Box Turtle Bulletin

A George Rekers Case Study: Where Is “Nathan”?

As time went on, George Rekers and his colleagues at UCLA began to investigate other forms of treatment for the gender-variant children that were being brought in to the Neuropsychiatric Institute’s Gender Identity Clinic. One of the things they discovered with Kirk Murphy, “Carl,” and “Wayne,” was that coercing a change in young boys’ outward behaviors in one setting didn’t necessarily translate into changes in other settings. And when the changes occurred, they depended upon other adults meting out demerits and punishments in order to coax the kind of outward behavior they were seeking, while driving the child’s natural personality underground.

There were other challenges as well. Rekers and his colleagues at UCLA had come under intense criticism in the professional literature and in student protest on campus over their use of punitive treatments for “Kraig,” their pseudonym for Kirk. Even Rolling Stone got in on the act with a 1975 investigative article shining a bright spotlight on UCLA and on “Kraig’s” treatment in particular. And so they not only had a practical challenge — how do you get a child to behave the way you want without an adult hovering and watching? — but a public relations one: how do you get a child to behave the way you want without punishing him?

What they needed was a self-monitoring and self-enforcement mechanism so that the child could police himself, rather than having adults policing him. And, they needed a system that involved only rewards and not punishments. That’s where four-year-old “Nathan” comes in:

Nathan was referred at the age of four years, and lived in an intact family with two sisters, aged five years and eleven years. Of etiological significance, Nathan had a chronic blood disorder which required that he remain indoors under very protective circumstances to avoid even mild physical injury. As a consequence. his peer play had been almost exclusively with his two sisters. There was limited interaction between Nathan and his father or any other male figure. He frequently verbalized his wish to be a girl, and identified himself predominantly with female roles, occasionally displaying pronounced feminine voice inflections. Even though both boys’ and girls’ dress-up clothes were available at pre-school. Nathan dressed exclusively in girls’ clothing. His stereotypic feminine gender-role behaviors elicited comments from other children, such as “You can’t be a little girl.” This concerned Nathan’s teacher and parents, and ultimately led to referral for treatment.

Nathan’s case study appeared in the December 1977 issue of the Journal of Behavior Therapy and Experimental Psychiatry. According to Rekers, Nathan was evaluated and found to be extremely effeminate in some ways, but when it came to his choice of games, he was almost equally masculine and feminine in the choices he made — insofar as how Rekers and his colleagues defined “masculine” and “feminine.” The finally settled on a diagnosis of “confused gender identity and moderate cross-gender behavior disturbance,” which didn’t appear in any diagnostic manual anywhere, let alone the APA’s.

For Nathan’s treatment, they decided to try to teach him how to “count” the number of times he played with “boys” toys. The treatment began in the playroom at UCLA, but instead of the mother or another adult wearing an earpiece in order to follow directions from another room, “Nathan” was the one receiving instructions:

The boy wore a wrist counter and was told that although he could play with any toy. he should press the counter only when playing with “boys’ toys.” Each toy was labeled as a “boys’ toy” or a “girls’ toy” for him. Initially the boy was cued with the “bug-in-the-ear” from another room to press the wrist counter after one minute of masculine play. This behavioral cue was gradually faded out by increasing the interval to 2 min. then 6 min. and 8 min. The “bug-in-the ear” device was then removed to increase the feasibility of replicating the procedure at school without the instrumentation.

“Nathan” was given the wrist counter and instructed it to use it when he was in nursery school during play time. He was told that he could play with any toy that he wished, but he couldn’t add points on the wrist counter when he was playing with the girls’ dress-up clothes. Points on the counter meant candy from a dish. After about thirty sessions in the school (Rekers doesn’t say over what period of time this covered), “Nathan” was graduated to “normalcy.” Rekers had another success on his hands. “The present study suggests that self-regulation strategies are effective in producing the same kind of gender role behavior changes previously obtained by social contingency management alone.”

“Social contingency management” is psycho-speak for “the systematic scheduling of consequences of behaviors” — in other words, rewards and punishments. According to this paper, there were no punishments involved, just rewards. But there was still something else involved as well: the stifling of a child’s curiosity and freedom of exploration while playing — even though they found that “Nathan’s” play was well balanced between “feminine” and “masculine.” Success was achieved, according to Rekers, when “Nathan” ceased all “cross-dress-up play” and “feminine role play.” Fortunately, the third goal of the treatment — to get him to stop playing with girls — was abandoned. “The decision was made to allow his frequency of play with girls to continue since it was within the same frequency range as his same-aged peers.”

Reports of follow-ups for “Nathan” were as sparse as they were for  Kirk Murphy, “Carl”, “Paul,” and “Wayne.” At a 1979 conference at the Université du Québec in Montréal, Rekers reported, “Response maintenance of these therapeutic gains was demonstrated by a one-year follow-up evaluation.” In the original paper, Rekers reported interviewing “Nathan’s” parents two years after the treatment ended, and found “gender behaviors within the normal limits.”

Robert Stoller, founder of UCLA’s Gender Identity Clinic, at one point challenged his colleagues to allow their patients to participate in the process of writing and publishing professional papers. It’s a challenge that none of his colleagues took up, leaving us only with the doctor’s word for how things went. There is much about “Nathan’s” case that we don’t know. He was trained to value “masculine” play at the expense of other forms of play, but it’s hard to know how “Nathan” would have internalized those lessons. It’s also hard to say how “Nathan” played when he wasn’t wearing the wrist counter. It appears that Rekers stopped following “Nathan” after the age of seven — or at least stopped reporting on him. This makes “Nathan’s” case an unfinished story, regardless of its ultimate outcome. And so if you remember wearing a wrist counter while you were in nursery school — that can’t be a common memory — we’d really like to hear from you so you can tell us your story.

See Also:
“Carl,” age 8½
“Joan,” age 14
“Nathan,” age 4
“Paul,” age 8
“Wayne,” age 7
And, of course, “Kraig” (Kirk Murphy), age 4