Gender identity disorder in children

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

The differential diagnosis for children was formalized in the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Children assigned as males are diagnosed with GIDC 5 to 30 times more often than children assigned as females. The majority of children diagnosed with GID in childhood cease to desire to be the other sex by puberty and instead grow up to identify as homosexual with or without therapeutic intervention.

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. Critics of treatment cite limited outcome data and questionable efficacy, and some liken it to conversion therapy.

Diagnostic classification
The current edition of 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.

"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.-."

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. Kenneth Zucker and Susan Bradley, the most prominent proponents of therapeutic intervention for GIDC, note patterns in family dynamics such as "a mother who is hostile toward men and a physically or emotionally absent father." Zucker notes, "If parents allow their child to continue to engage in cross-gender behaviour, the GID is, in effect, being tolerated, if not reinforced." 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 notes that for therapeutic intervention, "efficacy is unclear," and psychologist Bernadette Wren notes, "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
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." 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 notes:

"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. A 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-V controversy
Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-V 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 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.'"