Gender identity disorder of childhood. Introduction

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 identity disorder in children and adolescents

Gender identity disorder entered the psychiatric nomenclature in the DSM-III in 1980. This article reviews three domains of empirical research on gender identity disorder in children and adolescents: diagnosis and assessment, associated psychopathology, and developmental trajectories.

The interaction between young people with atypical gender identity organization and their peers

This exploratory study involved the qualitative analysis of the responses of eight children with atypical gender identity organization to open-ended questions about their experiences of secondary school. The aim was to develop an understanding of these young people's interaction with their peers. It became apparent that all but one of the participants had been bullied. In this context, participants reported difficulties in developing friendships, although each participant received support from at least one of their peers. Given the hostile school environment participants did not necessarily talk to these individuals about their experiences in relation to their gender identity. The clinical implications for working with young people on a developing gender identity, and the impact on their mental health, are considered.

Gender identity: a multidimensional analysis with implications for psychosocial adjustment

This study examined the relations between components of gender identity and psychosocial adjustment. The aspects of gender identity assessed were (a) feelings of psychological compatibility with one's gender (i.e.. feeling one is a typical member of one's sex and feeling content with one's biological sex), (b) feelings of pressure from parents, peers, and self for conformity to gender stereotypes. and (c) the sentiment that one's own sex is superior to the other (intergroup bias). Adjustment was assessed in terms of self-esteem and peer acceptance. Participants were 182 children in Grades 4 through 8. Felt gender compatibility (when operationalized as either self-perceived gender typicality or feelings of contentment with one's biological sex) was positively related to adjustment, whereas felt pressure and intergroup bias were negatively associated with adjustment. The results provide new insights into the role of gender identity in children's well-being, help identify sources of confusion in previous work, and suggest directions for future inquiry.

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.

Maternal reports of pregnancy, genital, and related fantasies in preschool and kindergarten children

OBJECTIVE

To test the hypothesis that there is no difference in the proportion of young boys with pregnancy fantasies versus young girls with penis fantasies and to explore the prevalence of pregnancy, genital, and related fantasies in 2-through 6-year-old children.

METHOD

The parents of 171 preschool and kindergarten children attending two private schools in New York City received questionnaires regarding the above fantasies. They were completed by the mothers of 31 girls and 34 boys (overall response rate of 38%).

RESULTS

There was no statistically significant difference in the proportion of girls reported to have penis/gender fantasies and the proportion of boys reported to have pregnancy fantasies. Reports of at least one fantasy were more common for girls (p < .006), as were reports of breast-feeding, other nurturing, and other reproductive fantasies (p < .03) and reports of wanting to urinate like a boy (p < .05). Reports of an "interest" in vaginas and breasts, as opposed to a fantasy about having them, were more common in boys (p < .03).

CONCLUSION

These data support the "overinclusive phase" of Fast's differentiation model of gender identity. Developmentally appropriate androgynous fantasies must be distinguished from gender identity disorder, a psychiatric condition that can emerge in the same age group.

Intersexuality and the diagnosis of gender identity disorder

Problems of gender identity development are the core concern in the psychosocial management of medical conditions involving ambiguous genitalia. This report discusses the difficulties encountered in applying the DSM category and criteria of Gender Identity Disorder (GID) to such patients. Data on prevalence, age of onset or presentation, sex ratio, and associated or predictive factors also suggest marked differences between intersex patients with gender identity problems and nonintersex patients with GID. Patients with intersexuality or similar medical conditions should be excluded from the GID diagnosis.

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.