Journal of Sex & Marital Therapy, 34:385412, 2008 Copyright Taylor & Francis Group, LLC ISSN: 0092-623X

X print / 1521-0715 online DOI: 10.1080/00926230802219398

Clinician Judgment in the Diagnosis of Gender Identity Disorder in Children

RANDALL D. EHRBAR
New Leaf Services for Our Community, San Francisco, California, USA

MARJORIE C. WITTY
Illinois School of Professional Psychology, Argosy University, Chicago, Illinois, USA

HANS G. EHRBAR
University of Utah, Salt Lake City, Utah, USA

WALTER O. BOCKTING
Program in Human Sexuality, University of Minnesota, Minneapolis, Minnesota, USA

Clinician judgment methodology was used to explore the inuence of gender nonconformity and gender dysphoria on the diagnosis of children with Gender Identity Disorder (GID). A convenience sample of 73 licensed psychologists randomly received a vignette to diagnose. Vignettes varied across sex of child, gender conforming behavior, and gender dysphoria (including all possible permutations). Eight percent of respondents given a vignette involving a child who met purely behavioral criteria for GID diagnosed the child with GID. When additional information was provided, which in addition to gender nonconforming behavior the child also self-reported a cross-gender identity, this increased to 27% (signicant at 5%).

Diagnosing children with Gender Identity Disorder (GID) listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) for children has been controversial. Researchers and clinicians disagree whether this category should exist at all,

We acknowledge Scott Pytluck, PhD, and Richard Carroll, PhD, who served as members of the rst authors Clinical Research Project committee. We thank Bruce Center, PhD, for providing advice on the analysis and presentation of the data; and Heather Haley, MS, and Anne Marie Weber-Main, PhD, for their critical review and editing of manuscript drafts. Address correspondence to Randall D. Ehrbar, New Leaf Services for Our Community, 1390 Market Street, Suite 800, San Francisco, CA 94102-5402. E-mail: rdehrbar@att.net 385

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whether it should be applied to children, and what diagnostic criteria should be applied (Bartlett, Vasey, & Bukowski, 2000; Hill, Rozanski, Carfagnini, & Willoughby, 2005; Langer & Martin, 2004; Lev, 2004, 2005; Minter, 1999; Pleak, 1999; Winters, 2005; Zucker, 2006). In addition to controversy about the diagnosis per se, whether, how, and why to treat children with GID has also been controversial. The argument whether GID should be a diagnostic category hinges upon the question of what makes a condition a mental disorder. The diagnosis of GID for children has been attacked on grounds of being sexist, homophobic, and stigmatizing (Corbett, 1999; Hill et al., 2005; Lev, 2004, 2005; Minter, 1999; Pleak, 1999; Winters, 2005), and of unnecessarily pathologizing gender nonconforming children. Another criticism of the diagnosis was the argument that pathologizing of gender nonconformity is based on and reinforces the social construction of traditional gender roles. In their view, gender nonconformity does not represent an inherent disorder in the diagnosed child, but is a problem arising from oppressive and sexist social norms (Lev, 2004). On the other hand, others suggest that this diagnostic category is appropriate as it reects both distress and dysfunction (Zucker & Spitzer, 2005). This study does not address the larger issue of whether GID should be a diagnostic category, but instead investigates how this category is in fact applied to children. As clinicians are the people who decide on the diagnosis in specic cases, clinician judgment was used to explore this question. Our study focused on two specic issues regarding a clinicians use of GID: 1) the criticism that the current criteria (summarized in Table 1) allow for a diagnosis of GID in children who are nonconforming in gender role but are not gender dysphoric; 2) the concern that gender nonconforming children might be assessed by clinicians as more pathological in comparison to gender-conforming children. We also examine the impact of clinician characteristics, such as sex, sexual orientation, and age, on diagnosis. The relevant background is briey summarized next, followed by a description of our studys research questions and hypotheses.

What is Included in the GID Diagnosis as Applied to Children?

A key concern in the diagnosis of GID in children (Bartlett et al., 2000; Langer & Martin, 2004; Minter, 1999, but see Zucker, 2006) has been that the criteria might not adequately differentiate between two groups: 1) children who are truly gender-dysphoric, that is, who have discomfort with their gender assigned at birth, which may include discomfort with primary or secondary sex characteristics (Bockting, 1997); and 2) children who are not genderdysphoric but are gender role nonconforming, that is, who do not conform to the characteristics in personality, behavior, and appearance culturally dened as masculine or feminine (sometimes referred to as social sex role or

TABLE 1. DSM-IV Diagnostic Criteria for GID in Children1 Criterion B Disturbance is not concurrent with a physical intersex condition Criterion C Criterion D Disturbance causes clinically signicant distress or impairment in social, occupational, or other important areas of functioning Examples of distress or impairment used in vignettes: 1. Occasional bedwetting following arguments with family members 2. Frequent arguments with family members 3. Forgetting to do chores

Criterion A

Strong and persistent cross-gender identication as shown by at least 4 of the following:

1. repeatedly stated desire to be, or insistence that he or she is, the other sex 2. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypically 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

Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex as shown by any 1 of the following: In boys, 1. assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis 2. aversion towards rough-and-tumble play and rejection of male stereotypical toys, games, and activities In girls, 1. rejection of urinating in a sitting position 2. assertion that she has or will grow a penis 3. assertion that she does not want to grow breasts or menstruate 4. marked aversion toward normative feminine clothing

1 For

diagnosis, clients must meet criteria A, B, C, and D.

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gender typicality) (Bockting, 1997). Gender role nonconformity is not the same as gender dysphoria. A gender role nonconforming sissy boy who still identies himself as a boy is different from a boy who wishes he were a girl. This could imply that current criteria encourage the overdiagnosis of gender nonconforming children even if they are not gender-dysphoric. The DSM-IV-TR (APA, 2000) attempts to differentiate between these two phenomena. The manual specically states, This disorder [GID] is not meant to describe a childs nonconformity to stereotypical sex-role behavior as, for example, in tomboyishness in girls or sissyish behavior in boys. Rather, it represents a profound disturbance of the individuals sense of identity with regard to maleness or femaleness (p. 580). Nonetheless, it is possible that in children, the criteria for GID as currently delineated (Table 1) can be met through gender role nonconforming behavior, without any indication of gender dysphoria. For example: A girl might meet criterion A through behaviors 25 (these are largely reective of gender nonconformity), meet criterion B through rejection of female clothing or urinating in a standing position, meet criterion C by not having an intersex condition, and meet criterion D through distress or impairment resulting from social stigma or parental disapproval. In this situation, the child could be diagnosed with GID without ever stating a desire to be, or insisting that she is, the other sex (under criterion A), and without expressing or displaying any aversion toward her assigned gender or physical sexual characteristics (e.g., the idea of developing breasts or menstruating, under criterion B) or desire for physical characteristics of the opposite sex (such as a penis, under criterion B). Thus, some argue that the diagnosis of GID may be applied to two different groups who are improperly conated (Bartlett et al., 2000). An alternative hypothesis is that rather than there being two separate groups of children (some of whom are truly gender-dysphoric and some of whom are not), there is one group of children who are at risk for gender-dysphoria and only some of whom develop it (Zucker, 2005). If these children are conceptualized as one at-risk group, then it would be appropriate to identify gender nonconforming children as at-risk for gender-dysphoria. This highlights one of the controversies about the GID diagnosis as applied to children: Is the difference between children who are gender-conforming in behavior and those who also report crossgender identication or distress with their bodies a difference in degree or kind? Zucker and Bradley (1995) describe how the DSM-IV criteria were informed by research on the earlier DSM-III criteria (Zucker, Finegan, Doering, & Bradley, 1984). This investigation was primarily focused on how well the identied cases t the diagnostic criteria (and vice versa). According to their analysis of data from 36 consecutive referrals to their clinic, one of the differences between children who met the DSM-III criteria and those who did not is that older children were more reluctant to report a cross-gender identity (a requirement for diagnosis in DSM-III). Consequently, younger children

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were more likely to meet full criteria. Factor analysis gave some empirical support to viewing stated desire to be the opposite sex as simply one in a series of behavioral markers suggestive of GID (these behavioral markers were based on gender nonconforming behavior rather than on gender dysphoria) (Zucker & Bradley, 1995). However, this analysis did not explicitly focus on the DSM-IV criterion B requirements, and thus does not fully address the concern described above about conation of gender dysphoric and gender nonconforming children. In contrast, our study is a preliminary investigation of how clinicians implement the current criteria, specically in cases where issues of gender dysphoria are separated from issues of gender nonconformity.

Pathologization
Are children who express atypical gender role behaviors perceived by healthcare providers to be less healthy than other children, regardless of diagnosis? There is some literature indicating that client gender role conformity has an impact on how mentally healthy clinicians perceive them to be (Garb, 1998). In one example, counselors rated a hypothetical male client played by an actor in a video as less masculine (e.g., less independent, assertive, forceful, ambitious) and as having more severe pathology (based on assigned diagnosis, Likert severity ratings, and estimated length of treatment) when he was the primary caregiver for the home and children as opposed to the primary breadwinner (Robertson & Fitzgerald, 1990). Conversely, Dailey (1983) reported that clients who were perceived as having both masculine and feminine traits were considered better adjusted compared to clients with only masculine or feminine traits. This perception is consistent with theories that a strong pressure for gender conformity results in restricted development of the self, including a rejection of positive gender role nonconforming traits and adoption of negative gender role conforming traits (Bem, 1981, 1993; Bussey & Bandura, 1999; Carver, Yunger, & Perry, 2003; Pollack, 1998). Thus children who display a mixture of gender-conforming and nonconforming behaviors may be perceived as healthier than those who act in only gender conforming ways, while those who behave in only gender nonconforming ways may be perceived as less healthy.

Clinician Characteristics
In addition to client characteristics (such as degree of gender conformity), clinician characteristics can also impact diagnostic decision-making. As there is a clear social component to how gender conforming or nonconforming behavior is perceived, clinicians from a social background that is more likely to be supportive of gender role nonconformity would seem less likely to

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diagnose a child with GID. For example, gay, lesbian, and bisexual clinicians, women, and younger clinicians may be less likely to give a GID diagnosis. Whether or not clinicians believe that GID should be a diagnosis is likely to inuence their decision of whether to use the diagnosis. Clinicians who practice from a feminist perspective, who work with gay, lesbian, and bisexual clients, or who identity as gay, lesbian, or bisexual themselves are more likely to be aware of concerns that the diagnosis is sexist or homophobic.

Research Questions and Hypotheses

Given the range of opinions about whether and how GID should be diagnosed in children, we conducted an exploratory study of clinician judgment. Our primary goal was to assess what clinicians might actually do when child clients present to them with different degrees of gender nonconformity and with the expression/no expression of gender dysphoria. In our study, a convenience sample of 73 licensed psychologists randomly received one of six different clinical vignettes. The vignettes differed from one another in the sex of the child, the degree of gender-role conformity, and whether or not the child expressed a desire to be another gender. The vignettes were constructed in such a way that they unambiguously met or did not meet DSM-IV criteria for GID in Table 1, and did not meet criteria for any other diagnosis. Participants were asked to rst diagnose the described child. They were then asked to rate the child on the Global Assessment of Functioning Scale (GAF), often included as Axis V in a multi-axial DSM diagnosis. When asked for a diagnosis, they were not specically prompted to use a DSM diagnosis. However, as this group of clinicians regularly give DSM diagnoses in practice, respondents replied within this framework. None of them used alternative diagnostic classication systems such as ICD-9. Through use of this methodology, we sought to learn: How are gender nonconforming behaviors and gender-dysphoria related to diagnosis? Do clinicians apply a diagnosis of GID to gender nonconforming children when the children are not expressing gender dysphoria? Does this vary by the sex of the child? Overall, based upon arguments in the literature about the potential for GID to inappropriately be applied to children who are gender nonconforming, we were expecting overdiagnosis to be a problem. We hypothesized that 1) children who meet current DSM criteria for GID will be given a diagnosis of GID; 2) gender-role conforming children will not be given a diagnosis of GID; 3) moderately gender-role nonconforming children will be diagnosed at an intermediate rate; they are more likely to be inappropriately given a GID diagnosis than gender-conforming children, but are less likely to be given a diagnosis than the most gender-nonconforming children; 4) boys will be more likely to be diagnosed with GID than girls.

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We were then interested in exploring the relationship between clinician characteristics and over- or under-diagnosis. Specically, we sought to learn: Is the decision to diagnosis GID in children inuenced by clinician experience with relevant client populations, and/or by clinician demographics? We hypothesized that 1) clinician experience with transgender clients, with GLB clients, and with children will be associated with less overdiagnosis of GID; 2) clinicians who are male, heterosexual, and older will be more likely to give a GID diagnosis than clinicians who are female, nonheterosexual, or younger. Because of our interest in how general practitioners would respond as well as our hope to explore whether more expert subpopulations of clinicians would diagnose differently, our sample included clinicians who did not have experience with transgender or gender-variant clients, as well as clinicians who primarily worked with adults. Lastly, given previous ndings that a clients gender role conformity can impact clinicians perceptions of the clients mental health status (Garb, 1998), we asked the research question: Do clinicians perceive children who are more gender-role nonconforming to be more pathological, as evidenced by the assignment of lower GAF scores? We hypothesized that 1) clinicians will assign lower GAF scores to children described as most gender-role nonconforming; 2) there will be greater variance in GAF scores for the vignettes describing the moderately gender-role nonconforming boy or girl due to a wider range in whether these behaviors are seen as normal or pathological. Some may potentially see these children as more healthy due to engaging in a mixture of gender-conforming and nonconforming behavior, while others may see them as less healthy based upon their gender-nonconforming behavior.

METHODS
This study was reviewed and approved by the Institutional Review Board of the Illinois School of Professional Psychology prior to data collection.

Participants
Participants (n = 73) were a convenience sample of licensed doctoral-level psychologists. Because this was a preliminary exploratory study, a convenience sample was deemed sufcient. Participants were recruited from three sources: 1) e-mail listserves for different divisions of the American Psychological Association (School Psychology; Child, Youth and Family Services; Family Psychology; Clinical Child Psychology; the Society of Pediatric Psychology; Society for the Psychology of Women; Society for the Psychological Study of Lesbian, Gay and Bisexual Issues; and Society for the Psychological Study

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of Men and Masculinity); 2) attendees of the 2002 American Psychological Association Convention; and 3) attendees of the 2002 Fall Washington State Psychological Association Convention. Thus, potential participants were recruited in two ways: e-mail targeted to clinicians likely to have experience with relevant populations (children and LGBT) or an interest in gender issues; and in-person solicitation at conventions. The study was described as a research investigation of clinician judgment, with data collection by anonymous return of pencil and paper survey. Persons who indicated via e-mail that they were willing to participate were mailed questionnaires, whereas those recruited in person were handed questionnaires at that time. The questionnaires contained all relevant information for informed consent. Postage-paid envelopes were provided for return of the completed questionnaires to researchers. Participants were recruited until at least 10 responses were received for each vignette, which were randomly assigned. This resulted in a total sample size of 73 clinicians. The mean age of the 73 participants was 49 years (range 3070). Nearly two-thirds were female. Almost all (92%) were Caucasian/White. The majority (61%) were heterosexual. Over three-fourths had a PhD, and the remainder had a PsyD. All but one participant were licensed in the United States. Mean years in practice was 16.6 (range 142), with a median of 15. Participants reported a wide variety of theoretical orientations, the most prevalent of which was cognitive behaviorally based (38%) (see Table 2).

Instruments and Procedure

The questionnaires rst collected demographic information about the participant (age, sex, race/ethnicity, sexual orientation), then presented the vignette and asked for a diagnosis and GAF score (this was done in three rounds, as described later), and nally inquired about the participants professional experiences including years of experience, populations worked with, theoretical orientation, experience with GLB clients, experience with transgender clients, and knowledge base on GLB and transgender issues. We estimate that the full questionnaire took 15 minutes to complete. VIGNETTE
DEVELOPMENT

Prior clinician judgment studies have investigated the reliability and validity of clinicians decisions, as well as their cognitive processes, including how their beliefs, preconceptions, and biases inuence their judgments (Garb, 1998). One of the most common methods for assessing clinician judgment is the clinical vignette. When properly applied, clinical vignettes have good ecological validity; that is, they contain the type of information that judgments are commonly based upon, and these judgments are made by people who commonly make them.

Diagnosis of Childhood GID TABLE 2. Clinician Demographics and Professional Experience (N = 73) Mean Age (years) Sex Female Male Race/Ethnicity Caucasian/White People of color (African American, Latino, Native American) Sexual orientation Heterosexual Lesbian Gay Bisexual Declined Degree PhD PsyD Where licensed USA (36 states, DC) Canada (1 province) Years in practice 48.5 (range = 3070) N 45 28 N 67 6 N 45 10 11 5 2 N 57 6 N 72 1 Mean 16.6 Median 15 (range = 142) N 49 16 8 N 28 13 12 20

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% 61% 39% % 92% 8% % 61% 14% 15% 7% 3% % 78% 22% % 99% 1%

Patient population Mostly adults Mostly children Both Theoretical approaches to care Cognitive behaviorally based Eclectic/Integrative Psychodynamically based Other (Humanistic, Feminist, Systems, not given)

% 67% 22% 11% % 38% 18% 16% 27%

Six clinical vignettes were created, describing either a boy or girl and three levels of gender role conformity (conforming, moderately nonconforming, most nonconforming). Gender-role nonconformity and genderdysphoria were treated as separate dimensions. To add the dimension of gender-dysphoria, the vignettes were presented to clinicians in three rounds. In round 1, participants received no information about self-report of genderdsyphoria (see Appendix A for information given in round 1). In round 2, participants were given the additional information that the child denied any desire to be the other sex, thus explicitly denying criterion A1. In round 3, participants were presented with an alternate scenario, with the child reporting a persistent desire to be the other sex, thus meeting criterion A1 (see Appendix B for additional information given in rounds 2 and 3). In each round, participants were asked for a diagnosis and GAF score. Participants

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were reminded that no diagnosis might be necessary. This served to discourage participants from assigning a diagnosis that almost ts. Participants were not supplied with DSM diagnostic criteria as part of the questionnaire nor were they specically asked for a DSM diagnosis, but were free to use a DSM when assigning a diagnosis. The vignettes were constructed by the rst author in such a way that they unambiguously met or did not meet the criteria for GID in Table 1, and did not meet criteria for any other diagnosis. An expert in transgender issues with adults and children reviewed the vignettes to ensure proper construction. Only the extremely gender-role nonconforming vignette met the criteria for a diagnosis of GID. The gender conforming and moderately gender-nonconforming vignettes did not meet sufcient criteria to justify a diagnosis according to the DSM. More specically:

r Criterion A: The most gender nonconforming child met all criteria except r Criterion B: The behaviors used to meet criterion B addressed enjoyment
or avoidance of rough and tumble play, gendered clothing preference, and urination in a standing or sitting position. r Criterion C: All children were described as not suffering from an intersex condition. r Criterion D: Behaviors used to meet criteria D were occasional bedwetting following arguments with family members (below the threshold for diagnosis with enuresis), frequent arguments with family members, and forgetting to do chores. These indications of distress or impairment were included in all vignettes. r The behaviors engaged in by the most gender-nonconforming girl and most gender-conforming boy were the same (masculine), as were the behaviors of the most gender nonconforming boy and the most gender conforming girl (feminine). The behaviors engaged in by the moderately gender-nonconforming boy and girl were the same, except that the boy stood to urinate and the girl sat to urinate. Moderately gendernonconforming children were described as behaving in a mixture of gender-conforming and nonconforming behaviors, while the most conforming or nonconforming children were described as behaving in only feminine or masculine behaviors. (See Appendix A for the vignettes.) In all vignettes, the childs age was 6 years. This age was chosen because according to the DSM-IV-TR (2000), typically, children are referred around the time of school entry because of parental concerns that what appeared to be a phase does not appear to be passing (p. 579). At age 6, the children are older than the age at which the gender role nonconforming behavior is considered socially acceptable, at least for boys (Rekers, 1990). Also, a A1.

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6-year-old is clearly preadolescent, and GID is expressed differently in preadolescent and adolescent children (Zucker and Bradley, 1995). GLOBAL
ASSESSMENT OF FUNCTIONING SCALE

The GAF was chosen as a measure of psychological adjustment because of its familiarity to participants. It has acceptable reliability of 0.620.82 (Sajatovic & Ramirez, 2001, p. 160). The GAF is used to rate a clients social and occupational functioning on a hypothetical continuum of mental health illness (DSM-IV-TR, 2000, p. 34), scored from 1 to 100. The scale is broken into 10-point clinical ranges with anchoring descriptions for each 10-point range. This score is generally included as Axis V when giving multi-axial diagnoses.

RESULTS Analysis
Some participants indicated discrete GAF scores, while others endorsed 10point ranges. When ranges were indicated, these were recoded as discrete scores falling in the middle of the range; thus, a response of 7180 was recoded as 75.5. A proportional odds logistic regression model for ordered categorical data was intended to be used to examine which clinician characteristics predicted diagnosis, as well as the impact of the childs sex on diagnosis. However, since there were only one GID diagnosis in the moderately gender atypical vignettes, and none in the gender typical vignettes, these two vignettes contained very little information about the factors inuencing GID diagnosis. After seeing these data, we decided not to pool the vignettes but to use the most gender-atypical vignettes only for most of our tests. This gives far more robust results with little loss of information. Because the gender of the child was found to be insignicant (using Fishers exact test) data was pooled for the boy and girl vignettes.

GID Diagnosis
Table 3 presents the number and percentage of GID diagnoses given by participants for each of the six conditions described in the vignettes. Boys were no more likely than girls to be diagnosed with GID in any of this studys conditions. For the vignettes describing children who do meet DSM criteria for GIDrecall, by explicit design these were the vignettes describing the most gender role nonconforming childrenclinicians underdiagnosed. Only 8% (2/26) of respondents assigned a diagnosis of GID in round 1 or round 2. In round 3, when the child reported a persistent desire to be the other gender, 27% (7/26) of respondents assigned a diagnosis of GID. Thus in round 3, the

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TABLE 3. Frequency of GID Diagnosis Given by Clinicians (n = 73) Vignette case meets criteria for GID diagnosis?1 Gender Role Behavior Yes No No Most nonconforming Moderately nonconforming Conforming Self-Report of Gender Dysphoria No information Denied by Reported by (round 1) child (round 2) child (round 3) 2/26 (8%) 0/23 (0%) 0/23 (0%) 2/26 (8%) 0/23 (0%) 0/23 (0%) 7/26 (27%) 1/23 (4%) 0/23 (0%)

1 Vignettes were purposefully constructed so that for all gender role conforming children, the described behaviors did not meet any DSM-IV GID criteria; for all moderately nonconforming children, only two of ve Category A criteria were met, and the child should not be diagnosed with GID according to DSM-IV criteria; and for all most nonconforming children, behaviors met four of ve Category A criteria, and the child should be diagnosed with GID according to DSM IV criteria.

diagnosis rate was signicantly higher than in rounds 1 or 2. The signicance level of the one-sided (exact conditional) McNemar test is 3.125%, and that of the exact unconditional test according to Suissa and Shuster (1991) is 1.38% (computed using Cytel StatXact Ver 7) (see Table 4). For the vignettes describing moderately gender role nonconforming children and gender conforming childrennone of whom met the criteria for GIDmost respondents did not give a diagnosis of GID. Only one respondent did so. This occurred for a boy, moderately nonconforming, in round 3 when he expressed a persistent desire to be a girl. None of the respondents assigned a diagnosis of GID to the gender role conforming vignettes, even when the child self-reported a desire to be the other gender (round 3). Again, this is consistent with the vignettes content and GID criteria. Five participants gave the children other diagnoses (such as enuresis). This occurred across levels of gender role conformity (Table 5). A number of participants assigned V-codes focused on the conict between the child and family. V-codes are used to indicate conditions that may be a focus of clinical attention other than or in addition to individual level diagnoses of mental health problems. These might include relational problems, such as between a parent and child. Some participants spontaneously wrote in comments giving various reasons for their decision not to assign a GID diagnosis. These reasons included the following: 1) they perceived GID to be a problematic diagnostic category
TABLE 4. Contingency Table of Diagnosis With and Without Self-Reported Gender Dysphoria GID Diagnosis Before Self-Report GID diagnosis after self-report Non-GID diagnosis after self-report 2 0 Non-GID Diagnosis Before Self-Report 5 19

Diagnosis of Childhood GID TABLE 5. Breakdown of Clinician Diagnoses Based on Childs Self-Reported Desire to be Other Gender (n = 73) Round 3 Diagnosis1 GID Rule out GID Other 2 Total Gender Conforming 0 0 23 23 Moderately Gender Nonconforming 1 4 18 23 Most Gender Nonconforming 7 6 13 26

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1 In round 3, clinicians were presented with the information that the child stated a persistent desire to be the other gender, displaying gender dysphoria. 2 Other includes no diagnosis, V-code, and other diagnoses.

that should be eliminated, that it is sexist and/or homophobic; 2) they did not believe the child met criterion D, indicating distress or impairment; 3) they preferred to use the least stigmatizing diagnosis possible. One respondent wrote she perceived the researcher as attempting to trap respondents into using the diagnostic category of GID, which she indicated was a poor one. Other respondents wrote they saw a diagnosis as necessary, but were uncertain what diagnosis to give. Even though respondents were not asked for this information, and this study was not designed to explore clinicians concerns about GID as a diagnostic category, this information appears to shed important additional light upon our results, and for this reason we are including it here.

Clinician Characteristics
Because with one exception, only participants who were given the most gender nonconforming vignette gave a diagnosis at all, only those 26 respondents could be included in an analysis of what clinician characteristics were associated with the diagnosis of GID. Perhaps due to small sample size, none of the characteristics hypothesized were signicantly associated with GID diagnosis, although there was a trend in the direction of sexual orientation having an effect. In this trend, heterosexual clinicians were more likely to give a diagnosis than nonheterosexual clinicians (see Table 6). Lastly, contrary to prediction, older clinicians were less likely than younger clinicians to give a diagnosis of GID, although this trend did not reach signicance. The

TABLE 6. Contingency Table of Diagnosis by Heterosexual and NonHeterosexual Respondents Heterosexual Clinician GID diagnosis Non-GID diagnosis 6 14 Non-Heterosexual Clinician 1 5

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trend was due to the fact that in the sample of 26 clinicians, 6 were 56 years and older, and none of this older cohort gave a GID diagnosis. Among the younger clinicians, no trend was discernible.

GAF Scores
Across all vignettes (regardless of gender typicality), 11 respondents (15%) gave a lower GAF score upon receiving the additional information about the childs self-report of desire to be the other gender (round 3) compared to round 1. Specically, GAF scores decreased by 225 points, with a modal drop of 10 points. This is a signicant decrease at 5% using a t-test for paired data. A drop of 10 points is equivalent to a drop in the GAF clinical range, suggesting that the difference is clinically as well as statistically signicant. In round 2, when the child denied any desire to be the other gender, several respondents wrote in comments suggesting that the child was overly rigid about their gender or responding to parental pressure; however, in general, the GAF score increased slightly in round 2. The difference between round 1 and round 2 GAF scores did not reach signicance. On the other hand, when comparing vignettes to each other, analysis of variance did not show a signicant difference in mean GAF scores across vignettes. The range of GAF scores was largest for the moderately gender role nonconforming boy (5590).

DISCUSSION Interpretation of Results

Children who were gender conforming, gender nonconforming, and who displayed a mixture of conforming and nonconforming behavior were overall seen as having the same level of functioning. Taken together, our results do not support the concern voiced in the literature that gender nonconforming children, especially boys, would be pathologized (Hill et al., 2005; Lev, 2004, 2005; Winters, 2005). In this convenience sample, few participants gave a diagnosis of GID to a child who behaved in gender role nonconforming ways, regardless of the childs sex. Further, no signicant differences in mean GAF scores were observed across the six conditions. It is possible that participants in this study were less likely to be biased against gender nonconformity, due in part to being recruited from groups of clinicians who have an interest in the impact of gender role and sexual orientation, and indeed participants in this study did express concern about pathologization and sexism associated with a GID diagnosis. On the other hand, respondents did distinguish between children who were gender nonconforming and children who reported gender dysphoria (specically, cross-gender identity). Across vignettes, when gender dysphoria was reported, respondents often gave signicantly lower GAF scores,

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reecting their perception that a child with gender dysphoria is not functioning as well as a child who does not have gender dysphoria. In the case of the most gender nonconforming children, when gender dypshoria was reported, clinicians were more likely to give a GID diagnosis. Importantly, our ndings do reinforce concerns about factors that inuence a clinicians use of a GID diagnosis with children. Contrary to expectations, few clinicians in our sample gave a diagnosis of GID when warranted. Indeed, instead of overdiagnosis, there was profound underdiagnosis of GID. Although rates of diagnosis increased when clinicians were informed about the childs self-reported desire to be the other gender, most children who met GID criteria were still not given the diagnosis. Thus, among clinicians in our sample, the diagnostic criteria for GID in children were not being applied as written, indicating a problem. Participants unsolicited written comments suggest several possible reasons for underdiagnosis: dislike or opposition to the diagnosis of GID, reluctance to give any diagnosis in order to avoid stigma, and not knowing what to do. The rst two reasons reect the discourse in the scientic literature that challenges the current diagnostic category. Choosing the least stigmatizing diagnosis for children may be common practice among clinicians who work with children; for example, one participant also indicated that she avoid giving the diagnosis of enuresis to children. This practice may be part of the reason that there was not a difference in diagnosis rates between clinicians who regularly treat children and those who do not. Across vignettes, many participants gave a diagnosis of parent-child relational problem. This is similar to arguments in the literature, for example, Pleak (1999) stated that he does not use the diagnosis of GID for his child and adolescent clients because of the associated stigma. He explained that diagnoses can nd their way into a variety of systems, including the school system and potential employers. Thus, he suggested using a different diagnosis based on other issues or problems the gender dysphoric child struggles with when brought to therapy, such as ADHD or parent-child relational problems. Thus is appears that Pleak sees the diagnosis of GID as more stigmatizing than other possible diagnoses This suggests a disjunction between diagnosis and treatment in some cases. Additionally, in our study other written comments such as, She is too young to have personality [diagnosis] made but shows denite diffusion at this time, indicated that some respondents simply lacked an understanding of GID. Regardless of clinicians reasons for not diagnosing, our ndings suggest that children who experience gender dysphoria may be at risk of not being identied.

Potential Implications of Results

Two general challenges to the use of the GID diagnostic category are suggested by our data. First, some clinicians do not appear to understand gender

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dysphoria, or they lack awareness of GID as a diagnostic category. While our group of participants did not allow in-depth exploration of how specialists in various areas respond to gender nonconforming and gender dysphoric children, they do shed some light into how generalists may respond. In this regard, it is concerning that some respondents did not seem to be able to identify what the issue of concern was. Although not every clinician needs to have the specialized knowledge necessary to treat children with GID, clinicians should be able to recognize it when it comes up and to make appropriate referrals. Childhood GID should be covered in clinical training, possibly as part of learning about developmental issues related to gender and sexual orientation. Alternatively, issues related to gender identity (including but not limited to the issues of GID) could be taught in parallel with other aspects of diversity. More in-depth training in this area needs to be accessible for clinicians who are interested in developing specialties related to working with children, with GLBT populations, and in the area of human sexuality. The second major challenge to the use of the GID diagnostic category is that among clinicians who do recognize gender dysphoria, many appear uncomfortable with or opposed to the formulation of the GID diagnosis. Currently, the value of this diagnostic category is undermined by the perception that it is based on prejudice rather than grounded in science and the experiences of people in need of services. This may lead to a situation in which gender dsyphoric children and their families have difculty accessing needed services. It is worthwhile, therefore, to reform this diagnostic category so that clinicians will have more condence in it and children can receive appropriate care. Of course, any reforms made must continue to reect the scientic evidence about these children, while taking into account the mistrust that appears to be limiting the utility of the diagnosis. It is also important to consider conceptual differences, for example, between seeing gender nonconforming children as comprising two groups (those who are and those who are not also gender dysphoric) or comprising one group of children who are all at risk to develop gender dysphoriaonly some of whom do. Finally, while some clinicians may be more willing to use a diagnosis of GID if they see this diagnosis as tied more directly to gender dysphoria rather than gender nonconformity, others will continue to chose not to use it because they do not believe that GID or gender dysphoria should be considered a mental disorder at all. Reform of the diagnosis cannot resolve this fundamental disagreement between those who see the experience of gender dysphoria as warranting a diagnosis and those who do not. One suggestion for revision proposed by others (for example, Zucker, 2005), and which we support, is to more narrowly focus the criteria for GID on gender dysphoria. The parts of the current diagnosis that clearly reect gender dysphoria are: under A, a childs repeatedly stated desire to be, or insistence that he or she is, the other sex or persistent fantasies of being the

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other sex, and under B, indications of distress with ones anatomical sexual characteristics:
in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis,. . . ; in girls,. . . , assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate,. . . (DSM-IV-TR, 2000, p. 581).

These indicators of distress with anatomical sexual characteristics are currently based upon the childs self-report. Also, these symptoms rarely apply to preschool and early school age children, such as described in the vignette. This is problematic, and suggests that further research is needed to identify symptoms that reect gender dysphoria in young children rather than mere gender nonconformity. Discomfort with the body may also be seen in behaviors based on eliminating aspects of the body the child is uncomfortable with (such as a boy hiding his penis or testes) or adding aspects of the body the child sees as missing (such as long hair, penis or testes, or breasts). As Zucker (2005) has pointed out, indications of gender dysphoria are characterized by persistence, an aspect that is implied but not explicitly stated in current diagnostic criteria. The rest of criteria A, and all of the other behaviors currently included in criterion B (e.g., aversion towards rough-and-tumble play and rejection of male stereotypical toys, games, and activities in boys and rejection of urinating in a sitting position or marked aversion toward normative feminine clothing in girls), are primarily reective of gender role nonconformity. Historically, gender nonconforming behavior has been used as a proxy for cross-gender identity or gender dysphoria; however, these particular criteria are confusing, appear to be fueling concerns about the unnecessary pathologization of gender nonconforming children, and in our estimation should be removed. Many children who have gender dysphoria also display gender nonconforming behavior, but this is not the aspect of their situation that is in need of treatment. It may be necessary to replace these criteria for GID with other criteria found to more directly reect cross-gender identity and gender dysphoria. At the same time, this suggested change in diagnostic criteria is not meant to suggest that gender nonconforming children and their families are not in need of psychosocial services. Gender nonconformity places children at risk for negative outcomes, and adequate support can be important to help them avoid these outcomes (Minter, 1999). One of the main reasons that criteria for GID in children and other childhood diagnoses are so behaviorally oriented is that children may have difculty adequately expressing their distress. Also, as indicated above in Zucker and Bradleys (1985) study in which older children were less likely to state a desire to be the other gender, children may be unwilling to talk about feelings or desires which they have come to be aware are stigmatized. Because of this, diagnostic reform will face the interesting challenge

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of identifying both behaviors and self-report of children which reect gender dysphoria but do not reect simple gender nonconformity. Further, the empirical question arises as to how many or often such behaviors or utterances are necessary to give a diagnosis. A change in diagnostic criteria focusing on gender dysphoria rather than gender nonconformity implies a similar shift in treatment. Depending upon the treatment provider, this may or may not suggest a shift in what is done in treatment, although it implies a shift in why treatment is done. Treatment would focus upon reducing the childs dysphoria, distress, or impairment. This might include providing a supportive environment in which the child can express him or herself without shame or ridicule, and helping the child to internalize a positive sense of self-worth regardless of gender role behavior. Specic strategies might be helping the child learn to navigate discrimination, develop a less rigid view of gender, or nd physical activities that interest him or her (Bockting and Ehrbar, 2005). Depending upon the situation and the therapists approach, treatment might include increasing a childs social competence and condence in his or her assigned gender role. This might include helping a child identify gender-conforming interests, rewarding gender-conforming behavior, and discouraging gender nonconforming behavior (Zucker, 2007). Alternately, in cases of severe and long-standing gender dysphoria and cross-gender identity, it may be appropriate to help the family make decisions about whether and how to allow a child to present in his or her preferred gender (Lev, 2004). Thus, even after a proposed change in diagnostic criteria, there would continue to be a range of opinions about what treatment approaches are best. Such a change in diagnostic criteria would suggest however that future research on treatment outcome should include measures of gender dysphoria both relative to physical characteristics as well as to gender identity.

Study Limitations and Suggestions for Future Research

As an exploratory study, this research is limited by its reliance on a small convenience sample. For example, nonheterosexual and Caucasian respondents were overrepresented, limiting the generalizability of our results. Also, there were too few participants with experience working with transgender clients to adequately explore the hypothesis that clinicians with more exposure to this population will apply the diagnosis differently. Similarly, future studies of GID as applied to children should include more clinicians who regularly see children, although this did not make a difference in this sample. Additionally, a larger sample is needed to explore the trend toward heterosexual clinicians being more likely to give a diagnosis than nonheterosexual clinicians. More research needs to be done in larger samples to conrm or dispute our ndings about how clinicians are applying the diagnosis of GID in children.

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The use of vignettes rather than actual clients as a predictor of behavior is another limitation, as only a brief description was available for participants to base their judgments on. Another limitation is our measure of psychological adjustment: although the GAF scale has good ecological validity, its reliability is less than optimal (Sajatovic & Ramirez, 2001, p. 160). Future research might explore how clinicians react to different ages of children, different levels of social rejection and related distress, and evidence of anatomic gender dysphoria. Because clinicians were asked about diagnosis in an open-ended way, rather than the specic question whether they believed the child met the criteria for GID, the reasons for whether or not a diagnosis was given are less clear, especially in those vignettes in which the diagnostic criteria were fully met. It would be interesting to explore whether clinicians respond similarly to vignettes based upon another disorder which do not show symptoms, show some symptoms but not enough for diagnosis, and show enough symptoms for diagnosis. Finally, this research focused upon certain narrow questions: do clinicians differentiate between gender dysphoria and gender nonconformity when giving a diagnosis of GID? (The results suggest that they do.) Do clinicians see gender nonconforming children as less healthy than gender conforming children? (Apparently not, at least in this sample.) There are many other issues that need to be explored. While several respondents spontaneously shared their views about GID, and we reported this because it shed light upon an important additional dimension, this study was not designed to explore what clinicians think about the diagnosis, and in what circumstances they would or would not give it. Such issues are better studied qualitatively. Additionally, issues of whether treatment is needed and what kinds of treatment clinicians see as potentially helpful, and conceptualizations based upon either differentiating children who are gender dysphoric from those who are not versus seeing gender nonconforming children as at risk for gender dysphoria are also well-suited to qualitative exploration. This includes the question of whether children who engage in gender nonconforming behaviors but do not report cross-gender identication or dissatisfaction with their bodies are less likely to experience gender dysphoria as adults. Zucker (2004) describes the case of a child who was subthreshold for a diagnosis of GID but who grew up to be transsexual. The question also remains to be studied as to what impact diagnosis might have upon children over time. How many children who are given a diagnosis of GID later suffer negative consequences because of it? Conversely, do some of these children or their families benet from this formulation of their situation, as Zucker (2005) has suggested may happen? These are questions that require longitudinal study of children. If as a eld we decide to continue to have a diagnostic category based on gender dysphoria, what the best diagnostic criteria are is a question which can be explored both through expert input from experienced clinicians who work with these clients and through research with people who experience gender

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dysphoria. In short, there are a great many research questions in this eld that would benet from further investigation of various kinds.

CONCLUSIONS
It is hoped that this study can help inform the debate about whether and how to reform the GID diagnostic category and criteria as applied to children. While it cannot directly inform the debate of whether or not GID should be a diagnostic category, it underscores the concern practicing clinicians feel about this and how this issue impacts their decisions about diagnosis. If as a eld the decision is made to retain a diagnostic category based upon gender dysphoria, this study may inform what the diagnostic criteria should look like. While participants in this study did not pathologize gender nonconforming children, they did express concern about this similar to that in the literature. The impact that clinician concerns over the current diagnositic category has on their diagnosis supports reform of the GID criteria. Clinicians can then be trained in a less ambiguous diagnosisone that is more likely to result in children receiving needed care.

REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed.). Washington, DC: Author. Bartlett, N. H., Vasey, P. L., & Bukowski, W. M. (2000). Is gender identity disorder in children a mental disorder? Sex Roles, 43, 753785. Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing. Psychological Review, 88, 354364. Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality. New Haven, CT: Yale University Press. Bockting, W. O. (1997). The assessment and treatment of gender dysphoria. Directions in Clinical and Counseling Psychology, 7, 122. Bockting, W.O., & Ehrbar, R. D. (2005). Commentary: Gender variance, dissonance, or identity disorder? Journal of Psychology and Human Sexuality, 17, 125134. Bussy, K., & Bandura, A. (1999). Social cognitive theory of gender development and differentiation. Psychology Review, 106, 676713. Carver, P. R., Yunger, J. L., & Perry, D. G. (2003). Gender identity and adjustment in middle childhood. Sex Roles, 49, 95109. Corbett, K. (1999). Homosexual boyhood: Notes on girlyboys. In M. Rottnek (Ed.), Sissies & tomboys: Gender nonconformity & homosexual childhood (pp. 107 139). New York: New York University Press. Dailey, D. M. (1983). Androgyny, sex-role stereotypes, and clinical judgment. Social Work Research and Abstracts, 19, 2024. Garb, H. N. (1998). Studying the clinician: Judgment research and psychological assessment. Washington, DC: American Psychological Association.

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Hill, D. B., Rozanski, C., Carfagnini, J., & Willoughby, B. (2005). Gender identity disorders in childhood and adolescence: A critical inquiry. Journal of Psychology and Human Sexuality, 17, 733. Langer, S. J., & Martin, J. I. (2004). How dresses can make you mentally ill: Examining gender identity disorder in children. Child and Adolescent Social Work Journal, 21, 523. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender variant people and their families. New York: Haworth Clinical Practice Press. Lev, A. I. (2005). Disordering gender identity: Gender identity disorder in the DSMIV-TR. Journal of Psychology and Human Sexuality, 17, 3569. Minter, S. (1999). Diagnosis and treatment of gender identity disorder in children. In M. Rottnek (Ed.), Sissies & tomboys: Gender nonconformity & homosexual childhood (pp. 933). New York: New York University Press. Pleak, R. (1999). Ethical issues in diagnosing and treating gender-dysphoric children and adolescents. In M. Rottnek (Ed.), Sissies & tomboys: Gender nonconformity & homosexual childhood (pp. 3451). New York: New York University Press. Pollack, W. (1998). Real boys: Rescuing our sons from the myths of boyhood. New York: Henry Holt. Rekers, G. A. (1990). The relationship of measure of sex-typed play with clinician ratings on degree of gender disturbance. Journal of Clinical Psychology, 46, 2834. Robertson, J., & Fitzgerald, L. F. (1990). The (mis)treatment of men: Effects of client gender role and life-style on diagnosis and attribution of pathology. Journal of Counseling Psychology, 37, 39. Sajatovic, M., & Ramirez, L. F. (2001). Rating scales in mental health. Hudson, OH: Lexi-comp. Suissa, S., & Shuster, J. J. (1991). The 2 2 matched-pairs trial: Exact unconditional design and analysis. Biometrics, 47, 361372. Winters, K. (2005). Gender dissonance: Diagnostic reform of gender identity disorder for adults. Journal of Psychology and Human Sexuality, 17, 71 89. Zucker, K. J. (2004). Gender identity disorder. In I. B. Weiner (Ed.), Adult psychopathology case studies (pp. 207228). New York: Wiley. Zucker, K. J. (2005). Gender identity disorder in children and adolescents. Annual Review of Clinical Psychology, 1, 467492. Zucker, K. J. (2006). Commentary on Langer and Martins (2004) How dresses can make you mentally Ill: Examining gender identity disorder in children. Child and Adolescent Social Work Journal, 23, 533555. Zucker, K. J. (2007). Gender identity disorder in children, adolescents, and adults. In G. O. Gabbard (Ed.), Gabbards treatments of psychiatric disorders (4th ed.). Washington, DC: American Psychiatric Press, 683701. Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press. Zucker, K. J., Finegan, J. K., Doering, R. W., & Bradley (1984). Two subgroups of gender problem children. Archives of Sexual Behavior, 13, 2739.

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Zucker, K. J., & Spitzer, R. L. (2005). Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note. Journal of Sex and Marital Therapy, 31, 3142.

APPENDIX A
Vignettes have been modied from their original presentation to participants as follows: Aspects of the vignette that correspond to the GID diagnosis have been italicized and numbered as in Table 1 with an indication as to whether the criteria is met. For ease in comparison, these aspects have been italicized both in the vignettes in which the child is gender nonconforming and in which the child is gender conforming. For example, having friendships exclusively with members of the other gender meets criteria A5. Thus friendship choice has been italicized in all of the vignettes.

Gender Conforming Girl, does not meet criteria for GID

Tammy is a 6-year-old Caucasian girl in the rst grade. She usually wears jeans, T-shirts, and tennis shoes. She enjoys wearing feminine clothing when given a chance. [Does not meet criteria A2 or B4 for girls.] Tammy is popular and has a number of friends and playmates, all of whom are girls. [Does not meet criteria A5.] She likes to build forts and decorates them creatively. She also likes to draw and play with clay. Games she likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When she plays X-men, Tammy prefers to play Storm and will occasionally play Rogue, both Storm and Rogue are female characters. [Does not meet criteria A3.] When she plays dress-up, Tammy dresses in girls clothing. She says she prefers girls dress-up clothes to boys because they are softer and prettier. [Does not meet criteria A2, A4, or B4 for girls.] Tammy really enjoys playing house and strongly prefers to play the Mommy but will sometimes play the kid. She says she wants to be a parent when she grows up. [Does not meet criteria A3 or A4.] Tammy dislikes rough and tumble play. [Relates to criteria B2 for boys.] Tammy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bedwetting. Her bedwetting is not due to a medical condition. During the day, she does not wet herself and is able to go to the bathroom independently without difculty. Tammy sits down to urinate. [Does not meet criteria B1 for girls.] She does not need help wiping herself or getting dressed again afterwards. Tammy gets into frequent arguments with her older brother who teases her for being a Baby and often reduces Tammy to the point of tears. [criteria D]

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Her parents tell her if she wouldnt cry, her brother would stop. Her parents are concerned that Tammy is getting too old to behave this way and they are worried about her. They are pressuring her to behave properly more often, to which Tammy vigorously objects, resulting in frequent arguments. Tammy enjoys helping her mother cook and helping her father and brother work on the car. Despite being generally willing to help out, she often forgets to do chores such as sweeping up the cat litter if not reminded. Tammys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, she is performing at grade level.

Somewhat Gender Nonconforming Girl, does not meet criteria for GID
Tammy is a 6-year-old Caucasian girl in the rst grade. She usually wears jeans, T-shirts, and tennis shoes. [Does not meet criteria A2 or B4 for girls.] Tammy is popular and has a number of friends and playmates, both boys and girls. [Does not meet criteria A5.] She likes to build forts and decorates them creatively. She also likes to draw and play with clay. Games she likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When she plays X-men, Tammy prefers to play Rogue and will occasionally play Cyclops; Rogue is a female character, Cyclops is a male character. [Does not meet criteria A3.] When she plays dress-up, Tammy sometimes dresses in girls clothing. She says she prefers girls dress-up clothes to boys because they are softer and prettier. Other times when playing dress-up, she dresses in stereotypically masculine clothing [Does not meet criteria A2, A4, or B4 for girls.] to play games such as cops and robbers, and reghter and victim. Tammy really enjoys playing house and strongly prefers to play the daddy, but will sometimes play the mommy or occasionally even the kid. She says she wants to be a parent when she grows up. [Does not meet criteria A3 or A4.] Tammy likes rough and tumble play, she also likes to run, jump, and climb. [Relates to criteria B2 for boys.] Tammy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bed wetting. Her bedwetting is not due to a medical condition. During the day, she does not wet herself and is able to go to the bathroom independently without difculty. Tammy sits down to urinate. [Does not meet criteria B1 for girls.] She does not need help wiping herself or getting dressed again afterwards. Tammy gets into frequent arguments with her older brother who teases her for being a Baby and often reduces Tammy to the point of tears. [criteria D] Her parents tell her if she wouldnt cry, her brother would stop. Her parents

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are concerned that Tammy is getting too old to behave this way and they are worried about her. They are pressuring her to behave properly more often, to which Tammy vigorously objects, resulting in frequent arguments. Tammy enjoys helping her mother cook and helping her father and brother work on the car. Despite being generally willing to help out, she often forgets to do chores such as sweeping up the cat litter if not reminded. Tammys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, she is performing at grade level.

Gender Nonconforming Girl, meets criteria for GID

Tammy is a 6-year-old Caucasian girl in the rst grade. She usually wears jeans, T-shirts, and tennis shoes. She prefers to wear clothing that is more masculine in style and objects vigorously when her parents try to get her to wear more feminine clothing. [Meets criteria A2 and B4 for girls.] Tammy is popular and has a number of friends and playmates, all of whom are boys. [Meets criteria A5.] She likes to build forts and decorates them creatively. She also likes to draw and play with clay. Games she likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When she plays X-men, Tammy prefers to play Wolverine and will occasionally play Cyclops. Both Wolverine and Cyclops are male characters [Meets criteria A3.]. When she plays dress-up, Tammy dresses in stereotypically masculine clothing [Meets criteria A2, A4, and B4 for girls.] to play games such as cops and robbers, and reghter and victim. Tammy really enjoys playing house and strongly prefers to play the daddy, but will sometimes play the kid. She says she wants to be a parent when she grows up. [Meets criteria A3 and A4.] Tammy likes rough and tumble play, she also likes to run, jump, and climb. [Relates to criteria B2 for boys.] Tammy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bedwetting. Her bedwetting is not due to a medical condition. During the day, she does not wet herself and is able to go to the bathroom independently without difculty. Tammy stands to urinate. [Meets criteria B1 for girls.] She does not need help wiping herself or getting dressed again afterwards. Tammy gets into frequent arguments with her older brother who teases her for being a Baby and often reduces Tammy to the point of tears. [criteria D] Her parents tell her if she wouldnt cry, her brother would stop. Her parents are concerned that Tammy is getting too old to behave this way and they are worried about her. They are pressuring her to behave properly more often, to which Tammy vigorously objects, resulting in frequent arguments. Tammy

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enjoys helping her mother cook and helping her father and brother work on the car. Despite being generally willing to help out, she often forgets to do chores such as sweeping up the cat litter if not reminded. Tammys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, she is performing at grade level.

Gender Conforming Boy, does not meet criteria for GID

Tommy is a 6-year-old Caucasian boy in the rst grade. He prefers to wear jeans, T-shirts, and tennis shoes. He prefers to wear clothing that is more masculine in style. [Does not meet criteria A2 or B4 for girls.] Tommy is popular and has a number of friends and playmates, all of whom are boys. [Does not meet criteria A5.] He likes to build forts and decorates them creatively. He also likes to draw and play with clay. Games he likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When he plays X-men, Tommy prefers to play Wolverine and will occasionally play Cyclops, both Wolverine and Cyclops are male characters. [Does not meet criteria A3.] When he plays dress-up, Tommy dresses in stereotypically masculine clothing [Does not meet criteria A2, A4, or B4 for girls.] to play games such as cops and robbers, and reghter and victim. Tommy really enjoys playing house and strongly prefers to play the daddy, but will sometimes play the kid. He says he wants to be a parent when he grows up. [Does not meet criteria A3 or A4.] Tommy likes rough and tumble play, he also likes to run, jump, and climb. [Does not meet criteria B2 for boys.] Tommy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bedwetting. His bedwetting is not due to a medical condition. During the day, he does not wet himself and is able to go to the bathroom independently without difculty. Tommy stands to urinate. [Relates to criteria B1 for girls.] He does not need help wiping himself or getting dressed again afterwards. Tommy gets into frequent arguments with his older brother who teases him for being a Baby and often reduces Tommy to the point of tears. [criteria D] His parents tell him if he wouldnt cry, his brother would stop. His parents are concerned that Tommy is getting too old to behave this way and they are worried about him. They are pressuring him to behave properly more often, to which Tommy vigorously objects, resulting in frequent arguments. Tommy enjoys helping his mother cook and helping his father

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and brother work on the car. Despite being generally willing to help out, he often forgets to do chores such as sweeping up the cat litter if not reminded. Tommys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, he is performing at grade level.

Somewhat Gender Nonconforming Boy, does not meet criteria for GID
Tommy is a 6-year-old Caucasian boy in the rst grade. He usually wears jeans, T-shirts, and tennis shoes. [Does not meet criteria A2 or B4 for girls.] Tommy is popular and has a number of friends and playmates, both boys and girls. [Does not meet criteria A5.] He likes to build forts and decorates them creatively. He also likes to draw and play with clay. Games he likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When he plays X-men, Tommy prefers to play Cyclops and will occasionally play Rogue; Cyclops is a male character, Rogue is a female character. [Does not meet criteria A3.] When he plays dress-up, Tommy sometimes dresses in girls clothing. He says he prefers girls dress-up clothes to boys because they are softer and prettier. Other times when playing dress-up, he dresses in stereotypically masculine clothing [Does not meet criteria A2, A4, or B4 for girls.] to play games such as cops and robbers, and reghter and victim. Tommy really enjoys playing house and strongly prefers to play the Mommy but will sometimes play daddy or occasionally even the kid. He says he wants to be a parent when he grows up. [Does not meet criteria A3 or A4.] Tommy dislikes rough and tumble play. [Meets criteria B2 for boys.] Tommy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bedwetting. His bedwetting is not due to a medical condition. During the day, he does not wet himself and is able to go to the bathroom independently without difculty. Tommy stands to urinate. [Relates to criteria B1 for girls.] He does not need help wiping himself or getting dressed again afterwards. Tommy gets into frequent arguments with his older brother who teases him for being a Baby and often reduces Tommy to the point of tears. [criteria D] His parents tell him if he wouldnt cry, his brother would stop. His parents are concerned that Tommy is getting too old to behave this way and they are worried about him. They are pressuring him to behave properly more often, to which Tommy vigorously objects, resulting in frequent arguments. Tommy enjoys helping his mother cook and helping his father and brother work on the car. Despite being generally willing to help out, he often forgets to do chores such as sweeping up the cat litter if not reminded.

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Tommys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, he is performing at grade level.

Gender Nonconforming Boy, meets criteria for GID

Tommy is a 6-year-old Caucasian boy in the rst grade. He usually wears jeans, T-shirts, and tennis shoes. He enjoys wearing feminine clothing when given a chance. [Meets criteria A2 (B4 for girls).] Tommy is popular and has a number of friends and playmates, all of whom are girls. [Meets criteria A5.] He likes to build forts and decorates them creatively. He also likes to draw and play with clay. Games he likes to play include soccer, jump rope, and jacks, dress up, X-men, and house. When he plays X-men, Tommy prefers to play Storm and will occasionally play Rogue, both Storm and Rogue are female characters. [Meets criteria A3.] When he plays dress-up, Tommy dresses in girls clothing. He says he prefers girls dress-up clothes to boys because they are softer and prettier. [Meets criteria A2 and A4 (B4 for girls).] Tommy really enjoys playing house and strongly prefers to play the Mommy but will sometimes play the kid. He says he wants to be a parent when he grows up. [Meets criteria A3 and A4.] Tommy dislikes rough and tumble play. [Meets criteria B2 for boys.] Tommy still has occasional episodes of bedwetting, which occur on an average of once a month. This bedwetting occurs most often after an argument with a family member [criteria D] although not all such arguments are followed by bedwetting. His bedwetting is not due to a medical condition. During the day, he does not wet himself and is able to go to the bathroom independently without difculty. Tommy sits down to urinate. [Relates to criteria B1 for girls.] He does not need help wiping himself or getting dressed again afterwards. Tommy gets into frequent arguments with his older brother who teases him for being a Baby and often reduces Tommy to the point of tears. [criteria D] His parents tell him if he wouldnt cry, his brother would stop. His parents are concerned that Tommy is getting too old to behave this way and they are worried about him. They are pressuring him to behave properly more often, to which Tommy vigorously objects, resulting in frequent arguments. Tommy enjoys helping his mother cook and helping his father and brother work on the car. Despite being generally willing to help out, he often forgets to do chores such as sweeping up the cat litter if not reminded. Tommys physical development is normal in all respects, including not having an intersex condition. [criteria C] In school, he is performing at grade level.

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APPENDIX B
In round one, vignettes were presented as in Appendix A. In round two, clinicians were asked: If the vignette had included the following paragraph, how would this have changed your conception of the case? When asked if she is a girl or a boy, Tammy says girl. If asked if she ever wants to be a boy, she says Never. or When asked is he is a boy or a girl, Tommy says boy. If asked if he ever wants to be a girl, he says Never. In round three, clinicians were asked: If the vignette had included the following paragraph, how would this have changed your conception of the case? When asked if she is a girl or a boy, Tammy says girl. If asked if she ever wants to be a boy, she says Yes. When asked how often she feels that way, she says All the time. or When asked if he is a boy or a girl, Tommy says boy. If asked if he ever wants to be a girl, he says Yes. When asked how often he feels that way, he says All the time.