Is Gender Identity Disorder in Children a Mental Disorder?

Nancy H. Bartlett

Paul L. Vasey [1]

Empirical studies were evaluated to determine whether Gender Identity Disorder (GID) in children meets the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV, American Psychiatric Association, 1994) definitional criteria of mental disorder. Specifically, we examined whether GID in children is associated with (a) present distress; (b) present disability; (c) a significantly increased risk of suffering death, pain, disability, or an important loss of freedom; and if (d) GID represents dysfunction in the individual or is simply deviant behavior or a conflict between the individual and society. The evaluation indicates that children who experience a sense of inappropriateness in the culturally prescribed gender role of their sex but do not experience discomfort with their biological sex should not be considered to have GID. Because of flaws in the DSM-IV definition of mental disorder, and limitations of the current research base, there is insufficient evidence to make any conclusive statement regarding children who experience discomfort with their biological sex. The concluding recommendation is that, given current knowledge, the diagnostic category of GID in children in its current form should not appear in future editions of the DSM.

Controversy surrounding the pathologization and treatment of cross-gender [2] identity and behaviors, particularly in children, has been evident in the literature for over 20 years (Bem, 1993; Fagot, 1992; Menvielle, 1998; Morin & Schultz, 1978; Neisen, 1992; Nordyke, Baer, Etzel, & LeBlanc, 1977; Richardson, 1996, 1999; Winkler, 1977; Zucker, 1999). This paper addresses that controversy by asking the question: "Is Gender Identity Disorder (GID) in children a mental disorder?" To this end, our intention is not to provide a comprehensive review of the literature on GID, but rather an evaluation of the literature as it pertains to the question of whether GID in children is a mental disorder. Children with GID have (a) a strong and persistent identification with the other sex or with the culture-specific gender role associated with the other sex or with both and (b) discomfort with their own biological sex or the culture-specific gender role of that sex or with both. Estimates of the prevalence of the disorder range from .003% to 3% for boys, and .001% to 1.5% for girls (American Psychiatric Association [APA], 1994; Green, 1995; Zucker, 1990). The referral ratio of boys to girls has been reported to be as high as 7:1 (Bradley & Zucker, 1997). This paper begins with a brief historical overview of cross-gender identification and behaviors as mental illness, followed by an outline of the current definition of mental disorder, and then an evaluation of the relevant GID outcome literature. Then the central question of whether GID in children is a mental disorder is addressed using the DSM-IV definition of mental disorder as a comparison point. Our strategy in this comparison is to simply determine whether the extant literature regarding GID in children indicates that it constitutes a mental disorder. Finally, suggestions are made regarding the future of GID in children as a DSM disorder.

A HISTORICAL OVERVIEW

With a concept such as gender, a historical perspective can be useful in demonstrating that what is "deviant" behavior within a particular culture is far from stable across time. The labelling of "gender-deviant" individuals as mentally ill is not a new phenomenon. In late nineteenth century medical literature, accounts began to appear of individuals who deviated from the culture-specific social role expected for their biological sex (i.e., their gender role). Such individuals were considered to suffer from "sexual inversion," a reversal of gender identity (of which homosexual behavior may or may not have been one aspect; D'Emilio & Freedman, 1988). In 1884, George Beard, an American physician, wrote of sexual inverts: when "the sex is perverted, they hate the opposite sex and love their own; men become women and women men, in their tastes, conduct, character, feelings, and behavior" (as cited in Chauncey, 1989). Female inverts were described in the literature as possessing "masculine straightforwardness and sense of honor" (Ellis, 1942, p. 250), having "a dislike and sometimes incapacity for needlework" as well as "an inclination and taste for the sciences" (Krafft-Ebing, 1893, p. 280), being demanding of voting rights, and skilful at whistling (Browne, 1923; Claiborne, 1914; Ellis, 1942). Accounts of male inverts include such descriptors as, "sentimental," "something of a chatterbox" (Carpenter, 1911, p. 132), "never smoked," "entirely averse to outdoor games," and having a "fondness for cats" (Rivers, 1920, p. 22). Krafft-Ebing (1893) noted that this "abnormality of feeling and of development of the character [was] often apparent in childhood" (p. 279). On one such case, he wrote that "the boy likes to spend his time with girls, play with dolls, and help his mother around the house" (Krafft-Ebing, 1893, p. 279).

For several decades, little attention was paid in the literature to "pathologies" related to gender role, until Christine Jorgensen's widely-publicized sex-change operation in 1952. By the late 1960s and early 1970s, such operations were a sought-after and popular treatment for what was then known as transsexualism (and would later be termed GID). In an effort to try to prevent this condition, a number of psychiatrists in the 1970s designed programs to identify, study, and treat children "at risk" for developing adult transsexualism. The targeted children were those who displayed unusual amounts of cross-gender behavior (Bem, 1993). The treatments, as well as the very notion that children's cross-gender identification and behaviors warranted treatment, were renounced by several authors, including those from gay rights groups, as unethical (Morin & Schultz, 1978; Nordyke et al., 1977; Winkler, 1977). GID in children was first officially recognized by the APA as a disorder with the 1980 publication of DSM-III. Recently, there has been a resurgence of concern about its status as a disorder, both in published literature on the topic and among members of feminist and gay and lesbian organizations, who are calling for the depathologization of "gender-variant" youth (Bem, 1993; Burke, 1996; Conaty & Lobel, 1998; Neisen, 1992; Wilson & Hammond, 1996).

CONCEPT OF MENTAL DISORDERS IN DSM-IV

The definition of mental disorder used by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has remained essentially unchanged since the publication of DSM-III (APA, 1980). This definition is basically a simplified derivative (Wakefield, 1993) of a definition proposed by the editor of DSM-III and DSM-III-R, Robert Spitzer, and his colleagues, who were involved with the American Psychiatric Association's Task Force on Nomenclature and Statistics (Spitzer & Endicott, 1978). Remarkably, the DSM-III was the first edition of the DSM for which there was an official definition of mental disorder. The initial impetus for defining mental disorder, according to Spitzer and Endicott, was the controversy surrounding the removal of homosexuality from the psychiatric nomenclature. The associated debate apparently highlighted the need for the boundaries of the concept of mental disorder to be delineated, to make explicit a set of guiding principles for determining which conditions should be included in or excluded from the nomenclature, as well as how conditions should be defined.

The current DSM-IV definition of mental disorder is as follows (each sentence is numbered to facilitate later reference to the definition):

[1] In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. [2] In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. [3] Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. [4] Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above" (DSM-IV, pp. xxi, xxii).

Throughout this paper, the DSM-IV definitional criteria of mental disorder serve as the reference points for determining whether GID in children satisfies the manual's definition of "disorder."

DIAGNOSTIC CRITERIA FOR GID IN CHILDREN

Prior to beginning the discussion of whether GID satisfies the DSM IV criteria for mental disorder, it is important to consider the diagnostic criteria for GID as outlined in the DSM-IV. These criteria are shown in the Appendix. Each of the four diagnostic criteria for GID serves a different function. The items that comprise Criterion A are intended to refer to cross-gender identification but also include one item referring to cross-sex identification. The items in Criterion B refer to the child's discomfort with his/her biological sex or with the culturally prescribed gender role for that sex or both of these. Criterion C is intended to rule out a physical intersex condition, and Criterion D states that distress and impairment must derive from the "disturbance" implied in Criteria A and B. Criteria A, B, and D are problematic for the following reasons. In regard to Criterion A, the diagnostic significance of widely disparate items is treated as if it were equivalent for each. In this way, having a preference for other-sex playmates is equated with a stated desire to be a member of the other sex. Moreover, because it is necessary to meet only four of the five criteria, Criterion A can be met without the child stating he or she wishes to be the other sex. Importantly though, as specified in the Diagnostic Features of GID subsection in the DSM-IV, to make a diagnosis of GID, "There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the other sex" (p. 532). That a mental disorder can be diagnosed when a core feature of that disorder is absent is alarming, as well as scientifically invalid.

The items in Criterion B are similarly problematic because of the confusion of sex and gender. Discomfort with one's biological sex and discomfort with the gender roles ascribed to this category are very different phenomena; equating them confuses, rather than clarifies, the distinction between them. This confusion seriously challenges the validity of this set of items as a diagnostic criterion. An additional problem with Criterion B, which was highlighted by Richardson (1999) as well, is the similarity in diagnostic significance that is ascribed to being uncomfortable with one's biological sex and discomfort with one's assigned gender role. In so far as GID is meant to represent a "profound disturbance of the individual's sense of identity with regard to maleness or femaleness" (DSM-IV, p. 536), it is unclear why this symptom, for example, considering one's genitals disgusting, is given the same diagnostic weight as having a preference for particular play or clothing styles. Moreover, discomfort with one's biological sex is not even necessary for Criterion B to be met. Once again, it is disconcerting that a diagnosis of GID can be made in the absence of evidence that a child is uncomfortable with his/her biological sex, whether this discomfort is verbally expressed or not.

The possibility that two populations are subsumed under one diagnostic category is thus raised. One population could consist of those children who present solely with dissatisfaction with the culture-specific gender role prescribed for their sex and the other could consist of children who present with persistent discomfort with their biological sex, perhaps with accompanying gender role discomfort. Attempts have been made to determine whether two populations indeed exist. Bentler, Rekers, and Rosen (1979) reported a correlation of .71 between "cross-gender identification," as judged partly by verbalized cross-sex wishes, and "gender behavior disturbance," indicating an overlap of approximately 50% in these symptoms. These authors concluded that their data provided a basis for a distinction between the two phenomena. Zucker et al. (1998) conducted factor analyses of Green's prospective study (Green, 1987) of 66 feminine boys to determine whether the wish to be the other sex should be a distinct criterion in DSM-IV. Their conclusion was that the expressed wish to be the other sex should not be considered a distinct criterion, as it was "just one of several behavioral markers of cross-gender identification" (factor loading = .611), along with behaviors such as wearing girls' clothing and playing with dolls. Given the conceptual distinctiveness of expressing cross-sex wishes, which represent a statement of identity rather than a behavior, a more conservative conclusion might be warranted; that is, the data might better be viewed as reflective of a common cooccurrence of cross-sex wishes and cross-gender behaviors, but not a complete overlap. For example, perhaps those children who express cross-sex wishes may be expected to also exhibit cross-gender behaviors, though children who exhibit cross-gender behaviors may not necessarily be expected to also experience the desire to be the other sex. Given the lack of any irrefutable evidence to the contrary, the importance of remaining open to considering the existence of two populations--those with and without discomfort with their biological sex--cannot be overstated.

Finally, in regard to Criterion D, it is stated in the diagnostic criteria for GID that the "disturbance causes" distress or impairment, though in the definition of mental disorder, there is no causation implied, but simply an association. Thus, there is some inconsistency regarding whether a child's distress needs to derive directly from the "disturbance" per se, or can be associated in an indirect manner, through sources such as possible social ostracism. In these ways, the diagnostic criteria for GID cannot be treated as being problem free.

OUTCOME LITERATURE ON CHILDREN WITH GID

To address the question of whether GID in children meets DSM-IV criteria for mental disorder, outcome literature relevant to each criterion is reviewed. The criterion posited in Sentence [2] of the DSM-IV definition is not relevant to the present discussion, as it is clear that GID in Western cultures is not merely "an expectable or culturally sanctioned response to a particular event." [3] With respect to the remainder of the definition, the following questions are asked: (a) Is GID associated with present distress (Sentence [1])? (b) Is GID associated with present disability (Sentence [1])? (c) Is GID associated with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (Sentence [1])? and (d) Does GID represent a behavioral, psychological, or biological dysfunction in the individual (Sentence [3]) or is it simply deviant behavior or a conflict between the individual and society (Sentence [4])? It is important to mention a problem in interpreting the literature on children with GID, namely, the lack of consistency in the samples used. In some studies, samples are referred to as "effeminate boys" and "masculine girls," in others, the children are "gender-disturbed" or "gender-referred" (children referred clinically for gender-related problems), or they are children who meet DSM-III or DSM-III-R diagnostic criteria for GID. With such a lack of uniformity in the samples studied, it is difficult to compare data from one study to the next, and consequently to make general statements about children with GID.

Is GID Associated With Present Distress (Sentence [1])?

According to the DSM-IV definition of mental disorder, a condition that is associated with "present distress" (e.g., a painful symptom) meets the criteria delineated in Sentence [1]. In the criteria set for GID, as with other disorders, there exists a criterion (in the case of GID, this is Criterion D) which specifically states that "the disturbance causes clinically significant distress or impairment." As noted previously, from the distress criterion in the definition of mental disorder though, it is not evident whether the distress must be experienced as a direct result of a condition, or can be caused by situations that are secondary to the condition, such as social disapproval or rejection due to one's nonconformity to societal norms. As Wakefield (1992a) notes, not all conditions that are simply associated with distress can be considered disorders. Whether distress must be directly caused by a particular condition or can simply be associated with it is a crucial matter in determining whether a particular condition should be judged to be a disorder, and should be clarified in future editions of DSM-IV. In the present paper, "distress" will be interpreted according to the more conservative "direct causation" criterion, and the examination of the extant literature is conducted with the above issues in mind. The very concept of clinically significant distress presents another problem. Assessing its presence, as noted in the DSM-IV, is an "inherently difficult clinical judgement," and "reliance on information from family members and other third parties (in addition to the individual) ... is often necessary" (DSM-IV, p. 7). When the identified patient is a child, it is almost invariably the case that assessing the presence of distress involves a subjective judgement by individuals other than the identified patient.

There is a lack of empirical evidence to support the notion of distress caused directly by GID as opposed to simply being associated with it. Certainly, child distress does not seem to be a common reason for referral of children with GID. Rather, the basis for clinical referral is more often parents' or teachers' concern regarding the child's "intense involvement in overt cross-gender play" or the parents' desire to prevent homosexuality in their child (Doering, Zucker, Bradley, & MacIntrye, 1989; Scientific proceedings--Panel reports, 1993). As such, the validity of a subjective judgement of child distress is called into question.

In the literature, it is often reported that children referred for gender "problems" or diagnosed with GID express the wish to be the other sex or feel that they are the other sex (Babinski & Reyes, 1994; Bleiberg, Jackson, & Ross, 1986; Chazan, 1995; Di Ceglie, 1995; Dowrick, 1983; Gilmore, 1995; Green, 1974, 1987; Green, Newman, & Stoller, 1972; Haber, 1991; Herman, 1983; Loeb, 1992; Newman, 1976; Pruett & Dahl, 1982; Rekers & Lovaas, 1974; Rekers, Lovaas, & Low, 1974; Rekers & Mead, 1979; Sack, 1985), though this symptom has been found to be present in only a minority of cases. Zucker (2000) reported that between 17% and 36% of gender-referred boys in his sample expressed cross-sex wishes, though data on the associated distress experienced by these children was not reported. It is important to note that children beyond the age of 6 or 7 tend not to verbalize cross-sex wishes. Zucker and Bradley (1995) suggest that children's tendency to not voice cross-sex wishes is perhaps because of social reactions and not to the fact that the child does not have such wishes. The extent to which "feminine" boys expressed cross-sex wishes or beliefs was noted, by Green (1987), to subside with age. Thus the possibility certainly exists that many children "grow out of" their cross-sex wishes, and do not voice them simply because they do not have them. Although reported cases of children who are distressed as a direct result of their GID are not common, examples of such distress do exist in the literature, for children who present with discomfort with their biological sex. In case descriptions, children have been reported to make statements such as "I hate being a boy" (Zucker & Bradley, 1995, p. 57), "I don't want to be me. I want to be a girl" (Coates & Person, 1985, p. 707). In some cases, children are reported to dislike their genitals, wishing to have them removed if they are boys and wishing to acquire a penis if they are girls (see Loeb & Shane, 1982; Lothstein, 1992; Zucker & Bradley, 1995; Zucker & Green, 1992). From the literature, it is difficult to ascertain the rate of occurrence of such a disavowal of one's genitals. It has variously been reported that the symptom of "anatomic" or "genital dysphoria" is experienced by "virtually all" children with GID; is, compared to other symptoms, "less consistently present" among gender-disturbed children, is a "rare" occurrence among boys; but is "one of the most common first signs of GID" in girls (APA, 1994; Bradley & Zucker, 1990; Coates, 1990; Zucker, 1982). Thus, evidence indicating the frequency with which children with GID present with a persistent discomfort with their biological sex (as in Criterion B for GID) is equivocal. It does, however, appear that in those cases where distress is associated with this symptom, it may be in a direct manner.

Evidence from published case studies does not appear to support distress caused by "gender role disturbances." When child distress is reported at all in these cases, the distress is most often in the form of general unhappiness or unhappiness about poor peer relationships, or anxiety, frequently about separations (Coates, 1990; Hay, Barlow, & Hay, 1981; Herman, 1983; Meyer & Dupkin, 1985; Rekers, 1979; Rekers et al., 1974; Sack, 1985), and does not seem to pertain to any direct distress on the child's part about his/her gender identity or accompanying behaviors. Indeed, considering the minimal amount of attention in the literature devoted to the child's distress in comparison to that devoted to the child's tendencies to engage in cross-gender behaviors, one might infer that the child's own feelings of contentment or distress are treated as secondary to the distress felt by others as a result of the child's cross-gender behaviors. It is possible that this lack of attention to child distress in the literature is reflective of the actual state of affairs, that is, a lack of distress on the part of the child.

It has been proposed that distress among at least some children with GID is simply a response to having their desired manner of behaving thwarted (Di Ceglie, 1995; Meyer & Dupkin, 1985; Stoller, 1975; Sugar, 1995; Zucker, 2000). In the literature there are numerous accounts to sup port such a supposition. That is, many of these children are reported to be happiest when their preferred behaviors are permitted without restriction. Meyer and Dupkin (1985) reported on a "gender-disturbed" boy who, according to his mother "gets very mad at me when I won't let him dress in my dresses," "obvious[ly] ... feels like a million dollars when he has on high heels" and "seemed content and happy" when dressed as a girl (pp. 254,255). One mother reported regarding her son's "gender-disturbed" behavior: "He was very excited about [putting on a blouse of mine] and leaped and danced around the room. I didn't like it and I just told him to take it off and I put it away. He kept asking for it. He wanted to wear that blouse again" (Green 1987, p. 2). Where is the evidence in these examples that the gender role "disturbance causes clinically significant distress" to the identified patient? Rather, it appears that, like Stoller proposed, the distress, in cases of children whose discomfort lies with the culturally sanctioned gender role of their sex, is linked to the child's not being permitted to act in the gender-atypical manner he or she desires.

Additional support that distress, in many cases, is associated in an indirect, rather than a direct manner, can be found in what has been called a "chronicity effect." The existence of a chronicity effect has been noted among children with GID, in the sense that their associated psychopathology has been found to increase with age (Zucker, 1990). It has been proposed that this positive relation between age and psychopathology could be a function of the harmful additive influence of being exposed to peer ostracism over time. Moreover, it may be directly related to the children's experience of receiving constant censure for their behaviors. Research has indicated that cross-gender behaviors seem to diminish among children with GID as they get older (Green, 1975,1987; Zucker, 1982; Zuger, 1978). It has been suggested that this reduction occurs because of the social pressures felt by the child to conceal his or her nonconforming behaviors (e.g., Bates, Skilbeck, Smith, & Bentler, 1974). Former GID-diagnosed individuals who have spoken out concerning their treatment offer first-hand evidence of the ill-effects of social disapproval. They recall feelings of extreme shame about their gender-atypical behaviors; they were not accepted as they were (Burke, 1996). Daphne Scholinski (1998, p. x), a lesbian who was treated for GID as a child, writes of being "so false your own skin is your enemy." It is unreasonable to expect that an enforced repudiation of one's gender identity and accompanying behaviors would cause anything but a great deal of distress.

In summary, it appears that a minority of children diagnosed with GID have a sense of discomfort with their biological sex. For those who experience this symptom, some seem to experience distress as a direct result of their discomfort, and as an indirect result of social ostracism. In the majority of cases, in which children do not express discomfort with their biological sex, the evidence seems to point to distress being associated with their GID in an indirect manner.

Is GID Associated with Present Disability (Sentence [1])?

According to the DSM-IV definition of mental disorder, a condition that is associated with present disability meets the criteria in Sentence [1]. To meet the criterion for "disability" it must be shown that children with GID are impaired in one or more important areas of functioning. To this end, the social and school functioning as well as the general mental health of children with GID will be discussed. The data from studies in this area are not specifically reported separately for children who do and do not experience a sense of discomfort with their biological sex; however, this distinction is made here where the literature allows.

Social and School Competence

CBCL Data. Few studies exist in which social competence in children with GID has been systematically assessed. Those that do exist have relied heavily on the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1981). The CBCL scales assessing social competence in activities, social, and school domains were used in a comprehensive study by Zucker and Bradley (1995) to assess the level of functioning in gender-referred children. They compared CBCL data from gender-referred children to that of nonreferred and clinic-referred controls, as well as siblings of gender-referred children. It should be noted that not all the gender-referred children in their study met complete DSM criteria for GID. In brief, their results showed that gender-referred boys had lower maternal ratings in areas of total social competence and school competence compared to nonreferred boys, but did not differ from a group of clinic-referred controls on those scales. There were no differences across groups on the Activities or Social scales. Though Zucker and Bradley did not report the percentage of gender-referred children whose social competence scores fell in the clinical range, an examination of their data reveals that on none of the scales did the mean scores of gender-referred boys approach the clinical range. Thus, in terms of total social competence and school competence, gender-referred boys, including those with GID, may differ from the norm but not to a degree that would indicate serious maladjustment or clinical significance. It is important to note that, though gender-referred children, including those diagnosed with GID, appear to have lower competence in the school domain, their IQs have generally been found to be either average or above average (Coates & Person, 1985; Finegan, Zucker, Bradley, & Doering, 1982; Tuber & Coates, 1985, 1989; Zucker, Finegan, Doering, & Bradley, 1984), suggesting that any school difficulties do not stem from a lack of intellectual abilities on the part of the gender-referred child.

Among GID-diagnosed boys in a study by Coates and Person (1985), 24% of the sample scored in the clinical range on the Activities scale, 48% scored in the clinical range on the Social scale, and 43% scored in the clinical range on the School scale of the CBCL. A high percentage (64%) of the boys had a total score in the clinical range. Caution must be taken in interpreting the results of the Coates and Person study, however, as the sample of interest included boys from the ages of 4 to 14, and some of the analyses are not reported according to age. When the authors analysed the School scale scores separately for boys aged 6-11 and 12-14, substantial differences were found. Of the younger boys, 22% scored in the clinical range, compared to 80% of the older boys, suggestive again of a chronicity effect. The other competence scale scores were not reported separately by age. Thus, the findings of Coates and Person may paint a more disturbed picture compared to those reported by Zucker and Bradley (1995). This discrepancy may also be, in part, because of the fact that all the boys in the Coates and Person sample met DSM-III criteria for GID, whereas Zucker and Bradley stated that, in their sample, some met DSM criteria and some did not. It is unclear in the latter study which edition of the DSM was used for diagnosis. This point is not an insignificant one; in DSM-III, for a child to receive a diagnosis of GID, the child was required to have stated cross-sex wishes or insisted he or she was the other sex. Thus all the boys in the Coates and Person study expressed discomfort with their biological sex, whereas those in the Zucker and Bradley study did not necessarily meet this criterion.

With respect to the gender-referred girls in the Zucker and Bradley sample, total social competence scores as well as scores on the Social scale were lower than that of a sample of female siblings. No comparison was made, though, to nonreferred or clinic-referred control subjects, and again, none of their scores approached the clinical range. The evidence seems to point to the existence of disability only among those children who experience discomfort with their biological sex.

A difficulty exists with the interpretation of disability, namely, against what standard should scores be compared to determine the existence of disability? In the Zucker and Bradley (1995) study, gender-referred children differed from nonreferred samples, but did not fall in the clinical range of disturbance. Whether disability exists when a child exhibits some impairment, but not at a clinical level is an open issue, as there exist no general guide lines for making such decisions. It is the opinion of the present authors that, especially with disorders such as GID, which are entrenched in controversy, the criterion should be a conservative one. That is, it is perhaps more valid and ethical to require scores in the clinical range before determining that impairment exists. An additional difficulty exists in interpreting "disability," namely, that of subjective judgement. It is glaringly evident that children's own ratings of disability or impairment are not considered in the published literature. Rather, the emphasis is on parental report in determining disability, a limitation that will be discussed.

Peer Relations. No published research exists to date that provides an empirical examination of the peer relations of children with GID. Anecdotal evidence and clinical experience suggest that feminine boys have a great deal of difficulty in their peer relations, often experiencing teasing, rejection, and social ostracism because of their gender nonconformity (e.g., Coates & Person, 1985; Green, 1974; Rofes, 1993-94). Children's reactions to same-and cross-gender behavior in their peers has received some research attention in the form of analogue studies (Albers, 1998; Carter & McCloskey, 1984; Connor, Serbin, & Ender, 1978; Langlois & Downs, 1980; Zucker, Wilson-Smith, Kurita, & Stern, 1995) as well as naturalistic observations and peer assessment studies (Fagot, 1977; Hemmer & Kleiber, 1981; Lamb, Easterbrooks, & Holden, 1980; Sroufe, Bennett, Englund, & Urban, 1993), which may provide some information that can be extrapolated to children with GID. In general, the results of such studies indicate that cross-gender behaviors (not GID per se) are punished by peers and seem to have a negative effect on a child's peer acceptance. In the majority of studies, boys are found to receive more censure than do girls for their "gender transgressions," and it is generally accepted in the literature that the cross-gender behaviors of girls are better tolerated than are those of boys (e.g., Hemmer & Kleiber, 1981; Money & Lehne, 1993; Zucker, 1985). This is especially relevant in light of the much higher gender-referral rates for boys. A recent study demonstrated that significantly fewer cross-gender behaviors are required for boys, in comparison to girls, to receive a gender-related referral (Zucker, Bradley, & Sanikhani, 1997).

Based on maternal judgements, Green (1976) concluded that the feminine boys in his study were more likely than were control group boys to be rejected by male peers or to be voluntary loners. In a female sample, masculine girls were less likely than feminine boys to be rejected by same-sex peers, though the girls seemed to "mix" less well in female peer groups than did their more feminine counterparts (Green, Williams, & Goodman, 1982). Similarly, gender-referred children in a study by Zucker et al. (1997) received lower maternal ratings than their siblings did on CBCL items pertaining to peer relations, and this was especially true for boys. The vast majority of feminine boys have a strong affiliation with girls as playmates. Indeed, some have genuinely close friendships with girls, and only a minority have no close friendships with children of either sex (Coates, 1990; Zucker & Bradley, 1995). In general, children who engage only or primarily in cross-sex friendships have been found to be less popular and socially competent than those who have same-sex friendships. Importantly, though, they tend to be more popular and socially competent than are those with no friends at all (Kovacs, Parker, & Hoffman, 1996; Sroufe et al., 1993).

Many gay and lesbian adults recall childhood gender-nonconforming behaviors (e.g., Harry, 1982). A common peer problem among youth who do not conform to the gender norms expected for their sex is victimization. During adolescence, up to 71% of lesbians and 83% of gay males have reported experiencing high rates of verbal abuse from peers, and as many as 30% report having been physically assaulted (Pilkington & D'Augelli, 1995; Remafedi, 1987). These rates are considerably higher than the rates of victimization for boys and girls in the general population in North America, between 10% and 15% of whom report being victimized by peers (Bartlett, 2000; O'Connell et al., 1997; Perry, Kusel, & Perry, 1988).

Several researchers have reported a number of characteristics typical of children who experience peer victimization. In general, victims, particularly boys, tend to be physically weaker than their peers, poor at sports, and afraid of getting hurt (Boulton & Smith, 1994; Lagerspetz, Bjorkqvist, Berts, & King, 1982; Olweus, 1993). Both male and female victims tend to be anxious, sensitive, withdrawn, and are often unhappy or depressed (Boivin, Hymel, & Bukowski, 1995; Craig, 1996; Olweus, 1993; Slee, 1995). Interestingly, this characterization of a typical victim is similar to that of a child with GID. Children, particularly boys, with GID, tend to be less athletically competent than their peers, and are often afraid of being hurt, therefore avoiding rough and tumble play (Bates, Bentler, & Thompson, 1979; Green, 1976; Zucker, 1990). Additionally, as will be discussed, they may display internalizing problems, such as anxiety and depressive symptomatology (Coates & Person, 1985; Zucker, Bradley, & Lowry Sullivan, 1996).

The overall characterization of children with GID seems, then, with the exception of the gender identity issue itself, to be strikingly consistent with the profile of other children who experience peer rejection and victimization. It would be of empirical interest to determine the extent to which children with GID experience victimization compared to children who are victimized because of other types of "nonconformity." Research has shown that, in general, children's nonconformity to group norms is associated with peer rejection (Boivin, Dodge, & Coie, 1995; Wright, Giammarino, & Parad, 1986). Some types of nonconformity also appear to be associated with victimization by peers. Higher than usual rates of victimization have been found among children who, compared to controls, are considered less attractive, have more odd mannerisms (Lowenstein, 1978), and higher body weight (Lagerspetz et al., 1982; Williams, 1999), as well as those who have learning difficulties (Andison & LeMare, 1999; Martlew & Hodson, 1991; Thompson, Whitney, & Smith, 1994) and physical disabilities (Lowenstein, 1978; Yude, Goodman, & McConachie, 1998). Thus, it appears that, like children with GID, children who possess other non-"normative" characteristics can experience a heightened level of peer victimization. There is little question that gender nonconformity is associated with peer group difficulties in child hood. It is uncertain, though, whether the difficulties are any greater than are those of other children who stand out as "different."

Several studies have examined the existence of associated psychopathology in children with GID, with a heavy reliance on only one objective instrument with well-established reliability and validity: the CBCL. In the large-scale CBCL study of gender-referred boys and girls reported by Zucker and Bradley (1995), results are suggestive of a chronicity effect, with older boys appearing more disturbed than do younger boys. The CBCL data indicated that, for gender-referred boys aged 4-5 as well as 6-11, scores were higher than for a group of male siblings for the Internalizing T score and the number and sum of items rated 1 or 2. In addition, the 6- to 11-year-old gender-referred boys scored higher than did the male siblings on number of elevated narrow-band scales and Externalizing T. When the T scores on the narrow-band scales of the CBCL were examined, only one of the eight scales, Immature, was significantly higher for the 4- to 5-year-old gender-referred boys, whereas for the 6- to 11-year-olds, seven of nine narrow-band scales were higher: Schizoid--Anxious, Depressed, Uncommunicative, Obsessive-Compulsive, Social Withdrawal, Hyperactive, and Aggressive. In the younger age group (4-5 years) the percentage of gender-referred boys who showed elevated disturbance ratings was more similar to that of the nonreferred standardization sample than to that of the clinic-referred sample, based on maternal ratings. In the older age group (6-11 years), though, gender-referred boys were more disturbed than were the nonreferred, and were more similar to the referred sample, particularly with respect to the Internalizing scales, the Social Withdrawal scale, and one of the Externalizing scales--Aggressive. Although higher aggression scores would seem incongruous given the higher scores on the Internalizing scales, Zucker and his colleagues have not offered an explanation for this finding. Finally, 62% of gender-referred boys aged 6-11 had sum scores in the clinical range, compared to 29% of male siblings at this age. At age 4-5, 21% of gender-referred boys had sum scores in the clinical range, compared to 13% of siblings in this age group, a nonsignificant difference. Teacher reports on the CBCL, avail able for some of the boys, were quite consistent with the maternal ratings, indicating that the 6- to 11-year-olds were more similar to a referred sample with respect to Internalizing scores, but did not differ from a nonreferred sample in their Externalizing scores. CBCL ratings in a study by Zucker et al. (1984), however, revealed no significant differences in behavioral disturbance ratings between gender-referred children who did and who did not meet DSM-III criteria for GID. Regarding the data for girls in the Zucker and Bradley (1995) sample, the pattern was similar to that of the boys, with the girls in the younger age group resembling the nonreferred sample, and the older girls the referred sample. For both boys and girls in the older but not the younger age group, behavior problem scores exceeded that of the comparison group of siblings. Among GID-diagnosed boys in a study by Coates and Person (1985), at least 50% of those in the 4- to 5-year age range scored in the clinical range on the behavior problem scales of Social Withdrawal, Depressed, Immature, and Sex Problems. In the 6- to 11-year range, at least 50% scored in the clinical range for Schizoid, Depressed, Uncommunicative, Obsessive-Compulsive, and Social Withdrawal. In a study by Bates, Bentler, and Thompson (1973) gender-referred boys were found to be higher in behavior disturbance (e.g., disobedience, destructiveness, and bossiness) as measured using maternal reports on the Gender Behavior Inventory for Boys, though no significant differences in behavior disturbances were found by Bates et al. (1979) between "gender-problem" and "normal" boys.

The pattern of internalizing symptomatology among boys with GID, as reported in Zucker and Bradley's (Zucker & Bradley, 1995) as well as Coates and Person's (Coates & Person, 1985) samples, is consistent with that of other literature on boys referred for gender identity "problems." Using the Gender Behavior Inventory for Boys (Bates et al., 1973), Bates et al. (1973, 1979) found lower rates of extroversion in effeminate boys compared to "normal" boys. Coexisting Separation Anxiety Disorder has been noted by several sources, including the DSM-IV, in its section on Associated Features and Disorders of GID in children. The actual occurrence of Separation Anxiety Disorder in children with GID, though, is not reliably supported by empirical evidence. Coates and Person (1985) found that a large proportion (15 of 25, or 60%) of the boys in their sample met DSM-III criteria for Separation Anxiety Disorder. Zucker et al. (1996) found that there was a tendency for boys with a DSM-III-R diagnosis of GID to manifest symptoms of separation anxiety, though there was no significant relation between the presence of GID and Separation Anxiety Disorder per se. All the boys in the Coates and Person sample expressed discomfort with their biological sex, whereas those in the Zucker et al. sample, using DSM-III-R, were not required to express cross-sex wishes. Thus, Separation Anxiety Disorder may be more prevalent among the population of boys who experience a sense of discomfort with their biological sex. With respect to other aspects of psychological functioning, Coates and Person found that over 50% of their sample fell into the clinical range for the depressive factor on the CBCL, although none of the boys met DSM-III criteria for major depressive episode.

Research using projective tests to assess ego functioning and psychopathology in boys with GID has not provided clear evidence of psychopathology. Some researchers, using the Rorschach inkblot test, have found gender-referred boys to be more impaired than normal controls with respect to their ego functioning (Ipp, 1986, cited in Zucker & Bradley, 1995; Kolers, 1986, cited in Zucker & Bradley, 1995; Tuber & Coates, 1985, 1989). Both Ipp and Kolers, however, found the gender-referred boys to be no more impaired than their siblings, and boys with GID have not been found to fall within the psychotic range on the Rorschach inkblot test (Coates & Person, 1985). Goddard and Tuber (1989) found that boys with GID and Separation Anxiety Disorder were no more impaired, as rated using the Rorschach inkblot test, than were boys with only Separation Anxiety Disorder. Emotional disturbance indicators on the Draw-A-Person test were found by Skilbeck, Bates, and Bentler (1975) to be higher among gender-referred boys than those in the normative sample, but not different from boys who were referred for school problems. Zucker et al. (1984) found these indicators to be only marginally higher among gender-referred children who met DSM-III criteria for GID compared to those who did not.

It should be noted that not all authors agree that psychopathology, or internalizing symptomatology in particular, is specifically related to gender "prolems." Pleak and his colleagues (Pleak, Meyer-Bahlburg, O'Brien, Bowen, & Morganstein, 1989) reported no relation between higher feminine scores in their male sample (boys referred for problems unrelated to gender) and psychopathology in general or internalizing scores, as measured by the CBCL. It is also important to note that Zucker and Bradley (1995) reported that, in their sample, there was "tremendous range in the extent of the CBCL pathology" (p. 88), with some children exhibiting little behavioral disturbance and others a great deal (see also Zucker & Green, 1991, 1993). This suggests that blanket statements regarding associated psychopathology in children with GID cannot be made based on the available empirical evidence. It is also important to acknowledge a limitation in the literature regarding disability among children with GID, namely, the heavy reliance on the CBCL. One problem is that it provides only a rough measure of child psychological functioning, thus caution should be taken in using it to infer pathology (Richardson, 1999). A second problem is that the CBCL data are based primarily on parent-reports of competence and impairment. Research has shown that correlations between parent and child self-reports of behavioral and emotional problems tend to be low, and that, in clinical samples, parent-reports commonly imply a greater magnitiude of disturbance than do child self-reports (Achenbach, McConaughy, & Howell, 1987; Epkins, 1996; Handwerk, Larzelere, Soper, & Friman, 1999; Huddleston & Rust, 1994; Kazdin, Colbus, & Rodgers, 1986). With respect to peer relations, children have been found to report experiencing fewer difficulties than that reported by their parents. Taken together, research would suggest that caution must be taken in making definitive statements about the mental health of children with GID, when the preponderance of information is based on parent-report and rarely takes into account the child's subjective experience, which may paint a less disturbed picture.

Is GID Associated With a Significantly Increased Risk of Suffering Death, Pain, Disability, or an Important Loss of Freedom (Sentence [1])?

A condition that is associated with an increased risk for poor outcomes meets the criterion in Sentence [1] for mental disorder. Relevant to this criterion are the likely psychosexual outcomes of children with GID and the mental health correlates of those outcomes. As will be discussed, the most likely psychosexual outcome for children with GID is homosexuality in adolescence or adulthood (Green, 1985,1987,1994; Money & Russo, 1979; Zuger, 1984; see Zucker, 1985, for a review). Asking whether children who will go on to be homosexual are at increased risk for suffering death, pain, disability, or an important loss of freedom, should be an irrelevant issue, as it has been formally accepted in the mental health professions that homosexual individuals are intrinsically as mentally healthy as are heterosexuals (see Gonsiorek, 1991; Hart et al., 1978). Regardless of the fact that homosexuality is not officially considered a disordered outcome, the prevention of homosexuality remains a significant reason for referral of children with GID. It would be naive to believe that prevention of homosexuality is not a motivating factor for at least some of the clinicians who work with children referred for gender-a typicality. Indeed, some researchers and clinicians in the area of GID in children are quite open about such a goal, writing books (e.g., Rekers, 1982, 1991) or belonging to organizations devoted to the prevention of homosexuality (e.g., L. Loeb: see www.narth.com/menus/advisors.html). Thus, although the issue of the risk associated with a homosexual outcome should be moot, it is not. It is crucial that researchers and clinicians in the area of GID in children recognize that the most likely outcome for children with GID, with or without treatment (Green, 1987), is homosexuality, and that homosexuality is a nondisordered outcome.

Only a very few children with GID continue to have GID as adolescents or adults (Green, 1987; Zuger, 1984; see Zucker, 1985, for a review). No diagnostic signs have been identified to distinguish those children who will, from those who will not, go on to adolescent or adult outcomes of GID (Money & Lehne, 1993). For those children who will go on to be diagnosed with GID in adolescence or adulthood, there may be an increased risk of suffering death, pain, disability, or an important loss of freedom. Adolescents or adults, especially males, with GID are at increased risk for such negative outcomes as physical abuse, school drop-out, drug and alcohol addiction, prostitution, AIDS, and poverty (Seil, 1996). Rejected by peers and often their own families, adolescents with GID may be caught in a downward spiral similar to that which is found among other adolescents who have suffered rejection (see Kupersmidt, Coie, & Dodge, 1990, for a review). Again, the problem of direct causation versus mere association becomes relevant; the mere association of a condition with increased risk should not be sufficient for that condition to be considered a mental disorder.

Does GID Represent Dysfunction in the Individual (Sentence [3])?

According to the DSM-IV definition, for a condition to be considered a disorder, it must be shown that there is dysfunction in the individual. For GID to be considered a disorder, in accordance with the DSM-IV definition, it must be determined that cross-gender/cross-sex identification or behaviors or both represent a behavioral, psychological, or biological dysfunction in the individual. The use of the term "dysfunction" causes confusion, as the concept of dysfunction is open to interpretation, given that no definition is supplied for this nebulous term in the DSM-IV. In a series of recent papers, Wakefield (1992a, 1992b, 1993, 1997) has argued that mental disorder should be conceptualized as "harmful dysfunction." "Dysfunction," according to Wakefield, refers to the "failure of a mechanism in a person to perform a natural function for which the mechanism was designed by natural selection" (Wakefield, 1993, p. 165). Wakefield's notion of dysfunction has been criticised as flawed because of his misapplication of evolutionary concepts (Lilienfeld & Marino, 1995). To take just one example, Wakefield's argument that the current function for some "internal mechanism" must conform to past design in order for it to operate properly is specious. Just because some biologically based structure was designed (i.e., produced by natural selection) for a particular function (i.e., an adaptive response to some environmental problem), does not mean that it cannot be co-opted in the present to serve some potentially adaptive function or neutral role that it was not specifically designed by natural selection to perform. Our mouths evolved to masticate food, but past selection for this function did not prohibit the masticatory structure from being co-opted for language production, tool manufacture, or even sexual stimulation. Indeed, there are many examples of morphological or behavioral traits that were designed by natural selection for some function but were later co-opted to serve some other adaptive function or neutral role (Gould & Vrba, 1982), and Wakefield appears to be well aware of this literature (Buss, Haselton, Shackelford, Bleske, & Wakefield, 1998). Thus, a lack of some linear relationship between an "internal mechanism" and "past design" cannot be taken as evidence that the mechanism is dysfunctional. These concerns aside, gender is a cultural construct, not a heritable, biologically evolved trait (Walker & Cook, 1998). Consequently, it is entirely inappropriate to use natural selection theory as a framework for determining whether discomfort with the prescribed gender role of one's sex is, or is not, a dysfunction in the individual. The issue of whether discomfort with one's biological sex is a dysfunction in the individual is even more problematic. Outright repudiation of one's biological sex certainly seems "dysfunctional," at least in the folk sense of the word. However, this sort of intuitive "hunch" is clearly an unacceptable foundation upon which to base a clinical diagnosis. In this context, it de serves to be noted that an entire industry has developed around cosmetic surgery, which involves modification or removal of body parts which individuals dislike or "hate," yet these individuals are rarely, if ever, labelled as dysfunctional and, in some cases, are actively encouraged to pursue such behavior. Given the serious flaws inherent in Wakefield's definition of dysfunction, and the absence of any agreed-upon alternative, it is simply impossible to say whether disavowal of one's biological sex is, or is not, a dysfunction.

Is GID Simply Deviant Behavior or a Conflict Between the Individual and Society (Sentence [4])?

Deviant Behavior

A limitation of an evaluation of GID as a deviant behavior is that there exists no agreed-upon definition of "deviance." The latter is defined in the Penguin Dictionary of Psychology (Reber, 1985) as, "Generally, any pattern of behavior that is markedly different from the accepted standards within a society. The connotation is always that moral or ethical issues are involved and, in use, the term is typically qualified to note the specific form, such as sexual deviance (p. 196)." Relevant to an examination of whether GID in children simply represents deviant behavior is a review of the literature on the later psychosexual outcome of children with GID, that is, to what extent is their behavior simply a precursor to later sexual "deviance?" The link between cross-gender identification and behaviors in childhood with postpubertal sexual orientation or cross-gender/cross-sex identification or both has been examined using both retrospective and prospective studies. Extensive follow-up psychosexual information on cross-gender identified children is available from a number of sources. Taken together, the results suggest that between 61% and 100% of boys who had GID are homosexual or bisexual in adulthood, whereas only a very few (from 0% to 7%) have adult outcomes of GID. Heterosexual outcomes have been observed in up to 31% of the cases reported (Green, 1985, 1987; Money & Russo, 1979; Zuger, 1984; see Zucker, 1985, for a review).

Retrospective data show that homosexual men and women remember higher rates of childhood cross-gender behavior than do their heterosexual counterparts (see Bailey & Zucker, 1995, for a review). Data from retrospective studies of gay men and lesbians tend to indicate similar childhood gender nonconforming experiences as do prospective studies (cf. Phillips & Over, 1992). Compared to their heterosexual counterparts, for example, more gay men and lesbians recall having enjoyed "cross-gender" activities, dressing like the other sex, and pretending to be the other sex (Bell, Weinberg, & Hammersmith, 1981). Harry (1982) reported that between 36% and 58% of his sample of 1,500 gay men recalled playing primarily with girls and some cross-dressing behavior, rates significantly higher than those for heterosexual men. With respect to cross-sex wishes or discomfort with their biological sex, between 22% and 34% of the gay men in Harry's study recalled wanting to be girls, compared to 5% of heterosexual men, a significant difference. Importantly, though, the difference in cross-sex wishes among the gay and heterosexual respondents was reduced to a trend in adolescence and was nonsignificant in adulthood. One may wonder whether some of these gay men could have received diagnoses of GID as children for having wished to be girls, which was, for most, a transient desire. Regarding individuals with GID in adolescence and adulthood, there appears to be a strong link with re called cross-gender behavior. Bradley and Zucker (1990) reported that most of the adolescents they saw clinically who requested sex reassignment had a history of early cross-gender behavior, and would have met DSM-III-R criteria for childhood GID. It is not clear how many of these adolescents had cross-sex wishes in childhood.

To summarize the outcome literature, then, though a significant proportion of adolescents or adults with GID may have childhood histories of GID, very few children with GID go on to develop adolescent or adult GID. The likelihood is relatively high that they will grow up to be homosexual, though most homosexuals are unlikely to have had GID as children. Ironically, it seems to have been generally accepted in the literature that children with GID are at high risk for adolescent or adult GID (see APA, 1987; Bradley & Zucker, 1990; Rekers, Bentler, Rosen, & Lovaas, 1977; Rosen, Rekers, & Bentler, 1978; Zucker, 1985; Zucker & Green, 1992). Indeed, this line of reasoning has provided much of the basis for endorsing treatment for children with GID, which is unsettling given that a relatively large body of empirical evidence points to GID in adolescence or adulthood as being an outcome for only a small percentage of children with GID.

Western cultures recognize two gender categories: boy/man versus girl/ woman. There are, however, many cultures worldwide that have more flexible concepts of gender. Indeed, some cultures have three or even four gender categories (Herdt, 1994; Nanda, 1990,2000; Williams, 1992). Individuals who occupy these "alternative" gender roles are not identified by themselves or by the members of their social groups as boys/men or as girls/women. The manner in which gender roles are defined are also historically specific, and as such, vary within the same culture across time (e.g., Trumbach, 1994). If turn of-the-20th-century ideas about sexual inversion remained in place today, many of our society's members, including "stay-at-home" dads or career oriented women, could be labelled as mentally ill.

The cross-cultural and historical data demonstrate that binary Western gender roles are social constructs, not the inevitable outcomes of sex differences in biology. As such, failure for a biological male or female to conform to some historically and culturally specific gender role ideal cannot be interpreted as inherently "dysfunctional" or "disordered." Moreover, individuals who are categorized in non-Western culture as neither men nor women are not necessarily recognized as "deviant," because they often occupy respected social positions (Herdt, 1994; Nanda, 2000; Williams, 1992). This raises the question as to whether individuals identified as "gender-disturbed" and thus disordered in Western culture, would merely be recognized as gender variant (and perhaps even esteemed) if born into particular non-Western cultures that employ more pluralistic concepts of gender. Taken together, the cross cultural and historical data strongly suggest that the failure of a biological male or female to conform to some socially prescribed gender role represents nothing more than a conflict between the individual and a society that seeks to police the particular gender boundaries it legitimizes.

In contrast, it seems unlikely that discomfort with one's biological sex per se represents a conflict between the individual and society. Discomfort with one's sex indicates an underlying unease with how an individual experiences his or her actual biological make-up. Such discomfort would probably exist regardless of the degree of societal openness surrounding gender role expression.

IS GID IN CHILDREN CONSISTENT WITH THE DSM-IV DEFINITION OF DISORDER?

Using the evidence presented, we return to the questions posed to determine if GID in children is a mental disorder according to the criteria set out in the DSM-IV. First, is GID associated with present distress (Sentence [1])? The answer appears to be that children with GID, at least those who experience discomfort with the culturally prescribed gender role of their sex, but not with their biological sex per se, are somewhat distressed, but not necessarily at a clinically significant level. Furthermore, if distress is experienced, it is not likely caused directly by their condition, but is more likely secondary to it. For those whose discomfort lies with their biological sex, distress may be more evident and may be indirectly and directly associated with that discomfort.

Is GID associated with present disability (Sentence [1])? Children with GID may suffer from some degree of impairment in their peer group relations, social and school competence, and general mental health. Importantly though, especially for those with discomfort with the prescribed gender role of their sex, it cannot be concluded that their suffering is at a clinically significant level. The chronicity effect that has been reported among gender-referred children seems to imply an indirect link between GID and disability. There is limited evidence to suggest that those who experience a sense of discomfort with their biological sex may be suffering from more disability than those who do not experience such discomfort. Systematic research that separates children with and without discomfort with their biological sex is needed before any conclusive statements can be made regarding their degree of disability.

Is GID associated with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (Sentence [1])? For the majority of children with GID, whose later psychosexual outcome will be homosexuality, the answer to this question must be no. For the minority who develop into adolescents or adults with GID, the answer is yes, as the latter individuals in our society are likely to experience a great deal of disturbance. Again, though, we must consider whether the problems faced by adolescents and adults with GID are caused directly by or are secondary to their "condition."

Does GID in children represent a dysfunction in the individual (Sentence [3])? The answer to this question is elusive, given the lack of consensus regarding a definition of dysfunction. To date, there is insufficient evidence on which to base any conclusion that GID represents a dysfunction in the individual.

Finally, is GID in children simply deviant behavior or a conflict between the individual and society (Sentence [4])? GID in children whose discomfort lies solely with the prescribed gender role of their sex does represent a "deviant" behavior, in that it deviates from society's expectations for how children should behave along the gender norms prescribed for boys and girls in our society. Moreover, much empirical evidence points to GID in those children as nothing more than a conflict between the individual and society, given that the most likely psychosexual outcome, whether a child does or does not receive treatment for GID, is homosexuality. Several authors have noted that it is ironic that the DSM-IV has a category for a childhood psychopathology for which the most likely predicted outcome is homosexuality, which has not been formally considered a pathology for over a quarter of a century (Fagot, 1992; Green, 1994). Labelling children as gender-disturbed when their most likely psychosexual outcome is homosexual is of questionable value, when the DSM-IV does not include this outcome as disordered. It is troubling that in the current peer-reviewed literature, despite it not being officially considered a mental disorder, homosexuality continues to be labelled as a "sex-role disturbance," a "severe sexual problem," or even a "diagnosis" (e.g., Dahl, 1988; Rekers, 1986).

As data from across cultures and time indicate, the notion of cross-gender identification or behaviors or both as disordered is highly dependent on the cultural and historical context in which they occur. It is unlikely, however, that conflict between the individual and society characterizes children whose discomfort lies with their biological sex. A sense of discomfort with one's biological sex is not consistent with conflict between the individual and society, as it represents the individual's experience of his or her biological status, which may transcend cultural and historical contexts.

CONCLUSIONS

The comparisons presented in this paper fail to support a conclusion that GID in children, as it appears in DSM-IV, meets the criteria of mental disorder. Children who do and do not present with discomfort with their biological sex may represent different populations. In this paper, sufficient evidence has been presented to conclude that children whose discomfort lies only with the gender role of their sex should not be considered to have a gender-related disorder. Those who experience discomfort with their biological sex may meet some of the DSM-IV criteria for mental disorder. Shortcomings in the current definition of mental disorder, and the fact that studies published to date have not separated these two groups of children make it impossible to thoroughly evaluate the extent to which children with discomfort with their biological sex meet all the criteria for mental disorder. Longitudinal studies of children with discomfort with their sex are needed to clarify this issue. It is thus recommended that the category of GID in children in its current form should not appear in future editions of the DSM. With further study, perhaps sufficient data will be gathered to determine whether children who experience discomfort with their biological sex should be considered to have a mental disorder.

Agreeing that children with discomfort with the culturally prescribed gender role of their sex do not have GID does not preclude clinical attention to children with cross-gender identification. The reality of life in North American society is such that individuals who manifest gender identity and behaviors typical of the "opposite sex" face ridicule and ostracism. The resulting emotional difficulties, such as anxiety or depressive symptomatology, must be dealt with if the child is in sufficient distress. In consideration of the child as part of a family system, the value of family therapy should not be overlooked, as has been specified in The Standards of Care for Gender Identity Disorders (Harry Benjamin International Gender Dysphoria Association, 1998).

The previous notion of sexual inversion, and more recently, of homosexuality as mental disorders should be a reminder to mental health professionals about psychiatry's power to pathologize those who do not fit the social norm (Bem, 1993). With homosexuality as the most likely psychosexual outcome for a child with GID, APA's Position Statement on Homosexuality is relevant. In 1993, the American Psychiatric Association's Committee on Gay, Lesbian, and Bisexual Issues of the Council on National Affairs called on organizations and individuals to "do all that is possible to decrease the stigma related to homosexuality wherever and whenever it may occur" (p. 686). It seems as though the inclusion of GID in children as it appears in the DSM-IV does little in responding to this appeal. Although the focus of this paper was on GID in children, it raises a larger question about the concept of "pathology" in general. To what extent do other "disorders" represent conditions that simply violate societal norms? In this paper, we have provided a simple means of assessing whether a condition meets DSM criteria for mental disorder (i.e., a comparision between the definitional criteria and the extant literature). This kind of analysis could prove useful in the clarification of other forms of behavior that might constitute psychopathologies.

(1.) To whom correspondence should be addressed at Department of Psychology and Neuroscience, University of Lethbridge, 4401 University Drive, Lethbridge, Alberta, Canada T1K 3M4; e-mail: paul.vasey@uleth.ca.

(2.) In this paper, the term "gender" refers to the socially constructed roles that are related, in part, to sex distinctions. "Sex" refers to a person's biological status as defined by all, or some combination, of the following: chromosomes, sex hormones, gonads and other internal reproductive organs, gametes, external genitalia, and secondary sexual characteristics (for a discussion of the use of "sex" and "gender," see Walker & Cook, 1998).

(3.) Although this criterion does not characterize gender-atypical behavior in children living in Western cultures, it deserves mention that in a number of non-Western cultures, behaviors that would be identified as gender-atypical by Western observers, are expectable and culturally-sanctioned responses to particular events such as "transformation ceremonies" or dreams (see Williams, 1992). Among the Kaska Indians of the Subarctic, for instance, parents sometimes performed transformation ceremonies that "changed" daughters into sons. Parents would tie dried bear ovaries onto their daughter's belt when she was about 5 years of age and, in so doing, her gender was transformed. Following this type of transformation ceremony, such individuals were not treated as females by their communities, nor did they behave as such (Honingmann, 1964). Instead, they exhibited behavior that was gender-typical for males in their culture.

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APPENDIX: DSM-IV DIAGNOSTIC CRITERIA FOR GENDER IDENTITY DISORDER IN CHILDREN

A. 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 at tire; 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 pas times of the other sex

(5) strong preference for playmates of the other sex

B. Persistent discomfort with his or her sex or sense of inappropriate ness 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 to 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.

C. The disturbance is not concurrent with a physical intersex condition. D. The disturbance causes clinically significant distress or impairment

in social, occupational, or other important areas of functioning.

ACKNOWLEDGMENTS

The authors sincerely thank the following individuals for their support and their valuable comments on earlier versions of this paper: Rebecca Anweiler, William Brender, Ilana Frank, Tod Kippin, Anne Lawrence, Richard Pawsey, Jim Pfaus, David Perry, Anne Russon, Lisa Serbin, and two anonymous reviewers. NHB and PLV gratefully acknowledge support from the Fonds pour la formation de chercheurs et l'aide a la recherche (FCAR). PLV also thanks the University of Lethbridge for support. WMB expresses gratitude to the W.T. Grant Foundation and the Social Sciences and Humanities Research Council of Canada (SSHRC) for their support.

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