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

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.

Measurement tools for gender identity, gender expression, and gender dysphoria in transgender and gender-diverse children and adolescents: a systematic review

Increasing numbers of children and adolescents are being referred to gender services for gender-related concerns. Various instruments are used with these patients in clinical care, but their clinical validity, strengths, and limitations have not been systematically reviewed. In this systematic review, we searched MEDLINE, PubMed, and PsycINFO databases for available tools that assess gender identity, gender expression, or gender dysphoria in transgender and gender-diverse (TGD) children and adolescents. We included studies published before Jan 20, 2020, that used tools to assess gender identity, expression, or dysphoria in TGD individuals younger than 18 years. Data were extracted from eligible studies using a standardised form. We found 39 studies that met the inclusion criteria, from which we identified 24 tools. The nature of tools varied considerably and included direct observation, child and adolescent self-report, and parent-report tools. Many methods have only been used with small samples, include outdated content, and lack evaluation of psychometric properties. In summary, a paucity of studies in this area, along with sparse reporting of psychometric properties, made it difficult to compare the relative use of tools, and current tools have substantial limitations. Future research is required to validate existing measures and create more relevant, culturally appropriate tools.

A Follow-Up Study of Boys With Gender Identity Disorder

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

Gender Encoding in Gender Diverse and Gender Conforming Children

Previous research suggests that people encode gender starting in childhood. The present research asked whether gender diverse children (i.e., children whose gender identity or expression differs from that expected based on assigned sex) encode gender. Results showed that 3- to 5-year-old gender diverse participants (N = 71), siblings of gender diverse children (N = 52), and gender conforming controls (N = 69) did not significantly differ in degree of gender encoding. These results converge with prior research to suggest that gender diverse children process gender in ways that do not differ from gender conforming children, and provide further evidence that gender encoding may be a common aspect of person perception in societies that support a binary view of gender.

A developmental, biopsychosocial model for the treatment of children with gender identity disorder

This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto. The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provide clinical examples of how the model is used in the treatment.

Assessment of gender variance in children

This article focuses on the assessment of children who display gender-atypical behavior and, perhaps, identity. The aim is to provide an overview of assessment techniques that can be used clinically with children who show this behavioral pattern and that complement the routine use of DSM-IV criteria for the diagnosis of gender identity disorder in clinical practice. It will also provide an overview of some common approaches to the assessment of other types of behavioral and socioemotional issues that may require clinical attention in these youngsters.

Gender monitoring and gender reassignment of children and adolescents with a somatic disorder of sex development

Individuals born with a somatic disorder of sex development (DSD) have high rates of gender-atypical behavior, gender uncertainty, gender dysphoria, and patient-initiated gender change in childhood, adolescence,and adulthood. This article addresses the issues a mental health services provider has to consider in evaluating and assisting such patients and provides examples of assessment-method batteries. To date, the World Professional Association for Transgender Health's Standards of Care, 6th version, for non-DSD patients with gender dysphoria, may be cautiously used for guidance, taking into account the considerable differences in presentation and medical context between gender dysphoric patients with and without a DSD.

The DSM diagnostic criteria for gender identity disorder in children

In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as "disorder," as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.

Gender role behavior in children with XY karyotype and disorders of sex development

Children exhibit gender-typical preferences in play, toys, activities and interests, and playmates. Several studies suggest that high concentrations of pre- and postnatal androgens contribute to male-typical behavior development, whereas female-typical behavior develops in the absence of high androgens levels. This study aims to explore the consequences of hypoandrogenization on gender-typical behavior in children who have an XY karyotype and disorder of sex development (DSD). Participants included 33 children (ages 2-12 years) with an XY karyotype and DSD; 21 reared as girls and 12 reared as boys. Children's preferred activities and interests and playmate preferences were assessed with parent report questionnaires, a structured free-play task, and choice of a toy to keep as a gift. Participant's responses were compared to those of children recruited in a pre-school and elementary school survey (N=166). In this study, the degree of hypoandrogenization as indicated by genital stage and diagnosis showed a significant relationship to nearly all of the gender-related behaviors assessed, supporting the hypothesis that masculinization of gender role behavior is a function of prenatal androgen exposure. Despite the fact that children with partial androgen effects reared as girls showed increased "boyish" behaviors, they did not show increased signs of gender identity confusion or instability on a group level. We conclude that androgen exposure plays a decisive role in the development of gender-typical behavior in children with XY karyotype and DSD conditions.

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.

"Any decision is better than none" decision-making about sex of rearing for siblings with 17beta-hydroxysteroid-dehydrogenase-3 deficiency

Children with 17beta-hydroxysteroid-dehydrogenase-3 (17beta-HSD-3) deficiency have a defect of testosterone biosynthesis with subsequent diminished virilization in XY individuals. Some are raised as girls and some as boys. There were two purposes of this case report: First, it analyzed the process of decision-making in a family with a pair of siblings with identical mutations leading to 17beta-HSD-3 deficiency whose parents chose to raise one child as a boy and one as a girl. This analysis was based on narrative interviews with the parents. Second, we assessed the gender role behavior and gender identity in the children to examine if the psychosexual development of these children correspond with the sex of rearing their parents chose. When participating in the study, the children were 7 (boy) and 5 (girl) years old. Parents described a difficult process of decision-making and voiced concerns about lack of appropriate and understandable information, and anticipated decision regret. However, they did not feel that the decision to "normalize" the external genitalia should have been deferred. Both children appeared to show age-typical gender-related behavior and did not show any signs of physical or mental distress.

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.

Adoptee overrepresentation among clinic-referred boys with gender identity disorder

OBJECTIVES

To test the hypothesis that adoptees are overrepresented among a sample of clinic-referred boys with gender identity problems (N = 238). To compare the adoptees and nonadoptees on demographic, behaviour problem, and gender-typed measures.

METHOD

The percentage of clinic-referred boys with gender identity problems adopted in the first 2 years of life ("early adoptees") was compared to the base rate of boys adopted in Ontario. Parent-report and behavioural measures were used to compare the early adoptees with "late adoptees" (adopted after the second year of life) and nonadoptees.

RESULTS

The percentage of boys with gender identity problems who were early adoptees (7.6%) was significantly higher than the base rate of males adopted in Ontario in the first 2 years of life (1.5%). Both the early and late adoptees were significantly less intelligent than the nonadoptees. The early adoptees also had significantly higher externalizing T scores on the Child Behavior Checklist than did the late adoptees and the nonadoptees. The 3 groups did not differ in the percentage who met the complete Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for gender identity disorder and on 4 other measures of gender-typed behaviour.

CONCLUSION

Adoptees are overrepresented among clinic-referred boys with gender identity problems. The reasons for this finding are not clear but may be accounted for by general risk factors that increase the likelihood of clinical referral or by psychosocial and biological factors associated with adoption.

Sex differences in referral rates of children with gender identity disorder: some hypotheses

From 1978 through 1995, a sex ratio of 6.6:1 of boys to girls (N = 275) was observed for children referred to a specificity clinic for gender identity disorder. This article attempts to evaluate several hypotheses regarding the marked sex disparity in referral rates. The sexes did not differ on four demographic variables (age at referral, IQ, and parent's social class and marital status) and on five indices of general behavior problems on the Child Behavior Checklist; in addition, there was only equivocal evidence that boys with gender identity disorder had significantly poorer peer relations than girls with gender identity disorder. Although the percentage of boys and girls who met the complete DSM-III-R criteria for gender identity disorder was comparable, other measures of sex-typed behavior showed that the girls had more extreme cross-gender behavior than the boys. Coupled with external evidence that cross-gender behavior is less tolerated in boys than in girls by both peers and adults, it is concluded that social factors partly account for the sex difference in referral rates. Girls appear to require a higher threshold than boys for cross-gender behavior before they are referred for clinical assessment.

Evidence of sex-specific differences in masticatory jaw movement patterns

The complexity of human oral functional movements has not been studied in detail quantitatively, and only recently have studies begun to evaluate whether such movements contain sex-specific characteristics. Therefore, the purposes of this study were: (1) to quantify in detail the jaw movements and associated masticatory electromyographic activity occurring during gum chewing, and (2) to explore these data for evidence of sex specificity. Fourteen male and 17 female subjects participated in the study. Approximately 11 right- and 11 left-sided chewing cycles and associated masticatory electromyographic activity were sampled from each subject. The samples were quantified into 165 variables per chewing cycle, averaged to create a single multivariate vector for each subject, and then analyzed by a step-wise discriminant analysis. With a combination of 6 variables, a jackknifed cross-validation test found the probability of correct classification to be 93.5%. These findings support the hypothesis that masticatory jaw movements contain sex-specific features.

Sex-typed responses in the Rorschach protocols of children with gender identity disorder

A coding system was developed to measure sex-typed responses in the Rorschach protocols of children with gender identity disorder (n = 79). Their responses were compared to that of sibling (n = 25), psychiatric (n = 26), and normal (n = 28) controls. Results show that children with gender identity disorder gave significantly more cross-sex responses than same-sex responses, whereas the psychiatric and normal controls gave significantly more same-sex responses than cross-sex responses. The siblings did not differ in the number of same-sex and cross-sex responses. Results are discussed with regard to various assessment issues in the study of children with gender identity disorder.

The relationship of measures of sex-typed play with clinician ratings on degree of gender disturbance

Forty-nine boys, aged 3 to 11 years, who were referred for an evaluation of a potential gender identity disorder of childhood, were assessed with a standardized in vivo behavioral observation of sex-typed play in an alone condition and with the parent-report Bates-Bentler Games Inventory. Without access to these measures of sex-typed play, an independent clinical psychologist rated each of the subjects on a 9-point scale that indicated the degree of severity of a gender disturbance, based upon child and parent interviews and a complete psychological test battery. The percentage of feminine play in the behavioral observation procedure was found to be correlated significantly with the clinician rating of degree of gender disturbance (r = .55). The Games Inventory was found to differentiate significantly the gender-disturbed boys from the nonclinical reference group on its feminine/preschool games, masculine nonathletic games, and athletic games subscales and on its composite index of feminine play preference; however, only the composite index (and none of the 3 subscales) was correlated significantly (r = .34) with degree of severity of gender disturbance.

Effects of neutral toys on sex-typed play in children with gender identity disorder

This study assessed the relative influences of approach and avoidance behaviors toward same-sex and cross-sex toys in the play of children with gender identity disorder and in normal boys, normal girls, and psychiatric controls. Three forced-choice situations with toys and three forced-choice situations with dress-up apparel were presented that paired same-sex and cross-sex stimuli, same-sex and neutral stimuli, and cross-sex and neutral stimuli. In the same-sex/cross-sex situation, the gender-disordered group played a significantly shorter time with the same-sex stimuli and a significantly longer time with the cross-sex stimuli than the normal boys and the psychiatric controls, whereas the play patterns of the normal girls fell in between that of the gender-disordered group and the two control groups. Within-groups analyses showed that the normal boys and the psychiatric controls preferred the same-sex toys, whereas the gender-disordered group and the normal girls showed no preference. When the neutral toys were the alternative, avoidance of cross-sex toys appeared to be stronger than the attraction to same-sex toys in the normal boys and in the psychiatric controls. The relative influence of approach-avoidance tendencies was more equivocal in the gender-disordered group, though they appeared to have a weaker attraction to same-sex toys and less avoidance of cross-sex toys in comparison with the normal boys and the psychiatric controls. The approach-avoidance patterns of the normal girls fell in between that of the gender-disordered group and the other two control groups.

Perinatal factors in the development of gender-related play behavior: sex hormones versus pregnancy complications

This report addresses the question of biological factors that may contribute to the development of gender-typical and gender-atypical play behavior. In lower mammals, sex differences in juvenile behavior are to a considerable extent determined by organizational effects of prenatal or perinatal androgenic hormones. Birke and Sadler (1983) showed that not only perinatal androgens but also progestogens such as medroxyprogesterone acetate (MPA) affect (in this case: demasculinize) the play behavior of both sexes in the rat. Here, we report on a study of sex-dimorphic play behavior of children born from pregnancies that were treated with various sex hormones. The Child Game Participation Questionnaire (Bates and Bentler 1973) was administered to 13 boys and 15 girls prenatally exposed to MPA, 22 boys and 15 girls exposed to a variety of synthetic progestogens or estrogens singly or in combination, and to pair-matched control subjects, all between 8 and 14 years old. Pregnancy complications were assessed by two scores, 1) "Pregnancy Complications Summary Score (excluding bleeding)," 2) "Vaginal Bleeding During Pregnancy." The results of paired t-tests showed a number of hypomasculinization effects for the hormone-exposed groups. Controlling for the effects of pregnancy complications and age at study by exploratory hierarchical multiple regression analysis indicated that these variables did not account for the hormone-exposure effects. Our results provide further evidence that prenatal hormones influence the sex-dimorphic play behavior of human children in the same direction as that of other mammals.

Gender dysphoria in a child with true hermaphroditism

This case report describes the psychosexual development of a child with true hermaphroditism who was assigned to the male sex at birth, but reassigned to the female sex at age two months. Given this child's excessive exposure to male sex hormone in utero, relative to physically normal females, one would predict a biological predisposition to behave in a masculine manner. This has occurred since two years of age. In addition, this child has had periodic episodes of gender disturbance, dysphoria, and ambivalence. In contrast, a physically normal fraternal twin sister has been conventionally feminine. A number of psychosocial factors appeared to have exacerbated the biologic predisposition to behave in a masculine manner, and thus may have been responsible for "pushing" this child into varying degrees of gender identity conflict. These included a closer father-daughter than mother-daughter relationship, parental tolerance of cross-gender behavior, and a mother who has been psychologically disturbed since the birth of her children. The heuristic value of this case will be discussed in relation to contemporary models of psychosexual development which emphasize the interaction of biological and psychosocial factors.

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.

Patterns of gender-role behaviour in children attending traditional and non-traditional day-care centres

Using a sex-typed free-play task and the Draw-a-Person test, the gender-role behaviour of children attending a day-care centre whose staff adhered to a "non-sexist" child-rearing philosophy was compared to the gender-role behaviour of children attending a more traditional day-care center. Parental provision of sex-typed and neutral toys and approval of cross-sex role behaviour was also assessed. On both measures, the two groups of children showed culturally typical patterns of gender-role behaviour. The parents of the two groups of children were generally similar in terms of the kinds of toys they provided and in their attitudes toward the expression of cross-sex role behaviour. Potential explanations for the inability to demonstrate effects of the "non-sexist" child-rearing philosophy were discussed.

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.