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The Validity of the Diagnosis of Gender

Identity Disorder (Child and Adolescent
Criteria)

IAN WILSON
Central Manchester and Manchester Children’s University Hospitals NHS Trust, UK

CHRIS GRIFFIN
University of Birmingham, UK

BERNADETTE WREN
Tavistock and Portman NHS Trust, UK

A B S T R AC T
This article looks at the diagnosis of gender identity disorder (child and
adolescent criteria) as used in the fourth edition of the Diagnostic and Statisti-
cal Manual (DSM-IV). It considers how gender identity disorder came to be in
the fourth edition, and explores some of the problematic aspects of the DSM-IV
criteria. The authors argue that research has focused on cross-gender behaviours
and gender role, and consequently muddled issues of pathology. In particular, that
this has served to pressurize boys to conform to traditional gender and hetero-
sexual roles. The authors suggest that the pathology accompanying gender
identity dysphoria should be the focus of the clinical work rather than treating
gender role behaviour. It is proposed that the model of atypical gender identity
organization, is able to account for the diverse factors that may be contributing
to a discordant gender identity, without labelling what may be a normal develop-
mental pathway as pathological.

K E Y WO R D S
disorder, DSM, gender, identity, validity

Introduction
G E N D E R I D E N T I T Y D I S O R D E R of childhood and adolescence was included in the
third edition of the Diagnostic and Statistical Manual (DSM-III, American Psychiatric
Association [APA], 1980). In the present, fourth edition of the DSM, the diagnosis
requires evidence of a strong and persistent cross-gender identification, and a persistent
discomfort with one’s sex or sense of inappropriateness in the gender role of that sex

Clinical Child Psychology and Psychiatry 1359–1045 (200207)7:3 Copyright © 2002

SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 7(3): 335–351; 024032

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(see Table 1). Since the diagnosis of gender identity disorder was introduced, there
has been considerable debate as to whether the cluster of symptoms required for the
diagnosis does in fact warrant being described as a psychiatric disorder (see for example
Bem, 1993; Fagot, 1992; Le Vay, 1996). For as Fagot wrote (1992):
One major concern about cross-gender behaviour in childhood is that it leads to
non-heterosexual behaviour. It is ironic that as homosexuality was dropped as a
psychiatric diagnosis, the diagnosis of gender identity disorder of childhood was
added to DSM-III. We now have a category of childhood psychopathology in
which the main prediction is that it leads to an erotic preference no longer
considered pathological. (pp. 327–328)
This literature review is an attempt to look at the validity of the psychiatric diagnosis of
gender identity disorder for children and adolescents. We consider how the disorder
came to be in the third and subsequent editions of the DSM (APA, 1980, 1987, 1994).
This is then followed by a review of how behaviours and identity statements, which form
the criteria for the diagnosis of gender identity disorder, may be used by clinicians and
researchers. The implications of the varying impact that the diagnosis has upon boys and
girls, and children and adolescents, are discussed. The view that a discordant gender
identity may be a precursor to homosexuality is then considered. Finally, the use of the
term atypical gender identity organization is discussed as an alternative approach to the
diagnosis of gender identity disorder.
The authors argue that research has focused on cross-gender behaviours and gender
role, rather than on cross-gender identity, and consequently muddled issues of pathol-
ogy. It is suggested that the pathology accompanying gender identity dysphoria should
be the focus of clinical work rather than treating gender role behaviour.

Gender identity disorder and DSM-IV

Gender role and gender identity
It was the introduction of the terms gender role and gender identity in the 1950s and
1960s that made it possible to begin to make theoretical sense of the notion of discordant

IAN WILSON is a Clinical Psychologist with South Manchester Child and Adolescent
Psychology Service. He has a special interest in the relationship between the development of
adolescent identity and mental health, particularly as applied to gender and sexual identities.

C O N TA C T : Ian Wilson, Carol Kendrick Unit, Withington Hospital, Nell Lane, Manchester,
M20 2LR [E-mail: IDW807@bham.ac.uk].

C H R I S T I N E G R I F F I N is Senior Lecturer in Social Psychology at the University of Birming-

ham. Her main research interests are gender relations, young people’s experiences of tran-
sitions to adulthood, and the use of qualitative methods in social psychology research. She is
a founding editor of the journal Feminism and Psychology and is organizing an ESRC
Research Seminar Series on ‘New Approaches to Inter-disciplinary Youth Research’ from
2000–2002.

BERNADETTE WREN is Consultant Clinical Psychologist and Systemic Psychotherapist in

the Child and Family Department at the Tavistock Clinic, London and a co-editor of this
special issue.

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Table 1. DSM-IV diagnostic criteria for gender identity disorder. (American Psychiatric Association,
1994, p. 532)
A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural
advantage of being the other sex).
In children the disturbance is manifested by four (or more) of the following:
1. Repeatedly stated desire to be, or insistence that he/she is the other sex.
2. In boys, preference for cross-dressing or simulating female attire, in girls, insistence on only
wearing stereotypical masculine clothing.
3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent
fantasies of being the other sex.
4. Intense desire to participate in the stereotypical games and pastimes of the other sex.
5. Strong preferences for playmates of the other sex.
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be
the other sex, frequent passing as the other sex, desire to live and be treated as the other sex, or
the conviction that he/she has the typical feelings and reactions of the other sex.
B. Persistent discomfort with his/her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following: in boys, the assertion that his
penis and testes are disgusting or will disappear, or assertion that it would be better not to have a
penis, or aversion towards rough and tumble play and rejection of male stereotypical toys, games
and activities; in girls, the rejection of urinating in a sitting position, assertion that she has or will
grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked
aversion towards normative female clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with
getting rid of primary and secondary sex characteristics (e.g. request for hormones, surgery or
other procedures to physically alter sexual characteristics to simulate the other sex) or belief that
he/she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational or other
important areas of functioning.

gender identity (Di Ceglie, 1995). The term gender role was used to refer to behaviours,
attitudes and dispositions stereotypically associated, in a given culture at a particular
period, with either the male or female social role (Money, Hampson, & Hampson, 1955).
The term gender identity was used to mean the psychological sense of maleness or
femaleness (Stoller, 1964). Money and Ehrhardt (1972) emphasized this distinction by
highlighting that ‘gender identity is the private experience of gender role; gender role is
the public expression of gender identity’ (p. 146).
Neither gender role nor gender identity are seen to bear a necessary relation to the
sexual body. Indeed, gender identity disorders can be seen as involving an incongruity
between sex and gender. This is distinct from conditions of intersex, which are thought
to arise due to a discrepancy between the child’s chromosomal, gonadal and phenotype
sex (Brain, 1998).

The pathologization of cross-gender behaviour

In 1910, the German sexologist Hirschfield published Die Transvestiten, in which he
noted that cross-gender behaviour had been described in the German literature since
1877 (Ettner, 1999). With the book’s translation into English the term transvestite came
into being, and was used to describe any form of gender-variant behaviour (Pauly,
1992).
As early as 1930, the magazine Sexology occasionally received letters to the editor
from individuals asking if treatment or surgery existed to alter men who wanted to be
women or vice versa (Ettner, 1999). The condition of transsexualism became more widely

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recognized with the publication of Harry Benjamin’s The Transsexual Phenomenon

(1966). This book proposed a physiological causation for cross-gender identification. Yet
despite this growing recognition of transsexualism, there was a polarization of views on
how best to intervene with such individuals. One approach sought to enable individuals
to live according to their preferred gender. This eventually led to the establishment of the
Harry Benjamin International Gender Dysphoria Association and the development of
Standards of Care for Gender Identity Disorders (Harry Benjamin International Gender
Dysphoria Association, 2001) that are still in use today for professionals working in the
area. An alternative approach had as its focus, the aim of supporting individuals to find
a way to live according to their sex.
This debate has, of course, largely taken place within contemporary North American
culture. Within other non-Western cultures there is evidence that what has come to be
called gender roles and gender identity, may be conceptualized very differently. The
Mahu population in present day Hawaii is one example where it is seen to be acceptable
for both men and women to take on the opposite gender identity. Such people are often
viewed as creative and compassionate (Robertson, 1989). In present day India there is
reported to be a large population of Hirjas; a word used to indicate individuals who are
considered as neither male or female (Jaffary, 1996). According to Jaffary they are toler-
ated as they are thought to bring good luck, although at the same time they are treated
with derision; an attitude common towards individuals who cross gender boundaries.
Nonetheless, considerable flexibility of gender roles and gender identity appears to be
acceptable in some cultures.

The diagnosis and treatment of gender dysphoric children

Largely as a result of the difficulty in effecting change for adults with a discordant gender
identity, psychiatrists started to attempt to identify children at risk of transsexualism and
homosexuality (Bem, 1993; Rekers & Lovaas, 1974). Particularly focusing on boys, the
conventional treatment of a child with cross-gender behaviour was to help the child
conform to more stereotypical gender role behaviour (Bem, 1993). Two distinct
approaches were used. Rekers and colleagues, at the University College of Los Angeles,
encouraged parents and teachers to use behaviour modification in a bid to eliminate all
inappropriate gender behaviours. Green (1985, 1987), in contrast, emphasized the
development of gender appropriate activities and relationships.
Rekers and Lovaas (1974) outlined four justifications for their approach. These were:
1. To reduce the amount of ridicule that these children would receive by increasing their
masculine options;
2. To prevent severe adjustment problems in adulthood, which included transsexualism,
transvestism and homosexuality;
3. To change behaviour patterns in childhood, when there is more malleability, than in
adulthood;
4. To eliminate stereotyped feminine gestures that are often of concern to parents.
Bem (1993) argued that Green’s motivation for treating children with cross-gender
behaviour was more compassionate but still resulted in the child being pathologized, and
being asked to change an aspect of their self. As Green (1985) stated:
The primary goals of intervention for those boys unhappy over their current behav-
iour are to increase their comfort in being anatomically male, to enable them to
perform some behaviours culturally appropriate for boys their age, and to promote
a positive anticipation of being an adult male. (p. 643)

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Gender identity disorder and DSM-III

Gender identity disorder as a diagnosis for adults had been long argued for by Harry
Benjamin as the acknowledgement of a condition that needed to be recognized by the
medical community (Bem, 1993). It was first introduced into the 1980 edition of the
DSM.
The category of gender identity disorder of childhood and adolescence was introduced
at the same time. Why the diagnosis was introduced for children and adolescence at this
point is interesting to consider. Zucker and Bradley (1995) argued that, prior to its in-
clusion, it had certainly been possible to identify a cluster of characteristics suggestive of
a marked cross-gender identification. Bem (1993) suggested, more politically, that it may
have occurred in response to the removal of homosexuality from the same edition; a
decision that occurred in the context of the emergence of affirmative lesbian and gay
politics (Bayer, 1981).
Indeed, a parallel may be drawn with both the introduction of homosexuality in the
forerunner of the DSM, the Statistical Manual for the Use of Hospitals for Mental
Diseases (APA, 1942), and its subsequent removal from DSM-III (APA, 1980). It
appears that these decisions were based not on a clear and confident evaluation of
empirical research, but on a show of hands by the members of the American Psychiatric
Association; a procedure regarded as unscientific by critics of its removal (Le Vay, 1996;
Silverstein, 1991). Thus both its inclusion and removal appear to have been more depen-
dent on the social norms of the time than on a more dispassionate assessment of the
status of homosexuality as an clearly identifiable disorder (Bayer, 1981).
It has been argued that mental disorder per se is a social construction (Busfield, 1996;
Gergen, 1994; Sedgwick, 1982), and it is for this reason that the arbitrary nature of the
classification of gender identity disorder and homosexuality can be understood. The
boundaries and meanings of any mental disorder vary over time and place, and are also
highly contested at any one time. As a result, there is no one system of classification that
is universally accepted, and those systems that exist are under continuous revision. Thus,
the Diagnostic and Statistical Manual of the American Psychiatric Association is in its
fourth edition, and the International Classification of Diseases is in its tenth.
Despite its inclusion into the DSM, the prevalence of children with gender identity
disorder has not yet been established, although Di Ceglie (1995) cited Green (1968) who
asserted that for boys cross-gender behaviour is not a common phase. There is insuffici-
ent data to make a similar assertion concerning girls.

Problems arising from DSM-IV criteria

Four points can be identified which highlight the problems in using the current edition
of the DSM (DSM-IV; APA, 1994). The first of these is that the diagnostic criteria in
DSM-IV for gender identity disorder in children and adolescents involve the presence
of symptoms from two main categories. These, as noted earlier, are: (i) a strong and
persistent cross-gender identification, and (ii) a persistent discomfort with one’s sex or
a sense of inappropriateness in the gender role of that sex. Different symptoms within
the categories are required for children and adolescents.
No empirical research could be identified that has looked at the validity of these
DSM-IV criteria. However, the validity of the DSM-III criteria has been discussed by
Zucker, Finegan, Doering, and Bradley (1984). Reviewing 36 consecutive referrals of
children to their clinic in whom gender identity issues were of concern, Zucker et al.
compared the children who met the complete DSM-III criteria for gender identity
disorder, with those who did not. Zucker et al. made the comparison on the following
measures: Draw-a-Person Test, Free-Play Task, Gender Behaviour Inventory, Play and

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Games Questionnaire, and Vocabulary–Block Design Difference Score. According to

the authors the results from this comparison demonstrated that the DSM-III-identified
subgroup differed significantly in showing more severe cross-sex-typed behaviour
compared with that of the non-DSM-III subgroup.
Although these behavioural differences between the two subgroups permit the
diagnosis of gender identity disorder to be made reliably, this finding does not in itself
demonstrate that the behaviours required for a diagnosis actually constitute a psychiatric
disorder. First, for Neisen (1992), the diagnosis of gender identity disorder simply results
in some boys being identified as too feminine, thereby pathologizing ‘the individual while
perpetuating sexist and heterosexist standards of behaviour as the only acceptable norm’
(p. 66). Neisen went on to note that the differentiation between feminine boys and
normal boys is based largely on definitions of ‘feminine’ behaviour in a way that goes
against research of the previous 25 years recognizing that aspects of femininity and
masculinity may co-exist within an individual (e.g. Bem, 1974, 1977).
Second, with a diagnosis based on behavioural criteria, proponents of the disorder
must face the problem of the great variability in the degree of cross-gender behaviour
deemed acceptable. As with some other psychiatric diagnoses (e.g. enuresis), the age and
sex of the child is highly relevant, with some level of tolerance or acceptability of cross-
gender behaviours maintained until it is felt that a child should have outgrown them.
However, in this case, unlike with other childhood psychiatric diagnoses, there may be
less of a consensus about the way gender roles are defined and what the limits of the
acceptability of certain behaviours are. This variation may occur within the same family
(Zucker & Bradley, 1995) and certainly between families and across different cultures
(Newman, 2002). Western cultures tend to enforce gender boundaries more rigorously
for boys than for girls. It is also interesting that this is the case in relation to gay men’s
sexuality rather than lesbian sexuality, for instance in relation to the UK age of consent
for gay men but not lesbians.
Third, under part A of the DSM-IV criteria (APA, 1994, p. 537), ‘strong and persist-
ent cross-gender identification’, there is a requirement for four of five possible criteria
to be present before a diagnosis is made. This can seem an arbitrary cut-off point; as
acknowledged by the Subcommittee on Gender Identity Disorders for DSM-IV
(Bradley et al., 1991). Such an arbitrary requirement is a common feature in DSM-IV
for those disorders that have variable manifestations and vague clinical boundaries, as
in the case of depression for example.
Finally, the criteria indicate a trend towards gender asymmetry, in that for girls the
cross-gender behaviour needs to be more extreme before a diagnosis can be made.
Under part B of the criteria for a diagnosis, for example, boys need only show an
‘aversion towards rough and tumble play and rejection of male stereotypical toys, games
and activities’, whereas girls must show a ‘marked aversion towards normative female
clothing’ (APA, 1994, p. 537). This would appear to indicate a greater tolerance of cross-
gender behaviour among girls than amongst boys, at least by those who compiled, and
use, DSM-IV criteria.

Emphasis on gender conformity

Yet despite the apparent shortcomings of these diagnostic criteria, much research has
been based on trying in various ways to substantiate them. One example is Rekers and
Morey’s study (1989a) demonstrating a relationship between the extent of a boy’s effem-
inate body movements and a clinician’s independent rating of gender disturbance. Zucker
(1992, cited in Zucker & Bradley, 1995) developed this same theme with his detailed
research on maternal ratings of gender-related motoric or speech behaviours in boys, that

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was thought to distinguish gender-deviant boys from control boys. A comparison of 133
boys, who were referred because of concern over their gender identity development, was
made with 148 boys acting as a control group. The boys were assessed by their mothers,
on a 5-point scale. This ranged from never to always on the following behaviours: he talks
with the inflection of a girl, he uses feminine gestures with his hands when talking, he
moves in a feminine way when excited, he swishes and swings his hips when he walks, and
he talks in a high-pitched voice. From maternal ratings Zucker identified a significant
difference between the two groups for each of the behaviours, thus concluding that
aspects of motoric and speech behaviours could distinguish boys with a gender identity
disorder from non-diagnosed groups of boys. However, such a finding does not identify
that such behaviours are in themselves disordered. All that may have been identified is a
difference in the level of parental concern over the behaviours that were assessed.
The importance that Zucker and Bradley (1995) placed on children confining them-
selves to gender typical behaviours can be seen in their references to children who
appear to fall below the threshold for diagnosis. Discussing what Meyer-Bahlberg (1985)
called the ‘zone of transition between clinically significant cross-gender behaviour and
mere statistical deviations from the gender norm’ (p. 682), Zucker and Bradley (1995)
suggested that boys with behaviours in this zone typically
do poorly in male peer groups, avoid rough and tumble play, are disinclined to
athletics and other conventionally male activities, and feel somewhat uncomfort-
able about being male; however these boys do not wish to be girls and do not show
an intense preoccupation with femininity. (p. 50, our italics)
Despite Zucker and Bradley (1995) acknowledging that such children do not appear to
have explicitly expressed concern around their gender identity, they go on to specify the
need for a diagnosis. In this case, they suggested that of gender identity disorder not
otherwise specified (DSM-IV, APA, 1994); a diagnosis based on behaviours deemed not
to be gender appropriate. A ‘catch all’ category such as this, is not unique to gender
identity disorder as defined by DSM-IV, and only serves to give unwarranted clinical
license to professionals.

Is cross-gender identification a disorder?

Zucker and Bradley (1995) acknowledged that they needed to argue a case for estab-
lishing that the phenomenon of cross-gender behaviour constitutes a disorder. Notori-
ously, of course, there is no general agreement on the definition of mental disorder. They
cited Spitzer and Endicott (1978) who argued that distress, disability and disadvantage
needed to be present if a behavioural syndrome is to be called a disorder.
In considering whether, and why, children with cross-gender behaviour are distressed
by their condition, Zucker and Bradley (1995) noted that children become distressed
about their cross-gender behaviour either when it is interfered with, for example, by their
peers, or when it is associated with other psychological difficulties in the child or in the
family.
In both of these circumstances, however, it is not clear why the fact of the children’s
distress should result in the relevant behaviours being classified as a disorder. In the first
case, the behaviours themselves may not be undesirable, but rather may be seen by
certain others as such. In the second case, rather than giving the child’s behaviour the
label of a disorder, an attempt to resolve the difficulties associated with the behaviour
would appear to be a more profitable approach (Di Ceglie, 1998).
Zucker and Bradley (1995) went on to argue that in three domains children with a
gender identity disorder are disabled by their condition.

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Children with gender identity disorder have more trouble with basic cognitive
concepts concerning their gender. They cited an article by Zucker et al. (1993) who found
that children with gender identity disorder were more likely than controls to misclassify
their own gender. Zucker and Bradley (1995) stated that ‘given the ubiquity of gender
as a social category, surely [this] must lead to confusion in their social interactions’
(p. 58). Here Zucker and Bradley surely highlight the fact that any difficulties that these
children experience may arise from normative social categories inadequately describing
their experience. That the problem occurs because of societal expectations to conform
to gender stereotypes needs recognition. This is more important than describing the
child’s uncertainty as itself a form of disorder.
Zucker and Bradley (1995) stated that a number of studies have identified that
children with gender identity disorder demonstrated a similar level of general psycho-
pathology to other children with clinical problems (see for example Coates & Person,
1985; Rekers & Morley, 1989a, 1989b; Tuber & Coates, 1989).
Zucker and Bradley (1995) went on to discuss the findings that were identified by
Zucker (1985, 1990). Zucker compared boys and girls, labelled with gender identity
disorder, with pair-matched clinic controls and same gender siblings in regard to the
degree of behavioural disturbance identified by using the Child Behaviour Checklist
(Achenbach, 1978). The sample was divided according to gender and age group (4–5 and
6–11 years of age). Zucker reported that the gender identity disorder-identified boys
were comparable with the pair-matched clinic controls with regard to degree of behav-
ioural disturbance, but that they were more disturbed than their male siblings. Using the
same methodology, girls identified with gender identity disorder were comparable with
pair-matched clinic controls, with regard to degree of behavioural disturbance, for the
6–11 year age group. They were also more disturbed than their female siblings, but again
only for the 6–11 year age group.
However, despite Zucker and Bradley’s (1995) assertion of the link between gender
identity disorder and accompanying psychopathology, this still does not provide a justifi-
cation for the behaviours that are taken to constitute gender identity disorder to be
themselves described as a disorder. Indeed, Zucker and Bradley went on to conclude
that, ‘multiple factors, including social ostracism and familial risk variables, appear to
account for the associated psychopathology’ (p. 123).
It is worth noting that Zucker and Bradley (1995) highlighted social ostracism as a key
factor because this again relates to the consequence of how children with cross-gender
behaviour may be perceived. Such issues need to be addressed in their own right, and
this task is not helped by labelling the cross-gender behaviours as an additional psycho-
pathology.
Furthermore, other examples of a relationship between behaviour and, for example,
social ostracism may be identified, as in the case of young gay adolescents (Gibson, 1989;
Remafedi, Farrow, & Deister, 1991) or children with cancer (Benner & Marlow, 1991;
Treiber, Schramm, & Mabe, 1986), in whom the initial behaviour is not labelled as
psychopathological.
That children with a cross-gender behaviour may experience considerable difficulty is
not questioned, but this does not necessarily mean that the behaviours themselves are
disordered. For as Allport (1954, cited in Morin & Schultz, 1978) in a study on prejudice
stated,
a child who finds himself rejected and attacked on all sides is not likely to develop
dignity and poise as his outstanding traits. On the contrary, he develops defences.

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Like a dwarf in a world of menacing giants he cannot fight on equal terms. He is

forced to listen to their derision and laughter and submit to their abuse. (p. 142)
Zucker and Bradley (1995) pointed to the difficulty that children with gender identity
have in peer relations. Yet, although the importance of peer relationships must be
acknowledged (see for example Unger & Crawford, 1996), it is not clear how children
with these poor relationships are further understood or aided by the use of a psychiatric
diagnosis. Many studies have highlighted the difficulties that young gay adolescents, for
example, have with their peers (Douglas, Warwick, Kemp, & Whitty, 1997; Nayak &
Kehily, 1996). Yet these difficulties are not taken as a reason to reinstate homosexuality
as a disorder in the next edition of the DSM.
Zucker and Bradley (1995) do not address the third requirement identified by Spitzer
and Endicott (1978), that of disadvantage, for a behavioural syndrome to be called a
disorder.

Identity statements
One of the criteria for gender identity disorder (children and adolescence) in DSM-IV
is the stated desire by children and adolescents to be the other sex, or alternatively for
children, the insistence that he or she is the other sex. Zucker and Bradley (1995)
identified three kinds of identity statements that may meet this requirement. The first of
these is that younger children may claim that they are members of the opposite sex.
Second, older children, aware of their sex, may claim that they want to become members
of the opposite sex. Finally, in other cases, children may not state that they wish to be
the opposite sex, but it is inferred from their sex-typed behaviour that there is a cross-
gender identification.
In relation to the first point, it is known that some children use idiosyncratic criteria
in determining their gender identity (Kessler & McKenna, 1985). Consequently, caution
should be taken that statements in relation to gender identity are not taken at face value.
Usually, by the age of five or six, an understanding develops that gender identity and
gender constancy are usually fixed (Kessler & McKenna, 1985), and as a result it would
be expected that the use of such statements would diminish. It is interesting to note that
according to Zucker and Bradley (1995) the use of such statements may diminish even
by those children who continue to show apparent cross-gender behaviours.
In relation to Zucker and Bradley’s (1995) second point, that children may be aware
of their sex but claim that they want to become members of the opposite sex, no empiri-
cal research looking at such statements could be identified. Yet such explicit statements
would appear to be an important aspect of cross-gender identification, and must surely
differentiate between those individuals who will continue in their cross-gender identifi-
cation and those who come to identify as homosexual (for further discussion, see below).
When considering peer appraisal of cross-gender behaviour by children, Zucker, Wilson-
Smith, Kurita, and Stern (1995) suggested that identity statements might be a more
salient influence on such appraisal than the use of behaviours alone. However, from a
review of the literature, any subsequent use of identity statements could not be identified
(although see Wilson, Griffin, & Wren, 2002a, 2002b).
It is not apparent why the third point, that children may not state that they wish to be
the opposite sex, but it is inferred from their sex-typed behaviour that there is a cross-
gender identification, was included. It would seem that it was not the children that were
making an identity statement but rather others, especially parents and clinicians, were
inferring a cross-gender identification.

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Additional problems with the diagnosis of gender identity

disorder
Differential adjustment in boys and girls
Although the diagnosis of gender identity disorder of childhood is presented in gender-
neutral terms (Sedgwick, 1991), the diagnosis is far more likely to be given to boys.
Ettner (1999) argued that girls with cross-gender behaviour are better psychologically
adjusted because of the greater acceptance of cross-gender behaviour expressed by girls,
implying perhaps that if left to their own devices, cross-identified girls at least would not
suffer undue distress. Green, Williams, and Goodman (1982) studied 50 non-traditional
sex-typed girls and 49 traditional sex-typed girls, the majority aged between four and 12.
They detected a trend for non-traditional girls to be loners, but found that none of these
girls were rejected by their peers. In an earlier study Green (1976) looked at 60 boys,
aged between four and 12 years at evaluation, who were referred as a result of cross-
gender behaviour. Compared with a control group of 50 boys, Green found that the boys
exhibiting cross-gender behaviour were also loners but they were also more likely to be
rejected by their peers.

Higher referral rate for boys than for girls

Related to this last point is the higher rate of referral of boys compared with girls to
specialist gender identity services (Meyer-Bahlberg, 1985; Zucker & Bradley, 1995).
Zucker and Bradley reported that in their own work they experienced a referral ratio of
6.3 boys to 1 girl (n = 249). This is probably because of greater parental/clinician concern
over boys’ effeminacy than about girls’ masculinity that is seen in society in general
(Archer & Lloyd, 1995; Martin, 1990; Zucker & Green, 1993). Martin (1990) for instance
assessed the attitudes of 80 students, aged 19–42 years of age, towards children with
cross-gender behaviour. Participants gave a more negative evaluation of boys with cross-
gender behaviour than girls. One of the concerns identified by participants was that the
boys would be more likely than the girls to carry their cross-gender behaviour into
adulthood. They also reported that they believed the boys to be more likely to become
homosexual.
Both the differential adjustment in boys and girls and the findings such as those
identified by Martin (1990) suggest that it is again the perception of the behaviours that
is the problem rather than the behaviours themselves being inherently problematic.

Differential criteria for children and adolescents

DSM-IV (APA, 1994, p. 537) distinguishes between the child and adolescent criteria of
gender identity disorder. Although in terms of broad categories they are identical, the
criteria required to fulfil these categories differ. For part A of the criteria: a strong and
persistent cross-gender identification, the emphasis for children is on cross-gender
behaviours. For example, one of the criteria refers to ‘the intense desire to participate
in the stereotypical games and pastimes of the other sex’. Where as for adolescents the
emphasis is on the identification with the opposite gender. So, for example, ‘frequent
passing as the other sex or the desire to live and be treated as the other sex’. This differ-
entiation continues under part B of the criteria: ‘Persistent discomfort with his/her sex
or sense of inappropriateness in the gender role of that sex’. Children may fulfil this
category by the assertion that ‘his penis and testes are disgusting’ or the assertion that
‘she does not want to grow breasts’. However, merely an aversion towards rough and
tumble play for boys or the rejection of normative female clothing for girls will also
count. Adolescents are required to have a ‘preoccupation for getting rid of primary and

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secondary sex characteristics’ for example, with the behavioural criteria required for
children being again absent.
One of the implications of this distinction between children and adolescents, is that it
is harder for adolescents to receive a diagnosis of gender identity disorder, as the absence
of the behavioural elements make the diagnostic criteria more focused. However, it is
the investigation of these more focused criteria that appear to be largely absent in the
literature, even though it would seem that those who meet them would be more likely
to go forward into adulthood with gender identity disorder (see McCauley & Ehrhardt,
1984).
It may be argued that use of behaviours in the diagnosis of children is necessary in that
they are unable to vocalize their beliefs or feelings in relation to their gender identity.
In this case, it may be expected that research had identified a relationship between these
behaviours and subsequent difficulties in adolescence and adulthood. Not only is this not
the case, an alternative trajectory may be seen in the literature.

Homosexuality
Long-term follow-up data have suggested that the majority of children with gender
identity disorder go on to become homosexual adults (Green, Roberts, Williams,
Goodman, & Mixon, 1987; Money & Russo, 1981; Zuger, 1984, 1988). Zuger (1988), for
example, claimed that ‘early effeminate behaviour in boys and later homosexuality
constitute a developmental sequence’ (p. 517).
Only a small minority of cross-gender identified children, followed prospectively, go
on to develop transsexualism (Green, 1987). This dual pathway was acknowledged by
the DSM-IV subcommittee on Gender Identity Disorders (Bradley et al., 1991),
the first group of cases progresses from gender identity disorder of childhood and
are sexually orientated towards members of their own biological sex; the second
appears to progress from transvestic fetishism over time to a full blown gender
identity disorder. (p. 339)
It was the decision in 1973 by the American Psychiatric Association to drop the diag-
nosis of homosexuality from the third edition of the DSM that led to the question of
whether it was ethical to treat gender non-conformist children as disordered (Le Vay,
1996). In 1978, Morin and Schultz wrote an article that asserted the rights of such
children, who they termed pre-homosexual, to follow their own developmental pathway
free from professional efforts to direct them towards a more conventional sexuality. In
that article, they viewed the work of Rekers and colleagues as an attempt to halt the
development of a gay identity in young children. Indeed as noted above, one of the
explicit aims of Rekers’ clinical work was the prevention of homosexuality.
Zucker and Bradley (1995) argued on two grounds that there is not a direct correlation
between cross-gender behaviour in childhood and an adult homosexual sexual orien-
tation. The first is that unless sexual orientation and gender identity are viewed as
separate entities, it is not possible to explain, for example, the situation of a man who is
erotically attracted to another man, and who also wants to undergo sex reassignment
surgery. Second, they stated that there is no research that identifies a complete concor-
dance between gender identity disorder in childhood and later homosexuality. Despite
this, Zucker and Bradley acknowledged parental concern about the disproportionate
likelihood that the child will grow up homosexual as a reason to treat gender identity
problems on children. They went on to cite Green (1987) who argued for the right of
parents to raise their children in a way that maximizes the possibility of a heterosexual
outcome.

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When they consider the prevention of homosexuality as a therapeutic aim for children
with a discordant gender identity, Zucker and Bradley (1995) recognized that the
majority of professionals no longer consider homosexuality as pathological. They also
stated that there is a lack of evidence demonstrating the possibility of changing the
developmental pathway for sexual orientation. Thus, although not arguing that homo-
sexuality per se is undesirable, they appear to hold the view that attempts to prevent
homosexuality, however unlikely to succeed, are justified because of the social stigma
that continues to be attached to that sexuality.

Atypical gender identity organization

This review has considered research on cross-gender behaviours and statements that are
used in the diagnosis of gender identity disorder (child and adolescent criteria) (DSM-
IV; APA, 1994). Research in this field has focused on cross-gender behaviours, and thus
on gender roles. This appears to have been to the detriment of research relating to the
making of cross-gender identity statements, which appear to be associated with more
clear-cut gender identity disturbance. The child who does not adhere to typical gender
role behaviour is likely to experience difficulties that are qualitatively different to the
child who is unclear about their gender identity. It is possible for a child to adopt the role
and behaviour typically associated with the opposite gender without feeling that he or
she is the opposite gender. Ettner (1999) referred to this distinction by referring to the
difference between gender nonconformity and a discordant gender identity. Thus, the
boy who likes to play with toys and games which are categorized by society as inappro-
priate for his gender, is distinct to the boy who may use the term ‘I feel like a girl inside
but I have the body of a boy’.
Children and adolescents, who do not conform to behaviour that is attributed to their
expected gender role, may receive a psychiatric diagnosis of gender identity disorder.
Further, the diagnosis of gender identity disorder may be followed by an attempt to alter
what may be a normal developmental pathway to homosexuality. However, not only is
homosexuality no longer considered to be pathological by the majority of professionals,
but also gender roles, which are the basis of a diagnosis of gender identity disorder, are
themselves becoming more flexible. As a result, the validity of the diagnosis of gender
identity disorder that is based on gender role expectations should be questioned.
Research has considered the aetiology of a discordant gender identity from both
biological and psychosocial perspectives (for a discussion see Brain, 1998; James, 1998).
However, no one developmental pathway has been identified, indeed Di Ceglie (1998)
argued that a discordant gender identity may involve diverse developmental pathways.
Taking a more focused medical perspective in the use of a diagnosis of gender identity
disorder, Di Ceglie argued, may result in such diversity being lost.
An alternative approach to the consideration of a cross-gender identity is that of
Ettner (1999), who argued that gender should be seen as a continuum. Such an approach
recognizes that not all of those who disclose a cross-gender identity go on and seek to
live full time in their preferred gender. Some may live intermittently in that gender,
whereas others may prefer to be androgynous. In allowing for this diversity, the clinician
is able to explore with the child or adolescent, how they view the way they behave, and
how they see themselves, rather than expecting them to conform to societal, or even
clinician, expectations.
Taking into account this diversity, as well as recognizing the developmental aspects
that may be contributing to cross-gender behaviours and statements, Di Ceglie (1995)
proposed the model of atypical gender identity organization. Di Ceglie (1998) used this

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Table 2. Clinical features of atypical gender identity organization

Rigidity–flexibility
Timing of the atypical gender identity organization formation
Presence or absence of identifiable traumatic events in the child's life in relationship to the atypical
gender identity organization formation
Where the formation of the atypical gender identity organization can be located on the continuum
from the paranoid-schizoid position to the depressive position

Table 3. Primary therapeutic aims proposed by Di Ceglie (1995, p. 254) when working with
children with atypical gender identity organization
To foster recognition and non-judgemental acceptance of the gender identity problem
To ameliorate associated emotional, behavioural and relationship difficulties
To break the cycle of secrecy
To activate interest and curiosity by exploring the impediments to them
To encourage collaboration of mind–body relationship by promoting close collaboration among
professionals with a different focus in their work, including a paediatric endocrinologist
To allow mourning processes to occur
To enable the capacity for symbol formation and symbolic thinking
To promote separation and differentiation
To enable the child/adolescent and the family to tolerate uncertainty in the area of gender identity
development

approach to denote an ‘internal psychological configuration whose phenomenology is

represented by the typical characteristics of a gender identity disorder’ (p. 9).
Di Ceglie (1998) argued that the usefulness of this approach is that it enabled the
consideration of a number of clinical features that may be seen with children and
adolescents, who according to the DSM-IV criteria would be considered to have a
gender identity disorder (see Table 2). For example, Di Ceglie proposed that an explo-
ration over time may identify how rigid or flexible a child’s gender identity organization
is, and thus how likely to change. Alternatively, that a traumatic event may have led a
child to identify with the opposite gender. Therefore, in this case rather than focus on
the replacement of cross-gender behaviour, the emphasis is on the resolution of the
trauma.
Thus, for Di Ceglie (1998) the primary therapeutic aims focus on the diverse develop-
mental pathways that may be leading to an discordant gender identity (see Table 3),
rather than being confined to the more medical perspective of a diagnosed gender
identity disorder. In taking such an approach, the resolution of a discordant gender
identity may result, but it is not the primary aim.
Using the term atypical gender identity organization allows the clinician to assess issues
around atypical gender role and identity, without the child or adolescent receiving a
pathological diagnosis. In taking this supportive stance, the individual needs of the child
can be accommodated without coercing them to conform to a gender-typed behaviour
that society may deem more acceptable.

Summary
Gender identity disorder of childhood and adolescence was introduced into DSM-III
(APA, 1980) at the same time that the disorder of homosexuality was removed.

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Consequently, some have argued that its introduction was a political move in that by
focusing on gender identity disorder in childhood an attempt was being made to prevent
homosexuality in adulthood (Bem, 1993; Le Vay, 1996; Morin & Schultz, 1978).
The criteria stipulated in DSM-III and subsequent editions (APA, 1980, 1987, 1994)
for a diagnosis of gender identity disorder are based upon cross-gender behaviour and
statements made by either the child or adolescent. However, research has largely focused
on the criteria in relation to cross-gender behaviour.
Zucker and Bradley (1995) attempted to establish that the phenomenon of cross-
gender behaviour did indeed constitute a disorder. However, it is evident from their
argument that the distress and disability experienced by those individuals with cross-
gender behaviour, was the consequence of the perception of the behaviour by others,
and not as a result of the behaviour itself.
Research has indicated that the majority of children given the diagnosis of gender
identity disorder go on to become homosexual (Green et al., 1987; Money & Russo, 1981;
Zuger, 1984, 1988). Thus, rather than being an indication of a disorder, cross-gender
behaviour may in fact be a normal developmental pathway to later homosexuality.
There is very little empirical or clinical research that considers the validity of gender
identity statements, even though the voicing of such statements by older children and
adolescents may be closely linked to an intense and persisting sense of gender dis-
comfort. Neither is there much research looking at the validity of the diagnosis of gender
identity disorder with adolescents, yet again it is these gender dysphoric adolescents who
are more likely to remain committed to living as the other sex. Both of these areas, there-
fore, warrant further research in order to clarify the implications of a cross-gender
identity as opposed to cross-gender behaviour and gender role.
From a review of the literature, the validity of the diagnosis of gender identity disorder
is far from clear. What is apparent is that the behavioural criteria used in DSM-IV (APA,
1994), emphasize the requirement for children and adolescents, especially boys, to
conform to traditional gender and heterosexual norms.
Whilst acknowledging that children and young people with cross-gender behaviour
and who use cross-gender statements may experience great difficulty, a more useful
approach than a psychiatric diagnosis is that of atypical gender identity organization (Di
Ceglie, 1998). This approach is able to account for the diverse developmental pathways
that may exist within a discordant gender identity (see Brain, 1998; James, 1998), without
pathologizing what may be a normal developmental pathway. In doing so, the focus of
clinical work remains on the pathology accompanying gender identity dysphoria rather
than on treating gender role behaviour.

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