Gender Identity Disorder
Laura Edwards-Leeper
Norman P. Spack
I. Description of the issue.
Gender refers to the psychological and societal aspects of being male or female and sex refers to the physical aspects.
Gender identity refers to one’s inherent sense of being male or female, regardless of anatomic make-up, and should not be confused with sexual orientation, which refers to the individuals to whom one is sexually or romantically attracted (i.e., to one’s heterosexuality, homosexuality, or bisexuality).
Gender dysphoria refers to the discomfort individuals experience with their biological sex and/or with the gender role assigned to it.
Gender variance is a behavioral pattern of intense, pervasive, and persistent interests and behaviors characterized as typical of the other gender. Gender-variant behaviors in children include play activities, toys and hobbies, clothing and external appearance, identification with role models of other gender, preference for other-gender playmates, and statements that indicate a wish to be of the other sex. This pattern is described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as “gender identity disorder” (GID), although some question whether this diagnostic label is appropriate based on current knowledge.
Transgender is not a formal diagnosis but is an umbrella term that describes individuals whose gender identity is different from their biological sex.
Prepubescent boys with gender variance may, for example, be consumed by an interest in Snow White, or want nothing for their birthday except a new Barbie doll. Their interests tend to be restricted to those that are typically feminine. They may show observable discomfort with typically masculine pursuits and avoid rough-and-tumble play. Similarly, prepubescent girls with marked gender variance typically show distinct discomfort with activities that are typically associated with girls, they may refuse to wear skirts and dresses, and insist that they “want to be a boy.”
Transgender adolescents often appear androgynous, but those who have already transitioned socially may present convincingly as the other gender, wearing opposite gender clothes, including underwear. Biological females may bind their breasts tightly, wear multiple layers to hide breasts, and choose a short haircut. Biological males may wear their hair long and fold their genitalia in an effort to hide or avoid contact with their phallus or testicles. The more physically developed the adolescent is, the more difficult it is for him or her to “pass” as the desired gender without medical intervention.
A. Etiology. GID does not result from a dysfunctional family system, childhood abuse, trauma, or an emotional disorder. However, the debate continues whether GID should remain a psychiatric disorder and be included in the next edition of the DSM. No known anatomical or biochemical disorders exist in transgender individuals, and although some evidence does suggest a biological explanation for transgenderism, a specific biological explanation is elusive.
B. Natural history of gender variance. Gender variance often becomes evident during the preschool period, and most adolescents seeking treatment for the first time have experienced gender dysphoria from an early age. Some report not having had the courage to express their gender dysphoria openly until later because of shame, embarrassment, or fear of others’ reactions. A subset of transgender adolescents does not report gender dysphoria in early childhood. This late onset of transgenderism is somewhat atypical and should be evaluated carefully, but it does not preclude consideration of medical treatment. Research has found that most (80%) preadolescent children with GID are likely to “desist” from a transgender identity when they enter adolescence; many go on to identify as gay or lesbian.
In the past, healthcare professionals saw fewer girls than boys experiencing gender dysphoria; however, this trend has been changing with a ratio closer to 1:1 appearing in recent years. The higher prevalence of genotypic males presenting for treatment previously
could be due to the fact that the range of acceptable gendered behaviors in most modern societies is broader for girls than for boys.
II. Significance of the issue. Transgender children and adolescents are at high risk of anxiety and depression before receiving a medical intervention. Many engage in self-harming behavior and report suicidal ideation and attempts. They often exhibit low self-esteem and a lack of self-worth and report being socially isolated or bullied by peers and adults. Psychological problems typically intensify when transgender children reach puberty, when they cannot escape the reality of their biological sex, which is at odds with their gender identity. Although there are cases of co-occurring psychiatric disorders (e.g., depression, anxiety), these psychological symptoms are often a result of the discomfort transgender individuals feel in their own bodies and the social rejection they experience. It is common for these symptoms to decrease and even disappear after the adolescent begins a social or physical transition to the other gender. Diagnoses of major disorders, especially mood disorders (e.g., major depressive disorder, bipolar disorder) should therefore be reevaluated in this context.
III. Management.
A. Children. Although the gender identity and sexual orientation of individual children with gender variance cannot be predicted with certainty, many of these children will identify themselves as gay, lesbian, bisexual, or transgender (GLBT) as adults. The serious risks that GLBT adolescents often face, such as being misunderstood, harassed, and rejected by others, which often leads to increased psychological problems, may be partly averted if children have the clear knowledge early in childhood that they are loved and accepted for who they are. Therefore, an important role of the pediatric clinician is to provide parents with information and support for diversity in gender roles and behavior, as well as sexual orientation, from early childhood onward. Heterosexual parents may initially know little about or harbor negative views about transgenderism, homosexuality, or bisexuality. However, many, if not most, parents will be able to modify their attitudes over time to support their child. This support will bolster the child’s self-esteem and his or her ability to cope with social stigma. Parents who maintain persistently negative, harsh, and judgmental beliefs should be counseled about the potential effects of their attitudes on their children’s long-term well-being.
When parents initially express concerns about their child’s gender-variant behaviors, pediatric clinicians traditionally have offered reassurance (“Don’t worry, he’ll outgrow it”). But this approach may not be in the best interest of the child and the family. Denial of the child’s differentness deprives families of an opportunity to fully understand and support the child’s needs.
1. Recommended assessment for children. It is often helpful to refer gender variant children to a mental health therapist who has experience working with these issues. However, parents should confirm that the therapist perceives his or her role as one of supporting the child’s development into the gender identity that the child deems as appropriate. A therapist who aims to alter the child’s self-affirmed gender identity will likely cause more psychological and emotional harm than good.
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