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Gender dysphoria in children
Specialty	Psychiatry

Gender identity disorder in children (GIDC) or gender dysphoria is the formal diagnosis used by psychologists and physicians to describe children who experience significant discontent with their biological sex, assigned gender, or both.

GIDC was formalized in the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 and primarily referenced gender non-conforming behaviors. GIDC remained in the DSM from 1980 to 2013, when it was replaced with the diagnosis of "gender dysphoria" in the fifth revision (DSM-5), in an effort to diminish the stigma attached to gender variance while maintaining a diagnostic route to gender affirming medical interventions such as hormone therapy and surgery.

Gender identity disorder in children is more heavily linked with adult homosexuality than adult transsexualism. According to limited studies, the majority of children diagnosed with GID cease to desire to be the other sex by puberty, with most growing up to identify as gay or lesbian with or without therapeutic intervention. Hepp, Milos, and Braun-Scharm state in their study on gender identity disorder and anorexia nervosa in male monozygotic twins that the correlation between childhood gender identity disorder and adult homosexuality is stronger than the correlation between childhood gender identity disorder and adult transsexualism (Hepp, Milos, Braun-Scharm, 2004). Cohen-Kettenis and Gooren note in their review of the literature on transsexualism that children with gender identity disorder are more likely to identity as gay or lesbian later in life, as opposed to identifying as transgender. Additionally, gay and lesbian adults report having exhibited more opposite-sex gender role behavior than heterosexual adults.

Controversy surrounding the pathologization and treatment of cross-gender identity and behaviors, particularly in children, has been evident in the literature since the 1980s. Proponents argue that therapeutic intervention helps children be more comfortable in their bodies and can prevent adult gender identity disorder. Opponents say that the equivalent therapeutic interventions with gays and lesbians (titled conversion or reparative therapy) have been strongly questioned or declared unethical by the American Psychological Association, American Psychiatric Association, American Association of Social Workers and American Academy of Pediatrics. The World Professional Association for Transgender Health (WPATH) states that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical." Critics also argue that the GIDC diagnosis and associated therapeutic interventions rely on the assumption that an adult transsexual identity is undesirable, challenging this assumption along with the lack of clinical data to support outcomes and efficacy.

Diagnostic classification

DSM-IV TR (2000)

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV (TR)) makes a differential diagnosis coding based on current age:

• 302.6 Gender Identity Disorder in Children
• 302.85 Gender Identity Disorder in Adolescents or Adults

The current edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) has five different diagnoses for gender identity disorder, including one for when it manifests during childhood. It is important to note that the diagnoses of gender identity disorder is not given to intersex individuals, or those who are born with male and female sex organs. Additionally, it is important to note that, as with all psychological disorders, these symptoms must cause direct distress and an impairment of functioning of the individual exhibiting the symptoms (Bradley, Zucker, 1997).

F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.-.

In the DSM of mental disorders used by psychologists in the United States, gender identity disorder is given two sets of criterion. Criterion A indicates that a child identifies as a member of the opposite sex. The child needs to demonstrate four of the five following symptoms: dressing as a member of the opposite sex, primarily befriending members of the opposite sex, demonstrating a desire to engage in play activities characteristic of the opposite sex, and actively stating that they wish to be the opposite sex. Criterion B, on the other hand, indicates that the child does not identify with the sex they were born.This could manifest itself as a dislike of styles of dress characteristic of the sex they were born, avoidance of association with members of their born sex, and distress towards the aspects of their physiology which indicate their born gender (Bradley, Zucker, 1997).

DSM-5 (2013) diagnosis of gender dysphoria

In May 2013, the American Psychiatric Association published the DSM-5 in which the GIDC diagnosis was removed and replaced with gender dysphoria, for the first time in its own distinct chapter. Lev states that gender dysphoria places the focus on distress with one's body rather than conformity with societal gender norms, and that this change was accompanied by changes to sexist language and a reduced reliance on binary gender categories. Gender dysphoria reframes the diagnosis as a time-limited distress of the body which is potentially rectified with access to gender transition procedures, rather than a lifetime disorder of the identity.

Therapeutic intervention

History of therapeutic interventions

The introduction of the GIDC diagnosis into the DSM-III in 1980 was preceded by numerous US studies and treatments on feminine boys beginning as early as the 1950s and 1960s, most prominently by John Money and Richard Green at the Johns Hopkins Hospital and the University of California, Los Angeles (UCLA). The prevention of transsexuality and / or homosexuality was explicitly stated as the goal of many of these studies: "My focus will be what we might consider the prevention of transsexualism." Bryant notes that feminine boys were not a new phenomenon at this time, however the public emergence of adult transsexual women (male to female) in the 1950s was new and created a number of problems for psychologists, motivating some to undertake efforts at preventing their further emergence. Meyerowitz chronicles the deep disagreements which erupted between psychologists and physicians after Christine Jorgensen's public gender transition, namely over whether transsexuals should be permitted to align their bodies with their inner identities or whether their inner identities must be brought in line with their bodies. At the time, transsexual women were beginning to publish first-person narratives which highlighted their awareness of their femininity at a young age and Bryant notes that some clinicians and researchers thus turned their attention to feminine boys, constructing sissies as a new "medicalized patient and research population."

One early researcher was George Alan Rekers who focused his 1972 doctoral research on the treatment of feminine boys. In this work, Rekers describes a litany of feminine behaviours which he catalogues including: feminine posture, gait, arm and hand gestures, feminine inflection in speech, as well as interest in feminine clothing, games and conversation topics. Using classical behaviour modification techniques he and a team of research assistants set about extinguishing 'problem' feminine behaviours in three boys in particular, enlisting the help of parents and occasionally teachers to provide rewards and punishments corresponding to behaviours identified as wanted or unwanted. Rekers' dissertation describes in detail, the case of Kraig (a pseudonym for Kirk Andrew Murphy) whose mother was instructed over earphones to alternately praise or ignore him depending on whether he played with a table of toys deemed to be feminine (typically dolls) or masculine (typically weapons). She was also trained to monitor his behaviour at home, with research assistants visiting weekly to ensure she was correctly completing her four times daily observations of Kraig's gendered behaviour. Physical punishment from Kraig's father is named as one of the primary consequences for feminine behaviour at home. Throughout Rekers future work, he cites his treatments with Kraig as a success, claiming that "Kraig's feminine behaviours have apparently ceased entirely ."

In contrast to this, a number of facts about Kraig have become public information, including: that he was a gay man; that according to his family, he never recovered from these treatments; and that in 2003, at the age of 38, he committed suicide. Even without confirmed knowledge of such outcomes, by the mid 1970s Rekers' publications on his treatment modality were already attracting harsh criticism from scholarly and popular media sources and Bryant speculates that this is one possible explanation for why many clinicians do not publish on their treatment techniques, focusing instead on less controversial aspects of GIDC, such as diagnostic criteria. At present, the nature of current treatments administered on children diagnosed with GIDC are poorly explained in the work of prominent clinicians such as Kenneth Zucker, however first-person accounts of treatment in popular media sources would seem to indicate that feminine behaviours in boys continue to be identified and selected for elimination, hence the mounting opposition to this practice.

Proponents

Therapeutic approaches for GIDC differ from those used on adults and have included behavior therapy, psychodynamic therapy, group therapy, and parent counseling. Proponents of this intervention seek to reduce gender dysphoria, make children more comfortable with their bodies, lessen ostracism, and reduce the child's psychiatric comorbidity. The majority of therapists currently employ these techniques. "Two short term goals have been discussed in the literature: the reduction or elimination of social ostracism and conflict, and the alleviation of underlying or associated psychopathology. Longer term goals have focused on the prevention of transsexualism and/or homosexuality."

Individual therapy with the child seeks to identify and resolve underlying factors, including familial factors; encourage identification by sex assigned at birth; and encourage same-sex friendships. Parent counseling involves setting limits on the child's cross-gender behavior; encouraging gender-neutral or sex-typical activities; examining familial factors; and examining parental factors such as psychopathology. Longtime researchers of gender identity disorder, Kenneth Zucker and Susan Bradley, state that it has been found that boys with gender identity disorder often have mothers who to an extent reinforced behavior more stereotypical of young girls. They also note that children with gender identity disorder tend to come from families where cross-gender role behavior was not explicitly discouraged. However, they also acknowledge that one could view these findings as merely indicative of the fact that parents who were more accepting of their child's cross-gender role behavior are also more likely to bring their children to a clinical psychiatrist as opposed to parents who are less accepting of cross-gender role behavior in their children (Bradley, Zucker, 1997). " Proponents acknowledge limited data on GIDC: "apart from a series of intrasubject behaviour therapy case reports from the 1970s, one will find not a single randomized controlled treatment trial in the literature" (Zucker 2001). Psychiatrist Domenico Di Ceglie opines that for therapeutic intervention, "efficacy is unclear," and psychologist Bernadette Wren says, "There is little evidence, however, that any psychological treatments have much effect in changing gender identity although some treatment centres continue to promote this as an aim (e.g. Zucker, & Bradley, 1995)." Zucker has stated that "the therapist must rely on the 'clinical wisdom' that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions."

Opponents

The consensus of the World Professional Association for Transgender Health is that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical." Clinicians have called Zucker and Bradley's therapeutic intervention "something disturbingly close to reparative therapy for homosexuals" and have noted that the goal is preventing transsexualism: "Reparative therapy is believed to reduce the chances of adult GID (i.e., transsexualism) which Zucker and Bradley characterize as undesirable." Author Phyllis Burke wrote, "The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse." Zucker dismisses Burke's book as "simplistic" and "not particularly illuminating;" journalist Stephanie Wilkinson said Zucker characterized Burke's book as "the work of a journalist whose views shouldn't be put into the same camp as those of scientists like Richard Green or himself." However, strong critiques of Dr. Zucker's approach do not come from lay activists and journalists alone, but also from psychiatrists and psychologists within his own field. Edgardo Menvielle, a child-adolescent psychiatrist at the Children's National Medical Center in Washington states, "Therapists who advocate changing gender variant behaviours should be avoided." Developmental and clinical psychologist Diane Ehrensaft told the Psychiatric Times, "The mental health profession has been consistently doing harm to children who are not 'gender normal,' and they need to retrain,"

Critics argue GIDC was a backdoor maneuver to replace homosexuality in the DSM, and Zucker and Robert Spitzer counter that GIDC inclusion was based on "expert consensus," which is "the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published." Katherine Wilson of GID Reform Advocates stated:

In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier revisions, to the concern of many civil libertarians. A child may be diagnosed with Gender Identity Disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls. Most psychologists who specialize in gender identity disorder in children note a higher level of male patients brought to them, rather than female patients. A possible explanation would be that cross-sex behavior is less acceptable and therefore more noticeable and more likely likely to be viewed by problematic by the child’s parents (Bradley, Zucker, 1997). preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical" clothing, toys and activities of the other sex are imprecise in an American culture where much children's' clothing is unisex and appropriate sex role is the subject of political debate. Equally puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination and segregation.

Clinicians argue that GIDC "has served to pressurize boys to conform to traditional gender and heterosexual roles." Feder notes that the diagnosis is based on the reactions of others to the child, not the behavior itself. Langer et al. state "Gender atypicality is a social construction that varies over time according to culture and social class and therefore should not be pathologized." Zucker refuted their claims in a response. Critics "contend that it is a precursor of homosexuality, that parents should simply accept it, and that the very diagnosis is based on sexist assumptions."

DSM-5 controversy

Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-5 committee on GIDC. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." Zucker is accused by LGBT activists of promoting "gender-conforming therapies in children" and "treating children with GID with an eye toward preventing adult homosexuality or transsexuality." Zucker "rejects the junk-science charge, saying that there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

The DSM-5 change to "gender dysphoria" was endorsed by transgender activists and allies as a way to lessen stigma but maintain a diagnostic route to trans-specific medical care. However, Lev states that the diagnosis of gender dysphoria continues to pathologize transgender experiences. Likewise, Bryant argues that many continue to argue that the diagnosis "harms the very children it purports to help".

Alternative approaches to gender diversity in children

The existence of two-spirit people (those understood to be connected to both the masculine and feminine spirit) has been documented in over 130 pre-colonial Indigenous nations in North America including the Zuni lhamana and the Lakota winkte. In some of these nations, the identification of a two-spirit child was regarded as a blessing for the family and the community. While the roles which two-spirit people held in their communities varied widely from nation to nation, in some cases they were held in high regard, for example We'wha who was the cultural ambassador for the Zuni people during the late 19th century. The historical and contemporary existence of alternative gender roles has also been documented worldwide, for example: the kathoey in Thailand and Laos, the hijra of India, the Muxe of the Zapotec people in Mexico, the Mukhannathun of what is now Saudi Arabia, the Mahu (person) in Hawaii, the fakaleiti in Tonga and the fa'afafine in Samoa. Though the historical meaning of these roles is often disputed, their existence is not.

Referencing contemporary Western views on gender diversity, psychologist Diane Ehrensaft states: "I am witnessing a shake-up in the mental health community as training sessions, workshops and conferences are proliferating all over this country and around the world, demanding that we reevaluate the binary system of gender, throw out the idea that gender nonconformity is a disorder, and establish new guidelines for facilitating the healthy development of gender-creative children." Child-adolescent psychiatrist Edgardo Menvielle and psychotherapist Catherine Tuerck offer a support group for parents of gender non-conforming children at the Children's National Medical Centre in Washington D.C., aimed "not at changing children's behaviours but at helping parents to be supportive". Other publications are beginning to call for a similar approach, to support parents to help their child become their authentic self. Community organizations established to support these families have begun to develop, such as Gender Spectrum, Trans Youth Family Allies, Gender Creative Kids Canada, and Trans Kids Purple Rainbow, as well as conferences such as Gender Odyssey Family Conference and summer camps such as Camp Aranu'tiq, all with the goal of supporting healthy families with gender non conforming children. Popular media accounts of parents assisting their children to live in their felt gender role have recently begun to emerge. These stories demonstrate that children and their parents face substantial stigma, however Menvielle maintains that "the therapist should focus on helping the child and family cope with intolerance and social prejudice, not on the child's behaviours, interests or choice of playmates". A host of new terms being applied to these children (such as gender variant), gender non-conforming, gender-creative and gender-independent) indicates that many are beginning to reject the label of Gender Identity Disorder in Children.

See also

• Childhood gender nonconformity
• Transgender youth
• List of transgender-related topics

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External links

• Gender Identity Disorder and Transsexualism via Merck Manual
• Issues of Psychiatric Diagnosis for Gender Nonconforming Youth via GIDreform.org
• Zucker: Manipulation of Young Feminine Boys

• Gender identity
• Sexual and gender identity disorders
• Transgender and medicine