Gender identity disorder in children and adolescents
Richard Green
Variance in psychosexual development
Psychosexual development of sex-typed behaviours spans a broad mix of the elements that comprise ‘masculinity’ and ‘femininity’. The possibility for variation is extensive. Among males, there are boys and men whose stereotypical masculinity may pose problems in mental health and criminality. They are not the focus here. Rather, here it is the marked deviation from the mean towards the ‘non-masculine’ or ‘feminine’ extreme. That pattern can also cause clinical concern and constitutes gender identity disorder (GID) as manifested in childhood. For females, conventional ‘tomboyism’ is not the focus here, but rather the extreme that can cause clinical concern and constitutes GID.
Epidemiology
No epidemiological studies exist of GID in children. Prevalence can be estimated only roughly from indirect sources. Two items on the Child Behaviour Checklist(1) are consistent with components of the diagnosis. They are ‘behaves like opposite sex’ and ‘wishes to be of opposite sex’. Among 4- to 5-year old boys, not clinically referred for behavioural problems, about 1 per cent of parents answer in the affirmative that their child ‘wishes to be the opposite sex’. For ages 6 to 7 it drops to near zero, but rises to 2 per cent at age 11. For girls, the highest rate was 5 per cent at ages 4 to 5, but less than 3 per cent for other ages. With respect to ‘behaves like opposite sex’, among the boys the rate was 5 per cent and among girls 11 per cent for all ages. However, these data do not indicate any longitudinal aspect of the reported behaviour, and do not detail the behaviour.(2)
An alternative source of estimation looks to the percentage of adults believed to be homosexually oriented. From this population the percentage of homosexual men and women who typically report childhood cross-gender behaviour is used for the estimate. If the rate of exclusive homosexuality is 3 to 4 per cent for men and 1.5 to 2 per cent for women,(3) with perhaps half of homosexual men and women recalling childhood cross-gender behaviour,(4,5) the estimate of childhood cross-gender behaviour is about 3 per cent for boys and under 1 per cent for girls. However, this estimate suffers from problems of retrospective recall and poor comparability between surveys of adults. Further, the recalled behaviour may not have constituted GID.
A disparate sex ratio is evident in referral rates with GID. Four to five boys to one girl are referred. One reason may be greater parental concern over cross-gender behaviour in boys and the greater stigmatizing peer group response to ‘sissiness’ than to ‘tomboyism’. An alternative explanation is that, as with most atypical patterns of sexuality, there is a higher ratio of males to females reflecting a common intrinsic predisposition among males.
Clinical picture
Children with GID differ from other children, including those who merely are not conventionally masculine or feminine as boys or
girls. Their behaviours are typical of other-sex children. Not only do they express a wish to be the other sex, at least in earlier years before they may learn not to verbalize it, but also their dressing preferences, peer group preferences, toy preferences, game preferences, and perhaps their physical mannerisms are those of the other sex.(6)
girls. Their behaviours are typical of other-sex children. Not only do they express a wish to be the other sex, at least in earlier years before they may learn not to verbalize it, but also their dressing preferences, peer group preferences, toy preferences, game preferences, and perhaps their physical mannerisms are those of the other sex.(6)
The picture of GID in children as described in DSM-IVTR,(7) can manifest, in part, by the repeatedly stated desire to be of the other sex: in boys by a preference for dressing in girls’ or women’s clothing or simulating female attire from available materials, and in girls an insistence on wearing stereotypically masculine clothing with refusal to wear traditional girls’ clothing. In role playing, as in make-believe play or imitating media characters, there is a strong preference by the child for other-sex roles. There is also a strong preference for toys generally identified with the other sex, such as Barbie dolls by boys. The peer group is composed primarily or exclusively of other-sex children. Pictures drawn are generally of other-sex figures. There may be cross-sex physical mannerisms. Concurrently, there is an avoidance of traditionally sex-typed activities. Criteria in ICD-10 are similar.(8)
The diagnosis of GID in girls can be more problematic than in boys. This is because ‘tomboyism’ is a more common part of paediatric psychosexual development than ‘sissyness’. There is, however, a distinction between GID in girls and tomboyism. Typical tomboys do not insist that they want to be boys and will wear girls’ clothes from time to time, will have both girls and boys as playmates, and will not work to present themselves as young boys.
Substantial cross-gender behaviours are generally manifest in the third or fourth year. Although they are believed by parents and perhaps professional advisors to be a passing phase, at least with those children, seen clinically they endure into school years. Most children are evaluated at about age 7 or 8, when parents become increasingly concerned that the ‘passing phase’ is not passing and negative reactions by the peer group are enhanced, causing the child social distress.(6)
Aetiology
Understanding the aetiology of GID considers typical influences on early psychosexual development in male and female children.
Early sex differences
Very early behavioural differences are evident between males and females. There may be recognition of the ‘like me’, ‘not like me’ dichotomy of one’s sex. When boys and girls aged between 10 and 18 months were shown pictures of faces of infants of the same and other-sex, males looked at faces of males longer and females looked at faces of females longer. This ‘like me’, ‘not like me’ dichotomy is also interpretable in the study in which two male and two female 1-year-old children were placed at the four corners of a room and permitted, one at a time, to crawl to any other child. Children more often crawled to a child of the same sex.(9,10)
In early play patterns, boys and girls may differ. When 12-month-old children were observed with their fathers in a waiting room, boys were more likely to handle ‘forbidden’ objects such as trays and vases.(11) The 1-year-old’s toy preferences may also differ, with girls preferring soft toys and dolls and boys preferring transportation toys and robots.(12,13)
Preference for mother or father appears to discriminate boys and girls early. When 2- to 3-year-old children were asked which parent in an adjoining room they would prefer to play a game with, or to build with using blocks, or make a sketch with, both boys and girls preferred their father. At 4 years, girls shifted to mother but boys stayed with father.(14)
When children aged between 2 and 3 years were observed in a free play setting, boys were more aggressive toward peers and showed more rough-and-tumble play. When paired in a test play situation with a boy, girls showed more passive behaviour, i.e. standing or sitting quietly and watching their partner play.(15)
The preference for a same-sex peer group emerges early. When 3.5- to 4.5-year-olds were shown pairs of photographs of boys and girls and asked to select the children with whom they would prefer playing, boys preferred boys and girls preferred girls.(16)
Children become aware of sex role stereotypes early. At 2 years of age, boys believe that boys like to play with cars and help their father, 3-year-olds believe that boys like to build things and that only boys like to play with trains. They also believe that girls like to play with dolls, help mother, and cook dinner. Girls are also seen as more likely to say ‘I need help’.(17)
The peer group influences psychosexual development. In mixedgender peer groups, boys more often receive positive responses for masculine activities than girls receive for feminine activities. Boys seem more responsive to peer pressure, in that they will discontinue feminine activities more rapidly than girls will discontinue masculine activities when they are the target of negative responses from either boys or girls.(18)
These findings suggest that if sex-typed attributes emerge in psychosexual development of typical children shortly after the basic dichotomization of ‘like me’, ‘not like me’, or male/female, then the first two components of gender identity are consolidated early: (a) the basic sense of male or female; (b) masculine or feminine gender role. The age at which they consolidate coincides with the emergence of significant cross-gender identity and behaviour as seen in the GID of childhood.
Parental influences
Fathers, when observed with 12-month-old children, were more likely to present their sons with trucks rather than dolls, whereas daughters were given both trucks and dolls equally. However, among those children who were given dolls, boys played with them less.(19)
Mothers of young children have been observed with infant actor/actress babies (Baby X experiments). Some of these stranger infants are cross-dressed or given cross-sex names. The perceived sex of the infant influences the mother’s behaviour. Children believed to be boys, whether they were or not, were more likely to be encouraged to physical action. Infants believed to be girls were more likely to be given a doll, whereas male infants were more likely to be presented with a football.(20)
None of these findings of early sex differences have been systematically observed with children followed up years later to determine whether early variation from the more common patterns are associated with later variation in psychosexual development.
In our prospective research of several dozen cross-gender behaving boys and conventionally masculine boys,(21) more mother-son shared time was not found in the group of feminine (prehomosexual) versus masculine boys. There was substantial variability in the extent to which mothers and sons were emotionally close. However, with respect to father-son experiences, feminine boys
shared less time with their fathers in their first years when compared with the contrast group of conventionally masculine boys or with their masculine preheterosexual brothers. There was an inverse relationship between the extent of father-son shared time in the first years and later Kinsey score of sexual orientation. Less father-son time was associated with a higher (more homosexual) score.
shared less time with their fathers in their first years when compared with the contrast group of conventionally masculine boys or with their masculine preheterosexual brothers. There was an inverse relationship between the extent of father-son shared time in the first years and later Kinsey score of sexual orientation. Less father-son time was associated with a higher (more homosexual) score.
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