▪ Gender Identity Disorder

Genetic sex is determined at the moment of conception. For typically developing children, an awareness of core gender identity (one’s sense of inner sexual identity) begins to develop early in life and is usually firmly in place by age 3 years. Expectations based on sex roles vary depending on cultural, familial, and ethnic expectations along with observation and imitation. The typical preschool child is typically very aware of the differences between the sexes, and this interest can be expressed in play. Since the time of Freud, interest in sexuality and in children’s understanding of sexuality and gender has been the focus of considerable attention by psychologists (see Chapter 2 and Martin et al., 2002, for a review).

Research on children with various intersex conditions has made it clear, however, that gender identity is very strongly a function of how the parents perceive the child’s external genitalia and consequently assign a sex to the infant and how they subsequently raise the child in the context of social expectations. The work of Money et al. (1957) and others demonstrated that children with intersex conditions can develop secure gender identity if clearly reared as belonging to one gender. On the other hand, studies of sexuality in adults with transsexualism have also made it clear that gender issues are often expressed early in life in these individuals.

DEFINITION AND CLINICAL DESCRIPTION

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) approach, crossgender identification must be “strong and persistent” and not simply a result of some presumed advantage to being the other sex. This identification is also associated with continued discomfort about the person’s assigned gender or gender role as well as impairment or distress. The condition is not made if a physical intersex condition is present. For children, multiple features of gender identity must be present (e.g., cross-dressing, stated desire, participation in stereotyped activities of other sex, persistent choice of other sex role in play). The DSM system allows for specification of the nature of sexual attraction (male, female, both, neither) in sexually mature individuals and notes that in adolescents, the individual may cross-dress or otherwise engage in activities typical of the other sex.

Typically, the onset of gender identity disorder (GID) is during the first years of life. From the point of the DSM-IV-TR, a critical issue is the degree to which “strong and persistent” signs of cross-gender identification are present and associated with enduring discomfort with
the person’s gender (or assigned gender). It is not uncommon for features of GID to be present but not of sufficient severity for the diagnosis to be firmly established.

When adolescents present for evaluation of GID, two major subgroups are noted. In one group, the adolescent (both males and females) had a pattern of onset beginning early in childhood and persisting; often, this pattern is associated with a homosexual sexual orientation. In the other group, the adolescent’s, almost always male, cross-gender features were not apparently present during childhood (i.e., the condition apparently has its onset in adolescence); these individuals may have various sexual orientations or may be asexual.

Boys with GID are typically preoccupied with, and engage in, activities traditionally viewed as more typically feminine (e.g., dressing in women or girls’ clothes, playing games that center on more traditionally “feminine” themes). They may play with dolls and may play more with girls than with boys. They often seem to avoid more stereotypically male activities (e.g., more physical and aggressive play sports, interests, and activities). They may also voice a wish that they had been born a girl or that they truly are a girl. On some occasions, they may report the feeling that their male genitalia are disgusting or pretend, for example, that they do not have a penis.

Similarly, girls with GID typically have strong feelings against engaging in more stereotypically female activities. They may voice the wish to be a boy, may dress in boy’s clothes, and may try to appear to look more like a boy. There play often is more focused on activities with boys with more stereotypically male play activities, fantasy figures, and so forth. Often, they have little interest in more sex stereotyped activities of other girls with little interest in dolls or taking feminine roles in play. The girl may claim that she will develop a penis and may voice aversion to bodily changes associated with adolescence. Fantasies and play typically revolve around opposite-sex themes.

Adults with GID may be very uncomfortable with their assigned sex or physical appearance and may seek to change this either through hormonal or surgical means. Often, these individuals adapt, to some degree, clothing and mannerisms typical of the other sex. Sometimes they are highly successful in assuming the role of the other sex.

Sometimes the diagnosis is difficult to make in children and adolescents and becomes clear only over time. Particularly in our society, where sex roles and their perception have changed
markedly in recent decades, children and adolescents may assume aspects of more stereotypically “female” or “male” presentations, and this clearly does not, of itself, necessarily qualify as pathological. Indeed, it can be an important aspect of identity consolidation for the adolescent (e.g., a teenage boy who is interested in caretaking other children or a girl who engages in highly competitive sports).

Case Study: Gender Identity Issues in a Boy

The parents of Bob, a 61/2-year-old boy, sought consultation because of his apparent preoccupation with feminine activities. He had long expressed an interest in cross-dressing and more stereotypically “girl” activities. He avoided rough and tumble play. His father was often absent from the home, and his mother described herself as “at a loss as to how to raise a boy.” The mother overtly expressed the wish that Bob had been born a girl and that she had picked out another name for him (Roberta) before his birth.

At the time of his initial assessment, Bob expressed, both in play and drawings, an interest in being a girl. At school, he tended to play only with girls. Interestingly, his parents had described a pattern of odd interests and social interaction early in life, along with speech delay, that had led to an earlier diagnosis of pervasive development disorder not otherwise specified. Part of the stimulus for the present assessment had been the growing concern on the part of parents and teachers about Bob’s relative social isolation, which only seemed to increase over time even though social skills training and other educational interventions had appeared to be of significant benefit for his social problems.

Over time, Bob became a somewhat eccentric and reclusive adolescent. He never had strong sexual feelings and as a young adult continued to live with his parents and was asexual with few friends and social interactions other than with colleagues at work and with family members.

Case Report: Gender Identity Issues in a Girl

Kara came for assessment at 12 years of age. She had a long history of being unhappy with her gender. She typically related better to boys than girls and was more likely to play with boys. Her parents had thought of her as a “tomboy” from early on. They became more concerned as adolescence approached and she refused to talk to her mother about menarche, almost never was willing to wear a dress or put on makeup, and so forth. Part of the parental concern, as well, was the worry that she might have a lesbian sexual orientation.

At the time of her initial assessment, Kara expressed a strong feeling that she was really a boy trapped in the body of a girl. She expressed disgust with her developing secondary sex characteristics.

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