GENDER
IDENTITY DISORDERS
The essential feature of the disorders
included in this subclass is an incongruence
between assigned sex (i.e., the sex that is
recorded on the birth certificate) and gender
identity. Gender identity is the sense of
knowing to which sex one belongs, that is,
the awareness that "I am a male,"
or "I am a female." Gender identity
is the private experience of gender role, and
gender role is the public expression of
gender identity. Gender role can be defined
as everything that one says and does to
indicate to others or to oneself the degree
to which one is male or female.
Some forms of gender identity disturbance are
on a continuum, whereas others may be
discrete. When gender identity disturbance is
mild, the person is aware that he is a male
or that she is a female, but discomfort and a
sense of inappropriateness about the assigned
sex are experienced. When severe, as in
Transsexualism, the person not only is
uncomfortable with the assigned sex but has
the sense of belonging to the opposite sex.
Disturbance in gender identity is rare, and
should not be contused with the far more
common phenomena of feelings of inadequacy in
fulfilling the expectations associated with
one's gender role. An example of the latter
would be a person who perceives himself or
herself as being sexually unattractive yet
experiences himself or herself unambiguously
as a man or a woman in accordance with his or
her assigned sex.
Although people who first present clinically
with gender identity problems may be of any
age, in the vast majority of cases the onset
of the disorder can be traced back to
childhood. In rare cases, however, an adult
will present clinically for the first time
with a gender identity problem and report
that the first sign; of the disturbance were
in adult life.
Gender
Identity Disorder of Childhood
The essential features of this disorder
are persistent and intense distress in a
child about his or her assigned sex and the
desire to be, or insistence that he or she is
of the other sex. (This disorder is not
merely a child's nonconformity to stereotypic
sex-role behavior as, for example, in
"tomboyishness" in girls or
"sissyish" behavior in boys, but
rather a profound disturbance of the normal
sense of maleness or femaleness.) In
addition, in a girl there is either
persistent marked aversion to normative
feminine clothing and insistence on wearing
stereotypic masculine clothing, or persistent
repudiation of her female anatomic
characteristics. In a boy, there is either
preoccupation with female stereotypic
activities, or persistent repudiation of his
male anatomic characteristics. this diagnosis
is not given after the onset of puberty.
Girls with this disorder regularly have male
companions and an avid interest in sports and
rough-and-tumble play; they show no interest
in dolls or playing "house" (unless
they play the father or another male role).
More rarely, a girl with this disorder
refuses to urinate in a sitting position,
claims that she has, or will grow, a penis,
does not want to grow breasts or menstruate,
or asserts that she will grow up to become a
man (not merely in role).
Boys with this disorder usually are
preoccupied with female stereotypic
activities. They may have a preference for
dressing in girls' or women's clothes, or may
improvise such items from available material
when genuine articles are unavailable. (The
cross-dressing typically does not cause
sexual excitement, as in Transvestic
Fetishism.) They often have a compelling
desire to participate in the games and
pastimes of girls. Female dolls are often
their favorite toy, and girls are regularly
their preferred playmates. when playing
"house," the role of a female is
typically adopted. Rough-and-tumble play or
sports are generally avoided. Gestures and
actions are often judged against a cultural
stereotype of femininity, and the boy is
usually subjected to male peer group teasing
and rejection, whereas the same rarely occurs
among girls until adolescence. Boys with this
disorder may assert that they will grow up to
become women (not merely in role). In rare
cases a boy with this disorder claims that
his penis or testes are disgusting or will
disappear, or that it would be better not to
have a penis or testes.
Some children refuse to attend school because
of teasing or pressure to dress in attire
stereotypical of their assigned sex. Most
children with this disorder deny being
disturbed by it, except that it brings them
into conflict with the expectations of their
family or peers.
Associated features. Some of
these children, particularly girls, show no
other signs of psychopathology. Others may
display serious signs of disturbance, such as
social withdrawal, separation anxiety, or
depression.
Age at onset and course. The
majority of the boys with this disorder begin
to develop it before their fourth birthday.
Social ostracism increases during the early
grades of school, and social conflict is
significant at about age seven or eight.
During the later grade-school years, grossly
feminine behavior may lessen. Studies
indicate that from one-third to two-thirds or
more of boys with the disorder develop a
homosexual orientation during adolescence.
For females the age at onset is also early,
but most give up an exaggerated insistence on
male activities and attire during late
childhood or adolescence. A minority retain a
masculine identification, and some of these
develop a homosexual orientation.
Whereas most adult people with Transsexualism
report having had a gender identity problem
during childhood, prospective studies of
children with Gender ldentity Disorder of
Childhood indicate that very few develop
Transsexualism in adolescence or adulthood.
Complications. In a small
number of cases, the disorder becomes
continuous with Transsexualism or Gender
Identity Disorder of Adolescence or
Adulthood, Nontrans-sexual Type.
Impairment. Positive peer
relations with members of the same sex are
absent or difficult to establish. The amount
of impairment varies from none to extreme,
and Is related to the degree of associated
psychopathology and the reaction of peers and
family to the person's behavior.
Prevalence. The disorder is
apparently uncommon.
Sex ratio. In clinic samples
there are many more boys with this disorder
than girls. The sex ratio in the general
population is unknown.
Familial pattern. No information.
Predisposing factors.
Studies indicate that characteristics of the
child, the parents, or of other social
agents, such as parental substitutes and
siblings, may be predisposing factors for the
development of the disorder. in boys, the
characteristics may Include
"feminine" physical features, an
aversion to rough-and-tumble play, separation
anxiety, and a history of early
hospitalization. The relevant characteristics
of parents and other influential people in
the child's environment may include weak
reinforcement of normative gender-role
behavior, absence or unavailability of a
father, and encouragement of extreme physical
and psychological closeness with her son by a
mother. In girls, a strong interest in
rough-and-tumble play on the part of the
child and weak reinforcement of normative
gender-role behavior by the parents may
contribute to the development of the
disorder.
Differential diagnosis. Children
whose behavior merely does not fit the
cultural stereotype of masculinity or
femininity should not be given this diagnosis
unless the full syndrome is present. Physical
abnormalities of the sex organs are rarely
associated with Gender identity Disorder of
Childhood.
Diagnostic Criteria for Gender
Identity Disorder of Childhood
For Females:
A. Persistent and
intense distress about being a girl, and
a stated desire to be a boy (not merely a
desire for any perceived cultural
advantages from being a boy), or
insistence that she is a boy.
B. Either (1) or (2):
- persistent marked aversion to
normative feminine clothing and
insistence on wearing
stereotypical masculine clothing,
e.g., boys' underwear and other
accessories
- persistent repudiation of female
anatomic structures, as evidenced
by at least one of the following:
(a) an assertion
that she has, or will grow, a
penis
(b) rejection of
urinating in a sitting position
(c) assertion
that she does not want to grow
breasts or menstruate
C. The girl has not
yet reached puberty.
For Males:
A. Persistent and
intense distress about being a boy and an
intense desire to be a girl or, more
rarely, insistence that he is a girl.
B. Either (1) or (2);
- preoccupation with female
stereotypical activities, as
shown by a preference for either
cross-dressing or simulating
female attire, or by an intense
desire to participate in the
games and pastimes of girls and
rejection of male stereotypical
toys, games, and activities
- persistent repudiation of male
anatomic structures, as indicated
by at least one of the following
repeated assertions:
(a) that he will
grow up to become a woman (not
merely in role)
(c) that it
would be better not to have a
penis or testes
C. The boy has not
yet reached puberty.
Page
12
Back to Special Needs
Index
