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

Coping with Gender Dysphoria in a Rural Environment during Adolescence

Gender dysphoria is socially more visible and discussed today, but still underdiagnosed. It refers to distress and/or impaired function caused by inconsistency between the sex assigned at birth and gender identification. Clinical manifestations are variable. Lack of training and investment in gender issues make the diagnosis and management in primary care complex, particularly in conservative and isolated communities, with poor access to information and specialized health services. We describe the diagnosis of gender dysphoria and use of a patient centered multidisciplinary and family approach in a 12-year-old rural born adolescent, assigned female at birth. Our aim is to raise awareness of early symptoms and signs of gender dysphoria and problems faced by transgender people and their families during childhood, leading to gender dysphoria, and we hope our successful approach might improve healthcare provision for these patients, particularly in rural areas.

"I feel like I'm living the authenticity of my being": gender identity developmental trajectories of trans youth in Portugal

Background

Research into the identity development of trans people has been emerging, but there is still a need for further study. While significant processes for identity construction take place during late adolescence and early adulthood, it is important to understand which milestones are associated with the trajectories of gender identity (GI) development.

Aims

The present study aimed at exploring the gender identity (GI) developmental trajectories of young Portuguese trans people and the processes associated with them.

Methods

Interviews were conducted with sixteen young people aged between 16 and 26, recruited through LGBTI+ formal associations and informal online groups, as well as through psychology and sexology consultations. The interviews were conducted face-to-face and online and were analyzed through thematic analysis, which aims to identify, analyze and report patterns in a qualitative data series.

Results

Six themes were identified and linked to developmental milestones. These were related to: (1) Discomfort in relation to the gender assigned at birth and its social roles; (2) Body discomfort; (3) Discovery of trans identities; (4) Disclosure of GI; (5) Perceived support; (6) Authentic living of GI. Linked to these themes, four sub-themes were identified as well.

Discussion

Based on the life course theory, moments of transition and turning points were identified, as well as social influences such as historical time and place. Thereby, this study contributed to a better understanding of trans youth's GI developmental trajectories in the Portuguese context, where the study on this topic is still emergent, also contributing to inform the path to be taken at the international level regarding socio-legal policies concerning trans youth.

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.

Examining the Relation Between Gender Nonconformity and Psychological Well-Being in Children: The Roles of Peers and Parents

No study to date has simultaneously tested how poor peer relations, generic risk factors, and parental attitudes impact the behavioral and emotional challenges of children who vary in their gender expression. In a community sample, the present study investigated various hypothesized psychosocial and generic risk factors regarding the association between childhood gender nonconformity (GNC) and psychological well-being. Canadian parents/guardians reported on their children aged 6-12 years (N = 1719, 48.8% assigned male at birth) regarding their child's GNC, measured by the Gender Identity Questionnaire for Children; behavioral and emotional challenges, measured by the Child Behavior Checklist (CBCL); and peer relations, measured by the CBCL and Strength and Difficulties Questionnaire. Parent/guardian gender-stereotypical attitudes toward child-rearing were assessed using an adapted version of the Child-Rearing Sex Role Attitude Scale, and attachment between the parent/guardian and child was measured with an adapted version of the Child-Rearing Practices Report. Based on regression analyses, GNC was related to elevated behavioral and emotional challenges, and this association was stronger for those who experienced poor peer relations as well as for those whose parents/guardians endorsed gender-stereotyped attitudes and were less willing to serve as a secure base for the child. Recommendations are provided for ways in which social environments can be altered to improve psychological well-being among gender-nonconforming children.

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.

How Large Are Gender Differences in Toy Preferences? A Systematic Review and Meta-Analysis of Toy Preference Research

It is generally recognized that there are gender-related differences in children's toy preferences. However, the magnitude of these differences has not been firmly established. Furthermore, not all studies of gender-related toy preferences find significant gender differences. These inconsistent findings could result from using different toys or methods to measure toy preferences or from studying children of different ages. Our systematic review and meta-analysis combined 113 effect sizes from 75 studies to estimate the magnitude of gender-related differences in toy preferences. We also assessed the impact of using different toys or methods to assess these differences, as well as the effect of age on gender-related toy preferences. Boys preferred boy-related toys more than girls did, and girls preferred girl-related toys more than boys did. These differences were large (d ≥ 1.60). Girls also preferred toys that researchers classified as neutral more than boys did (d = 0.29). Preferences for gender-typical over gender-atypical toys were also large and significant (d ≥ 1.20), and girls and boys showed gender-related differences of similar magnitude. When only dolls and vehicles were considered, within-sex differences were even larger and of comparable size for boys and girls. Researchers sometimes misclassified toys, perhaps contributing to an apparent gender difference in preference for neutral toys. Forced choice methods produced larger gender-related differences than other methods, and gender-related differences increased with age.

How Large Are Gender Differences in Toy Preferences? A Systematic Review and Meta-Analysis of Toy Preference Research

It is generally recognized that there are gender-related differences in children's toy preferences. However, the magnitude of these differences has not been firmly established. Furthermore, not all studies of gender-related toy preferences find significant gender differences. These inconsistent findings could result from using different toys or methods to measure toy preferences or from studying children of different ages. Our systematic review and meta-analysis combined 113 effect sizes from 75 studies to estimate the magnitude of gender-related differences in toy preferences. We also assessed the impact of using different toys or methods to assess these differences, as well as the effect of age on gender-related toy preferences. Boys preferred boy-related toys more than girls did, and girls preferred girl-related toys more than boys did. These differences were large (d ≥ 1.60). Girls also preferred toys that researchers classified as neutral more than boys did (d = 0.29). Preferences for gender-typical over gender-atypical toys were also large and significant (d ≥ 1.20), and girls and boys showed gender-related differences of similar magnitude. When only dolls and vehicles were considered, within-sex differences were even larger and of comparable size for boys and girls. Researchers sometimes misclassified toys, perhaps contributing to an apparent gender difference in preference for neutral toys. Forced choice methods produced larger gender-related differences than other methods, and gender-related differences increased with age.

Gendered Peer Involvement in Girls with Congenital Adrenal Hyperplasia: Effects of Prenatal Androgens, Gendered Activities, and Gender Cognitions

A key question in understanding gender development concerns the origins of sex segregation. Children's tendencies to interact with same-sex others have been hypothesized to result from gender identity and cognitions, behavioral compatibility, and personal characteristics. We examined whether prenatal androgen exposure was related to time spent with boys and girls, and how that gendered peer involvement was related to sex-typed activities and gender identity and cognitions. We studied 54 girls with congenital adrenal hyperplasia (CAH) aged 10-13 years varying in degree of prenatal androgen exposure: 40 girls with classical CAH (C-CAH) exposed to high prenatal androgens and 14 girls with non-classical CAH (NC-CAH) exposed to low, female-typical, prenatal androgens. Home interviews and questionnaires provided assessments of gendered activity interests and participation, gender identity, and gender cognitions. Daily phone calls over 7 days assessed time spent in gendered activities and with peers. Girls with both C-CAH and NC-CAH interacted more with girls than with boys, with no significant group differences. The groups did not differ significantly in gender identity or gender cognitions, but girls with C-CAH spent more time in male-typed activities and less time in female-typed activities than did girls with NC-CAH. Time spent with girls reflected direct effects of gender identity/cognitions and gender-typed activities, and an indirect effect of prenatal androgens (CAH type) through gender-typed activities. Our results extend findings that prenatal androgens differentially affect gendered characteristics and that gendered peer interactions reflect combined effects of behavioral compatibility and feelings and cognitions about gender. The study also shows the value of natural experiments for testing hypotheses about gender development.

Gestational exposure to phthalates and gender-related play behaviors in 8-year-old children: an observational study

BACKGROUND

Phthalates, used in a variety of consumer products, are a group of chemicals that are ubiquitous in the environment, and their metabolites are detectable in most humans. Some phthalates have anti-androgenic properties; a prior study reported an association between gestational exposure to phthalates and reduced masculine behaviors in preschool boys.

METHODS

Concentrations of 9 phthalate metabolites were measured in urine collected at 16 and 26 weeks' gestation from pregnant women enrolled in the HOME Study, a prospective pregnancy and birth cohort. Measures of gender-related play were collected at 8 years of age, including the Gender Identity Questionnaire (GIQ) completed by mothers, and the Playmate and Play Style Preferences Structured Interview (PPPSI) completed by children. We examined these measures as continuous variables using both bivariate and multivariable approaches with adjustment for covariates. Additional analyses included logistic regression of GIQ and PPPSI scores dichotomized by sex at the lower 25th percentile, indicating the least typical behavior.

RESULTS

Mothers' phthalate metabolite concentrations during pregnancy were similar to the reported national average among US women. All children scored within a typical range on both measures of gender-related play behavior. No statistically significant associations were found between averaged maternal phthalate metabolite concentrations and continuous PPPSI scores or any GIQ scores. For the dichotomized PPPSI; higher maternal monoethyl phthalate (MEP) concentrations were associated with more typical play behaviors for females (OR = 0.70, CI = 0.51-0.97). In contrast, higher maternal mono-isobutyl phthalate (MiBP) concentrations were associated with higher odds of membership in the least typical play behaviors group for males (OR = 1.69, CI = 1.00-2.86).

CONCLUSIONS

In this sample of typically developing children, higher maternal urinary MEP concentrations during pregnancy were associated with more typical gender-related play behaviors in both males and females, and increased urinary MiBP concentrations were associated with less masculine gender-related play behaviors in males.

Preschool children with gender normative and gender non-normative peer preferences: psychosocial and environmental correlates

We addressed several issues concerning children who show gender non-normative (GNN) patterns of peer play. First, do young children with GNN peer preferences differ from children with gender normative (GN) peer preferences in problem behaviors? Second, do GNN and GN children differ in sociability and isolation and do they have differential socialization opportunities with externalizing, internalizing, and socially competent peers? We employed a Bayesian approach for classifying children as GNN based on their peer preferences as compared to their peers using a sample of Head Start preschool children from a large Southwestern city (N = 257; 53 % boys; M age = 51 months; 66 % Mexican American). To calculate socialization opportunities, we assessed affiliation to each child in the class and weighted that by each peer's characteristics to determine the exposure that each child had to different kinds of peers. GN children of both sexes interacted more with same-sex peers, which may limit learning of different styles of interaction. As compared to GN children, GNN children exhibited more engagement in other-sex activities and with other-sex play partners and GNN children experienced somewhat fewer peer interactions, but did not differ on problem behaviors or social competence. Boys with GNN peer preferences had increased exposure to peers with problem behaviors. GNN girls experienced little exposure to peers with problem behaviors, but they also had little exposure to socially competent peers, which may reduce learning social skills from peers. Implications of these findings for future socialization and development will be discussed.

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.

Prenatal hormones and childhood sex segregation: playmate and play style preferences in girls with congenital adrenal hyperplasia

We investigated playmate and play style preference in children with congenital adrenal hyperplasia (CAH) (26 females, 31 males) and their unaffected siblings (26 females, 17 males) using the Playmate and Play Style Preferences Structured Interview (PPPSI). Both unaffected boys and girls preferred same-sex playmates and sex-typical play styles. In the conflict condition where children chose between a same-sex playmate engaged in an other-sex activity or an other-sex playmate engaged in a same-sex activity, boys (both CAH and unaffected brothers) almost exclusively chose playmates based on the preferred play style of the playmate as opposed to the preferred gender label of the playmate. By contrast, unaffected girls used play style and gender label about equally when choosing playmates. Girls with CAH showed a pattern similar to that of boys: their playmate selections were more masculine than unaffected girls, they preferred a boy-typical play style and, in the conflict condition, chose playmates engaged in a masculine activity. These findings suggest that prenatal androgen exposure contributes to sex differences in playmate selection observed in typically developing children and that, among boys and girls exposed to high levels of androgens prenatally, play style preferences drive sex segregation in play.

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.

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.

Empathy in boys with gender identity disorder: a comparison to externalizing clinical control boys and community control boys and girls

OBJECTIVE

The construct of empathy was examined in 20 boys with gender identity disorder (GID), 20 clinical control boys with externalizing disorders (ECC), 20 community control boys (NCB), and 20 community control girls (NCG). The mean age of the children was 6.86 years (range = 4-8 years). It was hypothesized that boys with GID would show similar levels of empathy to those shown by NC girls and higher levels of empathy than the NC and ECC boys.

METHODS

Three measures of empathy were administered: a maternal-report questionnaire, a self-report questionnaire, and an in vivo evaluation in which children's reactions to pain simulations to two adult actors (mother, experimenter) were coded for empathy levels.

RESULTS

On the maternal report and in-vivo measures, the NC girls had significantly higher empathy levels than the NC boys, but not on the self-report measure. By maternal report, the NC girls were rated as significantly more empathic than were the GID boys, with a "large" effect size. There were no significant differences between the GID boys and the NC girls on the self-report and in-vivo measures and the effect size differences were "small." No significant differences were observed between the GID and NC boys; however, there were "medium" and "small" effect size differences with boys with GID showing more empathy on the in-vivo and self-report measures, respectively. On the maternal-report measure, the GID boys were rated as significantly more empathic than the ECC boys and there was a trend for the GID boys to show greater levels of empathy than the ECC boys on both the self-report and in-vivo measures. The effect size differences on all three empathy measures were "medium" to "large," with GID boys showing more empathy than ECC boys.

CONCLUSION

Empathy as a dispositional characteristic in the genesis and perpetuation of GID in boys is discussed.