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Is Gender Identity Disorder in Children a Mental Disorder?

Sex Roles: A Journal of Research, Dec, 2000 by Nancy H. Bartlett, Paul L. Vasey, William M. Bukowski

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.

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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).

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Is Gender Identity Disorder in Children a Mental Disorder?

Sex Roles: A Journal of Research, Dec, 2000 by Nancy H. Bartlett, Paul L. Vasey, William M. Bukowski

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