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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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.