Gender Identity Disorder in Girls

Susan J. Bradley

Kenneth J. Zucker

This book is about women’s mental health, but the distinction between one sex and the other is not always clear, an observation that is best illustrated by a discussion of gender identity disorder (GID) (1,2). This chapter begins with the current diagnostic criteria in use for GID and explains what is known about the prevalence of the disorder in boys and girls. The chapter provides an overview of the clinical picture in girls specifically and then discusses the course of the disorder and its possible outcomes. We touch briefly on intervention, but there is little empirical evidence bearing on its effectiveness. We then address the overlap between gender identity disorder and sexual orientation and discuss the literature that attempts to understand GID and homosexuality. Finally, we relate the development of GID to other disorders involving difficulties with affect regulation and we suggest possibilities for further research. The focus in this chapter is on GID in girls. However, in examining the literature on girls, we also explore the literature generally and then point out differences between boys and girls.

DEFINITIONS

The term “gender identity disorder” refers to that class of disorders in which an individual exhibits “a strong and persistent identification” with the opposite sex and “persistent discomfort” (dysphoria) with his or her own sex or “sense of
inappropriateness in the gender role of that sex”. In children, such an identification is revealed in statements about either being or wishing to be the other sex, in dressing as and taking on the roles of the other sex, and in a preference for the playthings and play activities typically enjoyed by the other sex. Young children’s discomfort with their own sex is seen in avoidance or dislike of the activities and dress of their own sex. By contrast, in adolescents and adults, gender identification and dysphoria are manifested by a desire to be the other sex and the concomitant involvement in “passing” as the other sex. This includes attempts at disguising same-sex features and showing sexual interest in same-sex individuals. The same-sex attraction is experienced as “heterosexuality” because of these individuals’ cross-gender identification. To separate the gender identity disorders from more minor or fleeting cross-gender interests or role-taking, cross-gender behaviors must be persistent, affect several aspects of behavior, and result in distress or functional impairment (1,2).

PREVALENCE

The gender identity disorders are considered relatively rare, but there are no epidemiologic studies to provide accurate estimates of prevalence. Recent studies, based on referrals to GID clinics in Holland, estimate the prevalence in adults to be 1:10,000 to 1:30,000 (3,4). Sex ratios among adults are roughly equal, while among children the prevalence, determined by referrals to GID clinics, is substantially higher in boys than in girls, between 3 to 1 and 6 to 1 (5). Given the lack of epidemiologic data and subsequent reliance on rates of referral to GID clinics, it is quite possible that these figures are distorted by factors such as greater social sanction with respect to cross-gender behavior in boys than in girls. For a discussion of this issue, see Zucker and Bradley (6). In studies from our clinic, the Gender Identity Clinic for Children and Adolescents in Toronto, and from the Gender Clinic of the University Medical Centre of Utrecht in Holland, mothers of girls with GID report more cross-gender symptoms than do mothers of boys. Girls are older at age of referral, suggesting that the sex ratio is skewed by a greater tolerance for cross-gender behavior in girls (4,6).

Examining data from the standardization sample of the Child Behavior Checklist (CBCL) (7), a widely used parent-report instrument, 6% of nonreferred boys are reported by their mothers as “behaving like the opposite sex” at age 4 to 5, but such reports diminish to only 0.7% for boys 12 to 13 years old. In contrast, almost 12% of nonreferred girls “behave like the opposite sex,” and this percentage remains reasonably stable into early adolescence. Examining the other gender-related item, “wishes to be the opposite sex,” mothers of nonreferred boys report low levels of this behavior (0 to 2%) throughout childhood, while mothers of girls report it for 5% aged 4 to 5, a prevalence that declines to about 2% to 3% when girls reach early adolescence. Children referred to mental health clinics for other problems are generally reported as displaying relatively higher levels of both “cross-gender behavior” and “the wish to be the opposite sex.” For referred girls “behaving like the opposite sex,” there is only a modest decline, from 18.6% at ages 4-5 to 16.5% at ages 12-13. The item “wishes to be the opposite sex” is reported for 6.5% of girls referred at ages 4-5, 8.3% at ages 8-9, and 4.2% at ages 12-13.

What these data tell us is that cross-gender behaviors and wishes are not uncommon and, among children referred for clinical problems, appear to be more prevalent in girls than in boys. It is, however, impossible to estimate how
common the full syndrome of GID may be. What is interesting is that, in middle childhood, a significant number of girls wish to be boys, and that this wish is more common among girls already manifesting other clinical problems. Because these data were collected in the 1970s and we do not have current data, we cannot determine whether this is a cohort effect.

Although GID has been studied most systematically in Western countries, there is evidence that cross-gender behavior occurs in many, if not most, cultures. In some cultures, individuals who assume a cross-gender role are given special status. In other cultures, however, especially where there are religious proscriptions against such behavior, cross-gender behavior is highly stigmatized (8).

CLINICAL PRESENTATION

CHILDHOOD

Characteristically, girls with GID begin to exhibit interest in cross-gender activities when they are preschoolers, at a time when most children display awareness of sex and gender differences and begin to label themselves accordingly (10). Children are not usually referred for consultation, however, until those behaviors impress a parent or teacher with their pervasiveness and when they are accompanied by statements about wishing to be the opposite sex or statements that suggest the child believes she is a boy. Despite parents’ attempts to dissuade their daughter from either wishing she were a boy or believing she is a boy, in many cases the girl adheres tenaciously to her wish or belief. Not infrequently, one of the greatest points of conflict occurs when parents attempt to persuade their daughter to wear a dress for a special occasion. The intensity of the child’s refusal may begin to convince the parents that her belief about being a boy is not “just a passing phase.” Requests by girls to have their hair cut short are characteristic. Occasionally, younger girls’ play behavior may include simulation of being male by using brooms and other objects as a pretend penis. For more complete case information, see Zucker and Bradley (5).

Associated behaviors include traditional “tomboyish” interests, such as playing with guns or balls, and a variety of outdoor activities. Playmates are typically boys or occasionally other “tomboyish” girls. The activity level of these girls, according to parental report, is higher than that for sisters without GID, girls who are controls in clinical studies, and normal girls. Furthermore, activity is higher than that of GID boys and approaches the level of the general population of boys (5).

The majority of GID girls develop resistant or avoidant behavior that makes parenting a challenge. Clinically, some of these behaviors appear to arise from a mother’s being depressed, having difficulty being emotionally available to her daughter, and being unable to set limits. In other situations, GID girls meet criteria for attention deficit hyperactivity disorder (ADHD) and present behavioral challenges because of their hyperactivity and impulsivity. Quite regularly, there is conflict between parents and child and evidence of oppositional defiant behaviors. The parents of such a girl are often in conflict over the management of their daughter with respect to both the cross-gender behavior and other unwanted behavior. The extent of both internalizing and externalizing behavior increases in the period between preschool age and school age (5). Although this increase in symptoms partially correlates with increases in peer difficulties (10), it is also possible that
it reflects the increased conflict that ensues once a child’s oppositional behavior is left uncontrolled by parents. For a more complete analysis of associated behavior problems, see Zucker (10).

Most girls with GID express the fantasy of “protecting other females.” This appears to be related to their wish to be male and often occurs in the context of a perceived marital conflict in which the child perceives the male parent as the powerful one and the female parent as the vulnerable one. Many of these girls are anxious but may mask their overt anxiety by “macho” type behavior.

ADOLESCENCE

Girls with GID who present for help in adolescence have sometimes displayed the same pattern of behavior from early childhood. Generally in those situations parents have been overwhelmed or distracted by other issues and have not seen their daughter’s cross-gender behaviors as a high priority. In some instances, however, the extent of earlier cross-gender behavior has been modest and the full-blown GID syndrome appears to have either intensified with puberty or in the context of a trauma. Many of these girls appear depressed at the time of assessment, and it may be difficult to understand the factors that have been most salient in the onset of their cross-gender wishes. Several referrals have occurred following a sexual assault in which the trauma of the assault has reinforced the sense of female vulnerability.

Many girls with GID come to clinical attention when they make efforts to pass as males; some even convince girlfriends that they are male. Concern about the risks they face with such behavior may lead school authorities or parents to seek help. Adolescent GID girls continue to relate more comfortably to male peers with whom they share interests in sports and video games. Their clothing is typically very casual, often emulating “rap” characters. Short hair and baseball caps are characteristic.

Associated behavior problems in adolescent girls are more prevalent than in childhood, as are poor peer relations (10).

FAMILY PSYCHOPATHOLOGY

Generally, there is a high prevalence of anxiety, mood, and substance abuse disorders in the families of children with GID (5). Such families appear very similar to families of other children referred to mental health clinics.

CHILD CASE EXAMPLE

Sara was 5 when first seen in the Child and Adolescent Gender Identity Clinic in Toronto. She was the younger of two girls living with their mother. The father had committed suicide when Sara was 3 years 9 months old. It was thought that he suffered from an undiagnosed bipolar disorder, as had his father.

Sara’s mother indicated that the child had always been “boyish” and interested in boy’s activities. However, she dates the intensification of Sara’s preoccupation with boy’s roles and dress to around age 3½. This appears to have followed a dramatic fight between the parents in which the father “lost it” and physically attacked the mother. The children witnessed the attack and were very frightened by it. When the father committed suicide, Sara, for a time, believed
that her mother had killed him in retaliation for his attack on her. She had been close to her father, who was her main caregiver, the mother working outside of the home. Sara expressed much anger at her mother following the father’s death. The mother experienced a serious bout of depression following the father’s suicide and was hospitalized for three weeks.

The mother reported that Sara was unplanned and difficult as an infant. She cried a lot and slept poorly. When she became mobile, she was hyperactive and constantly into things. She frequently wandered off and she got lost several times, apparently with little overt fear. Both parents found her difficult and were regularly in battles with her over control and limits.

At the time of assessment, the mother was concerned that Sara might have bipolar disorder or ADHD in addition to GID.

Sara was adamant about being a boy and insisted that others address her with her chosen boy’s name. She refused to wear girls’ clothes but eventually agreed to wearing a girls’ bathing suit since her mother would not allow her to swim in boys’ bathing trunks. She often pretended she had a penis and tried urinating standing up, like a boy. She insisted on having her hair cut very short. In a laboratory free play situation, she gravitated to boys’ toys, particularly a dart gun, and dressed up as a soldier. Although she was apparently doing well at school, she appeared to show some difficulty understanding and processing academic material, often responding in unusual ways that seemed to reflect her preoccupation with being a boy. However, it was also not clear if she had fully understood what was being asked.

Sara was referred back to the referring agency with recommendations for stimulant medication to treat her hyperactivity and consideration of an atypical antipsychotic for her aggression and overly intense reactions to stimuli. Individual therapy was recommended to help Sara deal with her anger and her belief that she needs to be male to feel secure. Support for her mother concerning management of the daughter’s difficult behavior was also recommended.

ADOLESCENT CASE EXAMPLE

Ali presented to our clinic at age 15 having emigrated with her family (parents and three older siblings) from a Middle Eastern country three years previously. She was requesting sex reassignment surgery.

She indicated being first aware of cross-gender feelings between ages 8 and 9. In her country of origin, gender sex-typed rules and dress codes were quite strict. She reported no cross-dressing until she arrived in Canada, where she perceived the dress codes and expectations for sex-typed behavior as more free. At that time, she began to cross dress and preferred playing with boys. She described role playing male roles when younger and having tomboyish interests. She was also described as “always getting her own way.”

On entering high school, she presented herself as a boy. She was not discovered until one day her name was called out on the public address system and “she” was asked to report to the office. This “deception” caused enough fuss that she transferred to an alternate school in which her cross-gender behavior was understood from the start and accepted by the administration.

At the time of assessment, she had been dating two girls, both of whom (it was assumed) regarded her as a male. She was sexually attracted to females but regarded lesbianism as “gross.” Her cultural community regarded homosexuality negatively.

Ali displayed a depressed mood at the time of assessment but was not suicidal and had no evidence of anxiety or conduct problems, no psychotic features, and denied having experienced sexual abuse. On the gender interview, there was evidence of significant confusion between a masculine and feminine identification. Projective testing showed preoccupations with powerful male figures, themes of being trapped and pleading for help. She scored in the below average to mildly retarded range on standard intellectual testing. Her sister, who filled out the CBCL on Ali, reported elevations in the clinical range on scores in anxiousobsessive, somatic complaints, depressed-withdrawn, immature-hyperactive, delinquent, and cruel domains.

Ali’s family was split and angry about her cross-gender behavior. Her father accepted it, while her mother and the eldest sister, who had raised Ali, were very upset by her behavior. The inquiry about Ali’s growing up revealed a family with high levels of conflict. The father was very negative about his wife, referring to her as uneducated, harsh, unable to discipline the children, and constantly yelling. The patient described her father as scary when violent. She reported many efforts to protect her mother and older sister from his violence.

Ali had little insight into her condition and was not very amenable to supportive therapy. She was considered at high risk for continuing to want sex reassignment surgery. This was problematic because several of her associated difficulties were likely to prevent her from stabilizing her life adequately to meet the criteria for sex reassignment.

COURSE AND OUTCOMES

There have been limited follow-up studies of girls with GID. Based on our experience in our Toronto clinic and on experience in the clinic in Utrecht, the course is variable (10). Some of these girls appear to relinquish their desire to be the opposite sex and assume a more typically female identification. Others continue with some cross-gender identification into adolescence. Based on follow-up studies of boys with GID and our own limited follow-up, we speculate that many of these girls will adopt a lesbian orientation, but, again, there are few data to confirm or refute this assumption.

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