neighbors and tell them that the doctors are not sure as to the sex of the baby, but in the long run it is vastly preferable to the parents than to have to reverse the original decision after four or five weeks due to a hasty decision on the physician's part (Hampson, as cited in Bunge et al., 1959). If the sex of th e infant has already been announced and a change has to be made, the parents should be given practical guidance about legally recording the change on the birth certificate and other 23 documents as well as a thorough understanding of their infant's medical status (Hampson, Money, and Hampson, 1956). It is felt that par- ents should also be encouraged to discuss their feelings and how they will handle the corrections of announcements which they will now be sending out to friends and relat ives. They presumably will need professional assistance in deciding how they will go about this delicate procedure. Hampson (1955), Hampson, Money, and Hampson (1956), and Money (1963) feel that parents must be armed with sufficient knowledge to be able to answer a wide variety of questions adequately and they thereby will be much better able to face this difficult situation . Along with this knowledge parents must also have total confidence in the correctness of what they are doing plus the confidence that seems to come from rehearsal of how to answer questions. Simple medios cientific nomenclature and explanations can be "of almost magical help to parents dealing with inquiry" (Money, 1963, p. 2351). Money (1963) feels that if two or three key people in the family's environment (such as their minister, priest or rabbi) are given adequate information about the child, they can be specifically requested to inform the curious, as needed, and also request them, in the child's interest, not to indulge in gossip. It is also felt to be important that sufficient information be passed on to other children in the family. They may need to be given simple and understandable explanations about the baby's "unfinished" penis or vagina. It is recommended that this should be done without secrecy or deceit and in such a manner that the other children can be reassured "that sex reassignments are not indiscriminately imposed, 24 perhaps on them, too . Properly taken into confidence, they can be advised to keep family secrets abou t these 'private things' and not to talk about them outs ide" (Money, 1963, p. 2351). Thi s procedure is felt to be helpful and convi nci ng if the children can look at the baby's organs after surgical repair. This also is felt to be one of the best ways to silence relatives and friends, too (Money, 1963) . Hampson (1955) indic ates that there is a good deal of evidence pointing to the great diffic ulty that parents have when they must switch the sex of their c hild after living with that child for a year or more . She goes on to state that, admittedly, the parents may be helped over this hurdle but only if they re-establish their family in a new community and sever ties with casual friends and neighbors (Hampson, 1955). If this is not done, it is likely that the child will be harassed and disturbed by rumor and gossip in later years. This similar feeling is also shared by Money (1961c) and again by Hampson, Money, and Hampson (1956). Parental attitudes concerning the sex of the child are felt to be of utmost importance in that parenta l uncertainty and doubt even under attempted concealment c an easi ly be c ommunicated to the child (Newman and Stroller, 1967) . These aut hors go on to state that if this is so, the chi ld is fa ced wit h the unfortunate possibility of considerable damage to his emerging sense of who and what he is. Parental unce rta inty occurs fre quently and the physician involved in the case of such an infant must anticipate this parental uncer tainty which may remain hidden due to guilt or shame (Newman and Stroller, 1967) . Hamp so n ( 1955 ), Mone y ( 1961c), and Wilkins (1965) 25 express similar fe e l i ng s in t hat a c hi ld's pr iva te doubts about h is c orrec t s exual identity c a n be re info r c ed by unce rtaint ies and doubts which the parents th emselves have. Hampson, Money, and Hampson state : Whether or not th ere i s to be a r e assignment of sex , the parents will need to have the opportunity to reve al their private fears and doubts about t he child's future . The myths and misund e r st andings wh i c h torment parents of he rmaph r od i tic children have proved t o be r emarkably c onstant . Almost un iversal is a de e p c once rn about their c hild's future erotic inclinations. There is a we a lth of misconception circulating that homo sexual inc l inatio ns may likely be perverted . Parent's apprehension c onc erning th e problem of sexual behavior can often be forestalled if they are given an opportunity to speak frankl y about i t . (Hamp s on, Money, and Hampson, 1956, p . 554) What the authors seem to be indic at ing is the necessity and availability of some form of s upportive therapy to those parents wishing and needing assistanc e . This should be facilitated through th e family physician who if quali fied can handle the particular problems himself or if in doubt, refer t he parents to those medical pers onnel who can . Finally as th e hermaphroditic c hild grows up , he needs to feel free enough within t he fam i l y conste llation to be able to express his private misgiv ings to th em and to his do c tor. He may have prob - lems accept ing h is condi tion , but , like any other handicapped child, he can learn that there are ways and means in which he can face up to his condition i n a r e alist ic manner . If the hermaphrodit ic child is misinformed by evas ions or half-truths or if he is frightened by no explanation, he may conc l ud e t hat his c ondition is a mysterious misfortune, a shameful disgrace , or a crue l penalty for some legendary evil - doing. The psychologic manageme nt of the parents of 26 hermaphrodites and of the pat ients themselves is best conducted when specific details are given from a policy of frank and straightforward discussion and explanation (Hampson, Money, and Hampson, 1956). 27 CHAPTER III METHODOLOGY Sub jec ts The -s S were seven Cauc as i an he rmaphroditic children from the state of Oklahoma. Thes e 7 -s S were the entire available hermaphro- ditic population in the s tate of Oklahoma. 6 years, 2 months to 18 ye ars , 4 mo nths . They ranged in age from The S were free of any -s gross intellectual or physic al c ha r acteristics which might otherwise affect the testing . The control group c ons i s t ed of 7 .§.s ranging in age from 6 years, 2 months to 18 ye ars, 4 months . The S we re free of any gross intel -s lectual or physic al cha r a t e ri stics which might otherwise affect the testing . Each S in th e exper i me ntal group was paired with a .§. in the control group on th e foll owing variables: age, sex, race, socioeconomic class and cont a c t wi th t he Oklahoma Medical Center . Proc edu r e Ten psychological inst r ume nts we re individually administered to each experimental .§. on two separa t e occ a s ions with a 4 month period intervening between the first and second administrations. The same 10 tests were individually admin i stered one time to each control .§.. The tests were admin i ste red twice to the experimental S in order to -s obtain reliability d a ta on the s e t e sts for this particular population . The instruments consisted of : Rorschach Ink Blots (Rorschach, 28 1921); Draw-A- Person, forms land 2 (Goodenough, 1926); Thematic Apperception Test (Murray, 1943 ); Wechsle r Intelligence Scale for Children (Wechsler, 1949); Children's Apperception Test (Bellak and Bellak, 1949); Wechsler Adult Int e lligence Scale (Wechsler, 1955); It Scale for Children (Brown, 1956 ); Children's Form of the Manifest Anxiety Scale (Castaneda, McCandles s and Palermo, 1956); Family Relations Test (Bene and An t hony, 1957); Structured Child Interview (Wright, 1966) ; Bradley Se l f Conce pt Measure (Parsons, Davids, and Peterson, 1968); and Bradley Se ntence Comple tion Test (Davids, 1968). Age differences between -s S some times determined which specific tests were administered . The Wechsler I ntelligence Scale for Children was administered to five -s S , the We c hsler Adult Intelligence Scale was given to two -Ss . The Thematic Appe r ception Test (pictures 1, 3 BM, 3GF, 4, 5, ?BM, 8BM, 12F, 13G, 14 and 20) was given to five -s S , and the Children's Appercept i on Te st was administered to two -s S . Each S was interv i ewed individually for one hour on six separate occasions, with two weeks e l a psing between sessions. The first interview occurred after the initia l testing and the remaining interviews took place in the subsequent 3 months . occurred before the second testing . The last interview The six interviews took the form of diagnostic play inte rviews f or the 3 -s S under the age of 12 years. The diagnostic play interviews consisted of the investigator's attempting to establish rapport with each ~' thereby enabling the child to respond freely, but without pressure or undue probing . An attempt was made to pr ov ide the c hild with an opportunity to "play out 11 his feelings and problems . For the 4 -s S older than 12 years, 29 more adult type therapy inte rviews were utilized in whi c h the ~s were given the oppo rtunity to alk out their difficulties . All interviews began with the sta t ment ''can you tell me something about yourself," and included suc h mat ria l as l ife data information, free association periods , and ex pres s i on of attitudes and feelings concerning the -Ss sexually ambiguous c ondition. An experienced soc ial wo r ker was u ti lized in obtaining two case history interviews from eac h of the~~ parents. took place in the social worker ' s office. These interviews The first interview was conducted at the beginning of th e 4 month period, at which time the first psychological testing also took place. The second parent interview was conducted at th e c onclusion of the 4 month period, at which time the second psyc hologic al t e sting took place. The informa- tion collected contained spec ific biographical data on both the parents and children, suc h as soc io-economic status, religion, race, educational background, and parental occupation. In addition, an attempt was made to elicit par e nt attitude and disposition toward the sexually ambiguous child and his particular problem . Diagnostic Instruments l ! ~ for .Children is an instrument which measures the nature and extent of young chi l dren ' s prefere nce for objects and activities character istic of their own or the opposite sex (Brown, 1956) . The scale consists of 36 pic ture c ards, 3 x 4 inches, depicting various objects, figures, and a c tivities assoc iated with masculine or feminine roles. Several sampl e items from the toy picture section are: 30 loll, sold ie rs, trac to r, purs e and rac e r. The child is asked to nake choices for "It ," a f i gure of i nd e termi nate sex . The s c ale rields a quantifiabl e rati ng o f s ex - r ol e pre fer e nce , with a range : rom 0 , an exclusive l y f e minine s c ore , t hrough 84 , an exc lusively nasculine score . A s c ore o f 4 2 would re pr e sent a r e lativ e ly inter- nediate prefe renc e between ma s c uli ne and f emi n i ne roles (Brown, . 956). Brown (1956 ) r e po r ted sa t is f a c tory rel i ability f or the It :cale. Test - r e te s t da ta ( interva l a pprox imat e ly one month) yielded a · = . 71 for boys a nd . 84 f o r gir ls . He goes on to stat e (Brown , .956, p . 7), " reliabil ity o f the IT SC s e ems r e asonably ad equat e and '. Ompares favorably wi th o t her eval ua t ive i nst r uments that have been tsed in measuring va r io us ps yc ho l ogica l charac t e ristics of young •hildren . " Brown (1956) re po rt ed on item va l i d i t y f or both boy s and girls 1n th e ITS C. He fe l t t hat his va l i datio n r e sults justify th e hypothe - is that the toy obj ects c ommon l y as s oc iated with boys and those c ommonly a ssoc ia ted with gir l s co nsti tute one sourc e o f d i ff e rence in sex rol e pr efere nc e . To t he exte nt that boy s pre fer the mas c ul ine and g i rls t he femi n i ne roles, diff ere nce s in t heir choic es of p l ay ob jec t s c on nec ted with such roles should be ev i d e nt . . " . A gre ater perce ntage of girls than boys prefer eac h o f eigh t f ema l e toy obj ects, while a greater percentage o f boys t han gir l s prefe r e a c h of eight male toy objects . (Brown , 19 56 , P o LO ) Family Relat i ons Te s t is an obj ec tiv e i nstrument concerned with 1he psychologic al assessme nt of the child ' s f eelings toward the vari~s members of his f am i l y a nd t he ir recip rocal regard for h i m (Bene n d Anthony, 1957 ) . The t e st exp l ore s the following attitude areas : 31 (1) (2) (3) (4) Two kinds of pos itive at tit ud e ranging from mild to strong, the mi l d er i ems havi ng to do with feelings of friendly app roval , a nd t he s t ronger ones with the more "sexualiz ed" or " s e ns ua liz ed" fee lings associated with close physic al c o ntac.t and manipulation . Two kinds of ne g at ive att i tud e also ranging from mild to strong , the mi l der items re lat i ng to unfriendliness and disapproval and the s t ro nge r ones expressing hate and hostility . Attitudes to d o wit h pa r e nt al over-indulgence covered by such items as : "Th i s is t he person in the family mother spoils too muc h . " Attitudes to do wi t h par e nt al ov erprotection, covered by such items as : "Mother worr i es that this person in the family might c atc h c old. " The it ems o f the s e ar e as, apart from the overprotective and ove r -indulg en t ones, vary in the direction of the feelings the y c onvey according to whether the feeling comes from the c h i l d and go e s to some other person, or whether the c hild f ee l s himself the object of someone else ' s feeling . ( Be ne and Anthony, 1957, p . 4) The test mat e rial was d e s i gned t o give the child a concrete representation of his famil y a nd c ons i s t s of 20 figures representing people of both sexe s, a t var i ou s age s, shapes and sizes. Bene and Anthony (1957) f e el tha t t he 20 fi gure s are sufficiently stereotyped to represent the memb e rs o f a ny c h i l d' s family, yet ambiguous enough to become, under sugge st i on , a s pe c i fic family. family members, anothe r i mportan In addition to the fi gur e that is incorporated into the test is "Mr . Nobod y , " who s ere s to ac commodate those test items that the child f e els d oe s no t apply t o anyone in his family . Each of the 20 figur e s is a t t ac hed to a box-like base which has a split in the top. vidual cards. The t e s t items are printed on 100 small indi- The child is then told that each card contains a mes- sage, and that his task is t o pu t the card "into the person" whom the message it convey s fit s bes t ( Bene and Anthony, 1957). There have be en f ew s udies me asuri ng the reliability and 32 validity of this test, but Bene and Anthony (1957) feel that the results obtained s eem to justify c onfid e nce in this instrument. None of th e usual methods of assessing the reliability of a test is quite suitable for the Family Relations Test . If the test - retest method is us ed with a short interval the child may be influenced wh .n tested on the second occasion by his memory of the first occ asion . If this method is used with a long interval th en we must expec t c hanges both in the home environment o f the child and i n th e maturing child himself. This is especially true i n the case of clinic children who are in thera py and whos e mother s are s ee n by psychiatric social worke rs. Nor is the spl it - half met hod suitable for this test, since the items with in any area are not sufficiently homogeneous and since the number o f cho ic e s the child can make with regard to each item varies from case to case. However, an attempt has been mad e to us e a modified form of this method in the following way. The test consists of 86 items, each of which could be allotted to Nobody, Self, Fat her, Mother, various numbers of Siblings and Others i n the family. Out of this, by a combination of items, thre e typ e s of score s were used. Positive feelings, to and fr om combined Negative feelings, to a nd fr om c ombined Overprotec t io n and overindu lg ence combined 34 items 34 items 18 items Separate reliability c oefficients were obtained for each of these score s for eac h of the people i n the family, regarding each score as if it were the resu lt of a separate test . Within each score two sub -sc or e s were computed, for the odd and for the even numbered i t ems r e spe ctive ly . (This was done only where the scor e reached or exceeded 6 ). Thus, for each subject, we have two separa te sub -score s in relation to Mother, and so on . The number o f subjects who gave 6 or more items to the self, second or th ird mentioned siblings, and others in the family were too small to warrant computation of a coefficient. Statistic al res ul ts a re shown in Table 19 . 33 Table 19 Correlat i ons be twee n odd and eve n numbered items where total number of items per per son and area reached or exceeded 6 . Positive feelings to and fr om c omb i ned Father Mother First mentioned s ibling N 48 76 34 r . 66 . 65 . 82 Correc ted r .79 . 79 . 90 Negative feelings to a nd fr om combined Father Mother First me ntioned sibling 31 11 31 . 71 . 64 .52 . 83 . 78 . 68 Overprotection and overind ulgence 17 .67 .80 To correct for halv ing the l e ngth of the test, the SpearmanBrown prophecy formula was us ed . Table 19 s eems t o indicate tha t the Family Relations Test is reasonably reliable . (Be ne and Anthony, 1957, p . 36) The validity o f the Family Relations Test has been investigated from s ev e ral po i nts of view. Although the number and variety of thes e inve s tigations is far from sufficient, the results obtained so fa r seem to justify some reasonable confidence in the t est. Two sets of subjec ts were used for the validation studies that have been carried out . They both consisted of children who were out-patien ts in t he children's department of a large psychiatric hospital in South Eas t London, and who were mainly resident in this area . Most of them came from working class and lower middle c lass fami lie s . They have been referred for any of the reasons t hat ar e usual with child guidance cases. Their I . Q. 's ranged from 67 to 144 with a mean of 98 and a S. D. of 16 . As there were not enoug h young children available for the study of the form for younger c hildren all validity studies were done on th e form for old e r c hildren; the ages of the children ranged from 7 to 15 year s with a mean of 11 . 0 years . The test r e sult s i n the first s et of subjects were used to compare various aspec ts of the test with relevant psychiatric and case history mat e rial . The test was administered to children, who had been newly admitted as outpatients, on the morning of their first visit to the hospital . The psychologist who did the testing knew no thi ng about t hem except their name . About a year later thes e t e st results were compared with the case material that had since be en obtained by psychiatrists and psychiatric soci al wo rkers . Th e second set of subjects consisted of curr e nt outpatie nt cas e s. The test results of these children we re compared with data obtained from their mothers 34 who had been asked by me ans of a questionnaire how their children got along with othe rs in the ir families . (Bene and Anthony, 1957, p. 28) The validity r e port ed fo r the comp aris on between t e st results and case history mat eria l , as well as for the comparison between test results and que st ionnaire mat er ial obtained from mothers, at tests to reasonable confide nce in this instrument as a clinical tool in the assessment of the c hild 's fee lings toward his family members and his perception of their fe e lings toward himself . Children's App e rcept i on Te st i s a projective test applicable for children betwee n the ag e s of 3 to 10 years. It consists of 10 pictures in which all c haracters are animals, based on the assumption that childr en will more readily identify with them than with humans (Bellak and Be llak , 1966) . These authors go on to state that the Children's Apperception Test is not a substitute for the Thematic Apperception Test, but rather a c omplementary tool . That is, the test is designed (Bellak and Bellak, 1966, p . 1) "to facilitate understanding of a child ' s relationship to his most important figures and drives" whereas the Thematic Apperce ption Test is better suited for this purpose with old er c hildren and adults . The pictures of the Childr en's Apperception Test were designed to e licit responses to feeding problems specifically, and oral probl ems generally; to investigate problems of sibling rivalry; to illuminate the attitude toward parental figures and the way in wh ic h these figures are apperceived; to learn about the child's relationship to the parents as a coupletechnically spoken of as the oedipal complex and its culmination in the primal sc e ne ; namely, the child's fantasies about seeing the parent s in bed tog e ther . Related to this, we wish to elicit the c hild's fantasi e s about aggression; about acceptance by the adu l t world , and h is fear of being lonely at night with a possibl e relation t o masturbation, toilet behavior and 35 the parents' response to it . We wish to learn about the child ' s structure and his dynamic method of reacting to and handling--his problems of growth. (Bellak and Bellak, 1966, p. 1- 2) Bellak and Bellak ( 1966 ) f ee l that their test is primarily c oncerned with what the child sees and thinks as opposed to how the child sees and thinks whic h is be tter tapped by the Rorschach test. The Children's Apperception Test, the authors feel, is relatively culture free and thus can be used equally well with different socioeconomic classes as well as with different races . They (Bellak and Bellak, 1966, p . 2) state that the test is presented to th e child not as a feat but as a game , "in wh ic h he has to tell a story about pietures; he should t e ll what is going on , what the animals are doing now. At suitable points, the c hild may be asked what went on in the story before and what will happe n lat e r . " The pictures are numbered a nd are administered in a set order. Freeman (1962) and Be llak and Bellak (1966) feel that a great deal of research still needs to be done on the test's reliability and validity. Even with this criticism, Wirt (1965) states that the Children's Appercept i on Test is a very useful instrument, but that its value comes mainly from the sensitivity and experience of the clinician using it rather than the particular stimulus material used. Bradley Sentence Completion Test is a new sentence completion test now in print (1968). This test presents the individual with a series of 50 incomplete open-ended sentences to be completed by him in one or more words. The test is similar to the word association test in that the word or phrase us ed to complete the sentence follows from and is associated wit h the given part of the sentence. The 36 sentence-completion test, Fre eman (1962, p. 669) states, "is regarded as superior to word-associa tion because the subject may respond with more than one word, a greate r flexibility and variety of response is possible, and more areas of personality and experience may be tapped." The content of a part ic ular sentence completion test and the nature of the stimulus phrase s depend upon the population being tested and the purpos es for wh ic h the test is intended . Some of the things that the Bradley Sentence-Completion Test taps are satisfactions and annoyances, likes and dislikes, fears, attractions, hopes, motives, needs, and home and outside environmental forces. Several sampl e items are the following: He hates .,. What makes me sad .. . I'd like to be ., . He likes best o f all . . . I dream of. , . I am afraid of .. , Other people think he 0 s ... He is scared .. . The directions read to each subject are as follows: "Complete these sentences to the best of your ability, try and express your real feelings and do every one, making sure to make a complete sentence . " At present there are no validity or reliability studies available concerning th e test. 37 Structured Child I nte rview is a projective questionnaire of twelve questions with s ev e n o f the questions having more than one p:irt. The subject is asked "to answer each question in his own way." U1less the child is soph i sticat ed enough to be aware of the psychobgical signific ance o f the que s t ionnaire, he will not grasp the inplications of the ques tions or of his answers (Freeman, 1962) . is thus possibl e to obta in information as Money t'le guise of fiction . " It (1957) states "under The infor mation obtained can relate to the SJbject's emotional li fe , h is va lues , his attitudes, his sentiments, a~d, in addition , the c h i ld 's feelings toward various members of his family. Several sample it ems are t he following: What do you l ik es pec ia lly to do with your father? With your mo ther? With your brothers and sisters? Think of a time you we re happy. Think of a t i me you were sad . Tell me about it. Tell me about it . If you could hav e any th r ee wishe s c ome true, what would be your first wish ? Your second wish ? Your last wis h? Freeman (1962) stat es tha t t he value of this type of diagnostic indicator, at present , does not lie in a numeric al s c or e ; indeed rating schemes have not yet been dev i sed, s ince this technique is quite recent and has not been us ed ex t ens ive l y . The value of the projective questionna ire l ies rather , in the fact that the answers are interpreted as re .aling certain traits and serve as a basis for psychologica l in t e rview. (Freeman, 1962, p. 670 - 671) 38 The investigator would add to Fr e eman' s statement concerning the test's value as a pr oj ec t i ve t ec hn i que t hat its administrat i on is pleasant and children s e em t o find t he ques tions easy to answe r . Draw-A- Pe rson Te st , Sundb e rg ( 196 1) states, is a project i ve instrument whic h i n usa ge ra nks s ec o nd only to the Rorschach . Kittay (1965, p. 229 ) f ee l s t hat t h i s d i agno stic i nstrument is so popular because it i s easy to "admin i ste r and inter pret, economical o f time and interesting. " Ma c Hover (as c ited i n Kittay, 1965) feels that the test can bes t be put t o use by t he c l i ni cian in combination with other psychologica l i nstrume nt s and s hould not be used alone as the only diagnostic i ndica t or . In this t es t t he s ub j ec t i s prov ided with an 8 inch by 10 inch sheet of unl i ned wh i t e pape r and a pe nci l . The instruct i ons given are simple and st raightforward : "draw a pe rson . " When th e subject has complet ed his first drawi ng he i s g ive n another piec e of 8 inch by 10 inch unlined wh i t e pape r and as ked to "draw a person of the opposite sex ." ta t ive. ing. Sc o ri ng o f t he Draw-A-Pe rson is essentially quali- Eac h f igure is analy zed f or s peci f i c features of the draw- Some o f the f ac to rs considered i n th i s regard are the absolute and relative s ize o f the male and female figures, their position on th e pa ge , qual i t y of lines, sequence of parts drawn, stanc e, f ro n t or profi l e view, position of arms, depic tion of c lothing , and ba c kg r ou nd and grounding effects. Special interpr e t a tions are giv en f or the omission of different bodily parts, di s proport i ons , s hading, amount and distribution of details , e rasur es , symmetry , and other stylistic features. (Anastasi, 1962, p . 581 ) Goodenough (1926 ) l is t s ce r ta in s c o ring c riteria (head present, legs present, arms pres e nt, e t c . ) . terion met. The S is given one point for each cri- The s um of a ll points e arned can be converted into a 39 mental age score. Not only are the individual drawings analyzed, but intercomparisons of the two drawings are also made to discern the subject's attitudes and feelings toward himself and toward his own as well as the opposite sex (Freeman, 1962, p. 674). Analyses and interpretations of one's drawings are based upon the assumption that they represent the pers on' s conception of his body in the environment. The drawing of th e figure representing one's own sex is regarded as a "body image" of one self. The term body image refers to the person's feelings and attitudes toward his own body. McCarthy (1944), from a study in which 386 third and fourth grade children were us ed, reports one week retest reliability of .68 and split-half reliability of .89 . Rescoring of the identical draw- ings by a different scorer in the McCarthy study yielded a scorer reliability of .90, and r esc or i ngs by the same scorer correlated .94. Anastasi (1961) reports that the Goodenough Draw-A-Person Test correlates between .41 and .80 wi th other intelligence tests, principally the Stanford-Binet. Many psychologists who have evaluated the Draw-A- Person Test, such as Anastasi (1961), Freeman (1962), and Kittay (1965), feel that there is still a great deal of research to be done in the areas of re liabil i ty and validity . But, according to Kittay (1965, p. 230), in spite of the uncertainties about its reliability and validity, "clinic ians appear to be impressed by the extent and congruency of its co ntribution to the evaluation of personality." Children ' s Form of the Manifest Anxiety Scale was adapted from Taylor's Adult Scal e of Manife st . Anxiety (Castaneda, McCandless, and Palermo, 1956). The scale c ontains a total of 42 anxiety items and 11 lie items. The lie items are designed to provide an index of the subject's tendency to falsify his responses to the anxiety items. The lie scale items ar e simi l ar to thos e found on the L scale of the MMPI, in that they c onta in no anxiety-relevant content. The index of the level of anxiety is obtained by summing the number of the 42 anxiety items answe r ed "yes. " The lie scale items are not included in the A score, but in a s e p arate L scale score. The test then gives two scores, an A s c ore and a L score. Several sample items from th e A scale are the following: I blush easily . I get angry e asily . My f ee lings get hur t ea sily. I have bad dre ams. I am nervous. Several sample items from the L scale are the following: I like everyone I know . I am always k ind. I never get angry. I never lie. I am always good. In the present study th e instructio ns given to each S were modified from the original instructions because of the wide age range . Instead of having each S read the instructions for himself the examiner read them to all -S s , keeping administration consistent throughout . The instructions were: "Put a circle around the word YES if 41 you think it is tru e about you , Put a circ l e around the word NO if you think i t is not true about you.'' Castaneda, McCandless, and Pal e rmo ( 1956), from a study with fourth, fifth, and s ixt h grad e c hildren, re po r t one week retest reliability at abou t .90 for t he anxiety scale and at about .7 0 for the L scale. Intercorr e lat ions between the anx iety scale and L scale clustered around the zero value , Girls were found to s co re signific antly higher than boys on both scales. Significant differe nces on the L sca l e were f ound to be asso c iated with grade. (Castaneda, McCand l e ss, and Palermo, 1956, p . 323) Kitano (1960) administered the Chi ldre n 's Manifest Anxie t y Scale to adjustment and regu l ar c las s boys i n th e fourth, fifth and sixth grades. Acco rding to h im (Kitano, 1960, p . 71), "The reliability of the anxiety scale was .86 . . . . There were no significa nt me a n differences be twee n adjustme nt c la ss and r egular class childr en on the L scal e or in s ocio -ec o nomic sta t us. " As for the test's validity, it has been reported that . . high anxie ty was . . . found to relate negat ive ly to I.Q . and achievement score s and positively to teachers' ratings of malad justme nt, discre pancy between self and desired self , tend ency to nom i nate ones e lf or to be nom inated by pe ers for ne gative ro l e s i n a soc i ometric situat i on, and manifestation of physic al complaints i n the school setting. (Cowen et a l ., 1965 , p. 685) Penney (1965 , p . 697) found "for mos t groups of children, low a nx iety was associated with h igh reac t ive c uriosity . " Wechsler Adult Int e ll igenc e Sca l e is one of the most wid e ly used adult intellige nce tests for ages 16 years and above . scale consists of 11 s ubt e s t s . The Six of these are grouped into the verbal scale: Informacion, Compre he nsion , Arithmetic, Simi larities , Digit Span and Vocabulary. Five s ubt e sts c omprise the Performance 42 Scale : Digit Symbol , Picture Comp l etion, Block Design , Picture Arrangement and Object Assembl y . the full s c al e. All 11 tests are comb ined to make Bec aus e of the popularity of this diagnostic instrument, f urther des crip t i on of i ts c ontent or standardized instructions for e ac h subt e st will no t be given . Reliability c oeff icients have bee n computed for each of the 11 subtests, as well as for th e verba l , performance, and full s c ale I. Q. 's within the 18-19 j 24-34 and 4 5-54 year sample. These three groups were selected as be ing r e pre sentative of the age range covered by the standardization sample . Anastasi (1961) states j Full scale I. Q. ' s yielded reliability coefficients of . 97 in all three age samples. Ve rbal I . Q. 's had identical reliabilities of . 96 in the three groups, and performance I. Q. had reliability of . 93 and . 94. All three I. Q. 's are thus highly r e l iable in t e rms of coefficients of equivalence . (Anastasi j 1961 , p. 309) The individual subtests yie ld ed lower reliabilities, as might be expected, with coefficients ran ging from . 60's found with Digit Span, Picture Arrangement and Ob ject Ass embly, . 70's found with Comprehension, . 80's found with I nformation, Arithmetic, Similarities, Picture Completion and Block De sign to as high as .96 for Vocabulary . The Digit Symbol Test, Wec hsl er (1955, p . 12) reports, "is a speeded test and the split-half t echnique for computing reliability is inappropriate." Consequently, a special study was conducted to estimate the reliability of this subtest which is described in detail in the WAIS Manual (1955) on page 12 . The reliability was . 92 for the 18- 19 year old group . In consideratio n o f the tes t' s co nstruct validity, Anastasi (1961) states: 43 In the process of standardizing the WAIS , intercorrelations of verbal and perfor ma nce s c ale s and o f the eleven subtes ts were computed on the same t hre e age groups on which reliability c oefficients had bee n found, name ly , 18- 19, 25-34, and 45-54 . Verbal and performa nce s c ale s cor e s corre lated .7 7, . 77 and . 81 , respectively, in t he se three groups. Intercorrelations of separate subt ests we r e a lso ve ry simila r in the thr ee age groups, running h igher among ve rba l than among performance subtests . Correlations be twee n verba l and performance subtests, although still lowe r on the whole, were substantial . For example , in the 25 -34 ye ar group , c orrelations among verbal subte sts ranged from , 40 to , 81 , among performance subtests from .44 to , 62 and be twe e n pe rforma nce and verbal subtests from . 30 to . 67. Both i ndividual sub t e st c orrelations and correlations be tween total verba l and per formance scale scores suggest that the two s c a l es have much in common and that the allocation of tests to one or th e other scale may be somewhat arbitrary . (Anastas i , 1961, p. 310-311) Wechsler Int e ll i genc e Sc ale for Children is a widely used children's intelligence t e st for ages 5 through 15 years. The scale is similar in principle and form to the Wechsler Adult Intelligence Scale : verbal subtests, performanc e subt e sts, a verbal I . Q. , a performance I . Q. , and a f ull s c ale I . Q. The subte st types are identic al with those of the Wechsler Adult Intelligence Scale with th e exc e ption that Digit Span has been made optional and an optional ma ze t e st i s availa ble . In place of the Dig i t Symbol Test a Cod i ng Test ha s be e n substituted. Becaus e of the popularity of this diagnostic i nstrume nt, further description of its content or the standar di zed ins truc tio ns for each subtest will not be given . Split-half reliab ili t y coeff i cie nts were computed for each subtest of the test, as we ll as for the verbal, performance and full scale scores . Thes e re lia b il i ti e s were found for three age groups (7 1/2, 10 1/2 , 13 1/2 ) , e ach group c onsisting of 200 cases. 44 The full scale reliability coefficients for the three age levels were . 92 , . 95 and . 94 , respectively. The corresponding reliabilities for the verbal scale were . 88, . 96 and . 96; for the performance scale, they were .86, . 89 and .90. Thus both the full scale and the verbal and performance I . Q. 's appear to be suff icient l y r e l iab l e for most testing purposes. (Anastasi, 1961 , p . 317) In a study of test-retest r e liabil ity of this scale, Gehman and Matyas (1956) reported the following correlations: performance scale I. Q. , .74; verbal scale I. Q. , . 77; full -sc ale I. Q., . 77 for 60 children who were first give n th e WISC in the fifth grade and then re-examined four years lat e r in the ninth grade . In consideration of the test ' s validity, Freeman states that . . . the intercorrelation coefficients among the individual subtests are, on the whole, not as high as would be expected . At the 7 1/2-year l e ve l , these coefficie nts are concentrated within the .20 ' s and . 30 °s; at the 10 1/2-year level, they are concentrated with in the .30's and . 40's; while at the 13 1/2year level , t hey are distributed within the . 20's, .30's, and .40's. On the other hand each verbal subtest correlates quite significantly with total v e rbal score, the range for the three age groups being from .44 to . 82, with the coefficients fairly evenly distributed . The non-verbal subtests correlate somewhat lower with total performance scores, the range being from . 32 to . 68, with some c onc entration in the 50's . The correlation c oeffic ients between total verbal scores and total performance s c ores are, respectively, . 60, . 68, and .56 for these same age groups . These findings indic ate that, on the whole, although each subtest has only a moderat e amount of communality with the others taken singly , verba l subtests combined have much more communality with eac h individual verbal subtest. The same is true of combined performance and separate performance scores. Finally, the data i ndicate that all the verbal subtests taken as a whole have consid e rable communality with all the performance subtests as a whole. (Freeman, 1962, p . 272-273) Bradley Self Concept Measure is a new self concept measure. The test is s i milar in some respects to the Adjective Check List (Gough, 1952) exc e pt for the following: this test has fewer adjectives, 45 a total of 66; the t e st can be u sed with young children ; the child not only responds to the adjec t ives i n terms of himself but also in terms of his sex in ge nera l . Thi s become s clearer with the instruc- tions given by the ex am i ne r : "Th is te st c onsists of 66 adjectives, tell me whether you f ee l a ll ma l e s/female s (depending on th e sex of the S) should be . . .. " Af t e r te n minute s, the test is administered again with the instruct i o ns : "Th is t e st consists of 66 adj ectives, tell me whether you fe e l you you r s e lf are . . . . " Several sample adj ec t ive s are the following : bad, kind , little, small, lazy , brave, dumb . The Bradley Se lf Conc e p t Me asur e is concerned with the way the individual views himse lf a nd ot hers of his own sex. Anastasi (1961) states, The individual's se l f des c rip tion thus becomes of primary importanc e in it s own rig ht , rather t ha n be i ng regard ed as a second-best substitute f or other behavioral observations. Interest also ce nter s on t he ex t e nt of self acceptance shown by the indiv i dual . Anoth er c ommon feature of all (selfconcept) procedures , . . is the ir applicability to idiosyncratic, intensive inves t iga t i on of the individual case . (Anastasi, 1961, p . 623) There wer e no val i d ity or r e l iab i lity studies availabl e to the examiner concerning th i s test . The t est seems particularly useful with younger childr e n who find it pl e asant and interesting to work with. Thematic Appercept i on Te st has been used much more extensively than other story c onstruc tion t ec hniques and has also served as a model for the construc t i on o f lat e r t e sts in this class (Anastasi, 1961) . The TAT t e s t c ons is t s of 19 blac k and white picture cards, plus one blank card . The per son that is being tested is instructed 46 that this is a test of imagination, that he is to make up a story, and that there ar e no right or wrong answers . to the S one at a time . The cards are shown The S is told that each picture shows a scene and is then asked (1 ) what led up to the event shown in the picture; (2) describe what is happe ning at the moment, giving the feeling and thoughts of the c harac t ers; (3) and tell what the outcome will be. There ar e no time limits on the test. The TAT is use- ful in applying the actual dynamic s of interpersonal relationships. The very nature of the pic tures themselves gives basic data on the testee's relationship to peers, authority figures, and family members of both sexes . In interpreting the TAT stories Murray recommends (Freeman, 1962, p . 640) that , "the content of the stories be analyzed into (1) the forces emanating from the ' hero ' and (2) the forces emanating from the environment . " Thes e two di vis ions are analyzed under the following six categories : (1) the hero, (2) motives, trends, and feelings of the hero, (3) forces in the hero's environment, (4) outcomes, (5) themes and (6) interests and sentiments. Because of the popularity of this diagno stic instrument, further description of its content or scoring will not be given . TAT reliability has bee n studied in three ways: (1) extent of agreement among interpreters of the same stories in regard to traits of the persons examined; (2) similarities between stories on repeated examinations of the same persons, (3) split-half method, correlating frequency and intensity of needs expressed in the stories. (Freeman, 1962, p. 642) Freeman (1962, p . 643) states that "studies of agreement among interpreters, using for the most part rank-order correlation and the 47 coefficient of contingency , have reported coefficien ts ranging from approximately +.30 to +. 90 . " Thomkins (1947) reports t e st-retest reliability (Freeman, 1962, p . 644) in which he found "a reliability coefficient of +. 80 after an interval of two months, for fift e en young women; +. 60 after an interval of six months , using a different group of fifteen comparable subjects; and .50 after ten months for a third group." Using split-half method to measure reliability (Freeman, 1962, p. 644), "Sanford (1943) reported reliability coefficients of .48 and .46 . McClelland (1949), on the other hand, reports a re- liability correlation of .70 . " The reasons for the great degree of variability with this technique may be attributable to the fact that, according to Freeman (1962, p . 644), "not all TAT pictures are expected to elicit the same needs and press; each is intended to have its own major stimulus values, and the variables in the theme of one picture are not necessarily additive to those of the others." In examining the validity of the TAT, C. J. Adcock states in his review of the test (Bur os , 1965, p . 246), "the data avail ab le on reliability do not raise any high expectations with regard to validity. So far as statistic al data are concerned, there has been little advance in the last few years." Adcock goes on to report in this regard that Hafner and Kaplan (196 0) found no significant relationship between the TAT's overt and covert scales and Rorschach resu lts . Dreger (1960) found no r e lation between productivity as ueasured by the Rorschach and TAT . In contrast to these results, Freeman (1962) reports validity s t udies which are more optimistic 48 in nature . Freeman reports that Satisfactory results were obta i ned when stories of diagnosed groups, of known charac ter istics, were analyzed in detail to determine if significant d i fferences exis ted among them . The results showed that such differences exist among the following classifications, cons is ting of individuals who were relatively clear cases in each instanc e: conversion, hysteria, anxiety hysteria, obsessive-c ompuls ive neurosis, brain disease and head - injury cases. (Freeman, 1962, p. 646) Even though reliability and validity studies of the TAT do not satisfy certain psychometric standards, clinical psychologists have found this instrument a us e ful tool in the understanding of the individual's personal ity struc ture , particularly when used in conjunction with other diagnostic instruments. Rorschach Ink Blot Test is c onsidered to be the best known and most widely used projective instrument today . Because of the popu- larity of this diagnost ic instrument, description of its content and scoring pr ocedure will not be given. The cards are presented to the subject one at a time in a prescribed order . The instruct ions used in the present study were taken from Klopfer and Davidson (1962, p. 28) : "People see all sorts of things in these inkblots ; now t e ll me what you see, what it might be for you, what it makes you think of." The examiner did not impos e any time limits nor any fixed number of responses for each card. Beck's scoring system was used . Jensen (1965) indicates the following reliability findings : Scoring reliability is very good and has been reported as ranging from . 64 to . 91; Split - half reliability have also yielded high reliability from . 60 to . 95 ; Test-r_e test reliability ranges from about . 10 to about . 90, depending large ly upon the test-retest interval 49 and the particular score. Parallel forms reliability has been determined by use of the Behn-Rorschach, a set of similar blots which seem to meet all the psychometric criteria for qualifying as an equivalent form of the Rorschach . . . . The two forms seem to correlate as highly with each other as each correlates with itself. The correlations for various scores range from about zero to . 86, with a mean around . 60 . (Jensen, 1965 , p. 237) Reliability of Interpretation, Jensen states: is, of course, the most important matter of all . . . . Contrary to the usual c laim of Rorschachers _thaL<'this global interpretation is more reliable or more valid than any of the elements on which it is bas ed, such as the scores and the various derived combinations and indices, a systematic search of the literature has not turned up a single instance where the overall interpretation was more reliable than the separate elements entering into it. (Jensen, 1965, p. 237) Jensen, in reviewing the validity of the Rorschach, quotes Guilford's (1959) review of th e status of the Rorschach up to 1959 in which he states, Validities although quite varied are generally near zero, this statement regarding validity applies to use of the instrument in discriminating pathological from normal individuals, for diagnosis of more particular pathologies such as anxiety, for indicating degree of maladjustment in the general population, and for predicting academic and vocational success . (Jensen, 1965, p. 237) Again, as with the TAT, the Rorschach's usefulness lies not in reliability or validit y explorations, but rather in the hands of the skilled clinician for its practical usefulness in personality evaluation. 50 CHAPTER IV RESULTS The findings have been analyz ed with regard to relevant objective test data, case history interviewers obtained by the social worker and therapy interviews conducted by the investigator. Diagnostic Test Data Table 1 presents the means and t-test scores for the controls and experimentals on measures of intellectual functioning. For those comparisons, as well as for all others, a matched pair t-test was used with 6 df. There were no significant differences between the experimentals and controls on measures of intelligence. Table 1. Means and t-test scores for controls and experimentals on measures of intellectual functioning Variable Experimenta l Contro 1 t-test Full Scale IQ 105 . 14 106 . 57 . 17 Verbal IQ 103 . 14 99.29 .49 Performance IQ 106 . 43 113. 57 .78 7.95 9.79 . 15 Draw-A-Person Mental Age Table 2 presents the means and t-test scores for the controls and experimentals on some of the Rorschach data . There were no 51 Table 2. Means and t-test scores for controls and experimentals on selected Rors chach data Variable Experimental Control t-test Number of total responses 15.0 20 . 57 1. 93 Number of human responses 2.86 4.29 1. 17 Number of anatomy responses 1. 29 1.43 .23 F + % (reality testing) 75.62 76.66 .12 Number of actual and symbolic sexual responses 1. 57 2.57 .35 significant differences between the experimental and control groups on any of the Rorschach data but the controls gave more total responses and more human responses than did the experimentals. Table 3 presents the means and t-test scores for the controls and experimentals on measures derived from the Family Relations Test. There were no significant differences between the experimental and control groups on any of the Family Relations data. Even though there were no significant differences between the groups, the controls had more outgoing negative feelings toward mother and more incoming negative feelings from mother. Table 4 presents the means and t-test scores for the controls and experimentals on the remaining personality measures. There were no significant differences between the experimental and control groups on any of the remaining personality measures. However, the controls scored higher on the (L scale) of the Children's Manifest Anxiety Scale. On the other hand, the experimentals scored higher 52 Table 3. Mean and t-test scores for controls and experimentals on measures derived from the 'Family Relations Test Variable Experimental Control t-tes t Outgoing positive feelings toward father 3.00 2 . 71 . 17 Outgoing positive feelings toward mother 4.89 4.89 0.00 Outgoing positive feelings toward siblings 7 . 29 6 . 57 . 26 Outgoing negative feelings toward father 3.71 3.00 .38 Outgoing negative feelings toward mother 1. 28 2.86 1. 59 Outgoing negative feelings toward siblings 7.29 6.00 .46 Incoming positive feelings from father 2.43 3.43 .88 Incoming po sitive feelings from mother 4.57 2.86 . 99 Incoming positive feelings from siblings 6 . 43 3 . 86 1. 27 Incoming negative feelings from father . 86 2.00 .83 Incoming negative feelings from mother 1. 57 3.29 1. 52 Incoming negative feelings from siblings 7.00 4.14 1.40 Feelings of overprotection and overindulgence from father 1.14 . 71 .45 Feelings of overprotection and overindulgence from mother .43 .57 . 25 3.14 3.71 .36 Feelings of overprotectio n and overindulgence dire c ted towards self 53 Table 4. Means and t -test s c ores for c ontrols and experimentals on remaining persona lity measures Experimental Contra 1 t-test Bradley Self Concept Test 53.14 49.29 1. 11 Children's Manifest Anx iety Sca l e (A Scale) 19 . l 24.1 . 16 Children's Manifest Anxiety Scale (L Scale) 2.57 4.29 2 . 05 IT Scale for Children 62 . 14 41 . 14 1. 22 Draw-A-Person (point scale male ) 19.71 9 . 79 1. 76 Draw-A-Person (point scale female) 18 . 86 9 . 54 1. 94 Variable on the Draw-A-Perso n Point Sc ale, both male and female . Sununary There were no s i gn ificant differences between the experimental and control groups on any of the test data. A discussion of the experimental group ' s t es t data ca n be found in Chapter V. Case Hi st ories All parents of th e hermaph rodi tic population were cooperative, enabling the social worker to obtain pertinent biographical data on both the children and families . In two cases only one parent was interviewed due to divor ce and, in two case s, one parent was interviewed once due to d i stance from the Oklahoma Medical Center and employment obligations . In all cases, however, the mother of the 54 hermaphroditic child was interv iewed. The major in- depth family interv i ews which are presented as the body of this part of the r e sul ts were acquired through the assistance of Katherine Hudson, RSW , Cl i nic al Soc ial Worker. First case report General. Mrs. C' s primary conc e rn is with ]'s taking her medicine regularly and continuously . She understands that the medi- cation will be necessary indefinitely and that ] should not try to get along without it, as she does periodically, with adverse results. Mrs. f also worries about ] ' s somewhat cavalier attitude toward return appointments at the hospital . Unrelated to ]'s medical prob- lem in mother's mind, but also of concern, is ]'s acting out sexual behavior and other willful , impulsive, self defeating actions . Mrs. f also reports being embarrassed sometimes over ]'s deep, coarse voice. Family. ],the 18 year old patient, her mother, and mother's fourth husband make up the present family group. They have been living in Ft . Smith, Arkansas, for the past two years. that, the family home was in Sallisaw, Oklahoma. Prior to Mr. C is a union carpenter, and the mother, Mrs . f, works in a furniture factory and operates a cafe and bar in the factory district. B has been working in another furniture factory which burned and is being rebuilt, with reopening expected in the spring of 1968 . Mrs. f's first two children were by her first husband who was killed in Oklahoma City while resisting arrest. boy, then 5, and a girl, 3. The children were a Aft e r a year she married Mr . f, by whom 55 sre had a boy, then], then another girl. This marriage ended in divorce following ]'s hosp ita lization and surgery at age 5 1/2 becruse Mr. f was unsympathe t ic and unwilling to assume responsibility foc B's medical car e. Mrs. f worked co nt i nuously from that time on ani refers to herself as " a working mother." S~ial She also received Security for the two oldest c hildren . The oldest boy is now in the state prison at McAlester serving a ZO year term for robbery. He also served time at the state re- fO'.'matory at Granite, after having been sent to the boys' training sc1ool at Helena at the age of 16. h~ During his prison sentences, he attempted suicid e and is from time to time kept in the psychi- a tic ward. Mother sometimes thinks of him as mentally ill and also baieves that he has delib era t e ly chosen a criminal career in which he is hopelessly enmeshed . l~uries She writes to him and provides such as are permitted but has no expectation that he will ever be rehabilitated. The older half-sister married first at 13 . Mrs. C did not seek tohave the marriage annull ed be caus e she thought the girl might get ino worse trouble if separated fr om h er husband . Mrs. f's marriage, tothe second Mr. f, broke up over his having given the girl permiss i in to marry and forge his name to the request for a marriage li.ense. After having two children the girl obtained a divorce but tw• lawsuits~ were required to wres t custody of the children from th husband's family. She i s at present married to a somewhat older ma. who mother consid ers a good husband . He had custody of his two chldren, a 10 year old and a d eformed, r e tarded infant, at the time 56 of the marriage. The girl was devoted to this baby and cared for it co ns cientiously until it died. B's bro ther has lived most of his life with his paternal grandmother. He is now a senior in high school and plans to go to col- lege next year . He is a steady , ambitious youngster who chooses his friends carefully and who never has bee n in trouble. The younger sist er was given up for adoption as an infant . Mrs . C seems to have mad e this arrangement he rself and has kept in touch with the child and her adoptive paren ts, although she says she has tried not to interfere in any way . reared to be religious. Mrs. f says the child has been Mrs. ..Q' s reason for giving up this child is the fact that she knew B would need lots of medical care and at tention and that she did no t feel s he c ould provide for both girls under the circumstances. Mrs . .Q says that no one on e i t her side of the family has ever had a condition similar to ]'s . The family was not too concerned about the fact that her clitoris was e nlarged and looked like a little penis when she was born . They c onside red her a girl and tried to dress and treat her as a g ir l, although she preferred boys clothes and activitie s from the time she could express preferences . There were continual struggles over c lothing until mother realized she could not win and thus let] go he r own way . Whenever Mrs. f dressed her in feminine clothing, ] would wait for Mrs. f to turn her back then c hange into somet hi ng of her brother's and be off to play with the littl boys . She i nsisted on having a boy's haircut and when she got old er would pu t oil on her hair to make it look like boy's hair . 57 By age 5, the clitoris was enlarged to a size that required attention and mother took her to a pediatrician in Ft. Smith, Arkansas, who in turn referred her to a "kidney specialist." B was hospitalized at Sparks Hospital for a month during which time studies were made . ] was then operated on and kept in the hospital for another month . Mrs. £was with B as often as she was allowed and felt bewildered and frightened by the seriousness of the problem which had not seemed serious before. She thought that ] would die--if not im- mediately, then in the not too distant future. ] "suffered terribly" following surgery and mother was unable to understand the explanations that were given her about the condition. She thought the child had cancer and that it would run a fatal course. The explana- tion she gave to B and to family and friends was that B had a tumor pressing against her kidney and, for this reason, had needed surgery. Cortisone dosage was started after B was referred to Children's Memorial Hospital, Oklahoma City, following discharge from Sparks Hospital where her medical condition has been followed ever since. There have been breaks in treatment and difficulties over obtaining medication and keeping appointments, sometimes due to ]'s rebellion or indifference. ] enjoyed school, made lots of friends and was good at sports. She continued to dress as a boy and got boy's haircuts until she was 11 years old when she suddenly became interested in looking like a girl. B made friends, both male and female, but her best friends during latency were boys with whom she had boy-to-boy relationships. 58 Mrs. C believes that during this period B thought of herself as a boy. Mrs. f does not consider] hard to control or feel that] presented any serious behavioral problems until the last two years. After~ began dating at around 12, she followed mother's instructions about getting home on time and letting mother know where she was. She continued to get along well in school and was popular with her classmates. She was a star on the girl's baseball team and received good grades. At age 14, B married a serviceman who was due to go overseas. Mrs. C does not think she was in love with the boy and believes she was more interested in the allotment check than in him. In keeping with Mrs. f's theory about the futility of opposing early marriage, she paid for ]'s surgery--needed to permit intercourse--and otherwise facilitated the marriage . ] quit school but continued to live at home after her husband went overseas. Two years ago ] became involved with another boy while still married and lost interest in everyone else. This boy dominated her, took her money, her car and ran around with other girls. 'mistreated in every wayu "she worshipped him." Though This boy later illed a man and was sent to a mental hospital for six months instead Jf a penal institution. B no longer cared for her husband and when he came home from Jverseas, still in love with her, they were divorced. The affair vith the other boy went on in spite of mother's threats and pleading. {e would take B's pay check or allotment check, when she was getting 59 these, with her permission. Mother confronted the boy several times, hit him and offered to fight him. She told him and others that she would kill him if he married B. Whether due to her threats or not, he married someone else two months ago and ] has not seen him since, as far as Mrs. C knows. Mrs. £, however, still believes that B loves him. Another boy--"from a nice family"--was interested in ] and came to visit her while she was in the Oklahoma Medical Center. doubted whether] cared about him. Mrs. C However, ] married this boy during the summer of 1968 . ] stopped taking her medication after her last visit to Children's Memorial Hospital . Because, through some mix-up, the prescrip- tion did not state refill, the druggist refused to give her another supply. Ordinarily she takes it if she has the medication on hand. Mother can tell when ] is not taking the medicine because the facial hair becomes noticeable and her voice seems deeper. Regardless of whether she takes the medication, she dresses like other girls, goes to the beauty shop once a week, and rolls her hair at night. She and Mrs. C's husband do not get along and mother has decided they are jealous over who is getting the most of mother's attention. ] has expressed her resentment of Mr. £by stealing things of his such as a watch and a ring and pawning them. She had a habit of taking what she wanted without asking permission but had never carried it this far before . Mrs. £believes that] either will not marry again or will not stay married because she wants to live with mother . B has moved out briefly but always comes back . Mrs. C says 60 that if she had to choose between her husband and ], she could easily give up the husband . (She has left two husbands previously in con- flicts over the children . ) B has no interest in housework and does not help out at home, but is a good worker on jobs, gets along well with employers and fellow workers. Mrs. f thinks that] is self-centered, but knows how to take care of hers e lf and will never get into serious difficulties. Impression. Mrs . f ' s self-image is of a self-sufficient, hard working, sacrificing mother, who has had some bad luck but has managed rather well in spite of it. Four of her five children have turned out well (not in trouble with the law) and she is capable of earning a good living and of meeting the crises that come along. Mrs. f enjoys factory work; the cafe-and-bar operation is a sideline that she also likes. Mrs. f is very devoted to Bas a defective child whose life has been and may still be in danger . At times she implies that she thinks of ] as a retarded child and at other times she appears to regard her as extremely competent and admirable. She expressed no criticism of B's past behavior , except when she allowed herself to be victimized by the boy friend. Second case report General. Mrs. f accompanied her daughter to the Medical Center on this date as L was to become an in-patient. a reliable informant and good historian . rapport was easily established . Mrs. f appears to be She was very verbal and 1 was not present at the interview 61 as she was in the process of be i ng admitted. Mrs. £ is an obese, 34-year-old woman who was poor ly groomed with an unpleasant body odor about her. Family. .1, the 15 -year-o ld pat ient, is the second of eight children both to Mr . and Mrs . £ who are 40 years and 34 years of age respectively. The pregnancy , labor, delivery, and neonatal period of L were not remarkabl e; however , at birth the patient was noted to have an enlarged clitor is. Deve lopment seemed normal to Mrs . £up to the age of four when accelerated growth of the clitoris occurred along with increased mas c ularity and pubic hair in male distribution . Two children, both with b irt h defects, died in 1966 . Both Mr. and Mrs. C come from the lowe r c lass economically and socially, and Mrs . £ related that her husband had been reared in eastern Oklahoma under very deprived conditions. Mr . f's fa ther had been a gambler. He did not provide the nece ssities for his family who, because of financial depravity, were f orc ed to live in a dugout . sleeping on a dirt floor most of his childhood . Mr. C remembers He completed the 8th grade but has very few marke tabl e skill s. Mrs . £was born and reared i n Arkansas . grade in school . She finished the 9th She related that she had met her husband in a cot- ton patch when he had come to Arkansas to pick cotton and a year later married him. Most of their married life has been spent in eastern Oklahoma, but there have been short periods of time when they went to California for employment purposes . Mr. £ has always had a marginal income. At the present time he is working as a labo r er on a c onstruc tion job earning $1 . 75 per hour. 62 There have been many periods o f time when Mr. C has been unemployed or partially employed be c ause of bad weather or unemployed altogether. During the periods of par t i al employment or total unemploy- ment, they subsist on unemp loyme nt benefits or the decreased weekly income, plus surplus food commodities . family lived in a one r oom house. Until three years ago the About this time the paternal grandparents gave this fami ly one acre of land adjoining their own home on which Mr. f built his family a larger home . 24' x 24', and divided into two rooms. This house is It is not modern and they carry water from the pat e rnal grandpare nts' home. They have elec- tricity for T. V. and lighting, butane gas for cooking, but have no indoor bathroom facil itie s . One room provides cooking and eating space, while the larger room provides sleeping quarters for the entire family of eight per sons . Mrs. C related that there are four double beds plus a large baby bed . She seemed quite defensive in describing the house and remarked that there seemed to be no privacy. However, she attempts to give privacy to individual members of her family. In discussing the family habits, recreation--things about which Mrs. C was quite verbal- -it be c ame quite evident that she gave these things much thought. She mentioned that they all enjoyed T.V. but that she tries to keep her children from looking at things which are not good for them, such as "dirty movies . " She mentioned the fact that she tries to encourage them to look at the newscasts and scientific and educational programs . This family l i ves 10 mi les from Sallisaw, Oklahoma, where all 63 school age children attend school . The bus which transports the children stops right in front of the house. 1, who will soon be 16 years of age, will be in the 10th grade next year, as well as her brother R, who is now 17 . the past two years. 1 has been on the state honor roll during Her grades, according to her mother, are all A's and B's and science is her bes t subject. L reads both rapidly and profusely. voice and is in the school c hoir . Mrs. £mentioned that L is said to have a good singing Mrs . £ also encourages L in art because she feels L is very capable in this area. When participation in c ornrnunity affairs was discussed Mrs. C said that she thought of her family as being "anti-social" in that they did not mix with the people in the cornrnunity. She added that she supposed they were "clannish" as they only visited relatives. Mrs. C felt that she would not be at ease with persons in the community who were of a higher socio-economic class than herself . She thus avoids interaction with other women in the community because of her deprivation in these areas. The family does not attend church; however, she did mention that one of Mr. C's uncles was a preacher and that groups of the faith did mee t in relatives' homes where her husband, who plays the guitar, would often lead the singing. Mrs. C also said that many times her husband would play the guitar and the entire family would join in and sing. Neither Mrs. C nor her husband have visited the school where her children attend but feel that their children like school a great deal and have aspirations to complete their high school education. We discussed the fac t that L reads profusely and explored the 64 type of literature that is available in the home. scribes to the Readers Digest. The family sub- All of the family members who are able to read enjoy reading this periodic al . Also, books are often checked out of the school library with science being the favorite subject of all members of the family. One recreation ment io ned by Mrs. C was that occasionally the whole family would go fishing together. In fact, she said that all members of the family enjoy hunting and fishing. provides a part of the family food. with whom she went places. This activity also It was asked if L had friends The answer was negative; however, she said that L did write to a girl friend in Sallisaw during the summer. Mrs. C stated that as a family they do not often go into town. The 17 -year-o ld son has friends from Sallisaw who come out each Friday night. The group will often fish and sleep out all night. Neither of the teenagers have ever dated. The 17-year-old boy has stated that he hoped to wait much later for marriage and rearing a family, as he wants to be able to provide more for his family than his own parents have been able to do for them. We discussed b's feelings toward her bisexuality. Mrs. f and L have discussed what they should tell friends, the school, and the family when she comes to the Medica l Center as follows : "I have a disease of the adrenalin gland, and it is not catching . " No one has ever questioned the family further. Mrs . C believes the 17-year-old brother may know something about the abnormality of his sister because he has stated to his mother that it's most important that L get her medicine or she might develop masculine tendencies. Mrs . C 65 said that they had not shared the medical information with any family members of Mr. C's family but that one of her sisters who lives in Arkansas is aware of the fact that .£, who died in 1966, was b isex ual. Mrs. c feels that L is accepted as a full female. Her friends suspect nothing and the family accepts her as a perfectly normal girl. We explored Mrs . .£ 1 s f ee lings about her children, three of the eight having been born with abnormalities . had a heart defect. were bisexual. Mrs . .£'s third child, ]., 1 , the second c hild and the sixth child, .£, Both]. and f died in 1966 . Mrs. C said she could best explain her feelings by trying to relate to me an article which she had written to the Readers Digest this year, explaining what it meant to be the mothe r of three childre n who were defective . Mrs . C said that she had enough faith in her God to believe that there was a reason why she was chosen to be the mother of three defective children and that she hoped to proceed in such a way that the ones who remained living could develop to their best potential. She expressed great appreciation for the medical profession and the help that the doctors have given to her and her children. Mrs . C con- tinued by saying that of the three defective children she felt it was more difficult to accept B's cardiac problem than it had been, to this point, to accept the two girls who had the problem of bisexuality. Mrs . .£ felt this was true because B was more verbal about his defect and thus it was brought out in the open more. She remembers how he pray ed for a new body and had hoped that the open heart surgery would give him the opportunity to be active like other children. 66 When we discussed the fact that she, at 34 years of age, had had eight children, we asked her feelings toward the use of family planning. She admitted that she had practiced some form of birth control since her first pregnancy but had not been successful in preventing pregnancy . Mrs. £ has been advised and had the services of the medical profession in the use of contraceptives. L seemingly has accepted the diagnosis and treatment of her abnormality. She is just now becoming concerned about what the future holds for her . Last year she talked with her mother and asked whether or not she would be able to have children. Her mother advised her that she probably would not be able to bear children, but that it was always possible to adopt children. Mrs. C added that they have always treat ed her bisexuality as an illness stressing that it is necessary to always follow the doctors orders. For this reason, the medication is always taken without question . 1, as mentioned above, has always been accepted by her family as a girl. She has been taught to keep house and cook . She enjoys taking care of the baby and the female role is always stressed as the one she will be carrying out. Impression. 1, at 15 years, is the second of six living chil- dren living with their parents in a two room house in eastern Oklahoma. The father is a marginal wage earner and, at times, is un- employed; therefore, the family subsists on very little cash income. The father does supplement surplus commodities by hunting and fishing. Their house is not mod ern and bathing and shampooing of hair is carried out in the nearby stream during the warm months of the 67 year. The family participates in no community affairs and their relationships are exclusive ly with the paterna l relatives who live nearby. Cu lturally , the childre n are quite deprived but the child (Mrs. f is proud of her children and encourages their fe e lings of adequacy.) The personal relation- rearing practices seem to be good . ships and emotional climate in the home s eem to be warm and positive . The children attend school in Sallisaw which is 10 miles away. They are transported by bus . L is said to make good grades in school--mostly A's--and to participate in school activities during the school hours . However , the children do not participate in extra-curricular affairs at school and 1 has no girl friends with whom she associates . This patient's abnormality-- considered as an illness by family and friends--is explained as an adrenalin gland deficiency for which she must take medication . The true diagnosis has not been shared with family or friends in the community nor is the school aware of it. Other than the parents, only a maternal aunt, living out of the state, knows the true diagnosis . L has begun to question and wonder about future life, marriage , child bearing, etc. She is treated by all members of the family group as a complete female person . Mrs. C encourages her children and tries to help them develop aspirations to finish high school. There seems to be unexpected strength in this mother to guide her children and to help them accept their economic deprivation without striking out against society or developing feelings of hopelessne ss which is sometimes prevalent in the poverty groups . 68 L is being encouraged to learn homemaking skills as well as aptitudes such as sing ing and drawing. She is on the state honor role and is encouraged to do we ll in school. Even though they are economically deprived , the mother has stressed to her children that reading good books would be be nef i cial for them. This family seemed motivated to carry out the medic al recommendations required of them . Third case report Mr. and Mrs , Q were friendly and eager to cooperate in General . this study . Mrs . Q is a pretty , rather vivacious, outgoing person who thinks and speaks much mo re rapidly than her husband . He is somewhat stiff and shy but determined and methodical in the discussion of his daught e r and he r medical problem . Family . Mr. Q is a l i nema n for a public utility company and Mrs . U is a housewife . There are three children: .:!, the oldest, 15 years, and two brothers, 12 and 11 years of age . .:! is the responsi- ble, serious child in the family, who can be depended upon to keep her head and use good judgment , whereas the boys are more adventurous and impulsive. Mr. U always re fers to .:! as a "young lady" and cor- rected me once when I (the s ocia l worker) made a reference to her as their youngster. He s eems to have especia lly impressed his behavioral expectations upon.:!· Mrs , Q appea rs more relaxed but worries that.:! may be too mature for her age , The whole family was very ups e t last December when the older boy was accidentally shot in t he thigh by the maternal grandmother. An artery was s evered and he ne arly died , whether the leg would have t o b ampu tat ed . A question arose as to He recovered without a 69 disability but the whole family still feels the shock of this event. Mrs. Q felt that I was ca lm and helpful throughout the entire event . She even attended school but was so concerned about her brother that she might as well have stayed at home that week . The family has lived in Muskogee since April, 1967, and were in the process of moving (due to a job transfer of Mr . Q) when I was first hospitalized here . They had lived in Pawhuska previously. I (social worker) was not able to get an agreed upon time when Mr. and Mrs. Q first felt that something was wrong with I· They discussed the subject with eac h other in my presence but could not settle on a definite time when their first suspicions of I's anomaly occurred . Mrs . Q remembered asking their family doctor in Pawhuska about I's deepening voice around the age of 12, but he said girls' voices change in similar fashion to boys' voices and told them not to worry. She had noticed bulges in the groin area but the parents disagreed in the interview as to whether they thought these were hernias . In April of 1967, I had a sore throat . Mrs. U took her to another doctor in the absence of their regular one, and when this physician examined her, Mrs . Q expressed concern because J had not begun menstruation . really a boy." The doctor then said something like "She's Mrs. Q remembers feeling as if a bucket of cold water had been thrown over her, but her first reaction was that she must get I taken care of at once. Arrangements were made for her to come to the University Hospital in Oklahoma City the next day for studies. Readmissio n two months later was for surgery with I and 70 Dr. C working through th e decision of surgery , the date of readmission, etc. There is consider ab l e c onfusion pr ese nt in the parents' insistence that they and th e doctor have been perfectly frank with J, while at the same time they say she was told she had a hysterectomy with the removal of he r uterus . It is the understanding of the parents that the test es were removed, the clitoris made smaller, hernias not related to the mixed sexua lity were repaired, and that it was found that she had no uterus. Close relatives have been told that she had to have a hy st erec tomy because she was producing too much male hormone . Mr. Q says that like all yo ung ladies l have children. ex pected to marry and Recently l has r emarked that if they can transplant hearts maybe by the time she is old enough to have children they will know how to transplant a uterus. If not, she felt she could always adopt children . Mrs. Uhas remembered lately that l had two severe electrical shocks at age 10 and 11 , After the first one the doctor said the shock might upset her hormone ba l ance later on. J was not overly femi nine in her play activities as a young c hi ld , but on the other hand she did not have exclusively boy-type interests either. l played with dolls and enjoyed owning them but did not spend a lot of t ime wi th them. She had girl friends in elementary school but also e njoyed playing with her brothers and the boys in the neighbo r hood . l has always take n her s c hoolwork ser iously and is an above 71 average student. enter into She was never a joiner and had to be encouraged to ~xtracurricular activities at school . J has taken clarinet lessons and has played in t he band since junior h i gh school . She and two other students placed first in a trio in the state band contest last year. J' s music teacher has urged her to go out for choir because she has a good c ont r alto voice but she prefers playing the clarinet. 1 has many friends, but few c los e one s. Mrs. Q says she is careful about making c lose friends, but is nice to everyone because she does not want to hu rt anyone ' s feelings . She has shown no interest in boys and s eems to take teasing about "getting a boy friend" without becoming upset. J is her mat e rnal grandparents' favorite grandchild and they always seem to want to buy her things. Last fall they took her to a dress store expecting her to sele c t four or five outfits for school . 1 found only one that she l iked and said she preferred the dresses she makes for herself . and is a good cook. She sews beautifully, according to mother, She does not like cleaning house but , as mother states, few teenage gir ls do. J is interested in mec ha nics and has received two strong electrical shocks from playing with electrical equipment. also change a flat tire as well as any boy her age. She can 1 plays base- ball and enjoys going to football games but does not like the car races which the rest of the family attend. Her plan of becoming a vet eri narian goes back to the first grade, and has be e n a c onsist e nt amb i tion. Her favorite school 72 activity is th e Latin Club and she won a trip to Lansing, Michigan this c oming August t o a na t iona l meeting of the Junior Classical League . Impressions . Although parents have at tempted to treat J' s physical problem ma tter-of-fact l y and to be open in their dis cus sio n with her, they have many unreso lved fee lings and some confusio n as to facts . Although I (the social worker) have not seen J, I ass ume that she has been a n over l y cons ricted chi ld and at this age ha s made little progr ess in ado l es cent sexual i dentity . The di fferences in the parents' attitude s , suc h as father's rigidity in interfering with the working out of a heteros ex ual adjustment, could easily add to J's psychic problems. Fourth case r eport General . Mr. and Mrs . f state tha t their greatest over-all problem has be e n lack of knowledge or poor communication on th e part of many of the doctors they have gone to, the r e sulting treatment errors that have occurred, their own confusion, and th e unnecessary s t resses they feel they have had to bear with little he lp . Mr. and Mrs . I are highly motivat ed for participation in the study because they want information about c hildren with these problems mad e widely available to the medical profession a nd other parents . The primary problem has be e n the life and d e ath balance of the cortisone dosage and salt replacement for th e two children. The condition of sexual ambiguity did no t become known to them until P:..'s birth , and has not been a problem in the i r minds so far as R is concerned. Both Mr . and Mrs . I r e ported that there has been no family 73 history of similar endocrine problems. Family . Mr . K has worked for t he Pittsburgh Plate Glass Company since before £ was born , beg inning in Cheyenne, Wyoming. transferred to Denver, Colorado, when£ was 3. Mr. K was The family lived there five years, then returned to Cheye nne until a year ago when they were transferred to Ok l ahoma Ci ty. Mr . K feels that the job is financially rewarding but r e ports many pressures that ar e wearing and anxiety producing . Mrs . K is the manager of the household and the day-to-day l ives of the children. Mr. I says she does this very competently , which relieves him of worry about the family during his work day. are five children --1 16 , Q 12, £ 10, A 7, and B 3 . There The two older children and the baby are unaffec t ed by the glandular defect. 1 is described as be ing thoughtful and consid era te of the younger children. Q is a star athlete who consistently brings home trophies and is popular with his age group. He is, however, a self- centered aggressive boy who cares little for the feelings of others. In particular, he tends to ignore the other children in the family or to feud with them when they oppose him. because she "tattles" on h i m. Currently he dislikes A The parents are conc e rned about Q and Mrs. F wonders whether his behavior is related to the attention he missed out on from her at a crucia l age because of £ 1 s overwhelming needs. ] is the spoiled, adored baby of the family. Th e children vie for his favor and fight ove r who he will sleep with . Re cently Mr . K said "there should be more ] ' s to go around." £ lost weight dramat ically in the newborn nursery and the 74 pediatrician could not diagnos e the difficulty. Intravenous feeding was used but by 11 days he was de hydrated and at the point of death. The pediatricia n (t he only one in town) first said he had an enlarged heart, then lat er denied he had said this. Mr . and Mrs , f decided to take R to the Children's Hospital in Denve r. He was tra nsported by ambulance and given oxygen and intravenous fluids en route . The pediatrician told them£ was going to die and that seeking additional medical care was useless. He did have convul sions for two days but with cortisone injections and massive salt replac ement B: began to rally. He remained in the hospital for 30 days during which time he had cortisone implants as well as the injections. After th ey went home there continued to be differences of medical opinion with the pediatrician taking him off of medications or changing the do sage so that there were repeated crises and trips back to Denver . There were financia l strains as well- -t he cortisone at times cost $200 a month and father, as a trainee for the company, was earning $290 a month . B: had difficulty in adj usting to his formula because of the amount of salt which had to be added . As R progressed to table foods the addition of salt was easier. His sense of taste for salt is weak and he not only cr aves salt but can tolerate adding salt to food until it is white from th e salt. For years B: has eaten potato chips and other salty food, as other children e at sweets. His parents refer to B: as a sic kly child. His poor start and the continued drain on his strength from the chemical imbalances , as well as the cortison . itse lf, made h im susceptible to infections 75 and it was hard for him to recov er f rom ordinary illnesses. He was quiet and good, rather timid and had a sweet disposition . As R has grown older he has deve loped a happy-go-luc ky manner with a jovial , witty bent. He is well-be haved , gene rous and helpful at home . He does, however, feel his physic al infe riority , short energy span , and inability to play at th e sports his old e r brother stars in . His occasional wistful remarks ove r physical disability ar e one of the hardest emotional impac ts for Mr . !'.,to handle . His response to suc h expressions is to point out £'s good qualities that are better than athletic prowess. Because li had no anatomical anomalies in sex organs, the sexual aspe ct of the problem is minimized by the parents, although they do not know what to exp e ct in adolescence nor whether he will be sterile. In th e ad j ustme nt of medication dosages the re has been the danger of prematur e maturi t y but this has been avoid ed so far. R's final diagnosis mad e at th e University of Oklahoma Medical Center was that of salt - losing c ongenital adrenal hyperplasia . li and A are pals, having bee n drawn close because of shared treatments, trips to do c to r s and hospitals, precautions they have to take, and their rol e s as "sickly" children. When li was three and mother eight months pregnant with A, the family moved to Denver. Mr. and Mrs. Even though the pregnancy was normal, both K were afraid the new baby might have the same problem as R but were unprepared for the sexual ambiguity. They were told the child was a girl and mothe r had already sent out the birth announcements when the y we r e advis ed that tests had to be run to 76 determine the sex. Mrs . f's first reaction was fear of the effect of this announcement on the child later in life, if the sex were found to be male . Their anxiety during the three days that were required for the several tests was acute and is vividly remembered. Because of the knowledge of the doctors they had in Denver and their previous experience with ,S:, the replacement therapy was immediately started. A did not have the nutrition and fluid balance problems of R and so got a better start. On the other hand she had sex organ anomalies and has required a testosterone suppressant that had to be adjusted as well as the cortisone and salt adjustments. A has never required as much salt as ,S:, although she uses and craves salt high above the normal. Mr. and Mrs . I are aware that she is brighter than B: and accept th e fact that B: is below average in intelligence. better than B: in school, achieving very good grades. A does Her general health has been somewhat better than his although she has lower resistance than the ordinary child. Because of the fact that these two children have frequently been dependent on each other for playmates and their play has been dominated by ,S:, their toy and game interests have been primarily that of boys. Although Mrs. I was a tomboy, she frets over A's lack of interest in dolls and father says she pushes too hard in this regard. A likes paper dolls, perfume, makeup, and feminine clothes. Mrs. I is convinced that A is female in her orientation, but wishes she would like to dress and play the mother role with dolls . Mr. F feels that his wife ove rstresses A' s femininity and tries to push 77 her into making girl-type choices. They were advised in De nver to wa it until A was at l e as t six years old before having corrective su rg ery. Now they und e rs tand that the surgery could and shou l d have been done at or be for e age Their introduction to med ic al c ar e in Oklahoma City was trau- two . matic in that the first fo ur docto r s they took A to immediately said that she was a boy and that a grea t mistake had been made in rearing her as a girl. This arous ed all their ear lier anxiety and doubts. Part of the reason for this opinion was that the pharmacist i n Denver from whom they we r e gett ing the c hildren's prescriptions had made an error. A was getting only half the dosage she needed of the testos- terone suppressant and he r c l itoris had e nlarged till it looked l ike a penis . Another concern even after the y found Dr . Mand Dr . § (with whom they are very pleas ed) was the effect of pelvic examinations and surgery on genitalia in a girl so young. Mrs. f has handled this by telling A that she has had such examinations, surgery, and stitches in co nnection with child birth and that mothers and older girls have these procedures from time to time . The intent has not been to minimize the discomfort and embarrassment but to align it with a feminine identification , with the exce ption that, in A's situation , it happened to her much younger. A has accepted this fairly well , although she questioned her mother when she repeated her statements to Dr . § in A's presence. The sexual ambiguity has been ke pt secret within the family as well as without . Only t he maternal grandmother knows there was any 78 questions over ~'s sex . The affec ted chi ldren have not been told no r have the siblings. One re s ult of this is that when qu e st ions and doubts about med ical care or errors in treatment occur they have only each other to talk to . Whe n they have confidence in their doctors and the communica t i on is good, th ey can talk to th e doctors but, even then, time is a f ac tor . Mrs. E is more prone to be come discouraged or depress ed and Mr, E keenly feels the strain of raising her spirits whil e keeping his own up. If Mr. E is having busines s troubles at the same time, he feels he cannot share them with mother so he carries a triple load . Both parents agree with this assessment. Mr . F talks about the beneficia l effec t on character from standing up to stress es suc h as they have had . He believes they are more mature and more self-confident becaus e they have withstood the crises and the strains and have done a reasonably good job . Mr . E also feels that thes e children were give n to both he and Mrs . E because they would take good care of th em and that this "was determi ned from above." They do not feel that their marriage has been either strengthened or weakened by the troubl e s they have encountered over the children. Mrs. Eis more matter of fact and emphasizes the normal ity of their family life in spite of t he problems of these two children . Mrs . E brought up the genetics i nvolved in producing the two children and discussed the statist ics and probabilities that face their descendants with an air of obj ec tiv i ty . They reiterated their belief that the only real problems t hey have had are due to lack of 79 knowledge or mistakes on th e part of some of the doctors they have e ncounter ed. Mr. I expresses mild ange r at what he considers the irresponsibility of the "medical industry" in not knowing more about such children and at indiv idual doctors fo r not keeping themselves better informed. Advice and guidance about what could be anticipated and the available alternative courses of action would have made a great difference in their lives. The y wish parents of such children could have an opportunity to talk with other parents or adult patients for the information and emo tional support this could provide . Impressions . Mr. and Mrs. [ t a lked easily and comfortably about the children and their tribulations. While there were some disagree- ments over facts such as names of particular doctors or the sequence of some events, their opinions were similar and they present ed a united front. It was felt by the social worker that the parents' use of denial was within reasonable limits and serves them well in the circumstances. Their presentation of normal, wholesome family life was convincing and there was humor and warmth in the descriptions and examples they gave . The sexual aspects of the children ' s medical problems was played down and their c oncern appeared indirectly through the rather fierce ident ifica tion of the father with the boy and the mother with the girl . Both are apprehensive about these children's adolescence in view of the fact that no one has helped them to anticipate developmental stages or prepared them for obstacles that might be encountered. They do not expect this kind of he lp to be forthcoming in the years 80 ahead and yet they feel that others know from experience what might be anticipated . Over-all, Mr. and Mrs. K resembled parents of chronically ill children who have an uncertain prognosis and recurring crises requiring tedious and/or dramat ic treatment, such as glomerfulonephritis or severe heart conditions. Fifth case report Case history #5 had to be taken by the investigator as both parents preferred not to be interviewed by a social worker because of negative past experiences with them. General. regularly . Mrs. £ 1 s primary concern is that R take her medicine Mrs. £unde rstands that the medication will be necessary indefinitely if ~ is to l i ve a normal life . Both parents seem to understand ~'s problems quite well, particularly father who is a medical doctor at the Un iversity of Oklahoma Medical Center. It was Dr. C who first explained ~'s medical condition to mother and by so doing alleviated many of her fears and doubts. she is very thankful to father for this. understands R's condit i on adequately. Mrs . £stated that Mrs . £feels that she now None of the other siblings in the family know the exact nature of ~·s condition; neither does~· The only awareness that the children have of ~·s condition is that she takes her medicine daily . Both Dr. and Mrs. £ feel that ~·s "growing up" will be as normal as that of other children and anticipate no difficulties either medica lly or psychologically. Family . Dr . and Mrs . £ have lived in Oklahoma City since Dr . C began his residency in radiology at the University of Oklahoma 81 Medical Center two years ago . Oklahoma. ~ They are originally from Tulsa, There are two sibl ings in the family besides R age 6-- age 11, and tl age 6. Neither B nor tl have R's condition. Mrs. C describes the three children as being very happy and normal. The children are their own best friends and play activities seem to be primarily with each other . In this regard, Mrs. £describes Ras a tomboy who not only likes to "hang" around her two brothers but has similar interests. Thus R seems to prefer masculine activities such as ball playing, tag, cowboy and Indians, etc. According to Mrs . £, R dislikes dolls, playing house and "what little girls like to do. " It is difficult for Mrs . £ to understand R's play preferences because she recalls that when she was R's age, she enjoyed such things as dolls, playing house, etc . R does not have many girl friends. When she does have girls over to the house to play, she does not like to play feminine-type games . Other activities that R enjoys are color- ing, looking through books and working puzzles. Dr. and Mrs. £ felt R did well scholastically in kindergarten but that the quality of her work decreased in first grade . They attributed this change to R ' s poor concentration, messiness of her written assignments, and the fact that she hurries through her daily work. R's parents described her handwriting as "terrible . " R is not a discipline problem in school, however, and seems to enjoy school, particularly reading . She prefers playing with boys and appears to get along with them better than with the girls. Mrs . £describes Ras being very helpful around the house. likes to help cook , set the table, help with the dishes, etc. She 82 Mrs. f feels that li is particularly fond of her father and enjoys playing and being with him. One concern that both Dr . and Mrs. C have about li is that she still wets her bed nightly and feels very bad about doing so . ~. however, does not have any probl ems during the day with wetting and has expressed many times to her parents the wish that she was able to end her nightly bed wetting. Dr. C added that £ goes to the bathroom quite frequently during the day, usually urinating small amounts each time. Her eating habits are good but she does not have a big appetite. £does not seem to care for sweets such as candy or soda pop. as pickles, cottage cheese, and milk . She prefers such things She does not crave salty foods as might be expected considering her condition. In discussing £'s condition, Dr. C did most of the talking and explaining. Father stated there were no complications during preg- nancy and that labor was induced . The bag of waters was ruptured and pro lapse of the umbilica 1 cord occurred. performed. Emergency "C" section was Both Mrs. f and th e infant did well . At birth, ~ had ambiguous external genitalia, notably a large phallus and labia scrotal fusion. signed. As ~ ·s sex was in doubt at birth, no sex was as- Instead, Dr . and Mrs . ~gave~ a temporary name and sex for her birth certificate which , at the time, happened to be male. They named£ after Dr. f before final sex was determined but referred to the infant as "baby" rather than by name. £ suffered dehydration at birth, was inunediately started on cortisone and has had no reaction since the beginning of medic ation. At the age of three, £ had a clitorectomy and a slitting of the lab ia scrotal fold. Her condition 83 at this time was diagnosed as salt losing adrenal hyperplas ia. Thi initial operat ion was not satisfac tory and six to eight mon ths later the tunneling was ad e qua t e ly comp leted at J ohns Hopkins . time R' s clitoris was f ully amputa ted . Dr. At t h i s Q also stated t hat at the present time li's bone age is s l ightly r e tarded for her c hronological age and that s he is physica lly small. Both Dr . and Mrs. C f ee l that the y have accept ed R's condition quite well most like ly bec ause fa th e r is a doctor, bec aus e medical management has gone along fairly smoo thly , and because R' s conditio n was diagnosed early . Both Dr . and Mrs . C feel that they won ' t explain li's full condition to her until she gets older, approximately 18 years. Impression. It was th e interviewer's impression that both parents were very much on gua r d , partic ula r ly father who had origi~ nally expressed a great deal of r esi stance to being interviewed by a social worker. The interview lac ked spontaneity and the only informa- tion seemingly offered was di rect answers to the interviewe r ' s questions . Mrs . f seemed the mo re sensi tive of the two parents and at various times during th e i nte rview t he interviewer felt that she was becoming upset by the d i s c ussion and wanted to cry. Dr . Q, on the other hand, seemed rath er cold , he sitant, and c ontrolled . During the interviews all of the children were request ed by the parents to remain outside and not to come int o the home until the interviews had terminated . The family s eemed v e ry c lose as a unit in which parents and childre n appear ed t o have a good relationship with each other as did th par ~ nts thems e lves. The parents s eemed devoted to 84 the children , but along with this devo t i on there seemed to be a strong feeling of secrecy surrounding ,!i' s c ondition . Sixth and s eventh c ase r eport Case r e port 6 a nd 7 is c omb i ned as both L and R ar e f r om the s ame family . General , Mrs . S is so co ncerned about L 1 s acting out behav ior at this point that all other probl ems a re of no importance. 1 wa s released from Girl ' s Town , Tec umsen, Oklahoma, the state training school for deli nquent g ir ls , fo r the second t i me on January 12 , 1968 . She quickly reverted to her previous be havior pattern, slipping away from home and staying with Q, a boy now 21 yea rs old, with whom she has been involved for the past t wo years . 1 has been gone from home for a week now , although Mrs . ~is c onvinced that she and Q s l i pped back into th e hous e on two occ asio ns and stole first some money, then some clothes, groceries, a radio ~nd mother's driver s licens e. The Midwest City pol ice have a pickup them. order but have not locat ed Mrs. S be lieve s the pol i c e are not try ing very hard. Family . L i s th e only one of Mrs . S's seven children with whom she has had any d i sc ip l inary problems . The rest of the siblings ar e all girls except the youngest, a fo ur-y ear - old boy . The three old - e st girls are out of th e home , mar ried, and have children . home are : 1 , 18 ; 1 , 17 ; and .J, 4.. In the £, who i s s ix years old, is living with the maternal grandmothe r nearby . The first five children were by Mrs. ~ ' s first husband who di ed when 1 was three years old . After e ight years, Mrs . S remarried and had the two younger children by the second husband. The marriage lasted f i ve years; the husband 85 became involved with another woman the last two years of this time. He married this other woma n aft e r the divorce from Mrs. S. Land ~' who have different fath e rs, are the members of this generation affected by sexual ambiguity . L has not menstruated but has no outward evidence of male organs . Her condition was not dis- covered until her first stay at Girl's Town. The institution ar- ranged for a work-up at Children ' s Memorial Hospital, Oklahoma City, where L later had corrective surgery and the initiation of a hormone regime. Mrs. S has no idea of the psychological effect of L's con- dition on L because communication between the two of them is nonexistent. The fact that ~ was affected with sexual ambiguity was discovered at age three, when Mrs . S noticed inguinal bulging while bathing her. After consulting with the maternal grandmother, who thought she had hernias, mother brought~ to Children's Hospital where the condition was diagnosed. R has been under supervision while at the hospital but has not been corrected as yet. R thinks she has hernias. Mrs. S is a little worried because R's swelling seems to be increasing rapidly at the present time . Mrs. S's older sister never menstruated and has had inguinal swelling and discomfort from this . She sought medical care for a number of years but the condition was not accurately diagnosed and treated surgically until she was 47 years old. During surgery she was found to have rudimentary female organs and enlarged testes. When Mrs. ~and her sister were growing up, the family assumed also that the inguinal bulge s were hernias. 86 Mrs. ~reports that her younger sister menstruated but was never able to become pregnant " The maternal grandmother ' s family had several aunts who never me nst r uated and it is now thought that they had mixed sexuality . Mrs. ~grew up in the Oklahoma City area . After her first mar- riage to a construction worker, whose jobs required moving from one location to another, they moved to Ar izona where they stayed 15 years. Father and his brother lived on the locations while mother stayed at the family home in Globe after the children started school. Fourteen years ago , father and h is brother died from carbon mo noxide poisoning in the camper they were l ivi ng in. Mrs. ~brought the five c h i ldren bac k to Oklahoma City in ord er to be near her mother and older siste r and went to work as a waitre ss to supplement the Social Se curity payments she received for the children. She describes working long hours but arranged the hours so she could be with her children before and after school . Mrs. S's mother helped in looking after the children when the need arose and so did the older girls who took responsibility for the younger c hildren . Mrs . ~drove herself to make as much money as she co uld so that people would not feel sorry for "the poor widow woman's children" and also so they c ould dress as well as the other children at school. After eight years, Mrs . ~married another construction worker. They lived in Sand Springs for 3 1/2 years then moved to Arkansas for a year and a half . It was in Arkansas where this husband " t ook up" with another woman , the wife of t he coup le who were their best 87 friends. Mother eventually obtained a divorce then returned to Oklahoma City . The children seemed to a ppr ov e of the remarri ag e and we re o n good terms with t he second husband . The marr i ag e meant that mothe r could be at home with them and they were muc h be tter off financia lly, They sided with moth er over the divorce, howeve r , and had no adve rse reaction , that mother is aware of, over the loss of the stepfather . Since that time mother has worked as a cook in one of the restaurants in Midwest City, either on the night shift or the early morning shift . She r eceive s $7 5 a month child support for th e two younger children and Socia l Secur ity on the others at home. Mrs . ~·s right l e g is a mass of ul ce rs from septicemia she had two months ago. Her fee t swell bad ly from standing in her work as cook, but she does not comp la in about her physical condition . From the time 1 was a todd l er s he was diff e rent f rom the other children. She was stubborn and defiant and was never particu larly interested in school. L was "good" about helping with housework and was quiet and reasonable as lo ng as she was dir ec tly under supervision. When she was 15 she became u nc ontrollabl e, was truant fro m school, and seemed to make a game ou t of s lipp ing away when mother thought she had her und er surveil l a nce . 1 was allowed to come back to the aunt ' s home in Midwest City from Arkansas in an effort to find a place where she would be happie r . She began going with Q (t he only boy she has been involved wi t h) and, when all efforts to c ontrol her I running away or truancy failed, she was sent to Girl's Town. She was there for a year , then give n tria l l e ave and was hospitalized at 88 Chi ldren's Hospital for two mo n ths. After six months she returned to t he aunt's home where the s ame behavior, that of writing bogus c he cks , recommenced. She t he n re tu r ned t o Tec umseh in July, 1967 , for another six months . I· 1 °s pic ked up now she will undoubt edly be returned to Girl ' s Town again . Mo th e r c a nnot understand why 1 refuses all efforts of he l p a nd why s he be have s in a way that is s u re to get her i nto de t e nt ion . Mr s. S blames the boy and h is mothe r for e nc ourag ing L's ac t ing ou t, bu t thinks L is aware of what she is doing to herself. When 1 l eft last t ime , she d id not take her hormone pills with her. 1 is suppos ed to t ake th e e 22 days out of the month and be- comes highly nervous whe n she do e s not take them. Mrs . ~had littl e to say ab out R except that she is no problem and is doing all righ t i n kinde rgarten . She is living at the g r and- mother's house, ostens i bly, bec ause she is in school only a half day . She presumably is also c ompa ny for th e grandmother and helps l i ghte n Mother is wi th l during the day and the 18-year- the load on mother. old daughter looks aft e r h i m at night . Impressions. Mrs . ~ working class mother. has the resiliency and the fatalism of the She has endured many stresses and misfortunes, without se lf-p ity or loss of s e l f-respect . She is tied to her mother and older sister, who provide e mot ional support a s well as material he lp when need ed. She also feels the same responsibility toward them. The familial cond it ion of mixed sexual ity is a fact to be ac c ept ed and is not of major i mportanc e. Her girls ~ gir ls and 89 she is not particularly curious o r a nx ious about the effec t the condition may have on th em. She is i mpres s ed by th e progre ss i n medic al knowledge that make s it poss ib l e to di ag no s e and tr e at suc h anomalies. The family ' s us e o f the t e rm "morphodit e" is uns e l f- con- scious, but li is being allowed to be l ieve s he has hern i as that w i ll ~ in time, be corrected surg ic ally, As Mrs. SM, the gra ndmother of bot h b and li, has had v e r y c l ose contact with both childr en, a bri e f re port of her feelings i s inc luded . R is described as bri gh t a nd a liv e wi re who nevertheless mind s well, because that is the way Mrs . SM br i ngs up childre n . times is noisy and get s on he r R some- stepgrandfather ' s nerves, but both the old people enjoy he r and enjoy he r company . Mrs . SM is a littl e c onc erned because c hildren do not l e arn anything in kind e rgarten s o she is teaching li the alpha be t a nd c ounting and other "book work" which li learns quickly and wi th p l e asure . Mrs. SM feels tha t R i s j ust like any othe r girl and is psyc ho logic ally unaffected by he r c ond i tion . She is pleased that do c t or s now know how to take c a re of these c onditions and is confident t hat li will be "fixed up" and have no resulting problems. Mrs. SM is fond of La nd min i mi zes her ac ting out behavior, although she says she was always hard to manage. She blames L' s mother for some of the diffic ulti e s, saying she would have let her marry Q when she fi r st want ed to since nothing else was going to satisfy her. She has a poor op i nion of Q because he will not work and told 1 that she s hould be pre pared to support him . L i s a good 90 worker and Mrs . SM envi sions 1 having to e arn the money to keep both of them going . Since the las t social work h i story o n 1 was c ompleted befo re he r return t o Girl's Town on J u l y 15, 196 7, the investigator f ee ls i t appropriate to inc lud e a brief post soci al summary by Mrs . Ame lia Ries, social worker at Gir l 0 s Town : After her return to Gi r l ' s Town , Ju ly 15, 1967 , it was felt that 1 mad e progress although sh e co ntinued to be i mmature , dependent and demanding . However, she seemed to have develop ed a capacity for self-evaluation and some insight i nto he r fee lings. mother, Mrs. ~. Sinc e the began to t ake mo re interest in Land to attempt to provide understand ing and affec t i on , i t was decided to place 1 on trial leave with her moth er o n January 12, 1968. It was suggest ed that c onsider ation be give n to the possibility of mar riage wit h her boy friend of many years, Q, as he seemed to provide 1 with steady support and satisfied her depende nc y needs . During her stay at Girl 1 s Town, 1 rep ortedly had very few prob l ems associated with acce pta nce and und er standing of he r inherited malfo r mation . She was very re sponsible in taking her hormone med ic a- tion . After she r e turned to her mother' s home on January 12, 1968 , the F i e ld Youth Counselor attempt ed to c ontact both b and her mother, but re ceived no answe r to her mes sage s . On J anuary 23, 1968, b ' s sister , ~. called to r e port t hat 1 had l e ft with Q, after stealing $2 5 . 00 from her mot he r . A t emp t s to loc at e L were futil e and she remained AWOL until la te in Marc h . At t his time she was picked up 91 for shoplifting in ElCerrito, California, and placed in Juvenile Hall where she was descr i bed as "uncooperative." On April 8, 1968 , she was flown to Oklahoma Ci ty and returned to Girl's Town . L was interviewed on Apr i l 4 , 1968, the day she was admitted to Girl's Town . She gave information that she ran away from home on January 17, 1968, and reac hed Richmond, California, on January 20, 1968, by bus. ~. She went to th e home of her boy friend's mother, Mrs . in Richmond. Her boy fr iend, Q, age 21, came to Richmond and L reported that they were married January 27, 1968, in San Rafael, California, on San Pablo Street, by a Justice of the Peace. However, she said they could not find a record later and the Justice of the Peace must have been a "phony." to him by a friend of D's . She stated that they were referred At any rate, they went to San Francisco and lived together as man and wife , until 1 was caught shoplifting . She has stated that she does not know why she took a pair of men's pants from the store. L was very angry that it was necessary for her to return to Girl's Town and said that she had spent a week in the Juvenile Hall at Martines, California , prior to being sent back to Oklahoma . She cried as she talked about leaving Q and said he had never been in any kind of troubl e and was an accomplished carpenter and brick layer. He had a paper route in Oklahoma City and had allowed a friend to work it for him while he was in California. stay in California he worked in a filling station. During his L said that she would be 18 years of age in November and that her only plans were to go to D when she r e ached that ag e . 92 She complained bitt e rly about her mother and blamed her mother for everything that had happened co her and said that her mother had told her four times she would sign the pap e rs for her to marry D but when the time came she had refused . She said her mother never came to see her when she was in Girl ' s Town before and that she herself did not want to see her now. After L was given trial leave she enrolled in the tenth grade at Choctaw High Sc hool but never attended. She never liked school and could never make pass ing grades in ac ademic work and for that reason she asked to be placed in the la undry schedule all day during her stay here. Although b. was at first very resentful about her return to Girl's Town, her attitud e has progressively improved. She is responsible about doing her work in the Social Service Department and is cheerful and pleasant to be around most of the time. It has been observed that b's behav io r during her stay at Girl's Town has been markedly different from her behavior "on the outside." She is r es ponsible while institutionalized and then demonstrates marked irresponsibility in the community . L is a child who has very strong urunet dependency needs and when she receives emotional support as she does at Girl's Town, her behavior becomes much more mature. The person who has been able to give her the greatest support outside the Institution is her boy friend , Q. Although in some ways he is not a desirable compan i on for her, she is unable to tolerate any critica l discussion of him and reacts aggressively. Another out- standing characteristic of b's is her marked need for physical 93 contact with others . She likes to clasp hands or otherwise touch persons who ar e talk i ng to her . With r e f e r e nce to b's pres e nt adjustment toward her genetic problem, she seems to be increasingly aware of the fact that it wi ll deprive her o f motherhood. She has stated that "I would give my right arm if I could have c hildren." She recognizes that she might be able to adopt a child but stat e s that this would not be the same. b's goal for the future is to marry D as soon as she is releas ed from Girl ' s Town. She i s not at all interested in continuing her education but readily accepts the idea that she may need to be selfsupporting at some t i me in the future. She would like to do laundry work and has had some experience in "do-it-yourself" laundries . L will be 18 on November 24, 1968 , and at this time will ga in the legal status of an adult . We do not know at the pres e nt time whether 1 will be considered ready for release before that time . However, 1 is hoping that she may be able to leave Girl 's Town by t he end of the summer and has dis cussed this idea repeatedly in ind ivi.dua 1 and group the rapy s e ssion s . Therapy Interviews Case 1-- 18-ye ar-old female Rapport with subjec t . of the interview sessions. ~wa s very cooperative throughout most She was pleasant and able to converse easily with the investigator , The only time during their sessions together that B seemed ill at eas e and reluctant to talk was when the inve stigator initially asked her to explain her medical condition . 94 Interests. ]. d id not s eem to have a great variety of interests. She stated that she was not i n t e r ested in c ultural ac tivitie s such as reading , c lass ic al mus ic or educatio nal pursuits, but preferred ath l e tic activ ity such as bas ke tball , softba ll , and fi s hing. ]. als o sta t ed an int ere st in d r iving around in her car, " hanging around " her mother's c afe, play ing t he pinball mac hine , going out on occ asio n wi th " her marri ed man ," dancing, watc h ing te l ev ision (particularly wester ns and d e te ctiv e s t o r ie s ) , and just talking to either her mothe r or girl fri ends. However, t he r e was no indication that]. had any hobbies. Dislikes. ]. told t he investigator that "the one real thing that I dislike is when people make fun of me and don ' t treat me right. It hurts me on th e in side but I try not to let anyone know . " Descript ion of s e l f a nd other fami ly members. ]. said, " Well, I a m about 5 f ee t l 1/2 inches tall, weigh about 113 pounds, have dark brown hair, brown eyes, a dark c omplexion , fair personality but I have a deep voice and a hot temper. I am also pretty much of a l one r, like to drink oc ca sionally , dance , go to the movies, and just rai s e hell." The only person in her family that B talked about wa s he r mother , to whom she is very c lose. She feels her mother really c ares about her and und erstands her. But]. di s likes her st epfather a great d e al and wishes he was not part of the family . Earliest memory. B sat and thought for a moment and then said, " My e arliest memory was when I was around five years old . I was in the hospital and had an operation t o remov e a tumor on my kidneys . 1 had it mad e then. I got all kind s of t h i ngs while in the hosp it al : 95 funnybooks, toy yellow duck , and a piggy bank cat. I remember also when I got out of the hospita l my parents gave me a big sow which I later sold for fifty do llars and each one of her litter for ten dollars apiece." Dreams. ]. stated, "Occasionally I dream of snakes corning at me but I am for tu nate enoug h to avoid being bitten by them. I am sca red of snakes and even a big picture of one can scar e me . " ! could not think of any other dreams that she had had but just emphasized the recurrent nature of her dream about snakes. She stated that "Not only am I scared of snakes, but black cats also . If one crosses my path I will turn around and go the other way." Three wishes. When the investigator asked B if she could have any three wishes come true, what they would be? Her wishes wer e to have her voice changed, to marry~ . and to have a car of her own . B said, "If I had an unlimit ed sum of money I would first help out my mother by giving her whatever she wants. our bills and buy myself a new car. I would then pay of f all I next would put some money in the bank, quit work and th e n go on a vacation to the Riviera . I would also give a lot of money to the children in the poor areas around home. Finally I would buy my nephew, who is my pride and joy, anything he wants." Animal . To the investigator's question as to what kind of animal she would like to be i f she had her choice, ]. replied, "I would like to be a hors e because it's pretty. However, I wouldn't want to be a dog because they get kicked around too much." Typ ic al day . "My day goe s something like this . I get up and 96 have to be at work at 7 : 30 a.m . at W's furniture factory. sander and filler, and fin is h work at 4 : 15 . and go into town to my mother ' s c afe. I am a I then go home, clean up I usually spend about an hour or two at the cafe talk i ng to her and playing the pinball machine for money. I then go home to watch television and go to bed." Social life . ] stated that she had been married for about a yea r but that the relationship ended in a divorce. She felt that she really never loved her first husband but married him more for "convenience and obligat i on than for anything else." was married she was seeing another man. Even when B She still continues to see .Ra t the present time although he is now married. Since B's divorce she has not dat ed muc h except to see this one man whom she states, "I have always loved . " She does not think she will get married again unless it is to _B, the married man. loner. She describes herself as a "I usually don't run around with no one but stick pretty much to myself . Religion. oc c asion . It ' s a lone ly life. " B stat ed that she is a Baptist and goes to church on "I believe in the s ec ond coming of Christ when the world will become a better place t o l ive . religion seriously. Pe ople really don't take They shouldn ' t go to church unless they really believe i n God and can live their be liefs ." Philosophy of life . "Some of life isn't worth it. I read in the Bible that there will be another world better than this which will come after this . This world will have no sorrow but just hap- piness all day long " The world now is not a happy place . too much killing, st aling, and running around. There is People should treat 97 e ach other like they would like to be treated and not use each other fo r s e lfish means . " Sc hool and future plans. ] quit school at the end of the ninth gr ade when she was of legal age and went to work at W's furniture fa c tory. She stated that she never liked school and was not plan- ning to go back and finish. B f e els that her future does not look v ery bright as she has been seeing a married man and "might get shot if caught." She expressed very tender feelings toward this man, stating that he cares for her but uses and mistreats her. Secondly, B felt that she would probably be working at W's furniture factory for "a long time to come . " She stated the desire to have a family, consisting of one boy and one girL "I would like for my boy to be good in school and get a good educ ation and my girl to finish high s chool and go on to beauty or business college. marry somebody who will treat her right. I also want her to I would expect my husband to be home every night and not running around and drinking. should be able to pay the bills and to love me." He Finally,] stated he r desire to live out in the country because of her dislike for c ity life. Subject's explanation of medical condition. Initially B seemed uncomfortabl e in talking about her medical condition but in later sessions seemed l ess defensive and better able to communicate her feelings about it. "I've got a c ondition where unless I take my medicine regularly I don't feel well . produce the right hormones. The pills help my glands to In this regard, the medicine has helped me look more girlish and stopped a lot of hair growth that I had 98 be fore. I also have periods when I'm taking my medicine which I did not previously have." The investigator then asked~ if she were the doctor, and the investigator were the patient, what advice would she give concerning the condition . ~ replied, "I would tell you that it ' s no big thing and that everybody in the world has something wrong with them one way or another. I would tell you to be yourself and if anybody would ask you about why you were different tell them it isn't any of their business. I would also advise you to go to a voice trainer to see if you could get your voice to be higher. Finally I would tell you not to tell many people about your condition because they will talk and if the wrong people find out they can make life awful for you." B then went on to tell the investigator about he r intercourse activity saying that "before I had the opera t i on I couldn't have intercourse satisfactorily but after the operation I could . I got married shortly after the operation but the mar- ri age only lasted about one year and then I got divorced. After my ope ration, intercourse felt very good and I could experience a c l i rnax . " In what way would you like to be different?. B felt that she would not like to be different in any way except that she would like he r voice to be higher. B feels that her parents would also like to have her voice changed "so it could sound more girlish and less deep sounding . " B told the investigator that "It was about when I was 7 or 8 years old that I first noticed that something was different about my voice. Impression . It was deeper than the rest of the kids." ~ seemed to be concerned and very self-conscious about her sexual identity and acceptance as a female. She stated 99 more than once how various people had made fun of her by calling her name s , In this r e gard Ji stated, "I daydream a great deal about going to another city and making it big and then coming back to this town and showing the rest of t he kids up. th i nk t hey are much better tha n me. They look down on me and I try to show most people that my condition doesn't really bother me but deep down inside it really hurts." Ji seemed quite masculine to the investigator in appearance, bodily physique , dress, voic e and gesture. The difficulty in pro- jecting her female sexual identity seemed also to be hindered by her mas c ul ine interests and ac tivities. ]i's general outlook on life tended toward pessimism in wh ich she felt a need at times to over defend against an unfriendly and hostile outside world. Case 2- - 15-year-old femal e Rapport with subjec t , The investigator found 1 to be intelli- ge nt but anxious and difficult to establish rapport with, as she s eemed defensive in our meeting together. L seemed to feel that a large part of her uncomfortableness in our interactions was due to her- pr evious mistrust of doctors, whom she blamed for the death of he r younger brother and sister . "The doctors said that they would both be all right but they died." After 1 told the investigator about her feelings in this regard, she cried , excused herself from the room for a brief period of time, and returned later, apparently feeling better. L told the inve stigator that she also felt mor e at e ase if she could communicate with others through writing rather than a face to fac e c onversation . The stress that 1 felt about our meetings together was exempli fied from a paragraph in a letter she 100 wrote to me : "I don't se e any way that the tests could be made e asie r , exce pt to get them over with fast . under fire . I guess I ' m like a guy I can stand a small barrage, but when the heavy artil- l ery comes up, I crack . It 9 s an awful way to be, but I can ' t help it. 11 Interests . L stated, "I gue s s I have quite a f ew interests. F irst of al l , I am interested in doing well in school, particularly i n my two favorite subjects- - alge bra and science. I also enjoy singing in the chorus at school, the only extracurricular activity I have time for." 1 also ex pressed an interest in reading. "I read suc h magazines regularly as Saturday Evening Post, Life, Look, and Reader's Digest, and have also read such books as Tom Sawyer and Huckleberry Finn. I would have to say that adventure stories are my favorite to read." L then went on to tell the investigator how she e njoys camping out and hiking. As she was describing these activi- ti e s to the investigator, it was one of the few times that she smiled during our conversation together . L stated, "We have a mountain near our house and I like t o climb to the top of it. It is not only good exerci se but beautiful once you get to the top. I also like being alone a great deal because then I can think privately without having to e ntertain anybody or be entertained. When I am alone, I think about all sorts of things such as school, friends of mine and my family, etc." During one of these periods of thought, L sent me a l et ter in which the following reflects her sensitivity to nature : "It is truly beautiful here, now , for spring has just brought a promis e of new life. There are tiny, tiny , tiny, dark-purple flowers all 101 ov e r the grass, called forge -me-not s. There are big yellow ones , lit l e light purple ones, and med ium sized white ones that look jus t like miniature lillies of the valley. The grass is just coming up through last year 1 s old stubbl e, and the t r ees have brand new green l e aves, just big enough to see. I'd send you some pressed one s , bu t it 0 s really not fair to them, for you simply c annot imagine how l ove ly they are unless you see them." L a lso expressed how she enjoy s knitting and sewing . lot of my own c lothes and am pretty good at it." 11 1 make a 1. does not spend muc h time watching tel evis ion as she has numerous household chores to do daily. "But when I do watc h television I will watch almost anything except we sterns . I hate westerns." The investigator felt that 1 seemed most comfortable and spontaneous in discussing her interes ts rather than any other aspect about herself. In a l etter to the investigator 1 enclosed a poem that she had writte n entit l ed "Spring Light." This is a creative work that emphasized to the investigator .1's sensitivity to the wo r ld about her . Spring Light The water flowing by my s i d e reflects the sun above, And the crocuses playing in the grass sang a song of love . And so when the night is c losing down and everything is still, I s tand and watch the starlight outside my windowsill. The moonlight sparkles on the dew that's spread across the grass And reflects back the beam of light struck on a piece of glass. That's when I th ink of times long gone and things that I have done And how I played whe n I was a chi ld in the rays of the setting sun. 102 Dislikes. L stated that one of he r primary dislikes was the intrus i on of her privacy . "I l ike to be alone and it both e rs me when peopl.e inte r fe r e a nd d is tu rb me . 11 A s eco nd dislike was th e med ica l pro fes sion · n general "bec ause the doctors did not tell us t he truth and my brother and s i ste r died . " And finally j 11 1 don' t like people ask ing me abo u t my medic al condition becaus e the r e i s nothi ng really wr ong. l i ke eve rybody else . 11 I am jus t One f e ar tha t s eemed to the i nve st igato r to be c onstantly with 1, was th e f~ ar that due to he r med ic al situat i on , she would die like her brothe r and sis t e r. De s c ription of s e l f and o t he r family members. di ff ic ulty in descr i b i ng he rs e lf. L seemed to have At first she said, 11 1 don't know," t he n thought for about f ive minut e s and replied, "I am a f i fteen-y e aro l d g i rl who is short , ra th e r he avy a nd has long auburn hair. polit e, usu a lly happy, outgoing , and reliable. t icul ar l y algebra and s c ienc e . am like school, par- I also enjoy reading, hiking, camping out , sewing , kn i tting , and s i nging . me , " I I That's about it for describing He r reluctance to talk ab ou t he r family seemed to hav e be en prima r i l y due to the pain she s till felt about the death of her bro th e r and sister . Earliest memory . 1 thought for a moment and then said, "The f irs t th i ng that I can r ememb e r was the first paint set my Dad bought me when we lived in our first house on Brooklyn Street in California . I mus t have been three or four years old at the time." 1 could not remembe r a ny thing mor e about this memory but that it was a happy time in her l ife.. 103 1 stated, "I don't dream much," and she seemed very Dreams. re l uc ta nt to dis c uss this topic with the investigator . When the inve stigator express ed this f ee ling to 1, she said, "They are pr i vate and I don't wan t to talk about them . " Later L stated that she dreamed a great deal about her sister who had died but refused to dis c uss it. Three wishes . give n thre e? When asked what her wishes would be, were she L replied that he r f irst wish was "that me and all of my family could be in r e ally good health." Her second wish was "that eve ryone could be be tt e r pe ople, " and her third "that I could eat frui t, " 1 stated that i f she could have an unlimited sum of money to use, she would first travel and sight-see in Canada. Secondly, s he would us e a great part of he r wealth to help charitable organizat i ons because "it could be used to help people instead of lying a round i n a useless fashion." 1 emphasized "that money that lays a r ou nd and is not used for others is useless." Animal . To the i nve stigator's question as to what kind of ani- ma l s he would like to be if she had her choice she replied, "I would never want to be an animal bec ause animals don't think clearly but just follow their instinct . I think it's stupid to want to be an an i ma l . " Typical day. 1 described her typical day this way: "I usually get up early in the morning about 5:00 or 5:30 a . m., help with some morning chores, and then get r e ady for school . School is fifteen miles away and it take s the bus 1 1/2 hours to get there with all t he stops i t has to ma ke. Sc hool begins at 8 : 30 and is out at 3:00. 104 I usually come home right after school and help around the hous e ti ll dinner . Aft er dinner I study, sometimes watch a little television, and then go to bed around 10 : 00 . " Social life. 1 states, "I have no boy frie nds I gues s excep t for£, who is tall, dumb, and neve r knows what to say . We don' t date because he i s more of a fri end. and l ive s too far away . He has neve r been ove r to my house and most of our talking is done a t school ." Religion. L stated that she is a Fr ee- Will Baptist and goes to c hurc h "whenever pos sib l e. I be l ieve in God and feel that all people are be tte r off when they also be l ieve in God . Going to c hurch g ives me a good feeling but I c an ' t descri be it to you. Philosophy of l ife . I just feel b etter. " 1 s t ated, "The only purpos e any per s on has in l ife is to see how muc h he or she can help other people." In this regard 1 felt tha t her futur e career of nursing would fulfill this purpose in her li fe. School and future plans . b is a good student and seems to work hard to ma i ntain her high grades . She states that her two fav orite sc hool subjects were algeb ra and science. However, 1 express ed that she has to work hard in algebra c l ass to keep her grades up to a B l eve l . She wants to grad uate from high school, go on to c olle ge , and then attend nursing train ing at the Oklahoma Medical Center. 1 sta t ed, "I would like to become a nurse because they have the opportunity to help everybody, and i t seems like it would be fun . " It seemed unusual tha t in L's dis c us s ion of her future plans there was no me n tio n of a mal e figur e . In t his regard she stated, " I never 105 rea lly thought about it." Subj ect's ex planatio n of medical co ndition . .!: stat ed, 11 I have salt losing, adrenal hyperplas i a , which means my adrenal glands don 1 t function correc tly . Thus I hav e t o take cortis one regularly or I will get sick, vomit ofte n , and los e my appetite. However, i f I take my med icine r egul arly I can l ive pre tty muc h o f a normal life. The only adv ice that I would give someone with my condition i s to ta ke their medicine regularly . " In what way would you like to be different? . L felt that "the only way I 1 d like to be different would be to achieve all my goals in life and also that I co uld sing fairly well." L felt that her parents would probably answer this question concerning hers e l f in the fo llowing manner. " They would both want me to be fre e of this ailment and also to be a hard er worker around the house." .!: con- sid ers her family a clos e unit wher e communication is "good" between members and responsibility is taken by all. Impr ession. L's defensivene ss during our meetings mad e it dif- ficu lt to acquire more information about he r. There wer e ve ry few times in our meetings together when 1 seemed relaxed and spontaneous . She seemed to have a great deal of anxiety and hostility with in her s e lf c onc er ning her condit i on and he r feelings about the medic al professi on in general. The i nvest iga t or felt, however, that L was a very sensitive person, not on ly to other people but to the world about her. Life has bee n hard economically and emotionally for L and her family- -eve n so, she ex pre ss es the strong desire to complet e he r educational and profe ssional goals . 106 Case 3-- 15-year-old female Rapport with subject , The investiga tor found it easy to estab- lish rapport with 1 as she seemed comfortable and relaxed in our mee tings together . She was ple asant and able to converse easily with the investigator. In our initial sessions together, the i n- vestigator seemed more the initiator of the conversation . In late r sessions, however, the revers e bec ame apparent as l became more ou tgoing and spontaneous. Interests . l stated that her main interest is science . en joys it and likes th e s c ience c ourses offered in school . She l espe- c ially liked biology and seemed eager for the opportunity to take c hemistry and physics in the following school years. She enjoys reading a great deal, espec ially mysteries and science fiction stories, but stated that she " hates" love stories . When the investi- gator inquired as to why she said, "those types of stories are boring and just not exciting." J did not elaborate, instead mentioned her enjoyment of music, especially symphonies. She dislikes "rock and roll" and opera, but expressed positive feelings toward athletics, suc h as watching football and playing baseball--she did not like basketball because "I never played it." l stated that her primary hobbies are music and sewing. She showed the investigator a jump suit she had made and commented that when she had been a 4-H member she had placed eighth in the state of Oklahoma in a sewing contest. l feels that most of her leisure time is spent around the house either helping her mother or playing wit h her brothers . She stated 107 that she did not enjoy going window sh opping in town. "I guess I partic ularly like to stay at home and read, watch television, and listen to records . " l s e ems to particularly enjoy watching science fic tion and spy adventur e s on television. Some of her favorite pro- grams are Man From Uncle , Mi ssion Impossible, Star Trek, and Mannix. ln this regard l said , " If I wa s going to marry, I would like my husband to be like Mannix bec ause ' he is sharp, mysterious, and one neve r knows what he is going to do . u" Dislikes. "I really don ' t have many dislikes," she said, " but some that I do have are car racing, boys, city living , long car trips, vegetables, ruffles and frills on my clothes, lipstick , makeup, high heels, carrying a purse , bullies, people who dislike an i mals, and skeptica l people . " Description of s e lf and other fami ly members . difficulty in describing herself. At first she said, "I don't know how to," then sat and looked out in space. d i fficult to do." .:I seemed to have "Oh ! I can't, that's too After thinking about the question for a while .:I f i nally said, "I am a fifteen-year-old girl, who is fairly tall and thin , I am about a C+ or B student in scho ol and like music, out- d oor sports and animals." .:I seemed to find describing herse lf dif- f ic ult, and seemed uneasy in trying to do so . .:I's description of her fami l y members began by focusing on her mother, after which she described her father and two brothers. "Mothe r is a woman with a lot of common sense who is able to keep h r he ad at a ll time s . mo re so than Fath r . She d oesn't get emotional much but still Fathe r al s o has a lot of common sense. He 108 sometimes says things differently than I do but we mean the same thi ng . " .J felt th a t both parents were extremely unselfish and giving to all of the children. In describing her brothers .J sa id, "They both l ike cars, baseball, and model buildings. doesn't. 1 likes girls but D Q is more of a loner, while 1 enjoys a ' crowd ."' .J i s c los e to both of her brothers but feels especially clos e to 1· "When I play with 1 we usually play such things as chess o r checkers. However, when I play with Q we either watch television toge th er or play football. 1 often joins us when we play football. 11 .J seems to fe e l that both of her brothers are good natured but, on occasion, she gets into fights with them. This fighting usually occurs over the selection of a television program. l stated, "If T starts to fight with me I can just hold him down and that usua lly ends it, but when Q gets angry he is more of a battler, that's because he is older and stronger." Earliest memory. .J seemed to have a lot of difficulty remember - ing her early childhood. She felt that her earliest memory was when she was around four years of age . At that time .J remembered being at he r Uncle H's house along with seven or eight other children, all lined up waiting for a turn to ride on Uncle W's horse . J could not remember anything mor e about the incident but that it was a happy time in her life. Dreams , l stated that she did not dream a great deal but when she did it was usually of car toon characters such as Porky Pig and Mic key Mouse. She felt that the most frightening dream she had was of Franke nst ei n in wh ic h a witch had the power to create human beings 109 through using parts of other people's bodies. In the dream the witch wanted .:I's toes but, as she states, "I hid them under my blanket so she could not take th em. " :I went on to state that even today she "fee l s safer" with he r t oes covered up when she is in bed at nigh t. Three wishes. When the investigator asked J if she could have any three wishes come true, what would they be? 1 replied that he r f irst wish was to be a ve terinarian and her second, to live in a mansion with a large den and fireplace . Her third wish was to be a n exc ellent clarinet player. 1 said, "If I could tr ave 1 anywhere I wished, I guess I would first like to go on a safari in Africa. That is because I like ani- mals, and would enjoy seeing them in their natural habitat. I would take along my camera to take many pictures, but would only use a gun if needed for self protection. and finally Spain. Next I would go to Alaska, then Italy I think I would prefer to travel alone, then I could be my own boss and do whatever I wanted without having to worry about other peop le 's plans . " 1 said, "If I had an unlimited sum of money I would first do s omething for my mother and father such as pay off the house, buy them a new car, and then send them on a vacation to Hawaii . Second- ly , I would do something for my brothers such as paying for their tuition at Oklahoma Military Academy. And last I would use the money to enjoy life by buying myself a new car and by generally living it up." Animal. To the inv estigator's question as to what kind of ani- mal she would like to be i f she had her choice, :I replied, "If I 110 could be any animal in the world I would like to be a cat and belong t o a we althy family . mi nd of the ir own . That is be cause cats are mysterious and have a Th ey don ' t do everything that peopl e tell them t o do and, also, they ar e pr e tty animals . " l sa i d that he r typical day follows this sched ul e : Typ i cal day. " I ge t up at 5 : 30 a . m. and be gin to ge t ready for school. I usually don 't e at breakfast and leave th e house at 6 : 15 to catch the school bus . The bus ride is t e n mi les long and I arrive at school at 8 : 00 . My first class, Latin , begins at 8 : 20, Biology begins at 9: 40, Band a t 10 : 40, English to 12 : 15 and then lunch till 12 : 45. After lunc h, I have two other c lass e s, American History and Geometry, and then school is out at 3 : 25 p . m. I usually come home right after school a nd arr i ve at about 4 : 15 . At home I mostly goof off and watch tele - vision till dinner. After d i nne r I help with the dishes and then s tudy for a while . I then watc h tel evision till about 9 : 00 or 9: 30 and then go to bed." Social life. l state s that she has no boy friends and is not inte r e sted in dating even though many of her girl friends are . "O t her girls worry about dating and dieting, but not me," she said. Re ligion . quite r e gularly. l stated that she is a Methodist and goes to churc h She feels that history and the Bible "go hand in hand" as one is an integral part of the other. l also believes in heaven and hell and the supernatural, wherein events happen which sc ience cannot ex plain, suc h as spiritual life after death. Some relig i ons seem crazy to her because "I don't understand them; but th e n , they probably f e e l t hat way a bout mine." Howeve r, she f ee ls 111 that we must respect other people's beliefs even though they are d i f ferent from ours. Philosophy of life. J stated that her philosophy of life was to acquire a good education. everything. She felt that this was the key to She also said everybody should abide by the golden rule , that is live and let live. School and future plans. l wants to finish high school, hope- fully doing well academically, so that she can qualify to study l told the in- Veterinarian Medicine at Oklahoma State University. ve stigator that this training would take her eight years beyond high school with a great deal of science courses required . She stated that when she completed her degree for Veterinarian Medicine she would then like to go into private practice in a small town in Oklahoma . l then went on to describe the house that she would like to live in once her private practice got started. This house would be situated on the edge of a town extending over 20 acres. The house would be as large as a mansion with a den that would be J's favorite room. (She needed something, she explained, to represent her vast wealth and importance which she would like to attain.) In the den, as l describes it, there would be a huge fireplace, a big desk , lots of book shelves, and a picture of a sailing ship over the fireplace . The house would be furnished in Early American with big white columns in front of it. It seemed unusual that as l discussed her future plans, aspirations , and hopes there was no mention of a male figure. r e ga rd In this she stated tha t she would prefer not to be married and that 112 s he did not care for men very muc h. If she did get marr ied, which she fee ls unlike ly, th e man would have to be very handsome and ex tremely i ntelligen t . .§_ubject 1 s ex plana tion of medical c ondition . J stated , "I am not qu i te sure about all the detai ls but what I under stand is t hat I hav e a hormone i mbalance. In other words, I have too many male hor- mones instead of vice ve rsa. Because of this , I had to have the operation in the hospital so the c orre ction could be mad e . " The inve stigator then asked J if she we re the doctor, and th e investigator were the pat ie nt, what advice would she give concerning the c ondition. .:I replied, "I don ' t know," then thought for a moment and said, "We ll, maybe I would say something like this : be sure a nd take your medicine regularly and you will be able to live a no rma l life. Don' t let the condition bother you, it was just one of thos e unfortu nate things that couldn 1 t be he lped . Everything wil 1 be okay . " In what way would you like to be different ?. J felt th a t she would not like to be different in any way except to be more intelligent . .:I feels, howeve r, that her parents would like her to be more girlish by "wearing cloth es that have more bows and ruffles on them . 11 Impression . The investigator found J intelligent, sensitive, outgoing, and spontaneous . She seemed to be aware of her medical condition and of some of the resulting consequences. However , the investigator felt that J still has some strong reservations about bei ng with people in a social situation, partic ularly mal es of her own age group. At the present, .J' s interests and aspirations s eem to be rather mas c ul ine in nature ; however, this may be more of a c ultural phenomenon than a crisis in identity. 113 Case 4--seven-year-old female Rapport with subj ec t. The inves tigator found A intell i gent , frie ndly , and easy to establish rapport with. re laxed and she seemed comfortable. Our meetings were In the initial sessions to- gethe r, the investigator seemed more the i nitiator of the conversation and play activities. The reverse became apparent in later s es- sions, however, as A became more spontaneous and outgoing . Interests. A stated that she liked to do many things . "I like to go swimming, color, play Monopoly, go for a ride in the car with my father, ride my bike, play outside, jump rope, tag, hopscotch, play checkers, volleyball, dodgeball, play with my Easy Bake Oven and blender, help my mother in the kitchen, take care of my brother ~. and go to the stor e with my brother R." A then went on to t e 11 the investigator how proud she was over the chocolate chip cookies that she had baked and about her plan to make a vanilla pie in her Easy Bake Oven. Next, A told the investigator about some of the dis- likes she had: "I dislike doing the dishes, baby sitting for B when I have other things I would like to do, cleaning off the table after dinner, sweeping the floor, and cleaning up my room." Fears . A said, "I am sometimes afraid of the dark, especially after I see a scary program on television or hear a strange noise at night." Description of self and other family members. A replied, " I'm a seven-year-old girl who is in the second grade at 'S' school . I'm not cute. my brother." I am happy most of the time and like to play with];, 114 "My daddy and monuny are nice and I love them very much , My daddy can be so funny doing imitations when we take drive s i n the c ar. I like to help Monuny sometimes around the kitchen." Of all her brothers and sisters, A s eemed to be closest to her br other R. She not only expressed a lot of positive affection toward him , but stated that she enjoys playing and being with him . Her brothe r Q, A f e els, is difficult to get along with because they often argue and fight. "Q always wants his way . " A also seems to be close to]., the youngest member of the household. She seems to give him lots of at- tention and enjoys reading and playing with him. As A states, "I enjoy acting like Monuny and taking care of ].. " Earliest memory. A thought for a moment and replied, "I don't remember very much about it, but I remember the snow and cold in Wyoming where we used to live . We used to go sledding in the snow. I liked i t in Wyoming but I also like it here in Oklahoma." Dreams. in de pth . A spoke briefly about her dreams but did not elaborate "I have dreamed recently about Christmas and Santa Claus. I don ' t remember too much, but Santa Claus was putting my gifts und e r the tree. He brought me a blender and an Easy Bake Oven, just what I wished for." Three wishes. When the investigator asked A if she could have three wishes come true, what they would be? She replied that her first wish would be "to have a whole bunch of money so that I could buy a mansion to live in . " Her second wish was "to have some gold," and her third was "to have some diamonds." Animal . To the investigator's question as to what kind of 115 animal she would like to be if she had her choice, she replied, "One of Santa Claus' reindeer because it would be fun to ride around the whole world with Santa Claus." Typical day . A said that her typical day follows this s c hedule : "I get up early in the morning, go to the bathroom, wash, sometimes make my bed, eat breakfast, and go to school. home and play. dinner . After school I come I usually play with~ or some of my girlfriend s unt i l After dinner I like to watch television and then I go to bed, II Play activities. A's play activities throughout our sess io ns together were both creative and diverse. She played with such materials as crayons, clay, checkers, chess, playing cards, blocks a nd dolls. A particularly liked to draw . She drew a variety of pictures for the investigator : a scene at an amusement park, a por trait of the investigator, a picture of a rooster based on a story that A had been told in school, Santa Claus and his reindeer, and a modern art design. In early sessions with the investigator much of A's play activity was solitary in nature, but, as our contact increased, her act iv i ty centered around the two of us playing together . When A did engage in solitary play, a great amount of it was concentrated in the drawing area. She talked to the investigator as she drew, often describ- ing the picture that she was making. For example, when she was drawing a scene at the amusement park she told the investigator that "A giant roller coaster is taking you through the whole amusement park so you can see everything below : a lion, tigers, the circus and 116 a hot dog stand." picture. A then told the investigator a story about the "This man wanted to sell some hot dogs but no one would c ome around and buy any because the circus didn't have any good acts, so nobody came to s ee it . Then suddenly the circus got better and the man sold all of his hot dogs and made lots of mo ney. He be- c ame so happy that he threw all of h is money up into the air because he was a millionaire . " A' s activity with the investigator was varied. Some times we played checkers and chess and other times we were engaged in suc h activities as playing with bloc ks . playing checkers. A seemed to particularly enjoy The outcome of our games was always close with A winning occasionally . Her judgment and strategy seemed quite ma ture as s he rarely made the same mistake twice . her ability to play chess and c ards. This was also true in A card game that A was par- ticu larly good at was one in which all 52 cards were placed fac e down so the numbers were not visible. The person then selects two c ards, turning them over to see if the numbers match. If they do, they receive a point and remove the two cards from the r est of the deck. If not, they place them back down and the other person takes a turn. A's memory for card placement was considerably accurate, and v ery often she was victorious or finished a close second . As A and the investigator were involved in various play activit ies, A would often spontaneously tell the investigator about hers e lf . She would oft e n mention her past activities with both her girl and boy friends, her brother s, her parents , and how things were going for her i n school, her c atec h i sm class, the television programs she 117 lJked to watch , etc. Religion. A stated tha she was a Ca tholic and attends c hurch ar.d c atec hism c lass r e gularly . "My catechism c lass has 14 c hildren ir. it and a nun teac he s us," she said, "And we have a weekly reader , ar.d also co loring scenes from the Bib l e. I like catechism c lass and going to c hurc h." Philo ophy of life . "I think you should be nice to people and not try to be mean or hurt them. and be 1 ieve in God . 11 You should go to church regularly A then went on to te 11 the investigator how a 11 of the children in her second grad e class at school brought food in to give to the custodians for a Christmas present. A said, "That made me feel so good to see that our class had helped somebody." School and future plans. A attends second grade. l ike school a great deal and does we ll academically . She seems to A stated, "I par ticularly like art becaus e I like to draw and color . I also like reading and arithmetic bec ause they are fun and easy to do . " stated, however, that she dislikes singing. A "I don't like to sing and often forg et the songs that they teach us and I also don't like to wcite stories bec ause I am a bad speller." !::. told the investigator that when she grows up she would like to be a mother and a nurse . However, she did not state any particular reason why nursing appealed to her as a future occupation. Subject's explanation of medic al condition. her medical condition and knew nothing about it . A was not aware of All that she ex perienced was r gularly taking her medicine and on occasion going for a medic al c hec ku a t h . University Hospital . She knows that 118 she had an operation but does not know any of the details concerning it. Both parents feel that until A gets older, they will not dis - c uss her medical condition with her. In what way would you like to be different?. A thought for a moment and then replied, " To be able to jump rope higher and swim better. I would also like to be funnier so that I could make people l a ugh . " A also expressed that both of her parents would like for her to grow up and be more matur e, quit watching so much television, keep her room cleaner, and quit fighting with her brothers. Impressions. A seemed to be a very warm, spontaneous, and friendly seven-year-old girl whose interests and play activities seemed appropriate for her age. A great deal of A's play was in- v olved with th e use of higher cognitive processes which could be exemplified in such games as chess, checkers, and the various card games that we played together . A's ability in these particular act ivities seemed quite mature for a girl of seven years . On the one hand, A seemed to be the seven-year-old child she was, believing stil l in Santa Claus and fairy tales; but, on the other hand, an older and more mature girl whose cognitive abilities seemed to sur pas s her chronological age . Case 5--six-year-old female Rapport with subject . The investigator found ! to be a very warm, outgoing, and friendly six-year-old girl. She always seemed cheerful and eager to get involved in play activity and/or conversation. R was usually quite spontaneous in her actions and seemed to 119 look upon the investigator more as a friend than researcher. Intere sts . many things . £ told the inve stigator that she was interested in "I like to sew buttons on pajamas, read comic books , like to watch television, especially the cartoons, Space Ghost, Sup e rman , and all the westerns . I also like to play with dolls -- we ll, sometime s--help my mother cook , go to school, and play with my brothers , !:! and ]. " R the n went on to tell the investigator some of her dislikes, whi c h were "to go outside in bad weather, make my bed in the morning be fore I go to school and some times e at all of my food." ga tor asked whethe r there was any food she disliked. The investi- "Not really , " s he said, "but sometimes I can't finish my scrambled eggs and panc ak e s . " Fears . "Sometimes I am afraid of the dark," she said, like af ter watching a scary movie on t e levision. "I am also scared of monst e rs and giants and big animals like lions and tigers." Description of self and other family members. a gir l a nd I'm six years old . c ut e. £replied, "I'm I'm short, have dark hair and kind of I ' m happy most of the time. That's all." "My daddy and mommy ar e both nice and I love them. care of me and take me places . They take My brothers are also nice. I like to play with them, watch television with them, and go to school with t hem. " Earliest memory . par t y when I was six . pre se nts." "Let me see," B: said. "Oh! My last birthday It was lots of fun and I got many birthday R did not e laborate further but said that her earliest 120 memory was of a happy time in her life. Dreams. R thought for a mome nt and then replied, "I often dream of big monst ers who are c hasing me, trying to catch me to eat. I dreamed the other night about Christmas and of all the pr esents that I got. I saw Santa Claus and h i s reindeer." Three wishes. When the invest igator asked£ if she could have a ny three wishes come true, what would they be? £ repl ied tha t her fi rst wish would be to go to the State Fair for her birthday; her second, that she could be "grown up" and be a nurse; her third, that she looked like her mother when sh e grew up. Animal. R said, "I think I would like to be a dog because they are friendly, everyone likes them and they are fun to play with." Typical day. £ said that her typical day follows this sch edul e: "I get up in the morning, eat breakfast, make my bed and go to school . At school I learn how to read, write, and do arithmetic. co lor at school but don't like arithmetic or writing. I l i ke to After school, I come home and play with my brothers, eat dinner, watch television and go to bed . " Play activities. R's play throughout our sessions together was both creative and diverse. She played with such materials as clay, crayons, blocks, puppets, records, dolls, cars, checkers, and soldiers . li particularly liked to draw and drew a variety of pic- tures for the investigator such as a Halloween scene, a picture of "Mommy and Daddy," Santa Claus, her own house, a spiderman, and a picture of a boy that she found in the Jack and Jill magazine . I n ea rly sess i ons wi th th e investigator much of R's play 121 activity was solo in nature but as our contact increased with each other her activity centered around the two of us playing together " When R did engage in solitary play, a great amount of it was conc entrated in the drawing area. She talked to the investigator as she drew, often describing the pictures that she was making. In one, a Halloween scene, she told the investigator that the ghost in the picture was happy, that the skeleton was celebrating his birthday , and that the ghost and skeleton and lived in the same house . were good friends with each other "Every Halloween they both would leave their house and go outside to scare all of the children." 1's activity with the investigator was varied. Part of one session could be spent building a large house, or playing hide and seek. When R got tired of this activity she switched to coloring or playing with clay, ending the hour with a game of checkers or Parcheesi. She was very competitive in these games and enjoyed beating the investigator. In activities, such as cowboys and Indians or war games, 1 would designate herself as the "good guy." Battles would rage , victories would be few, but R would always win and the d spondent investigator would just have to lick his wounds or bemoan his loss. In our later sessions together, ~would often bring to the play- room a toy, record, or book that she wished to share with the investigator . Once she brought a Mr. Magoo coloring book and we spent half a session coloring together. She would occasionally ask the investigator to explain a game or to show her how to put a particular puzzle together. After this 122 s he would try it herself, usually completing the task successfully. R was quick to catch on and was e ager to learn new activitie s . Religion . ~'s parents be l ong to th e Baptist church whe r e R occasionally attends Sunday Sc ho o l . R said that she believ es in God, but did not elabora te any further about church activity or her pa rticular beliefs. Philosophy of life . ~ thought for a moment and sa i d, "To be a good gir 1 and nice to everyone." School and future plans . R attends first grade . She seems t o like school a great dea l and particularly enjoys such activ it ies as recess, playing with the blocks and toys, and looking through pic ture books . ~stated , however, that she dislikes getting up early and learning how to do arithmetic and writing. R told the investigator that wh e n she grows up s he would like to be a nurse and he lp sick pe ople. "I would also like to work in the same hospital as my father ." She also stated, "I guess I would get married and have chi ldr e n . " Subject's explanation of medical condition. R was not aware of he r medical condition and knew nothing about it. All that she experienced was regularly taking her medicine. "Mommy says that I must take my medicine regularly so I do . " Both parents feel that until B gets older they will not discuss her medical condition with her. In what one way would you like to be different?. ~'s reply to this question was, "I would like to be a nurse and grown up . " R' s interes t in nursing seems, in part, to be related to her father ' s 123 oc c upation as he is a medical doctor. In this regard B: stated, "I like to go with Daddy to the hospital. I want to work there some day with Daddy and be his nurse." B: expressed the feeling that bo th her pare nts would like he r "to be more grown up." Impressions. R seemed to be a very warm, spontaneous and friendly six-year-old girl whos e i nterests and play activities seemed age appropriate . .Q_ase 6-- 17 - year-old femal e Rapport with subject . L was anxious and difficult to establish rapport with as she seemed quite defensive in our meetings together. 1 seemed to feel that a large part of her uncomfortableness in our interactions was due to her previous mistrust and unresolved anger toward authority figures. Rapport between the investigator and sub- jec t increased with ensuing sessions together, but still did not approach a desired level of openness. Another contributing factor c ould be that L was first seen by the investigator while she was in att e ndance at Girls' Town. Interests. L stated that her favorite interest was dating Q and helping him with his paper route. "I also like to swim, play ping pong, tennis, volleyball and roller skating. I also like some of the classes up here at Girls' Town such as the ones where I make pillowcases and towels." 1 said she also liked being on the social service details in which she enjoys working in the laundry and/or d e liveri ng the mail . The investigator felt that L enjoyed being with D so much becaus e he is one of the few persons in her life that she trusted and felt comfortable with. Everyone else, L stated, 124 " never und er stood me and mistre ated me." L stated that sh e has no hobb ies and is not int e r e sted in muc h exce pt for her boy friend . Di slikes . As L d iscuss ed her dislikes the inve stiga to r fe l t s rang res e ntment and anger coming f r om her. "First o f a l 1 1 dis- l ike being lo c ked up in th i s pla ce up here (Gir ls ' Town). t oo many c ronie s up here." c ron ie s make me sic k . Cronie s is 1 ' s wo rd for l esbian . " These Lucky fo r them none of them hav e approached me ye t or I would hit them. hands . There are Rea lly a ll they do is kiss and hold I also don't like ge t ting up at 5 : 00 a . m. every morn i ng a nd Dur i ng our co nve rsation 1 would often cuss , part icu lar ly working. " as s he got mo re angry . L then wen t on to tell the investiga t or how muc h she d is liked he r fami ly , particularly her mother whom she r eferred to as a "no good b itc h." of t he kids there. weren' t . names . " I a lso d idn't like s c hool or most They thought they we re better than me bu t they I us ed to fight with th e girls a lot when they called me I showed them though . " _Desc ription o f self and other family members . s ~ lf 1 d escribed he r- as a big g ir l who was quick t empered and got into trouble easi l y. "I don 't take crap fr om anybody." This attitude s eemed to cover up a hurt, lone l y and depressed self . L did not feel that she was pretty or well liked by othe rs of her own age group . l one r and my only real fri e nd i s Q. de s cribed her mother as short , along wi th . c ha nged. "I am a He loves me and I love him." red headed, nice , and easy to get In lat e r interviews .k ' s attitude toward her mother " She do esn 1 t under s tand me, mistreats me and s e nt me up he r e to Girls' Town in the first place . She doesn ' t want me to <lat L 125 Q but just stay home and babysit while she goes out and gets drunk and bri ngs men home." L's mother has been married twice; her first husband died and her se cond got a divorce. "R is my 23-year-old married siste r and is big and fat . I do n ' t like her because she is snotty and always trying to butt in be tween me and D. She do e sn't l ike Q and keeps telling me to drop him. II "f, my half sister, is 21 years old and married. a ll right. We get al ong She keeps telling me that I am the black sheep in the family because I was here at Girls' Town, but when I went home I found out that she wasn't so good either. baby . She had an illegitimate This was before she got married." "~is my 19-year-old married sister . caus e s he is happy-go-lucky . I like her real well be - She doesn't care what peopl e think about her and accepts me better than anybody e lse . We are more than sisters-- like close friends." "My 18-year - old sister is not married. She doesn't like boys. I l ike her quite a bit and we are pretty close. She is real quiet a nd shy; however, when she gets mad she can really fight." "R is six years old and happy-go-lucky like A. I get along with her pretty well, and I am going to make sure that she doesn't end up he re at Girls' Town like me." "J is four years old and already knows how to cuss . He is okay but c an often be a pest . " Ea rliest memory. 12. arly memory. L had difficulty in trying to remember an She sat f or a wh ile looking down at her feet and 12 6 finall y said, "I can't r emembe r any thing happy . Once whe n I was young, abou t six years, I c an r emembe r my mothe r drunk , t hat 1 s al l." L c ou ld not elaborat e about th is par t icu lar memory o r a ny o t he r one, Dre ams . b stat ed : and i t wo rries me. "Mo s t of my dre ams s eem to be a bo u t e at h One dr e am that s eems to recur of t e n i s me and .h i s othe r gi r l fr om Gir ls ' Town a r e wa lking across a lo ng bridge and sudden l y we stopped i n th e mid dl e of the bridge and looked down a t t he wate r . At the bottom of the riv e r we saw Q, and he was d e ad. Eve r y time I have this dr e am it scares me ." d r eam that she oft e n has : L then related another "I hear Mama crying and the Girls ' Town Supe rint e nd e nt is t e lling her that her daughter is dead . I th e n could se e that everyone in the dormitory was covered up with a whi t e s he et as though they we r e a ll d e ad . " d r eam about her father . A third dream that b relat ed wa s a " Thes e ange ls came to me and said, ' Wou ld you like t o talk to Daddy ?' and I said 'Yes . ' ta l ked to me . He then c ame down a nd He came down out of th e clouds in a Navy uniform, hugged me and left . I c ried whe n he l e ft. I dream in color ve ry oit;:;n suc h as this dr e am was . " Thr ee wishe s. Whe n the inve stigator asked b if she c ould have any three wishe s c ome true what they would be? She replied that her fi s t wi sh was to be marr ie d to Q and live in California . L's s e c ond wish was to be we a l thy and to live in a beautiful home, and her t hird wish was to be "skinny and pretty." Ani mal . To the i nve stigator ' s que stion as to what kind of ani- a l L would like to be i f sh e had her choice, she replied "a big cat bec ause t hey're sly, strong, and pretty. " 127 Typical day . 1 replied "a typical day for me at Girls' Town is up at 5 : 00 a.m. every mor ni ng. As soon as I get up , I have to make my bed, th en shower, dust , swe ep , and mop up th e f l oors . Af t e r that we ( the girls) wait for th e be ll fo r bre akfast . Afte r break- ast, I sometimes go to gr oup ther apy or to s c hool . Lunc h is at noo n. Aft .r lunch I usually wor k i n the l aundry t i ll di nner. We (the girls) do n' t have much f ree t i me in t he evening and go to bed e arly , The rules up here are too strict. or have your boyfriend visi t you." Can' t smoke , wea r makeup There was a great deal of anger in b's voice as she described l ife at Girls ' Town . Socia l life. 1 stated her socia l life was entirely with Q, th e only boy s he has ever dated and the one she wants to marry . Most of thei r time is spent toge th e r alone as th e y have very few friends t hat they associate with . They usually do not go anywhere becaus e of their financia l means, but just either spend the time in Q's car or in _b's home, which is a trailer . Re l i gion . P~n _b's grandparents and mother belong to one of the ec ostal Church groups but 1 has not bee n attending church on a u.gular basis. 1 t old the investigator that she believes in God but other than that " I go to church when I feel like it." Philosophy of life . 1 tho ught for a moment and then replied, "I fee l t hat the key to life is happ i ness, and faith in God, yourself and ot her peop l e. Money isn't that important but you need it to eat and live,"- -a definite contrast to b' s life, up to this time . Muc h of b's condition se ems to st em from a poor home situation, l itt l e moti'i 'ltion for suc ces s and socio-ec onomic deprivation. 128 1 quit school at legal age, not com- School and future plans . p l eti ng the t e nth grade successfully. She told the inve stiga or t hat she never liked s c hool , was not interested in what it had to of f e r , and was not planni ng to re tu rn to finish her degre e. 1 doe s not know at the pre se n t t ime wha t k i nd of job she would like to s ecure i n the future and, furth e rmore, does not seem to c are , Sh e st a ted, "I can always work in a laundry or a drive-in hamburge r p lace, so I'm not worried . " Her future plans seem to revolve aro und marrying Q, her current boy fri e nd, and then moving to California to live and work . Q, a t the present time, has a paper route which is h i s only means of s e lf support. He also quit school at legal age and is hoping to marry L and then move to California. Explanation of her medical condition . 1 said, "I don't really know except that the doctors took out my female organs. I f I had to d o it again I wouldn't because I think I could have had kids if they hadn't operated on me. Now I will have to adopt kids." It is the inve s t igator's feeling from h is discussions with L that she knows l i. t t l ~ information about her medical condition and/or the c ons e - que nces surrounding proper and improper management of it. In what way would you like to be different? . "I would like to c hange my appearance," 1 said , "so I could be skinny and pretty and a lso wish I had never gotten into trouble and sent to Girls' Town. I also wish I could have children." I mpre ssion . It is the investigator's impression that 1 is very lo ne l y, de pre ssed, and an angry girl who feels the world is a mistrus f ul place whe r e t h~ only pe rson you an really depend on is 129 yourself. L's l ower socio-economic status , poor familial relation- ship s, and poor self concept are pr i me contri butors to the ma ny difficu lties she now faces and will face in her future . Gase 7--six-year -old female Rapport with subject. The i nve st igator found B: to be a very warm, outgoing, and fr ie ndly six-year-old girl . She always s eemed c hee rfu l and eager to ge t invo lv ed in play activity and/or conversation . R was usually quite spontaneous in her actions and seemed to look upon the investigator more as a friend than researcher. B: sa i d, "I like to play house, climb trees, color, Interests . play with my little brother d, ride my tricycle, and play with my dolls and dishes. I like best of all to play house . playing, I also like to watch television." When I'm not R then stated that her f avorite television programs are Bonanza "because it's a cowboy show , " I Dream of Jeannie "because she is so pretty, " and the cartoons "because they are so funny . " Fe ars. whi ~ h B: told the investigator that there are many things of s he is not afraid. However, two things that frighten her are "dark places and big dogs ." B: said, "You have to be careful of big dogs because if they bite you they can give you rabies ." Desc ription of self and other family members. de scribe herself, B: replied, 11 I 1 m a girl." When asked to The investigator then said , "Can you tell me something more about yourself?" .8_ thought for a moment and then said, " I'm also cute," and laughed loudly . .~ ' s parents ar e. Mr. and Mrs. S . ivorced and B: is living with her grandpar e nts, R seems to have mixed feelings about both 130 grandparents. On the one hand, she seems c lose and warm to them bu t on th e oth e r she states, "They bug me and I can 1 t wait to g t away fr om the m." It seemed that most of ,R's conflict with grandmother c ame over gr andmother' s attempt to make .R into a " Little Lady " and .B. ' s at tempt to ke ep he rself a "tomboy." The conflict with gra nd- f athe r , howeve r, occurs because .R wants to play with him , but his ag e and hea lth prevent him from doing so. R seems closest to he r younger brother , l, who is usually her only playmate and companion. She stated, "He is my favorite friend because he is fun to play wi th." R seems to dislike her older half sister, _1 , who has the same physical anomaly that she has . When .R expressed her feel i ng about L sh e seemed to also be reflecting feelings from other members of her fam i ly . "L is me an, bad, runs around with a no good boy- friend, and I hope she stays away from here forever." little about her mother , just that she was "nice." vestigator that "My pare nts are divorced. .R said v ery She told the in- I miss my father very much a nd haven't seen him for a long time." .Earliest memory. Ar kansa s. .R said, "I can remember when we lived in I liked Arkansas better than Oklahoma. how old I was but I was younger than I am now . 11 I don 't remember R told the investi- gator that she was thinking hard but could not remember ve ry much about her stay in Arkansas . Dreams . R thought for a moment and then replied, "I dreamed the other night that my mot her got raped by a huge monster. so scary that I couldn ' t go back to sleep. monste rs c hasing me . 11 I also dreamed of It was 131 When the investigator asked B: "If she could have Three wishes. any three wishes come true, what would they be?" she replied that her first wish was for Santa Claus to bring her lots of toys including a doctor's kit. Her second wish was for a play oven and stove, and her third wish was to go back and live in Arkansas instead of Oklahoma. B: then said, "If I had two more wishes I would wish for a million dollars and a million pieces of candy." To the investigator's question as to what R would do with an unlimited amount of money she rep lied, "If I had al 1 the money I wanted, I would buy myself lots of pretty clothes, candy, an airplane, and a truck, and if I could go anywhere I wished, I would go back to Arkansas to live--I like it better there than Oklahoma ." Animal . To the investigator's question as to what kind of ani- mal she would like to be if she had her choice, B: replied, "A lion because they are big and strong . " Typical day. R said that her typical day follows this schedule: "I get up early in the morning, wash my face, eat breakfast , and go to school. I stay at school till lunch time then I come home. I play at home for the rest of the day and then eat dinner and go to bed. On Sundays I go to church." R went on to tell the investigator how she sometimes "hates" to get up early in the morning because she is "so sleepy." Play activities. B,, who lives with her grandparents, does not have many friends in her vicinity to play with. Thus most of her play is by herself and with the many imaginary characters that she creates . In this regard, B: can play many parts: mother, father, 132 baby, sister, teacher, etc. In my first meeting with E, she told me how much she wanted to show me her playhouse but that at the present time it was "all messed up . When I get it fixed up it looks pretty nice and then I ' ll show it to you." Ethen took me on a tour of her grandparents' place pointing out and explaining the various things we came in contact with such as her cat named Cicero, the storm cellar where the family goes in case of tornadoes , her tricycle, and the chicken coup where grandfather keeps and raises chickens. During our sessions together, R would particularly enjoy showing off for the investigator by performing such stunts as cartwheels, back bends, hand stands, and somersaults. After finishing a stunt, she would occasionally turn and say to the investigator, "I bet you can ' t do them"--this was usually true. Other play activities that E s e emed to enjoy were coloring, cowboys and Indians, dolls, hide-andgo-seek, riding her tricycle, playing ball, climbing trees, and playing house. Her favorite activity, however, seemed to be playing hous e, during which time the investigator was usually designated as e ither R's baby or R's husband. R was very creative and imaginative in her play, acting out many different kinds of stories. She par- ticularly enjoyed playing the dominant female role in which she was both producer and director . Religion. R's grandparents belong to one of the Pentecostal Church groups where£ attends Sunday School regularly. She told the investiga tor that she believes in God and that one day soon "God was go ing to come back to earth on a black cloud and punish the bad 133 people and praise the good people." R then looked up at me and said, "You better be good." Philosophy of life. good and go to church. R said, "Let me see, I think you should be You shouldn't be bad because if you are you will get a whipping." School and future plans. R attends kindergarten for half a day. She seems to like school a great deal and particularly enjoys the activities of coloring and painting, listening to stories, and looking through picture books on her own time. ~stated, however, that she dislikes learning how to write and that she does not like it when the teacher scolds her for misbehaving. She was not sure what she wanted to be when she grew up but stated, "I think I would like to be a nurse, get married and have many children." Subject's explanation of medical condition . ~stated, "I don't know for sure but I have had two lumps in my tummy since I was a baby. My grandmother told me it was just a rupture--that's all I know." R then pointed to the lumps in her stomach and said, "Some- times they hurt me when I jump or run. My grandma told me that the doctors would take care of the lumps someday." In what way would you like to be different?. question was "I would like to be a queen." ~·s reply to this In R's later elaboration of the answer, she meant that she would like to be "prettier, older, and married." ~also expressed the feeling that both her mother and grandparents wished that "I would grow up and not be such a brat." The investigator felt that R's living arrangement with her grandparents was very difficult for both parties due to such a large age 134 difference. 1 In this regard, there seemed to be many times when ~ s e nergy and activity leve l became very irritable to both grandpare ~ts. Impression. R seemed to look forward to our hour together once eve ry two weeks and would usually be at the door waiting for me when I arrived. She would initiate the conversation by focusing it on herse lf . An example of this occurred in our third session together when, as I approached the door to R's house, she came run ni ng ou t and said, "Look at the new dress I have on that Grandma made me." The investigator felt that not only did R want to be noticed but that she wanted to be compl im ented by someone she cared about who in turn cared about her . R had an extraordinary amount of energy which seemed to come forth in our sessions together . She always seemed "in motio n" a nd the investigator usually found himself exhausted at the end of the hour. Our time together usually involved such active play as tag, skipping, running races, hide-and-go-seek, jumping contests, and jump rope. Less active play involved playing house, coloring, play- ing with clay, and just sitting down on the floor talking to each other. One typical scene from our playing house together went as follows: _R, "I will be mother and you will be my little boy. Now pretend that you are asleep and I will wake you when breakfast is ready. " Then B: would pretend that she was rocking me to sleep, singing to herself softly at th e same time. get up and eat your breakfast. your nap. Next R said, "Time to When breakfast is over it's time for Little kids don't snore so don't you do it. Now that your nap is ove r I am going to take you for a walk before lunch." 135 ~ would get annoyed if the investigator did not play his role ade- quate ly. The investigator felt that even with ~'s lack of appropri- ate aged playmates and present living arrangements, she was a warm, friendly, outgoing six-year-old girl whose play activity seemed norma l for her age. 136 CHAPTER V DISCUSSION The mat er ial in this c hapter wi ll be presented in three sections. The first part will be a discussion of the diagnostic t est ma terial of the exper i mental group, the s ec ond a discussion of their fam i l y histories , and the third a d i s c ussion of the investigator ' s inte rviews with the children of the experimental group . Diagnostic Test Material I ntell ec tual function ing Wec hsl er Intelligence Scales . On the Full Sc a l e IQ, the range of scores varied from 83 to 126 with a mean of 105 . 1. Two S scored -s in the superior, one scored in the bright normal , thre e sc ored in the average , and one s c ored in the dull normal range. On the Verbal Scale there was a range from 80 to 115, with a mean o f 103 . 14 . Thre 8 -Ss scor ed in the bright normal , three in th e average and one in the dull normal range. Within the verbal area there were no individual subtests in wh ic h the performance of these c hildren was particularly outstand ing or def icie nt . On the Perfo r manc e Scale the range va ri ed from 80 to 133 with a mean of 106 .4 1. One S scored in the very superior, one in the superior, one at the bright normal, three at the average, and one at the dull normal range. Withi n the pe r formance are a there wer e no individual subtests in which the pe rformance of the se children was particu larly outstanding o r deficient. 137 In each case the chi ld who scored at the dull normal range was from a cultura lly deprived ar e a in which there had been no exposur e to many of the test items . For th e most part, the experimental group s c ored higher on the v e rbal t e sts, where as the control group ge ne r ally scored higher on the perfo r mance tests . The control group exce lled over the experimental group when both the verbal and perf ormance r esults were combined into a full scale IQ score. Draw-A-Pers on . The over-all mental age score s of the ex per i - me nta l group were below their chronological ages and below the overall mental age scores of the control group . This seemed to be a result of the younge r children in the experimental group who s c ored at or above their chronological age, whereas the older children s c ored below their chronological age. The first drawing in eve ry instance was a male figur e followed by a female representation. In general, the experimental group's mal e representation was at a higher mental age level than that of the female representation. In two of the older children's drawings, only the head of the male and female figures were represented; the bodie s were a bs e nt. In another drawing by an older child both figur e s seemed asexual in nature . In all three of these cases the c h i ld had experienced, within the last few years, a medical operation for sexual correction. Body rejection or a lack of clarity in ma l e /fema l e representation cou ld have occurred in their drawings as a result of this medical operation. A typica l charac t e ristic o f the drawings of the experimental gr oup was an intr i cate l y d rawn he ad , whereas the body , arms, and 138 legs were simplified and fundamentally represented. The rejection or distortion of their own body and its parts could be due to conscious or unconscious negative feelings relating to thei r physica l anomaly . In this regard, doubt as to adequate sexual role and identity could be a result of inadequate feelings about one' body, which would contribute to feelings of inadequate sexual identity . It Scale for Children. On this test, all but one of the experi- mental ~s seemed to prefer objects and activities characterist ic of the masculine role. Three of the S had an exclusively masculi ne -s score of 84 points. The reverse held true for the control subjects in which four out of the seven preferred feminine objects and activities. All of the experimental S except one perceived "It," a figu re -s of indeterminate sex, as being masculine in appearance. This could ac count for the skewed distribution toward masculinity. A second hypothesis could be that five of the seven experimental s ubjects had rece ntly undergone corrective surgery and thus internalization of sex ro le and identity had not yet taken place . Family Relations Test. ~s On this test, four of the experimental expre ssed more outgoing positive feelings toward their siblings , wher eas two of the subjects expressed more outgoing positive feelings toward their father and one expressed such feelings toward her mother. Five of the experimental ~s expressed more outgoing negative feelings toward their siblings, whereas two of the S expressed more -s outgoing negative feelings toward their father and none expressed such feelings toward their mother. 139 Four of the experimental S felt that they received more in-s c oming positive feelings from their siblings, whereas two of the S -s felt more incoming positive feelings from their mother and one of the -s S felt this from her father. Five of the experimental -s S felt that they received more incoming negative feelings from their siblings whereas one of the ~s felt more incoming negative feelings from mother and one expressed such feelings as coming from her father. Two of the experimental S felt that father was more overpro-s tective and overindulgent, whereas two of the -s S felt mother was more so. Three S expressed indifference in the matter. -s It appears from this test that most of the experimental S have -s ambiguous feelings coming from and going toward their siblings. This may be due to just the individual family constellation and its self functioning, or it may reflect some definite feelings that the siblings have with regard to the subject and he to them. The siblings and -s S may be viewed as having rapport and experiencing a close and warm relationship. On the other hand, a feeling of resentment and lack of acceptance could be present due to the sexua l anomaly of the ~s which may alienate them from their siblings. Children's Form of the Manifest Anxiety Scale. On this test, the experimental group's range on the A Scale was between 14 and 27 whereas on t he L Scale the range was between 0 and 6. On both scales, t he experimental group scored below the control group; however, there was no significant difference. The experimental group sc ored highest on the following four anxiety items : "I notice my 140 heart beats very fast sometimes," "At times I feel like shouting," "My hands fee 1 sweaty," and "I worry about doing the right things." On the L scale the experimental group seemed to have the most difficulty telling the truth on the following three questions: "I never get angry," "I never say things I shouldn't," and "I like everyone I know." Due to the nature of the S anomaly, the investigator had -s expected the opposite relationship to exist. It would appear that the experimental subjects would be more anxious and apt to lie due to their medical condition but this did not prove to be the case. Structured Child Interview and the Bradley Sentence Completion Test. Some of the questions and material obtained from these two diagnostic instruments were used by the investigator in his individual therapy sessions with each experimental S. These instruments were particularly useful in helping the S feel at ease and more comfortable within the initial testing and therapy meetings. This seemed to be so because of the familiarity and open endedness of the questions. There were no right or wrong replies as the answers given by each subject were accepted. All of the children seemed to find these instruments easy and enjoyable to answer. The Structured Child Interview is found in Appendix A, and The Bradley Sentence Completion Test is found in Appendix B. Bradley Self Concept Measure. On this test, the scores for the experimental group ranged from 46 to 60 with a mean of 53.14. control group scores ranged from 39 to 56 with a mean of 49.29 . differences between the two groups were not significant. The The Due to the 141 nature of the subject's anomaly, the investigator had expected the reverse relationship to exist between the control and experimental groups. It would appear that the experimental subjects would have l e ss adequate self concepts because of their medical situations but this was not the case. In five out of seven cases the experimental S scored higher than the cont rol S on the self concept measure. -s -s The Bradley Self Concept Measure is found in Appendix C. Rorschach Ink Blot Test. There were no significant differences between the experimental and control groups on any of the selected Rorschach data as presented in Table 2. However, there were some differences between the two groups on this data which may have proven significant with a larger sample . One difference was that the experi- mental group gave fewer human responses than the c ontro l group. This was particularly evident with the older children of both groups. Fewer human responses within the experimenta l group may be an indication of greater anxiety and insecurity that they experience i.n close human relationships. Because of this , the tendency is not to get close and involved with others but rather to keep them at a safe distance. The investigator had expected this relationship between the two groups, considering the medical anomaly of the experimental S in which lack of self assurance about sex role and identity -s' would prevent close contact with others. The control group had more anatomical responses although the difference between the two groups was very slight. The investigator, howeve r, would have expected the opposite relationship, as the experimenta l group's medical condition seemed to focus on the 142 subject's total functioning as a "sexual" being as well as on a s pecific sexual area of the body. The reality testing for both groups was within normal l imits wit h very little difference between the two. The controls gave more a c tual and symbol ic sexual responses than the experimental group . The difference between the t wo gr oups was slight, however, and the investigator had expected a r everse relationship . It was felt by the investigator that due to the medical co ndition of the experimental -s S their unconscious and conscious concer ns about their sexual role and identity would manifest itself in actual and symbolic sexual responses on the Rorschach . S gave mor e total responses to the Rorschach cards The control -s than did the experimental -s S . The difference between the two groups on this variable was the most pronounced of th e selected Rorsc hac h data. One hypothesis for this distinction could be that the experi- rnentals were more constricted in their ability to deal with the unstructured tasks of the Rorschach. Also, the one to one relation- ship with the investigator may have created excessive anxiety within the subject, thus limiting the number of their total responses . Children's Apperception Test . This diagnostic instrument was administered to two of the experimental -s S . There were no gross distortions in the children's perception of the stories as compared to the typical themes that are given in the test manual for each of the ten pictures. The two ch i ldre n who were administered the test were R, S. and !1_. £., both six years of age. There seemed to be certain prevalent 143 themes throughout R.S . 's stories . One was a concern as to whether there would be enough food to go around to a ll members of the family. This concern on R.S. 's part could be related to the poor economic status of her family . At the present time they are having to re- ceive subsistance from the Welfare Department to meet the basic needs of food, clothing, and shelter. A second theme was the cr e ~­ tion of a conflict situat ion in which mother and child stood in continual opposition to father. In this regard, mother, the "good parent," seemed to take the role of the protector against a powerful , aggressive and possibly punitive father figure who symbolized the "bad parent . " This father figure was unpredictable, however, as he cou ld be a protecting agen t at times, whereas at other times he was not capable of defending the family against the destructive environmental forces. A third theme throughout .R.S. 's stories was the per- petual shad ow of death; at times she and her family were narrowly able to escape it but at other times they were not. Themes two and three may be related to R.S. 's unstable family situation in which mo th e r and father are divorced. At the present time, mother 's social activities of heavy drinking and promiscuous relationships with many men may be too overwhelming to R.S. Thus, this situation seems to only add to the ch i ld' s insecurity and need for stability and security within the family constellation. The other child, R.C., also seemed to have recurrent themes throughout her stories. One such theme was R.C. 's focus on eating. Some of the stories in which eating was a major theme were rather passive in nature, i. t-:. c ard 1, in which mother chicken and her 14.4 babies were eating food at mealtime. Other eating themes were more aggressive in nature, i.e. card 7, i n which a tiger was try ing t o capture a monkey in order to eat it . A second theme involved a strong father figure who was viewed as a powerful authoritarian and disciplinarian within the family . Mother, on the other hand, seems to represent the opposite position, that of a rather passive perso n. However, she takes good care of the needs of the children and. everyone seems happy. After the investigator's con tact with t his particu- lar family, he was inclined to be in agreement with R.C. 's perception of both mother and father. Thematic Apperception Test. This diagnostic instrument (pie- tures 1 , 3BM, 4, 5, 7BM, 8BM , 12F , 13G, 14, and 20) was administered to five of the experimental S -s A brief summary of eac h of the five S protocols will be given. -s The se nt ed . A. F., gave very brief stories for each card pre- first~. This seemed to be related more to her age and shyness during t he first testing than to any other factor. As a result of the brevity of her stories, interpretations beyond simple content were v ry difficult. Throughout A.F. 's accounts there did not seem to be any gross misperceptions of card content . Regardless of how her stories originated and progressed, the endings were one of either success, accomplishment, and/or happiness; there were no unhappy or disastrous endings. She seemed to visualize her parents as people who were concerned about her welfare and in turn she was able to be dependent upon them for support and help when needed. The second~. L.C. , also told short stories for the TAT cards 145 presented to her. The succinct ness of her stories, however, did not seem related to age but to the difficulty she had in establishing rapport with the investigator. Many of the endings throughout .L.C . 9 s stories were philosophical in nature. This type of ending could be a defense in which she detached herself from getting involved on a personal level with peopl e. Instead, the effect got externalized in a rather global, intellectualized manner which prevented her personal feelings from coming through . An example was the ending for her story to card 3GF in which she stated: "However, the heartbreak will heal, because without healing, there would be no future for man; he would become diseased in body and soul and die." L.C. 's difficulty in getting personally involved in the TAT stories was also carri d over to the therapy interviews with the investigator. This type of involvement in which personal closeness exis ted seemed to c reate anxiety within her which was difficult for her to reconcile. The third§, B.C., throughout many of her stories had difficulty mai nta ining consistency as she would fluctuate from one explanation to another. This inconsistency as to theme may be one way in which B, C. projects her own unhappiness and t ries to seek a happy resolution. Even though her stories change settings, her unhappiness can- not be overcome and despair still lingers. There seemed to be an e lement throughout her stories in which there was a fear of parental punishment for misbehaving. B.C . also expressed a concern about punishment from outside authority figures for certain antisocial acts . In these act s the person was usually found guilty and sentenced to jail. B.C. 's stories were often sad through loneliness, despair, 146 hopelessness, monetary problems, problems with the law, and/or poor personal life. Much of B.C. 's unhappiness could also be related to a disruptive home life in which her mother has been married four times and her relationship to her present stepfather is incompatible. This may contribute to her feelings of insecurity. The themes throughout the TAT stories of the fourth.§., L.F . , were typified by hostility, violence, occasional death, and sexual assault. Much of this material seemed to represent L.F . 's horn environment and present detention at Girls' Town, a home for delinquent girls. The scenes in which sexual involvement occurred were usually intense with heightened emotional overtones. tion to her stories was usually unhappy. Final resolu - The men in L.F. 's stories were often viewed as the aggressor and the women, as the result, were usually victimized. In this regard, the woman was generally emotionally or physically hurt and the man frequently punished for his aggression. The themes throughout the TAT stories of the fifth.§., P.U . , were varied in nature. In a few of her stories, she described some type of fictional character who was engaged in acting out a particular plot. One such plot was based around the story of Peter Pan, another was Perry Mason successfully solving a murder, and a third was Edgar Alan Poe's story of the "Tell Tale Heart." These types of storie s could be an indication of the vividness of P. U. 's fantasy life in which she identifies and visualizes activity through the actions of these characters. It may also be a defense in which in- volvement through fantasy life means detachment from personal 147 involvement in rea l ity. Another theme that is emphasized in P .U . 's s torie s is thoughts of accomplishment and. success in which her goal i.s for recognition and achievement over and beyond the or<l inary, A third theme seems to be a father-son closeness in which s ome kind of tragic event brings the two together and emphasizes their positive relationship and love for each other . Family His tori.es The parents interviewed for this study were mos t cooperat ive, not only in disclos ing information about t heir child's physica l a nomaly but also in discussing th e f amilial relationship itself, The degree of cooperation and information obtained varied fr om one family to another. Even with the discrepancies there were sti ll ce rtain trends that seemed to generate throughout. most if not a ll of the interviews. One such trend was that each of the families had th ree or more children, with subsequent children having been born fo llowing t he birth of the hermaphroditic child , In no case did the b irt h of a hermaphroditic child prevent the parents from conceiving another child . Some parents felt reluctance in having another c hi ld for fear of repetition of th e anomaly, while others felt that th anoma l y had been just an act of "fate" or " chance" with recurrenc e not likely to re.peat itself. In all of th e families, with the exception of two , only one hermaphroditic child was born . In the other two families, two sexually amb iguous children we re born . In the families whe re his particular phenomena occurred, the mother con~eived another 148 child following the birth of her second hermaphroditic child. Other physiological anomalies, however, were present among some of the other siblings in the families with two hermaphrodites as we 11 as among a third family in this study. One of the families in which there were two hermaphroditic children reported that this same condition had occurred in past generations. In this particular family, a genetic factor seemed to be the major contributor to the sexual ambiguity. A second general theme was that all of the families, with the exception of one (Dr. C's family), felt that they needed greater medical understanding and guidance with regard to the anomaly as well as with proper management of the condition once it had been diagnosed. In this regard, trust and confidence in their family pediatrician and/or obstetrician seemed to be essential for initial sexual assignment of the child and, if needed, referral for future correction, treatment and guidance. It was a consensus of opinion among all of the parents that it would have been easier emotionally if sex change in the child had occurred at birth and/or as early as possible in the child's development. This was substantiated by one family in which sexual correction had taken place before the child reached the age of two years. This family felt inte rnalization of sex role and identity occurred more naturally and with less anxiety to all concerned because of early correction. Where proposed and/or actual sex change occurred in the child after the age of 2 1/2 or 3 years, it was felt by most of the parents that this did or would have created emotional difficulty in their adequately adjusting to the new 149 c hild's role and identity. In other cases where proposed sex changP. was a possibility both parents either said "no" or expressed considerable reluctance as to the propos ed possibility . Of the paren ts interviewed all seemed to feel very content with the present sex of their hermaphroditic child which was female in gender. All families tended to keep the sexual anomaly issue closed and limited to their immediate family. The only other people aware of the particular anomaly were the medical personnel involved in tre at= ment of the child and, on occasion, a close relative who was often relied upon for social as well as emotional reinforcement . In three cases, none of the S were aware of their problem as it had not been -s discussed with them because of their young age. In these cases, the same unawareness existed with the other siblings because of age . For the investigator to conduct this study, a guarantee as to privacy and protection of identification was given to each family. It appeared that socio-economic factors made little difference in t:he parents' general concern for their child and its adequate ad ~ justme nt to the environment. Whether parents were well educated or not , financially independent or subsisting on welfare, living in an urban or rural section of Oklahoma, their needs, questions and feelings in dealing with this medical problem seemed to be similar in kind; the only differences were in degree. Because of the current infrequency of incidence and variations in condition, accessible and comprehensible medical information for the. layman who desires it seems almost unavailable. Due to this un- f ortunate circumstanc e. most of the parents in this study felt 150 "uneducated" as to their child's condition and did not know where to turn for proper medical assistance. In general, they did not seem to know what to expect and how to handle the child's future needs and fee lings. Therapy Interviews The hermaphroditic children interviewed by the investigator were generally cooperative and willing to share their feelings concerning their medical condition as well as feelings about themselves and their families. Most of the children seemed to have a great variety of interests which varied with the age of the child and the background from which she came. In all cases the interests of the older children and the interests and play activities of the younger children seemed age appropriate. There was, however, a tendency on the part of the older children to prefer activities which were more masculine rather than feminine in nature. Few heterosexual relationships were mentioned by the S . -s This pertains to actual experiences as well as dreams and fantasies . One of the older ~s had been married unhappily for a brief period of time and was at present divorced. One other S was contemplating mar- riage to the only boy she had ever dated. For the most part, boys were not looked upon as sexual objects, but as friends with whom one could play, talk, and joke, but not get involved with on a dating basis. The -s S feelings could possibly be related to their medical s ituation itself in which feminine sexual identity and role had not 151 been sufficiently internalized the r e by making it difficult to relate to others in a heterosexual setting. The age of the ~s may also have been a factor as some of the younger children may not have reached the stage in their psycho -sexual deve lopment in which heteros exual relationships were desirable . All of the children except two were attending school with future plans of acquiring higher education and pursuing their particular vocational interests. Four of the children stated that they would like to make nursing their career. This selection could have been based on a desire to be connected with the medical profession due to much positive contact with it. Another factor may be related to a desire to assist other individuals who have similar or other physiological anomalies thereby giving them comparable help which they had received as patients. By doing this they are also feeling needed and useful in trying to circumvent the pain in others that they themselves have had or still are having . As a group there was nothing unusual in their typical daily routine. Most of the children attended school during th e week and either church or Sunday School on a regular or irregular basis. Of the two children who were not attending school, one was employed at a furniture factory and the other was in residence at Girls' Town due to delinquent behavior. The children seemed to be self-conscious and reluctant in describing themselves to the investigator . This may be a reflection of their particular medical anomaly in which embarrassment over their physical ambiguity prevented openness on their part. It co uld also 152 be related to the difficulty that children may have in talking about themselves. Descriptions, when given, were usually physical and external rather than focusing on inner feelings and thoughts about themselves . It was generally easier for them to talk about other members of their families than it was for them to dis c uss themselves. The older children seemed to be more aware of their medical condition than were the younger children. In this regard the younger children were only aware that they needed to take medication regularly and did not seem cognizant of their physical anomaly. In one case in which the child had not had the operation, she was sometimes aware of pain and swelling in the abdominal area and expressed a hope of future correction. With regard to dreams experienced by the subjects, the content varied, although most of the children reported frightening dreams in which they and others were being chased by monsters. Some of the c hildren also had dreams in which the fear of death either to thems e lves or a loved one was expressed . The philosophy of life expressed by the subjects, on the other hand , was quite optimistic. They tended to place emphasis on religious values, the desire to help other people, and the ambition to live the golden rule . When asked how they would like to be different, most of the children referred either directly or indirectly to their medical condition. This seemed to be particularly true of the older children. In this regard, one child replied that she would like the quality of her voice changed so that it would not be so deep. Another child 153 felt that her parents would wish for her to be more girlish, and a third child responded with the hope that some day she would be abl e to bear children . The children wished for a variety of things with some making reference to their medical condition. Others wished for material things such as vast wealth, jewels, many toys, diamonds, etc. Only one child expressed a wish for somebody else or for society in general . This focus by the majority of children on themselves may again be related to their medical condition in which wishing for things for themselves may be used as compensation for their medical and health difficulties. It may, however, just be an age factor which is affecting their wish selection. Most of the children, when asked to relate their earliest memory, described one that was a happy event in their lives. Only one child mentioned anything concerned with her medical condition. When relating their dislikes, the older children generally seemed to have an aversion to people who did not respect them and their rights as individuals. The investigator had the feeling that all of them had at some time or another experienced criticism or had been made fun of because of certain manifestations of their medical anomaly. The younger children who had not had negative past experi- e nces similar to those of the older ones did not express such concerns. 154 CHAPTER VI SUMMARY The present study dealt with an in-depth personality and intellectual evaluation of a group of hermaphroditic children residing in the state of Oklahoma. The impact of this anomaly on the families of these children was studied extensively through the following techniques: psychological tests, parental interviews by a social worker, and diagnostic play interviews conducted by th e investigator. It was the purpose of this study to examine the psychological impact of sexual ambiguity on the child and his parents. Subjects for this study were seven Caucasian hermaphroditic children who ranged in age from 6 years, 2 months to 18 years, 4 months. Each subject in the experimental group was paired with a subject in a control group for purposes of comparison on test data. They were matched on the following variables: age, sex, race, socioeconomic class and contact with the Oklahoma Medical Center. A matched pair t test was used to compare the experimental and control groups on the various test data. There were no significant differences between the two groups on any of the tests given. This may be attributed to the small sample size. The following are summary statements which appeared to be apparent from this study . It must be kept in mind, however, that a limited sample was utilized which could have effected these trends. 1. The play activities and interests of the children appeared 155 to be age appropriate in relation to their socio-economic background . There was , however, a tend e ncy on the part of th e old er children to pr efer activities which were mor e mascul ine than f emin i ne in nature . 2. Few close heteros exua l relationships were me ntioned by the subjects. 3. Four of the c hi ldren stated that they would like to make nursing a career. 4. The three old e r children seemed more aware of thei r medical cond ition than the younger subjec ts and were aware that th ey were different in some ways from th e normal popul ation. 5. The three older subjects seemed mor e affected by the anomaly than the younger ones and were more sensitive to i t and to r e lations h i ps with others. 6. As a group there s eemed to be nothing unusual in their typica l daily routine except for the medication which had to be taken regula rly. 7. The children seemed to be self-conscious and reluctant in describing themselves to the inve stigator, particu larly as it pert a i ned to their medical anomaly . 8. An optimistic philosophy of life was ex pressed by the sub- jec ts in which emphasis was placed upon religious value s, a des i re to help others, and an ambition to live the golden rule . 9. In the children's explanations of how they would like to be different, reference was mad e to their medical condition . 10 . In no case did the birth of a hermaphroditic child into a family inhibit future conce ptions and subsequent births. 156 11. All families but one felt that they needed greater medical understanding and guidance with regard to the anomaly as we ll as with proper management of the condition once it had been diagnosed . 12 . It was felt by four groups of parents that desirable sex change should occur in the child as early as possible, pre f erably before three years of age . 13 . All families tend ed to kee p the sexual anomal y iss ue c los ed and l i mited to their immediate family. 14 . It appeared that socio- e conomic factors made little d i f- f e rence in the parents ' general concern for their child and its adequate adjustment to the environment . 15 . Accessible and compre hensible medical information about hermaphroditism is almost unavailable to thos e desiring it because of the current infrequency of incidence and variations in condition . Suggestions for Further Studies On the basis of the present investigation i t is suggested that the following studies may be beneficial in studying the hermaphro d i tic child . 1. Further studies similar to the present one need to be done utilizing a larger hermaphroditic population and comparing it with a comparable control group . This would insure more conclusive data which would allow more concrete analysis to be conducted. 2. Longitudinal inve stigations could enhance the nature of this study as relative progress of development is an important thing t o c he ck and this c ould be one way of doing it . 157 3. A similar study could be conducted testing a hermaphroditic sample before and after sexual c orrection noting differences pre operationally and post-operationally. 4. Further studies could be done focusing on the impact that this anomaly has upon the family. 158 BIBLIOGRAPHY Adcock, C. J. 1965. Review of the Thematic Apperception Test, p. 245-246. In O. K. Buras (Ed). The Sixth Mental Measurements Yearbook. The Gryphon Press, Highland Park, New Jersey. Anastasi, A. 1961. New York. Psychological Testing. The Macmillan Company, Bartalos, M., and T. A. Baramki. 1967. Medical Cytogenetics. Williams and Wilkins Company, Baltimore, Maryland. The Barton, D., and P . D. Ware. 1966. 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What was it like ? What did you do? 9. If you were stranded on a desert island with only one person and you could choose that person, who would that person be and why? --Who would be your second choice and why? --Who would your third choice be, and why? 10. If you could have any three wishes come true, what would be your first wish? --Your second wish? --Your last wish? 11. In what one way would you like to be different? 12. In what way would your mother most like to have you be different? --Your father? What do you do together? Why What things about him (her) 168 Appendix B Bradley Sentence Completion Test Name Date ~~~~~~~~~ 1. If I were bigger 2. She would like 3. I f I could only 4. She hates 5. Oh, how I wish 6. She used to love 7. What makes me sad 8. Someday 9. I miss so much 10 . I want to go 11. When she is alone 12 . I want to see 13. Once 14 . I would like to be 15. I love 16 . Girls 17 . My friends think 18 . She likes best of all 19. I want to know 20. When she gets older, she's 21 . My mother and father 22. I fee 1 like 23. He gets mad becaus e 169 24. I dream of 25. My mother does not 26. When she wakes up at night 27. God is 28 . Boys 29. I am afraid of 30. Other boys and girls 31. What makes her mad 32 . My father isn't 33. She is jealous of 34. I look like 35. She thinks most about 36 . I am proud of 37. Other people think she is 38. She is sorry 39 . I try 40 . She gets fun out of 41 . I feel unhappy sometimes because 42 . When I get home, I am going to 43. When someone in her family is sick 44 . If another person hit me, I would 45. At mealtime 46. She is scared 47. She likes to be 48. When I play games 49 . If I don't get what I want at home 50. When she hurts 170 Appendix C Bradley Self Concept Measure Age : Subj ec t ' s Name: Sex : M Word Grade: F Grade kind 2 big 2 little 2 girlish 2 weak 2 bad 2 happy 2 babyish 2 funny 3 fat 3 wild 3 clean 3 forgetful 3 srna 11 3 silly 3 fair 3 great 3 strong 4 lazy 4 c ute 4 afraid 4 Definition* Wrong Right Soc . Evaluation Yes No Self Go nce t Yes No 171 .§.' s Name"_ _ _ _ _ _ __ Word Grade bossy 4 quick 4 brave 4 mean 4 caref ul 4 loud 4 lucky 4 ashamed 5 polite 5 selfish 5 honest 5 healthy 5 lonely 5 important 5 helpful 5 angry 5 dumb 5 quiet 5 tough 6 favored 6 c l ever 6 lively 6 crue 1 6 serious 6 Definition* Right Wrong Soc . Evaluation Yes No Self Concept Yes No 172 Definition* Right Wrong jealous 6 naughty 6 handsome 7 ordinary 7 reckless 7 nervous 7 obedient 7 popular 7 stubborn 7 original 7 terrible 7 impatient 7 intelligent 8 curious 8 disagreeable 8 mature 8 dis couraged 8 capable 8 responsible 8 clumsy 8 Soc. Evaluation Yes No Self Gonce t Yes No VITA Peter Lewis Kranz Candidate for the Degree of Doctor of Philosophy Dissertation: A Psychological Investigation of Seven Hermaphroditic Children Major Field : Psychology Biographical Information: Personal Data: Born in New York City, New York, September 11, 1940, son of Benjamin D. and Rose G. Kranz. Education: Attended elementary school in Scarsdale, New York; graduated from Atherton High School, Louisville, Kentucky in 1959; received the Bachelor of Arts degree from Grinnell College, Grinnell, Iowa, with a major in psychology, in 1963; received Master of Science degree in psychology from Utah State University in 1965; attended Merrill Palmer Institute in Detroit, Michigan, 1964-65; did graduate work in psychology at Duquesne University, Pittsburgh, Pennsylvania, 1965-1966 ; attended Utah State University, with a major in psychology and specialization in child psychology, 1966-1967; served a Clinical Psychology Internship, University of Oklahoma Medical Center, in 1967-1968; completed requirements for Doctor of Philosophy degree from Utah State University, with a major in child psychology and a minor in special education, in 1969. Professional Experience: 1968-1969, graduate assistant, Utah State Univers{~y Psychology Department, also taught social development for the Vocational Improvement Program under the direction of the Logan Community Action Program; 19671968, child and adult therapy during pre-doctoral internship, University of Oklahoma Medical Center; 1967 (summer), taught math and science at the State Industrial School, Ogden, Utah; 1966-1967, graduate assistant, Utah State University Psychology Department; 1965-1966, graduate assistant and worked in counseling services, Duquesne University, also conducted play therapy at the Crippled Children's Horne, Pittsburgh, Pennsylvania; 1964-1965, play therapy, Merrill Palmer Institute , Detroit, Michigan.