• There are two basic criteria for the diagnosis of gender identity disorder (GID): A strong and persistent cross-gender identification and persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex. GID is not simply a child’s nonconformity to conventional sex roles but a significant and pervasive disturbance in the child’s view of himself or herself. The disturbance is generally severe enough to disrupt both familial and social interactions.

DSM-IV-TR Diagnostic Criteria

Gender Identity Disorder

1. 
   

   A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

   
   

   In children, the disturbance is manifested by four (or more) of the following:

   
   
   
   
   1. 
      

      repeatedly stated desire to be, or insistence that he or she is, the other sex

   
   
   
   
   2. 
      

      in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

   
   
   
   
   3. 
      

      strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

   
   
   
   
   4. 
      

      intense desire to participate in the stereotypical games and pastimes of the other sex

   
   
   
   
   5. 
      

      strong preference for playmates of the other sex

   
   

   In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reaction of the other sex.

   
   
2. 
   

   Persistent discomfort with his or her sex or sense of the inappropriateness in the gender role of that sex.

   
   

   In children, the disturbance is manifested by any of the following: In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

   
   

   In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics in such a way as to simulate the other sex) or belief that he or she was born the wrong sex.

   
   
3. 
   

   The disturbance is not concurrent with a physical intersex condition.

   
   
4. 
   

   The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(Adapted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)

Epidemiology

GID is an infrequent disorder. Boys are referred for evaluation and treatment of GID more often than girls. This may be due, in part, because our society is less tolerant of cross-gender behavior in boys than in girls. In European countries the prevalence of adult GID (which is also called transsexualism) has been estimated as 1 in 30,000 for men and 1 in 100,000 in for women.

Etiology

The etiology of GID is probably multifactorial. Overall, much more attention has been paid to the etiology and treatment of the disorder in boys, most likely owing to the greater social stigma attached to gender-atypical behavior in boys. However, recent studies have examined gender-atypical behaviors in girls as compared with boys. The disorder is located at the extreme of a continuum that begins with mild gender-atypical behavior through gender dysphoria and on to gender identity disturbance.

As with most psychiatric disorders, the etiology is probably best comprehended by a biopsychosocial approach. Research on the biological issues involved in this disorder have not yielded clear conclusions. Animal models suggest that prenatal hormonal influences play a significant role in gender-specific behavior. Although the significance is not clear, it has been found that boys with GID tend to have a higher rate of left-handedness, an excess of brothers to sisters, and a later birth order. It has been proposed that a mother who has multiple sons might produce antibodies to the male fetus resulting in reduced masculinity.