Gender-deviant boys compared with normal and clinical control boys

Gender Development in Gender Diverse Children

Within "mainstream" developmental science, gender researchers largely study the developmental trajectory of children considered to be "gender-typical", while research housed primarily in psychiatry and clinical psychology often documents the trajectories of gender diverse children. This article aims to bridge the studies of gender diversity and "mainstream" gender development. First, we review literature on the development of four commonly studied subgroups of gender diverse children - children referred to medical clinics because of their gender identity and expression, transgender children, female children with congenital adrenal hyperplasia, and tomboys - highlighting how these gender trajectories do or do not align with modal developmental patterns. We then describe social, cognitive, and biological determinants of gender in light of their implications for understanding diverse gender development. Finally, we note methodological suggestions for future research, with an eye toward better integrating research on gender diversity into "mainstream" gender development research.

Gender dysphoria in childhood

Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.

Self-Harm and Suicidality in Children Referred for Gender Dysphoria

OBJECTIVE

This study examined rates of self-harm and suicidality (ideation and behavior) in children referred clinically for gender dysphoria compared with their siblings, and referred and nonreferred children from the Child Behavior Checklist (CBCL) standardization sample. Predictors or correlates of self-harm/suicidality were also examined.

METHOD

The sample consisted of 572 gender-referred children, 425 siblings, 878 referred children, and 903 nonreferred children. Parent report for 2 CBCL items was used to assess self-harm and suicidality. CBCL total behavior problems and a metric of peer relationship problems were also used.

RESULTS

The gender-referred children and the referred children from the standardization sample had significantly higher scores than siblings and nonreferred children in terms of self-harm/suicidality, total behavior problems, and poor peer relations. Based on logistic regression analyses, gender-referred children were 5.1 times more likely than nonreferred children to talk about suicide and 8.6 times more likely to self-harm/attempt suicide, even after overall behavior problems and peer relationship problems were accounted for. In the final models, group, older age, and more total behavior problems, but not poor peer relations, were significantly associated with an increased likelihood of self-harm/suicidality.

CONCLUSION

By parent report, children with gender dysphoria show an increased rate of self-harm/suicidality as they get older. This risk was not simply an artifact of the presence of behavioral and emotional problems, although these problems were significant correlates of self-harm/suicidality. Clinicians should routinely screen for the presence of suicidal ideation and behavior in children with gender dysphoria, particularly during the second half of childhood.

Peer group status of gender dysphoric children: a sociometric study

In this sociometric study, we aimed to investigate the social position of gender-referred children in a naturalistic environment. We used a peer nomination technique to examine their social position in the class and we specifically examined bullying and victimization of gender dysphoric children. A total of 28 children (14 boys and 14 girls), referred to a gender identity clinic, and their classmates (n = 495) were included (M age, 10.5 years). Results showed that the gender-referred children had a peer network of children of the opposite sex. Gender-referred boys had more nominations on peer acceptance from female classmates and less from male classmates as compared to other male classmates. Gender-referred girls were more accepted by male than by female classmates and these girls had significantly more male friends and less female friends. Male classmates rejected gender-referred boys more than other boys, whereas female classmates did not reject the gender-referred girls. For bullying and victimization, we did not find any significant differences between the gender-referred boys and their male classmates nor between the gender-referred girls and their female classmates. In sum, at elementary school age, the relationships of gender dysphoric children with opposite-sex children appeared to be better than with same-sex children. The social position of gender-referred boys was less favorable than that of gender-referred girls. However, the gender-referred children were not more often bullied than other children, despite their gender nonconforming behavior.

The playmate and play style preferences structured interview: a comparison of children with gender identity disorder and controls

The present study compared the sex-typed preferences for playmates and play styles in children referred for concerns about their gender identity development (199 boys, 43 girls) with that of controls (96 boys, 38 girls). Each child was administered the Playmate and Play Style Preferences Structured Interview (PPPSI) developed by Alexander and Hines (Alexander, G. M., & Hines, M. (1994). Child Development, 65, 869-879). In the two single dimension conditions (playmates and play styles), the controls significantly preferred same-sex playmates and same-sex play styles whereas the gender-referred children significantly preferred cross-sex playmates and cross-sex play styles. Effect sizes ranged from 1.56-2.78. In the conflict condition (which required a choice between same-sex playmates and cross-sex play styles vs. cross-sex playmates and same-sex play styles), there was a general indication of a hierarchical preference for the preferred play style in the single dimension condition as opposed to the preferred playmate except for the gender-referred boys, who showed an inverted pattern. For the gender-referred group, the PPPSI data were significantly correlated with other measures of sex-typed behavior, providing evidence of predictive validity. The PPPSI also discriminated between probands threshold and subthreshold for the diagnosis of gender identity disorder. The results were discussed in relation to both basic and applied issues in the assessment of sex-typed behavior in children.

Gender divergence in physical education classes

We evaluate a group of students, presumed by their physical education teachers to be gender divergent. This study suggests that PE teachers confuse "gender-divergence" with uncoordinated motor behaviors. This may be because PE classes emphasize motor abilities and coordination and PE teachers may pay particular attention to these characteristics and use them (wrongly) as a criterion for gender divergence. However, the 10 presumed "divergent students" differ from their peers by being more likely to have friends of the opposite sex, interacting with groups of the opposite sex, preferring physical activities typical of the opposite sex, demonstrating less knowledge of sex, preferring interactive rather than collaborative activities and preferring more individual, less complex, less aggressive activities with less body contact.

Measurement of psychosexual differentiation

Since the early 1990s, there has been a surge in interest in the study of infants, children, adolescents, and adults with physical intersex conditions or other congenital conditions that affect, among other things, the configuration of the external genitalia. Regarding psychologic evaluation, an important aspect of both short-term and long-term outcome concerns gender differentiation. This article provides an overview of various measures pertaining to gender identity, gender role, and sexual orientation that have been used in assessment studies of samples of either children and adults with gender identity disorder and/or children and adults with various physical intersex conditions. All of the measures have good psychometric quality although some have been studied more systematically than others. It is hoped that this overview will provide a template for the new generation of studies that are looking at both gender development and sexual orientation in people born with physical intersex conditions.

Sibling sex ratio of boys with gender identity disorder

Sibling sex ratio (the ratio of brothers to sisters) was calculated for 444 boys with gender identity disorder (or with behaviors consistent with this diagnosis). The probands were ascertained from several researchers with expertise with this disorder and from the English language case report literature between 1938 and 1995. Among the probands with at least one sibling (N = 333), the results showed that boys with gender identity disorder had a significant excess of brothers to sisters, 131.1:100, when compared with the expected secondary sex ratio of 106:100. The excess of brothers replicated a previous study by Blanchard, Zucker, Bradley, and Hume (1995), in which the sibling sex ratio was 140.6:100. Further analyses showed that the probands were born later relative to their brothers than they were relative to their sisters. These findings are amenable to several psychosocial and biological explanations, which require further investigation.

Traits of separation anxiety in boys with gender identity disorder

OBJECTIVE

To assess the presence of traits of separation anxiety disorder in boys referred clinically for gender identity disorder.

METHOD

One hundred fifteen boys were referred to a specialty clinic for concerns about their gender identity development. They were divided into two subgroups: one group met the complete diagnostic criteria for gender identity disorder; the other group did not meet the complete diagnostic criteria. The mothers of the boys were administered a structured interview schedule pertaining to separation anxiety disorder according to DSM-III criteria.

RESULTS

A conservative definition of separation anxiety disorder showed no significant association with gender identity disorder; however, a liberal definition of separation anxiety disorder showed that it occurred significantly more often in the subgroup of boys who met the complete criteria for gender identity disorder than in the subgroup who did not meet the complete criteria (64.4% versus 38.1%, respectively).

CONCLUSIONS

Boys with gender identity disorder show a high rate of co-occurring traits of separation anxiety. Reasons for this linkage require additional empirical study.

Mothers of boys with gender identity disorder: a comparison of matched controls

This pilot study compared mothers of boys with gender identity disorder (GID) with mothers of normal boys to determine whether differences in psychopathology and child-rearing attitudes and practices could be identified. Results of the Diagnostic Interview for Borderlines and the Beck Depression Inventory revealed that mothers of boys with GID had more symptoms of depression and more often met the criteria for Borderline Personality Disorder than the controls. Fifty-three percent of the mothers of boys with GID compared with only 6% of controls met the diagnosis for Borderline Personality Disorder on the Diagnostic Interview for Borderlines or had symptoms of depression on the Beck Depression Inventory. Results of the Summers and Walsh Symbiosis Scale suggested that mothers of probands had child-rearing attitudes and practices that encouraged symbiosis and discouraged the development of autonomy.

Gender identity disorder and psychosexual problems in children and adolescents

This article provides a selected overview of the literature on gender identity disorder and psychosexual problems in children and adolescents, with a focus on diagnosis, clinical course, etiology, and treatment.

Childhood photographs of homosexual and heterosexual men

20 homosexual men and 20 heterosexual men, including a pair of discordant identical twins, contributed photographs of themselves at 6 mo. to 6 yr. of age for judging on personality. 18 traits were rated successfully. Factor analysis yielded two factors, Extroversion and Toughness. Data for only 19 homosexual and 11 heterosexual men were usable for the t tests; no significant differences were found, although trends for the homosexual group suggested less Extroversion and less Toughness. For the twins, photographs the mother identified as the homosexual twin were rated as showing less Extroversion and less Toughness. In conclusion, no obvious differences were found in the ratings of homosexuals' childhood photographs but slight differences were hinted at.

Indices of psychopathology in the Rorschachs of boys with severe gender identity disorder: a comparison with normal control subjects

Recent clinical and empirical studies of boys with Gender Identity Disorder (GID) of Childhood suggest that severe behavioral disturbance exists beyond their feminine preoccupations. This study examines the thought organization and object representational paradigms of a sample of GID boys (n = 26) in a blind comparison with a normal subgroup (n = 18). Rorschach test protocols were used to compare the groups along these two more internal measures of personality organization. As hypothesized, the GIC group was found to have more pathological scores than the normal group on the Mutuality of Autonomy (MOA) Scale and a thought disorder hierarchy. The findings suggest that GID boys do not suffer solely from gender symptomatology but are disturbed in other aspects of their ego functioning as well.

Is early effeminate behavior in boys early homosexuality?

This report continues the study of early effeminate behavior in boys. A previous article reported on the long term follow-up of 55 boys and the resulting outcome in homosexuality. In this paper an effort is made to explore further the nature of the connection between childhood effeminate behavior and adult homosexuality. Individual signs are discussed with regard to relevant aspects of their development. It is concluded that early effeminate behavior is not merely a forerunner of homosexuality in that it forecasts homosexuality, but that is is in fact the earliest stage of homosexuality itself.

Two subgroups of gender-problem children

Gender-referred children who met the DSM-III diagnostic criteria for gender identity disorder of childhood (n = 21) and gender-referred children who did not meet these criteria (n = 15) were compared with regard to demographic, gender role, and behavioral disturbance information. As judged by parental questionnaires and behavioral tests, the cross-gender role behavior of gender-referred children who met the DSM-III criteria was generally more extreme than that of their non-DSM-III counterparts. These two diagnostically defined subgroups did not, however, differ in the degree of their behavioral and emotional disturbance. The DSM-III children were significantly younger than the non-DSM-III children, but the extent to which the disparity in age accounted for the gender role differences appeared equivocal. The implications of these findings for the diagnosis and assessment of gender-referred children are discussed.

Sex-typed play in gender-disturbed children: a comparison to sibling and psychiatric controls

Gender-disturbed children (n = 14) were compared to their preadolescent siblings (n = 16) and psychiatric controls (n = 13) on a sex-typed free-play task previously shown to differentiate gender-disturbed boys from normal boys. On three separate trials totaling 20 minutes, the gender-disturbed children played for a significantly longer period of time with cross-sex toys and for a significantly shorter period of time with same-sex toys than did the two control groups. The gender-disturbed children also showed greater trial-to-trial consistency in their play preferences than the other two groups. The utility of this task in the assessment of childhood gender disturbance is discussed. In addition, the results are discussed in relation to a number of perspectives regarding both typical and atypical gender identity development in childhood.

Patterns of intellectual functioning and spatial ability in boys and gender identity disorder

Preadolescent boys with Gender Identity Disorder (N = 13), their brothers (N = 8) and boys referred for psychiatric assessment (N = 10) were administered age-appropriate Wechsler intelligence scales. Four hypotheses regarding patterns of intellectual functioning and spatial ability were tested. A previous suggestion that the development of boyhood femininity is associated with higher than average IQ was not supported, since the IQs of the feminine boys and their brothers did not differ. A report of enhanced verbal ability as compared with perceptual organization also was not replicated in these feminine boys. On Kaufman's "Freedom from Distractibility" factor, the feminine boys and their brothers obtained scores as low as the psychiatric controls; that is, all three groups were equally distractible. It was suggested that anxiety contributed to poor performance on this factor. Unlike the control groups, the feminine boys obtained low scores on a test of spatial ability (Block Design) as compared to their scores on a verbal task (Vocabulary). The association between a feminine gender role and relatively poor spatial ability was discussed.

The science of sex research: some methodological considerations

This paper represents a review of substantive theoretical, methodological, and statistical issues relevant to conducting research on human sexual behavior. Guidelines for maintaining rigor and precision in future investigations are also proposed. So as to able to address issues that pervade all research on human sexual behavior, six topic areas are discussed: theory-related issues, issues involving research design, issues involving subject selection, measurement issues, data-analytic issues, and issues concerned with human-subject protection. The ultimate objective of this paper is to make suggestions aimed at improving the quality of research on human sexual behavior.

Gender typing of game choices and qualities of boys' play behavior

Relationships between gender choices and both movement patterns and social behavior were studied in first- and second-grade boys. Three-child, structured play groups were each composed of a boy whose mother saw him as high masculine in play preference on the Games Inventory, one seen as average, and one low masculine. Behaviors rated from videotapes included gender presentation variables, (e.g., leg separation), indicators of dominance and personal comfort (e.g., range of movements), and indicators of social skill and peer response (e.g., interaction initiations). The low masculine boys were found to be the most feminine in their gender presentation, least dominant and aggressive, and the lest socially successful of the boys. The greatest difference was between the low and the high masculine boys. The average masculine boys' scores were generally intermediate, but more similar to the low masculine boys on some variables and more similar to the high masculine boys on others. These conclusions apply to a grou interaction play task, but not to an initial noninteractive play task. A secondary study in which girls played with low and average masculine boys is also reported. Here it was found that low masculine boys were generally intermediate between average boys and girls on gender presentation and dominance variables, but lowest of the groups on social interaction variables.