Perceptualand Motor Skills, 1990, 71, 771-779. O Perceptual and Motor Slulls 1990
PROJECTIVE TEST FINDINGS FOR BOYS WITH GENDER DISTURBANCE: DRAW-A-PERSON TEST, I T SCALE, AND MAKE-A-PICTURE STORY TEST ' GEORGE A. REKERS
ALEXANDER C. ROSEN
Hall Psychiatric Institute Department of Neuropsychiatry and Behavioral Science Universio of South Carolina School of Medicine
Na~ropsychiatricInstitute Department of Psychiatry ond Biobehavioral Science Universio of Caiifornia, Los Angeles, School of Medicine
SHASTA MEAD MOREY
Nashville, Tennessee Summary.-With 66 boys, aged 3 yr. to 17 yr. who were referred for potential gender-idencity disorder, this study examined intrapsychic manifestations as reflected in their projections to the Draw-A-Penon Test, the Brown I T Scale for Children, and the Shneidman Make-A-Picture Story Test. Without access co these projective rest findings, an independent clinical psychologist a diagnostic rating on the severity of gender disturbance on a five-point diagnostic rating scale, based on clinical interviews of the child and his p m n t s and a systematic behavioral assessment based on previously published normative standardization data. For each of the three projective measures, significant correlations were found between the clinician ratings on severity of gender disturbance and the test findings in the feminine direction (D-A-c r = .44; I T Scale, r = .64; M-A-P-S, r = .35). These results validated the use of intrapsychic phenomena of fantasy and self-perception as measured by these projective tests for the diagnosis of gender disturbance in male children and adolescents.
The task of assessment of children with gender problems requires a range of psychodiagnostic procedures measuring several dimensions of psychological functioning (Rosen, Rekers, & Friar, 1977). As our understanding of the complexity of gender-identity development improves (Roberts, Green, Williams, & Goodman, 1987), it becomes increasingly important to assess comprehensively the full range of the individual's gender identity, gender behavior, and sexuality as those dimensions are measured on the physical Ievel, the intrapsychic level, and the psychosocial level (see Rosen & Rekers, 1980). The diagnosis and monitoring of treatment of boys with gender-identity disorder (American Psychiatric Association, 1980) has included objective behavioral observations of the child's play (Rekers, 1975, 1988; Rekers & Lovaas, 1974; Rekers & Morey, 1989a; Rekers & Yates, 1976) and gestures 'This research study was supported by U.S. Public Health Service Research Grants Nos. MI328240 and MH29945 to Dr. Rekers from the National Institute of Mental Health. Appreciation is ex ressed to Josephine Evans for word rocessin of this manuscript. Requests for reprints shoul1 be addressed to Dr. George A. ~e!ers, ~rofessorof Neuropsychiatry and I3ehavlord Science, University of South Carolina School of Medicine, Columbia, South Carolina 29208
772
G. A. REKERS, ETAL.
(Rekers & Morey, 1989b; Rekers, Yates, W&s, Rosen, & Taubman, 1976), parent interviews (Rekers & Milner, 1979; Rosen, et al., 1977), and structured parent-report schedules objectively scored (Bates & Bentler, 1973; Bates, Bentler, & Thompson, 1973)-d of which may be limited by the capacity of the respondents to report relevant intrapsychic processes. The measures of behavior as objectively assessed by factor-analyzed questionnaires and in vivo observations provide adequate descriptions of the visible behavior of the children. I t is also important, however, to obtain measures of identity and more specifically to assess aspects of the complex relationships between self-perception, perceptions of gender roles, fantasy processes, and cognitions that describe the significance of specific gender behavior to the child. Other clinical measures have therefore sought to provide evaluations of less accessible variables which include self-image and a sense of personal identity. We selected three instruments to assess intrapsychic phenomena that accompany gender disturbance in childhood: Draw-A-Person Test (D-A-P), the Brown (1956) IT Scale for Children, and the Shneidman (1952) Make-A-Picture Story Test (M-A-P-S). The D-A-P was selected because many clinicians report that normal children are likely to draw the same-sex figure first (Gravitz, 1969; Heinrich & Triebe, 1972; King, 1975). Drawing the opposite-sex figure first has often been interpreted as suggesting some difficulty in gender adjustment, and studies have indicated that significantly more effeminate boys than masculine boys draw a female figure (Green, Fuller, & Rutley, 1972; Jolles, 1952; Zuger, 1988). The research literature, however, is equivocal in this regard. Several research workers (Hammer & Kaplan, 1964; Litt & Margoshes, 1966) reported that children who drew a figure of the opposite sex first were equally as likely to draw a same-sex figure first on the second administration. In general, however, the youngster who draws the same-sex figure first is likely to do so on the second administration (Haworth & Norrnington, 1961; Heinrich & Triebe, 1972; Litt & Margoshes, 1966). Parallel research with adults indicated that males with high Minnesota Multiphasic Personality Inventory M-F subscale scores (a measure of aesthetic and other interests associated with persons described in the standardization as homosexual) are likely to draw more opposite-sex figures than males with low M-F scores (Brown & Tolor, 1957). The D-A-P has not distinguished reliably and validly the figure drawings of homosexual from heterosexual adults (Barker, Mathis, & Powers, 1953; Buhrich & McConaghy, 1979; Hassell & Smith, 1975; Janzen & Coe, 1975). However, transsexual individuals have been described as more likely to draw opposite-sex figures first on the D-A-P than normals in percentages ranging from 100% down to 52% in adulthood (Buhrich & McConaghy, 1979; Money & Wang, 1966) and from 88% down to 32% in
774
G. A. REKERS, ETAL.
were available to administer the Wechsler Intelligence Scale for Children, and the mean IQ for the group was 105, with a range of 60 to 141. All 66 boys were administered the D-A-P (mean age 9 yr. 5 mo., and ranged from 3 yr. 8 mo. to 17 yr. 8 mo.). Because the IT Scale is appropriate for children but not older adolescents, only 43 subjects were administered the IT Scale (mean age 7 yr. 11 mo., with a range of 3 yr. 8 mo. to 13 yr. 9 rno.). One 17-yr.-old subject considered the M-A-P-S too "childish" and five other children were circumstantially unable to stay long enough for the entire planned test battery, therefore 54 boys took the M-A-P-S (mean age 8 yr. 7 rno., with a range of 3 yr. 8 mo. to 16 yr. 7 mo.). Procedure
The subjects were given the standard administration of the D-A-P, with no statement by the examiner as to the desired sex of the person to be drawn. Upon completion of the first figure, they were then given another sheet of paper and asked to draw a figure of a person of the sex opposite the one drawn first. The sex of the first figure was recorded. The standard administration of the Brown I T Scale for Children was followed. The IT Scale consists of a series of pictures of objects and figures that are clearly associated with either the stereotypically masculine or stereotypically feminine sex role. For each set of pictures the subject was asked to choose which toys, activities or figures, a stick figure of ambiguous sex ("it") would prefer. The M-A-P-S is a picture-thematic technique in which the figures and the background scenes are separate, allowing the subject to select the characters to be used in their stories and to place them upon the various background cards. Subjects received the standard administration of the M-A-P-S, with five background "sets." The number of feminine characters used in the stories was recorded and expressed as a percentage. Each subject was seen for separate sessions by an independent clinical psychologist who specializes in childhood gender-identity disorders (G. A. Rekers, Ph.D., A.B.P.P., Diplomate in Clinical Psychology) and who did not have access to the data obtained from the D-A-P, I T Scale, and M-A-P-S. This psychologist assigned a diagnostic rating based on (1) data systematically obtained from interview protocols of children and all available parents including history of development and cross-gender behavior, as well as a current description of the child's gender-related behavior and adjustment (see Rekers & Milner, 1979) and (2) standardized behavioral observations of sextyped play behavior in the clinic when alone, mother present, father present, female examiner present, and male examiner present [see Rekers (1975) for procedure and Rekers and Yates (1976) for normative standardization data on normal children] and coding of specific sex-typed body gestures and mannerisms; see procedures and standardization data on normal children by Rekers,
PROJECTIVE TESTS AND GENDER DISTURBANCE
775
Amaro-Plotkin, and Low (1977), Rekers and Rudy (1978), Rekers, Sanders, and Strauss (1981). A five-point rating scale was used in describing the severity of gender disturbance, which was defined as the maladaptive adoption of cross-sex-role behaviors in conjunction with atypical avoidance of same-sex-role behavior, potentially including the desire to be a member of the opposite sex; see empirical evaluation of this scale by Bentler, Rekers, and Rosen (1979) and typology for diagnosis by Rosen and Rekers (1980). O n the diagnostic rating scale, 1 indicated "extreme gender disturbance," 2 indicated "marked gender disturbance," 3 indicated "moderate gender disturbance," 4 indicated "mild gender disturbance," and 5 indicated "no gender disturbance." A prior study had established the reliability and validity of this diagnostic rating procedure across three independent psychologists, including the psychologist who provided the clinical ratings of subjects for the present study (see Bentler, et a/., 1979). As an index of the quality of this five-point diagnostic rating, one can use traditional psychometric indices of internal consistency, which are lower bounds to reliability. In a previous study involving this psychologist, the quality of this diagnosis expressed as agreement across two independent clinicians was indexed by internal consistency methods, with (w = a = 0.81, showing that the clinical rating score provided reliable discrimination among subjects in terms of the measurement dimension of gender disturbance; for more detailed explanation, see Bentler, et al. (1979).
Analysis of Data Pearson product-moment correlations were computed to estimate the relation between the rating of severity of gender disturbance and the scores on the three projective tests. These correlations were calculated to assess whether the scores on the D-A-P, the IT Scale, and the M-A-P-S correlated with the best diagnosis available which was the rating based on the independent clinical interviews and behavioral assessment procedures. The diagnostic ratings were correlated with the sex of the first figure drawn on the D-A-P, with the scores on the I T Scale, and with the percentage of female characters used on the M-A-P-S. Because prior investigators had reported the D-A-P and IT Scale were more valid in the use with younger children, the subjects were divided into two age groups of 7 yr, and younger and 8 yr. and older for subsequent computations of separate correlations between severity of diagnosis and the test scores. Tests for the significance of the difference between the two correlations were computed.
Of the 66 referred boys, 54 received a clinical rating of 4 or less, indicating the presence of gender disturbance. For each of the three projective
776
G. A. REKERS, ET AL.
measures, significant correlations between the test scores and the severity of diagnosis were found. The correlation between drawing of the opposite-sex figure on the D-A-P and the severity of diagnosis was .44 ( p < .005, n = 60) for the entire sample of subjects. The most severely gender-disturbed boys tended to draw the female figure first, while the less severely gender-disturbed boys tended to draw the male figure first. However, only 33% of the sample drew the female figure first. The correlations between sex of first figure drawn and severity of diagnosis was numerically higher for the younger subjects (r = .53, p < ,005) than for the older ones ( r = .3l, p < .05), but this difference between older and younger subjects did not reach statistical significance (p = .17). The correlation between severity of gender-disturbance diagnosis (lower number indicating greater severity) and IT Scale test scores (lower number is more feminine) was .64 ( p < ,0005). Those subjects with the most severe diagnoses tended to score towards the feminine end of the scale and those subjects with the less severe diagnoses tended to score towards the masculine end of the scale. The mean IT Scale score for the groups as a whole was 62.51. Correlations between IT Scale scores and the severity of diagnosis was .75 ( p < ,0005, n = 43) for the 3- to 7-~r.-oldgroup, and .47 ( p < .025) for the 8- to 13-yr.-old group. There was a nonsignificant trend (p = .08) for the scores of the younger subjects to be more highly correlated with diagnostic ratings than for those of older subjects. The correlation between percentage of feminine characters used in the M-A-P-S stories and severity of diagnosis was -.35 (pc.005, n = 54); the most severely gender-disturbed subje;ts tended to mention more female characters in their stories while the less severely disturbed subjects tended to mention fewer female characters in their stories. The mean percentage of feminine characters was 44%. The correlation between the percentage of feminine characters used in the severity of diagnosis was numerically higher for the younger subjects ( r = -.43, p
PROJECTIVE TEST FINDINGS FOR BOYS WITH GENDER DISTURBANCE: DRAW-A-PERSON TEST, I T SCALE, AND MAKE-A-PICTURE STORY TEST ' GEORGE A. REKERS
ALEXANDER C. ROSEN
Hall Psychiatric Institute Department of Neuropsychiatry and Behavioral Science Universio of South Carolina School of Medicine
Na~ropsychiatricInstitute Department of Psychiatry ond Biobehavioral Science Universio of Caiifornia, Los Angeles, School of Medicine
SHASTA MEAD MOREY
Nashville, Tennessee Summary.-With 66 boys, aged 3 yr. to 17 yr. who were referred for potential gender-idencity disorder, this study examined intrapsychic manifestations as reflected in their projections to the Draw-A-Penon Test, the Brown I T Scale for Children, and the Shneidman Make-A-Picture Story Test. Without access co these projective rest findings, an independent clinical psychologist a diagnostic rating on the severity of gender disturbance on a five-point diagnostic rating scale, based on clinical interviews of the child and his p m n t s and a systematic behavioral assessment based on previously published normative standardization data. For each of the three projective measures, significant correlations were found between the clinician ratings on severity of gender disturbance and the test findings in the feminine direction (D-A-c r = .44; I T Scale, r = .64; M-A-P-S, r = .35). These results validated the use of intrapsychic phenomena of fantasy and self-perception as measured by these projective tests for the diagnosis of gender disturbance in male children and adolescents.
The task of assessment of children with gender problems requires a range of psychodiagnostic procedures measuring several dimensions of psychological functioning (Rosen, Rekers, & Friar, 1977). As our understanding of the complexity of gender-identity development improves (Roberts, Green, Williams, & Goodman, 1987), it becomes increasingly important to assess comprehensively the full range of the individual's gender identity, gender behavior, and sexuality as those dimensions are measured on the physical Ievel, the intrapsychic level, and the psychosocial level (see Rosen & Rekers, 1980). The diagnosis and monitoring of treatment of boys with gender-identity disorder (American Psychiatric Association, 1980) has included objective behavioral observations of the child's play (Rekers, 1975, 1988; Rekers & Lovaas, 1974; Rekers & Morey, 1989a; Rekers & Yates, 1976) and gestures 'This research study was supported by U.S. Public Health Service Research Grants Nos. MI328240 and MH29945 to Dr. Rekers from the National Institute of Mental Health. Appreciation is ex ressed to Josephine Evans for word rocessin of this manuscript. Requests for reprints shoul1 be addressed to Dr. George A. ~e!ers, ~rofessorof Neuropsychiatry and I3ehavlord Science, University of South Carolina School of Medicine, Columbia, South Carolina 29208
772
G. A. REKERS, ETAL.
(Rekers & Morey, 1989b; Rekers, Yates, W&s, Rosen, & Taubman, 1976), parent interviews (Rekers & Milner, 1979; Rosen, et al., 1977), and structured parent-report schedules objectively scored (Bates & Bentler, 1973; Bates, Bentler, & Thompson, 1973)-d of which may be limited by the capacity of the respondents to report relevant intrapsychic processes. The measures of behavior as objectively assessed by factor-analyzed questionnaires and in vivo observations provide adequate descriptions of the visible behavior of the children. I t is also important, however, to obtain measures of identity and more specifically to assess aspects of the complex relationships between self-perception, perceptions of gender roles, fantasy processes, and cognitions that describe the significance of specific gender behavior to the child. Other clinical measures have therefore sought to provide evaluations of less accessible variables which include self-image and a sense of personal identity. We selected three instruments to assess intrapsychic phenomena that accompany gender disturbance in childhood: Draw-A-Person Test (D-A-P), the Brown (1956) IT Scale for Children, and the Shneidman (1952) Make-A-Picture Story Test (M-A-P-S). The D-A-P was selected because many clinicians report that normal children are likely to draw the same-sex figure first (Gravitz, 1969; Heinrich & Triebe, 1972; King, 1975). Drawing the opposite-sex figure first has often been interpreted as suggesting some difficulty in gender adjustment, and studies have indicated that significantly more effeminate boys than masculine boys draw a female figure (Green, Fuller, & Rutley, 1972; Jolles, 1952; Zuger, 1988). The research literature, however, is equivocal in this regard. Several research workers (Hammer & Kaplan, 1964; Litt & Margoshes, 1966) reported that children who drew a figure of the opposite sex first were equally as likely to draw a same-sex figure first on the second administration. In general, however, the youngster who draws the same-sex figure first is likely to do so on the second administration (Haworth & Norrnington, 1961; Heinrich & Triebe, 1972; Litt & Margoshes, 1966). Parallel research with adults indicated that males with high Minnesota Multiphasic Personality Inventory M-F subscale scores (a measure of aesthetic and other interests associated with persons described in the standardization as homosexual) are likely to draw more opposite-sex figures than males with low M-F scores (Brown & Tolor, 1957). The D-A-P has not distinguished reliably and validly the figure drawings of homosexual from heterosexual adults (Barker, Mathis, & Powers, 1953; Buhrich & McConaghy, 1979; Hassell & Smith, 1975; Janzen & Coe, 1975). However, transsexual individuals have been described as more likely to draw opposite-sex figures first on the D-A-P than normals in percentages ranging from 100% down to 52% in adulthood (Buhrich & McConaghy, 1979; Money & Wang, 1966) and from 88% down to 32% in
774
G. A. REKERS, ETAL.
were available to administer the Wechsler Intelligence Scale for Children, and the mean IQ for the group was 105, with a range of 60 to 141. All 66 boys were administered the D-A-P (mean age 9 yr. 5 mo., and ranged from 3 yr. 8 mo. to 17 yr. 8 mo.). Because the IT Scale is appropriate for children but not older adolescents, only 43 subjects were administered the IT Scale (mean age 7 yr. 11 mo., with a range of 3 yr. 8 mo. to 13 yr. 9 rno.). One 17-yr.-old subject considered the M-A-P-S too "childish" and five other children were circumstantially unable to stay long enough for the entire planned test battery, therefore 54 boys took the M-A-P-S (mean age 8 yr. 7 rno., with a range of 3 yr. 8 mo. to 16 yr. 7 mo.). Procedure
The subjects were given the standard administration of the D-A-P, with no statement by the examiner as to the desired sex of the person to be drawn. Upon completion of the first figure, they were then given another sheet of paper and asked to draw a figure of a person of the sex opposite the one drawn first. The sex of the first figure was recorded. The standard administration of the Brown I T Scale for Children was followed. The IT Scale consists of a series of pictures of objects and figures that are clearly associated with either the stereotypically masculine or stereotypically feminine sex role. For each set of pictures the subject was asked to choose which toys, activities or figures, a stick figure of ambiguous sex ("it") would prefer. The M-A-P-S is a picture-thematic technique in which the figures and the background scenes are separate, allowing the subject to select the characters to be used in their stories and to place them upon the various background cards. Subjects received the standard administration of the M-A-P-S, with five background "sets." The number of feminine characters used in the stories was recorded and expressed as a percentage. Each subject was seen for separate sessions by an independent clinical psychologist who specializes in childhood gender-identity disorders (G. A. Rekers, Ph.D., A.B.P.P., Diplomate in Clinical Psychology) and who did not have access to the data obtained from the D-A-P, I T Scale, and M-A-P-S. This psychologist assigned a diagnostic rating based on (1) data systematically obtained from interview protocols of children and all available parents including history of development and cross-gender behavior, as well as a current description of the child's gender-related behavior and adjustment (see Rekers & Milner, 1979) and (2) standardized behavioral observations of sextyped play behavior in the clinic when alone, mother present, father present, female examiner present, and male examiner present [see Rekers (1975) for procedure and Rekers and Yates (1976) for normative standardization data on normal children] and coding of specific sex-typed body gestures and mannerisms; see procedures and standardization data on normal children by Rekers,
PROJECTIVE TESTS AND GENDER DISTURBANCE
775
Amaro-Plotkin, and Low (1977), Rekers and Rudy (1978), Rekers, Sanders, and Strauss (1981). A five-point rating scale was used in describing the severity of gender disturbance, which was defined as the maladaptive adoption of cross-sex-role behaviors in conjunction with atypical avoidance of same-sex-role behavior, potentially including the desire to be a member of the opposite sex; see empirical evaluation of this scale by Bentler, Rekers, and Rosen (1979) and typology for diagnosis by Rosen and Rekers (1980). O n the diagnostic rating scale, 1 indicated "extreme gender disturbance," 2 indicated "marked gender disturbance," 3 indicated "moderate gender disturbance," 4 indicated "mild gender disturbance," and 5 indicated "no gender disturbance." A prior study had established the reliability and validity of this diagnostic rating procedure across three independent psychologists, including the psychologist who provided the clinical ratings of subjects for the present study (see Bentler, et a/., 1979). As an index of the quality of this five-point diagnostic rating, one can use traditional psychometric indices of internal consistency, which are lower bounds to reliability. In a previous study involving this psychologist, the quality of this diagnosis expressed as agreement across two independent clinicians was indexed by internal consistency methods, with (w = a = 0.81, showing that the clinical rating score provided reliable discrimination among subjects in terms of the measurement dimension of gender disturbance; for more detailed explanation, see Bentler, et al. (1979).
Analysis of Data Pearson product-moment correlations were computed to estimate the relation between the rating of severity of gender disturbance and the scores on the three projective tests. These correlations were calculated to assess whether the scores on the D-A-P, the IT Scale, and the M-A-P-S correlated with the best diagnosis available which was the rating based on the independent clinical interviews and behavioral assessment procedures. The diagnostic ratings were correlated with the sex of the first figure drawn on the D-A-P, with the scores on the I T Scale, and with the percentage of female characters used on the M-A-P-S. Because prior investigators had reported the D-A-P and IT Scale were more valid in the use with younger children, the subjects were divided into two age groups of 7 yr, and younger and 8 yr. and older for subsequent computations of separate correlations between severity of diagnosis and the test scores. Tests for the significance of the difference between the two correlations were computed.
Of the 66 referred boys, 54 received a clinical rating of 4 or less, indicating the presence of gender disturbance. For each of the three projective
776
G. A. REKERS, ET AL.
measures, significant correlations between the test scores and the severity of diagnosis were found. The correlation between drawing of the opposite-sex figure on the D-A-P and the severity of diagnosis was .44 ( p < .005, n = 60) for the entire sample of subjects. The most severely gender-disturbed boys tended to draw the female figure first, while the less severely gender-disturbed boys tended to draw the male figure first. However, only 33% of the sample drew the female figure first. The correlations between sex of first figure drawn and severity of diagnosis was numerically higher for the younger subjects (r = .53, p < ,005) than for the older ones ( r = .3l, p < .05), but this difference between older and younger subjects did not reach statistical significance (p = .17). The correlation between severity of gender-disturbance diagnosis (lower number indicating greater severity) and IT Scale test scores (lower number is more feminine) was .64 ( p < ,0005). Those subjects with the most severe diagnoses tended to score towards the feminine end of the scale and those subjects with the less severe diagnoses tended to score towards the masculine end of the scale. The mean IT Scale score for the groups as a whole was 62.51. Correlations between IT Scale scores and the severity of diagnosis was .75 ( p < ,0005, n = 43) for the 3- to 7-~r.-oldgroup, and .47 ( p < .025) for the 8- to 13-yr.-old group. There was a nonsignificant trend (p = .08) for the scores of the younger subjects to be more highly correlated with diagnostic ratings than for those of older subjects. The correlation between percentage of feminine characters used in the M-A-P-S stories and severity of diagnosis was -.35 (pc.005, n = 54); the most severely gender-disturbed subje;ts tended to mention more female characters in their stories while the less severely disturbed subjects tended to mention fewer female characters in their stories. The mean percentage of feminine characters was 44%. The correlation between the percentage of feminine characters used in the severity of diagnosis was numerically higher for the younger subjects ( r = -.43, p
