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Editorial: Sexual Identity and Gender Identity:

Understanding Difference

FIONA TASKER
Birkbeck College University of London, UK

BERNADETTE WREN
Portman Clinic, London, UK

WHY A SPECIAL issue on gender identity and sexual identity in Clinical Child Psychol-
ogy and Psychiatry? Although the numbers of clients with gender dysphoria or same-sex
sexual interests are relatively small, articles discussing these issues are under-represented
in the clinical and research literature, especially with regard to child and adolescent
services. Lesbian, gay, bisexual and transgendered (lgbt) youth are identifying, and
presenting at child and adolescent clinical services, at ever younger ages. They can
experience a range of mental health problems as varied as those of heterosexual and
non-transgendered youth and may encounter difficulties specifically related to the
development of a lesbian, gay, bisexual or transgendered identity. We have also extended
the special issue to examine issues relating to the children of lesbian, gay and trans-
gendered parents.
Among clinicians discussions of issues of sex, intersex, sexuality and transsexuality can
still be bedevilled by a lack of consensus on the meanings conveyed by particular terms.
In this special issue, most writers broadly go along with common usage, taking the term
sexual identity to refer to an acknowledgement of one’s primary sexual attraction to
people of one’s own sex, the other sex or both sexes. The self-consciousness inherent in
the idea of ‘identifying as’ homosexual, heterosexual or bisexual, linked to the idea of
‘coming out’, is a relatively modern phenomenon. At an earlier time there might have
been identifiable homosexual acts, but not identifiable homosexual people. The idea of
a relatively fixed sexual identity seems to be part of a drive to self-definition, and
we might ponder whether it is sometimes unhelpful in thinking about the experience
of young people. On the one hand, finding an identity may be liberating; previous
difficulties may dissolve with the recognition of a new sense of belonging to a community
and a purpose to life. On the other hand, identifying inevitably means that other avenues
of exploration peter out, possibly prematurely foreclosing, in the case of some young
people.
The term gender identity is widely used to refer to one’s sense of oneself as male or
female, or neither, and this is the usage broadly kept to here. Many writers draw a distinc-
tion between gender identity and gender role, seeing the latter as the set of conventional
expectations for masculine or feminine behaviour imposed on us in our social worlds.
For most people, gender identity and the sexual body are in line. In transgendered people
gender identity and the sexual body are at odds – although even this way of speaking is

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questionable if we hold a belief, as many transsexual people do, that a physiological basis
for cross-gender identification will one day be found. Knowing a person’s gender identity
should tell us nothing in principle about his or her sexual identity.
Our acceptance of common modern definitions does not imply, however, an un-
willingness to be persuaded of the value of changing our terminology. Diamond (this
issue) challenges us to think through our vocabulary in a more logical and consistent way.
He argues that his revisions pay greater respect to human diversity and the multi-faceted
nature of our experience of our sexual bodies, as well as producing greater clarity and
confidence in talking about these matters in a context in which fears and anxieties are
easily aroused.
In putting gender identity and sexual identity together in a themed issue, we run right
up against the fact that, whereas homosexuality is no longer classified as a psychiatric
disorder, a strong and persistent cross-gender identification is still so classified. Wilson,
Griffin, and Wren (this issue) explore the controversies around the retention of gender
identity disorder in DSM-IV and voice a particular unease about the application of the
diagnosis to children on the basis of atypical behaviour. Early diagnosis can be seen to
mark a powerful moral position on boyhood effeminacy, recognized as a frequent
precursor of homosexuality. One issue for the clinician to face is whether psychiatric
diagnosis contributes to the prejudice faced by young people with cross-gendered
identification: Is the main difficulty they experience dealing with others’ responses to
their identification and not primarily the identification itself? Indeed many of the debates
concerning therapy with gender dysphoric children and adolescents or transgendered
youth seem to mirror previous developments in working with lesbian, gay and bisexual
youth, not least the key debate of whether to treat (Meyer-Bahlburg, this issue) or to
affirm (Wilson et al., this issue).
Are gender identity and sexual identity related? If so, how? Several possibilities exist,
both aetiological and correlational. It is likely that a subgroup of children and adoles-
cents with gender dysphoria grow up to develop lesbian, gay or bisexual identities. We
know from Green’s unique longitudinal study of feminine boys that many grow up to
identify as gay or bisexual and relatively few become transsexual (Green, 1987). Yet
there are many lesbian, gay and bisexual youth who do not remember cross-gendered
interests in childhood. Some have argued that there is an underlying factor linking both
gender dysphoria and the development of same-sex sexual interest, one proposal for this
is a common biological substrate (Bailey & Dawood, 1998). Another possibility is simply
that lgbt persons have in common a feeling of being different from other boys or other
girls at a young age. This feeling of difference may then be socially constructed into a
transgendered or a homosexual/bisexual identity.
The articles in this special issue have a number of strengths, bringing together the work
of clinicians and researchers from different theoretical standpoints. They include
contrasting reports from Britain, Europe, the United States of America and Australia.
The research articles present findings from a number of different sources: community
surveys (Carragher & Rivers, this issue; D’Augelli, this issue); clinical audit (Freedman,
Tasker, & Di Ceglie, this issue) and reports of parents and carers of transgendered
youths (Cohen-Kettenis & van Goozen, this issue; Wren, this issue). Both quantitative
and qualitative methodologies have been used. Needless to say, authors from differ-
ing perspectives do not always reach the same conclusion, for example, the contrast-
ing findings from Canada (Zucker, Owen, Bradley, & Ameeriar, this issue) and the
Netherlands (Cohen-Kettenis & van Goozen, this issue) on the rates of mental health
problems experienced by adolescents with gender dysphoria.
Although there are methodological differences in the studies by the Utrecht and

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Toronto research teams which help to explain their differing results – not least that the
Toronto team study a more heterogeneous clinical group – nevertheless, the reported
findings do lead us to reflect on possible differences in the degree of tolerance for non-
standard sexual and gender identities in different societies, and the impact of this on the
mental health of youngsters who are different. In this context, it is certainly striking, for
example, that in the US East Coast clinic of Mayer-Bahlburg (this issue) many 3–6-year-
old boys are referred for help with feminine behaviour, whereas in the UK’s only
specialist gender identity service, this age group is rarely seen (unpublished audit data
from the Gender Identity Development Unit, Portman Clinic, London).
Sadly, none of the articles includes any longitudinal data on gender identity or sexual
identity. This reflects a lack of funding for vital prospective research in this field where
there is much speculation concerning cause and effect and a consequent need for caution
when attempting to move beyond the associations reported in these articles. Another
difficulty in interpreting reported research on gender identity and sexual identity
issues concerns sampling biases: samples recruited through community surveys are self-
selecting and possibly over-represent the ‘loud and proud’, whereas samples recruited
from clinic attendance are likely to over-represent those currently experiencing diffi-
culties. The continued stigmatization of lgbt persons and the understandable unwilling-
ness of many to identify in public contexts means that it is unlikely that the sampling
problems will be easily solved.
The almost exclusive focus on boys (biological males) is another limitation, mentioned
by Wilson et al. (this issue). As several authors note, this preoccupation with atypical
boyhood results from the greater number of boys referred because of parental concerns
about sexual or gender identity issues. But of course this referral pattern itself is of
interest and in need of theorizing. Linked to this, we might note in the field a general
absence of research on negative reactions to lgbt young people. While we build our
knowledge base concerning the degree of ostracism and denigration suffered at times by
these young people within families, schools and the wider community, we know little
about the conditions in which people will tolerate, or not, their differentness. In other
words, we need to study the bullies as well as the bullied.
Whether or not there are aetiological links between gender identity and sexual identity
the two communities are affected by the common experience of prejudice from main-
stream society. Dealing with this prejudice can have implications for mental health. Part
of the hostility experienced by lesbian, gay and bisexual youth seems to be associated
with prejudice against supposed gender role violations. Extending previous work with
lgbt youth who identified during their adolescent years, Carragher and Rivers (this issue)
report that young British and North American gay and bisexual men who were ‘closeted’
during adolescence remembered experiencing more peer group stigma during
adolescence if they also reported greater gender atypicality. Hostility also seems to work
the other way: fear of homosexuality is the underlying agenda for requesting treatment
for gender dysphoric children and adolescents (Wilson et al., this issue) and some
cultures have greater intolerance of gender atypicality because it is associated with
homosexuality (Newman, this issue). Zucker and colleagues (this issue) conclude that
children and adolescents diagnosed with gender identity disorder also tend to have high
levels of mental health disturbance, but report that this is especially pronounced among
adolescent clients and suggest that this is associated with the increased social ostracism
faced by this group.
One important point for clinical practice that is raised by a number of articles is the
need for the clinician to be aware that non-identified lesbian, gay, bisexual and trans-
gendered youth may be presenting at clinics. Consequently, sensitive questioning around

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issues of sexual and gender identity should not just be conducted in therapy sessions with
‘badge wearing’ lgbt youth, but we would also suggest that appropriate openings into the
topic should routinely be given during assessment interviews. This subject is particularly
highlighted in the present special issue articles that report the results of large-scale
surveys of the lesbian, gay and bisexual communities and demonstrate the mental health
concerns of youth who may not be open about their sexual identity (Carragher & Rivers,
this issue; D’Augelli, this issue). Contextualizing these results in community surveys also
gives due perspective on the likelihood of lesbian, gay and bisexual youth encountering
these problems and how they might be resolved outside of therapy – it can be all too
easy to lose sight of the healthy majority when engaging exclusively with clinical work.
Although we are still coming to recognize all the correlates of mental health problems
experienced by lgbt youth, the articles gathered here cast some light on the factors associ-
ated with difficulties. A negative response (or even fear of a negative response) from
family members and experience of victimization from family members and/or peers are
both associated with greater mental health problems. Many surveys of lgbt youths have
also noted correlations between substance abuse and suicidality (Hershberger &
D’Augelli, 2000).
Research has consistently indicated that the children of lesbian parents are no more
likely than children in comparable families to experience mental health problems
(Tasker, 1999). Yet little is known about the psychological well-being of children of gay
or transgendered parents. Freedman et al. (this issue) present findings from a clinical
audit of children of transsexual parents and indicate that these children are unlikely to
experience gender dysphoria themselves. The case notes of the children of transsexual
parents were also less likely to contain reports of episodes of depression compared with
the case notes of children referred to the same clinic with concerns about their own
gender identity. Freedman et al. suggest that the concerns of children of transsexual
parents generally centre around making the adjustments necessary in their changing
relationship with their transsexual parent and coping with high levels of conflict between
their transsexual parent and non-transsexual parent as the family system alters.
If the children of lgbt parents do present with difficulties, the clinician needs to be able
to work with the parents and children to solve problems, but how best to do so varies
according to the family constellation. James (this issue) highlights the unique issues faced
by lesbian and gay adoptive parents and their children and how useful family narratives
can be shared and developed in therapy. Both articles by Freedman et al. and James
also indicate how clinical work in this area may be linked to legal assessment of the suit-
ability of lgbt parents and carers.
A common theme running through many of the articles in this special issue is the need
for the clinician to consider the family response when seeking to help children and
adolescents with respect to gender and sexual identity issues. D’Augelli highlights (this
issue) the importance of parental responses to lgbt youth: facing rejection by one parent
can have a negative effect on the youth’s mental health but a good relationship with their
other parent may be protective. There is also a need to move beyond a simple consider-
ation of the family’s response and to consider the family system in relation to the other
systems that surround it. Wren (this issue) highlights this when considering how parents
respond to the challenge of parenting transgendered adolescents.
Newman’s article (this issue) also looks at the way that different cultural and religious
belief systems may determine different interpretations of atypical gender behaviour
amongst parents and professionals. She highlights the tensions for young people growing
up in a multicultural society in which different representations of sex and gender
may conflict. And she faces the dilemmas this can create for clinicians who may wish to

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understand and connect with views other than their own and yet also support a liberal
and emancipatory stance on questions of sexual and gender identity.
Many useful articles have been written concerning lesbian and gay psychotherapy (see
for useful leads Davies & Neal 1996, 2000a, 2000b; Perez, DeBord & Bieschke, 2000).
Consequently we decided to finish the special issue with two reflections on treatment
issues in gender identity. We have included here, in Castaways Corner and Soapbox, the
perspectives of a clinician (Domenico Di Ceglie) and the parent of a transgendered
adolescent (Margaret Griffiths). Their very different contributions shed light on the
struggle over the last decade or so to build a better understanding among professionals
of the issues raised by gender dysphoric and transgendered youth. In particular, they
describe typical professional reactions of confusion and puzzlement to the apparent
certainties of transgender children, their challenging insistence that they be related to as
the other sex and, for some, their demand to have the body altered to fit (see Wren,
2000).
It is always difficult to know how to utilize research findings in one’s own clinical
practice. All the authors in this special issue provide food for thought for clinicians and
most of the authors of the empirical articles have included a helpful section devoted to
elucidating the clinical implications of their work. We wanted, as editors of this special
issue, to allow a diverse spread of voices to be heard and we believe that the range of
theoretical, methodological and even moral positions displayed in the issue commands
thoughtful consideration. We have greatly enjoyed working on this special issue of
Clinical Child Psychology and Psychiatry and we hope that you are also intrigued by the
findings and debates raised in the articles that follow.

References
Bailey, J.M., & Dawood, K. (1998). Behavioral genetics, sexual orientation, and the family.
In C.J. Patterson & A.R. D’Augelli (Eds.), Lesbian, Gay, and Bisexual Identities in
Families: Psychological Perspectives (pp. 3–18). New York: Oxford University Press.
Davies, D., & Neal, C. (1996). Pink Therapy: A Guide for Counsellors and Therapists
Working With Lesbian, Gay and Bisexual Clients. Buckingham, UK: Open University.
Davies, D., & Neal, C. (2000a). Pink Therapy 2: Therapeutic Perspectives on Working With
Lesbian, Gay and Bisexual Clients. Buckingham, UK: Open University.
Davies, D., & Neal, C. (2000b). Pink Therapy 3: Issues in Therapy With Lesbian, Gay,
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Green, R. (1987). The ‘Sissy Boy Syndrome’ and the Development of Homosexuality. New
Haven, CT: Yale University Press.
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