Source: Bradley, S. J., & Zucker, K. J. (1990). Gender identity disorder and psychosexual problems in children and adolescents. Canadian Journal of Psychiatry, 35(6), 477-486. https://doi.org/10.1177/070674379003500603
The prevalence rate of gender identity disorder might also be derived from data regarding the prevalence of homosexuality. Unfortunately, this literature presents two main problems: first, the true prevalence of exclusive, or near exclusive, preferential homosexuality remains a matter of debate (8); second, the retrospective literature on childhood cross-gender behaviour in homosexual men and women often does not specify how to determine a cutoff score to dichotomize cases as cross-gendered versus not cross-gendered; and, as was noted earlier, cases classified as cross-gendered would not necessarily meet the complete DSM-III-R criteria for GIDC. Despite these problems, one could argue that GIDC, or its subclinical variants, may occur in two percent to five percent of children in the general population. Zucker (9) has reviewed studies that have assessed specific cross-gender behaviours in nonclinical populations, and Meyer-Bahlburg (7) has emphasized the importance in identifying the “zone of transition between clinically significant cross-gender behavior and mere statistical deviations from the gender norm.”
Girls with GIDC develop a preference for boys as playmates, particularly in conjunction with stereotypical masculine role activities, such as fantasy aggression and competitive sports. Fantasy dress-up play is somewhat less prominent, in part because the “regular” clothing of these girls is sometimes so masculine that they naturally pass as boys. A common clinical concern of parents is that these girls have incredibly intense temper tantrums if required to wear feminine clothing, even if only for special occasions (for example, to attend religious services or a wedding). When interacting with non family members, these girls often invent boy’s names or masculinize their given names.
In our clinic, about half the referrals have been initiated by the parents because of their concern about their child’s gender development (15). The other half are often referred on the suggestion of significant others, including teachers, pediatricians, and mental health professionals. Although parental ambivalence about the issue is commonly a part of the clinical picture (and must be addressed as such), it appears to be more common when the referral is initiated from outside the family.
In our experience, some parents have had concerns about their child’s gender identity development only to have them minimized by health professionals as being silly or exaggerated. Because this disorder does not typically appear to remit spontaneously, some parents will renew their concerns and eventually are referred for an assessment.
Chronic peer conflicts and social ostracism often lead school authorities to recommend clinical referral. By late childhood, however, many of these boys do not meet the complete criteria for GIDC (6,15), in part because these youngsters are more circumspect in describing gender dysphoric feelings in the presence of parents and significant others. In many cases, however, these boys would have met the DSM-III-R diagnostic criteria for GIDC when they were younger. It remains a matter of some debate whether the clinical picture has actually changed in these cases or whether it has been merely clouded by social desirability factors.
Our own preliminary follow-up data of children with GIDC (23) and our clinical experience with transsexual adolescents (24) have led us to believe that the risk for post-pubertal gender dysphoria is greatest among those children living in families in which their has been a high tolerance for the continuation of the cross-gender behaviour. This often results in the child not being referred (among our adolescent transsexual cases, almost none were seen clinically during childhood) or the treatment is severely hampered by parental ambivalence or outright resistance. The lack of intervention or limit-setting on the part of the parents faciliates, in part, the development of a fixed fantasy of the self as of the opposite sex. When this continues into the adolescent years, request for hormonal and surgical sex reassignment is seen by the adolescent as the only solution to his or her gender dysphoria.
Parental tolerance, or even encouragement, of the nascent cross-gender behaviour also appears to be an extremely important part of the clinical picture (3,10). Green (10) has shown that the degree of approval of initial cross-gender behaviour in boys correlated with a composite index of crossgender behaviour at the time of the initial assessment. In our experience, such toleration or reinforcement appears to be accounted for by many factors, including parental attitudes and values regarding psychosexual ideals, feedback from professionals that the behaviour is normative or “just a phase,” and parental psychopathology and discord, which render the parents less available to cope with their children’s developmental needs.
Based on these varied factors, Bradley (61,66) has developed the following conceptual framework which hopefully will have heuristic clinical value in understanding individual cases. In boys, the scenario is viewed as follows. The boy has a temperamental predisposition to poor anxiety tolerance.
Usually, parents start to become uncomfortable with what they have been perceiving as a “phase” that the child has not outgrown. Their discouragement of the behaviour at this point, if not accompanied by other manifestations of their valuing of the child, may drive the behaviour “underground” , leaving the child clinging to an internal but valued feminine self.
In girls, the scenario is viewed as follows. The girl has a temperamental predisposition to poor anxiety tolerance, but she is also oriented to activity and motion.
If the need for this defense continues and is not discouraged by parents, the girl will begin to consolidate a fantasied self as a male.
First, clinical experience suggests that intervention during childhood can more readily reduce gender identity conflict than intervention during adolescence. In fact, the prognosis is rather poor for reducing severe gender dysphoria after puberty. Accordingly, the earlier treatment begins, the better. Second, there has been much discussion in the literature regarding the importance of working with the parents of children with GIDC. When there is a great deal of marital discord and parental psychopathology, treatment of these problems will greatly facilitate more specific work around gender identity issues. Management of the child’s gender behaviour in his daily environment requires that the parents have clear goals and a forum in which to discuss difficulties. Because parental dynamics and ambivalence about treatment may contribute to the perpetuation of the disorder (69), it is important for the therapist to have an appropriate relationship with the parents in order to address and work through these issues.
With supportive therapy, some of these individuals will accept themselves as homosexual and relinquish the cross-sex wish. Others will decide that no matter why they feel the way that they do (that is, no matter how much “insight” they may have), being able to “be” who they feel they are internally is the only way that they can live comfortably.
Most adolescents who present with the request for sex reassignment have had a history of early cross-gender behaviour and the majority would have met DSM-III-R (1) criteria for GIDC. As noted earlier, these youngsters have rarely been seen for therapy in childhood and their parents have hardly ever attempted to limit their cross-gender behaviour. These youngsters often are psychosocially impaired and suicidal ideation and/or attempts are common (24). Supportive therapy can help reduce psychosocial impairment and help the patient develop a more realistic understanding of what hormonal and surgical sex reassignment can achieve. Referral to adult gender identity clinics is usually appropriate between the ages of 16 and 18.