Gender Identity Disorder: A Literature Review of Children and Adolescents from a
Developmental Perspective
Gender Identity Disorder (GID) is one of the most belligerent diagnoses of the DSMIV
(Shechner, 2010). For the diagnosis of GID, according to DSM-IV (American Psychiatric
Association [APA], 1994), the criteria includes: strong and persistent cross-gender
identification, preference for cross dressing and wearing typical clothing of the other sex,
strong preference for cross-sex role play, intense desire to participate in stereotypical games
of the other sex, and a strong preference for playmates of the other sex. For adolescents,
cross-sex identification is conveyed by a continual statement of the person’s aspiration to be,
live as, and be treated as the other sex. There is also persistent discomfort with one’s
assigned gender of a sense of inappropriateness in that gender role. Meyenburg (1999) added
to this definition for adolescents to include attempts to pass as the other sex or the belief that
one has the typical feelings and reactions of the other sex. Shechner (2010) confirmed the
view that many researchers in this field have – that mental health professionals working with
GID children and adolescent’s clinical experience is limited, as not many children meet the
complete diagnostic criteria. However, what is well-known is that parents are seeking
counselling about their child’s gender variant behaviour. The intention of this paper is to
briefly review literature on gender developmental theories, what constitutes a diagnosis, the
available research data, and cross-gender behaviour in children and adolescents.
Gender plays a major role in which people define themselves and experience their
social world. Research into understanding gender development have occurred through
extensive theoretical and empirical work (Shechner, 2010). Theories of gender development
have emerged over the past 50 years or so, and can be divided into four types. First, is the
psychoanalytical theory based on Freud’s early works. According to Freud, a child’s gender
development occurs during the phallic stage (ages 4 – 6 years) with fear of castration
motivating the child to identify with the same-sex parent. Secondly, gender essentialism
focuses on genetics, biological differences, hormones, and neurological factors (Liben et al.,
2002). Thirdly, cognitive theories claim that gender development is shaped by children’s
cognitive abilities (Kohlberg, 1966) as being self-driven, and not only environmental
experience, interests, knowledge, and other personal characteristics. This may also occur in
the form of direct learning (Bussey and Bandura, 1999). Fourthly, environmental theories
explain gender development according to the stimulus, the response to the stimulus, and the
resulting behaviour. Reinforcement increases the probability that the behaviour will recur,
whereas punishment decreases the probability. According to this theory, children learn
expectations about social gender by the reactions to their behaviour of parents, teachers, and
other people with whom the child associates (Mischel, 1970).
As with other DSM diagnoses and assessments, systematic clinical interviews serve
as the most comprehensive tool. Normative samples in the United States (Zucker, Cohen-
Kettenis, 2008), and Israel (Shechner, Liben, Bigler, 2007) have shown that using The
Occupational, Activity, and Trait Personal Interest and Attitude Measure Scales for children
(COAT-PM/AM) and pre-schoolers (POAT-PM/AM) can offer insight into a child ’s play
preference and toy preference when the child has been referred for concerns about their
gender development (Fridell, Anderson, Johnson, Bradley, Zucker, 1996). The assessment of
a child referred for this concern should include the child and their parents, and if considered
necessary, the child’s teacher and/or other relevant social agents involved in the child’s life
(Shachner, 2010). The involvement of parents in therapy is crucial for preventing or
alleviating problems in the child-parent relationship that has been brought on by the gender
variant behaviour. Zucker (2006) suggested that parents be trained in setting limits to the
child’s gender variant behaviour by encouraging gender-neutral activities and to find
activities that are seen as more gender appropriate, such as same-sex peer interaction. Langer
and Martin (2004) proposed that when a child is brought in for therapy by the parents who
fear their child will be homosexually-orientated, the therapy should in fact target the parents
rather than the child with the appropriate change-orientation intervention, while Zucker
recommended parents to be warned about the difference between empathetic encouragement
and harsh imposition. Bem (1993) suggested treating a child with gender variant behaviour
to help the child conform to the more stereotypical gender role behaviours in which they have
been physically assigned. Another view of dealing with treatment of children and
adolescents with GID was Steensma et al. (2010) who suggested that clinicians should focus
clearly on what happens within the ages of 10 – 13 years and to explicitly address the child’s
feelings concerning the factors that frequently come up as relevant in sessions. Parents and
caregivers ought to realise the unpredictability of their child’s psychosexual outcome, and
that they may help their child to cope with their gender variance in an empathetic way, but
without taking social steps long before puberty, which are hard to reverse. A dichotomy view
of gender was reflected in Rekers and Lovaas (1974) where parents and teachers were
encouraged to use behaviour modification techniques in an attempt to eradicate all
incongruous gender behaviours.
As GID did not become a psychiatric category until 1980 in DSM-III, as a possible
take-over of homosexuality (Bem, 1993; Bayer, 1981), suggests that the pathology
accompanying gender identity dysphoria should be the focus of clinical work rather than
treating gender role behaviour (Wilson, Griffith and Wren, 2002). Zucker (2009) reviewed
GID diagnostic criteria in children as they were formulated for DSM-III, DSM-III R, and
DSM-IV, and concluded that the persistent desire to be the other gender should, in contrast to
DSM-IV, be a necessary symptom for diagnosis. This would then result in a tightening of the
criteria and may result in a better separation of children with GID from the children who
display marked gender variance but without the desire to be of the other gender.
What is known about the prevalence of GID is hard to determine as there are no
reported epidemiological studies in children or adolescents (Shechner, 2010). However, what
is known, from samples of adults attending gender clinics for hormonal or surgical
treatments, who in turn represent only a very specific segment of the population with crossgender
identification and behaviour’s, is that GID varies by age (Zucker, 2006). Zucker and
Cohen – Kettenis (2008) point to consistent findings indicating significantly higher referral
rates for boys from age 3 to 12, than for girls. With age, however, this dramatically declines
to virtually no sex differences in referral rates for adolescents. This difference in preadolescent
boys and girls has been suggested by Zucker and Cohen – Kettenis as the ‘relative
tolerance (society has) for gender nonconformity in girls during childhood but not in
adolescence, when gender roles intensify’. Steensma et al. (2010) confirmed literature
findings on gender dysphoric children does not always result in gender dysphoria in
adolescence and adulthood, finding that both boys and girls showed that their changing
interests and friendships, and the physical changes during puberty made the gender distress
reduce and eventually disappear. However, their first experience of falling in love and
consciousness of sexual attraction were aspects that ensued in the withdrawal of their gender
dysphoria. Along with puberty, Steensma et al. suggested that adolescents regarded the
growing distance between the sexes in social settings (between the ages of 10 and 13 years)
they experienced seemed to create a desire to add gender-typical interests to their activities.
What are less clear for researchers and clinicians are the developmental trajectories of
GID as whether this leads to bi- or homosexuality. The prevalence rates vary (Steensma et al.,
2010). Green (1987) carried out a follow-up study of 66 gender dysphoric children and
reported a bi- or homosexual orientation of 75% of the boys in fantasy and 80% in behaviour.
Zucker and Bradley (1995) found lower prevalence rates with 31% (of 41 children) reporting
a bi- or homosexual orientation in fantasy and 18% (of 19 children) reported bi- or
homosexual orientation in behaviour, while 58% of the participants reported no sexual
experience at follow up. Drummond et al. (2008) studying 25 girls reported bi- or
homosexual orientation in fantasy for 32% and 24% for bi- or homosexual orientation in
behaviour.
The body of research that has been reviewed in this paper suggest that GID frequently
fades from childhood to adolescence and adulthood. Furthermore, cross-gender fantasies and
behaviours in childhood appear to be largely predictive of a homosexual orientation in
adulthood. It is hoped that during the 90 minute lesson parents and/or caregiver’s of children
with gender-variant behaviours become more aware of developmental views of GID,
treatments and how to help with a child who possibly fits the GID diagnosis criteria, and
what the future may hold for their child .
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