Gender Identity Development - LGBTQIA Healthcare Guild

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American Psychological Association Task Force on Gender Identity and Gender Identity Variance

In recent years, transgender people have increasingly been willing to identify themselves openly. Public awareness of transgender issues has increased dramatically, in part because of an increasing number of books, motion pictures and television programs featuring transgender characters and addressing transgender issues. Report of the APA Task Force on Gender Identity and Gender Identity Variance
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Gender Identity Development - From the National Academies “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding”

Similar to sexual orientation identity, gender expression is not necessarily constant throughout childhood development. Gender variance, as it relates to expressing and exploring gender identity and gender roles, is a part of normal development. A relatively small percentage of gender-variant children develop an adult transgender identity (Green, 1987; Wallien and Cohen-Kettenis, 2008; Zucker and Bradley, 1995). However, research shows that the majority of adolescents with a gender-variant identity develop an adult transgender identity (Wallien and Cohen-Kettenis, 2008). Data on the prevalence of childhood gender-variant or transgender identities are severely limited, largely because there is no national database available to collect such data. A relatively small number of studies using nonprobability samples have attempted to assess the incidence of childhood gender-variant identities. One such study, discussed in Chapter 2, found that 1 percent of parents of boys aged 4–11 reported that their son wished to be of the other sex; for girls, the percentage was 3.5 percent (Zucker et al., 1997).

Other studies using small nonprobability samples have documented trends in referrals to gender identity clinics by gender and persistence of gender identity concerns into adolescence and adulthood. One study examining children aged 3–12 with gender identity issues in a Toronto clinic (n = 358) and a Utrecht clinic (n = 130) showed that boys were referred more often and at an earlier age than girls for such concerns (Cohen-Kettenis et al., 2003). In another small study (n = 77) examining psychosexual outcomes of gender-dysphoric children at age of referral and then at follow-up approximately 10 years later, 27 percent of those with childhood gender identity concerns were still gender dysphoric (Wallien and Cohen-Kettenis, 2008). (It should be noted that at follow-up, 30 percent of the sample failed to respond to recruitment letters or were not traceable.) Research with small clinical samples of gender-variant children has shown that, compared with controls, gender-variant children have more difficulties with peer relationships (Zucker et al., 1997); this is the case particularly for boys compared with girls (Cohen-Kettenis et al., 2003). Poor peer relations was found to be the strongest predictor of behavior problems in both gender-variant boys and girls (Cohen-Kettenis et al., 2003). One small study showed that children with gender identity disorder (n = 25) may have a more anxious nature than gender-conforming children (n = 25) (Wallien et al., 2007).

Grossman and D'Augelli (2006) conducted focus groups with young self-identified transgender males and females aged 15–21 and explored factors related to physical and mental health. In this qualitative study, most of the youth reported experiences of family and peers reacting negatively toward their gender-atypical behaviors. Therapy or counseling that aims to change an individual's sexual orientation, often based on the presumption that LGBT orientation/identity is abnormal or unhealthy, is known as conversion or reparative therapy (Just the Facts Coalition, 2008). The nation's most prominent medical and mental health professional organizations, including the American Medical Association, the American Psychiatric Association, and the American Psychological Association, oppose the use of conversion therapy with both youth and adults (AMA, 2010; American Psychiatric Association, 2000a). The American Psychological Association formed a task force to review peer-reviewed studies on efforts to change sexual orientation. The task force concluded that evidence is lacking for the effectiveness of efforts to change sexual orientation and that conversion therapy may cause harm to LGBT individuals by increasing internalized stigma, distress, and depression (American Psychological Association, 2009). Instead, the task force expressed support for the use of affirmative, culturally competent therapy that helps those facing distress related to their sexual orientation cope with social and internalized stigma and strengthen their social support networks (American Psychological Association, 2009).

DSM-IV includes diagnoses of gender identity disorder for children as well as for adolescents (and adults) (American Psychiatric Association, 2000b). The criteria for diagnosis of childhood gender identity disorder are listed in Box 4-1. This diagnosis has been controversial, particularly when applied to children. One objection raised is that including this phenomenon as a psychiatric diagnosis identifies gender-variant identity and expression as pathological, even though many gender-variant children do not report emotional distress; rather, distress may be related to the reaction of the social environment to the child's gender variance. Also, as noted earlier in this chapter, most children with gender-variant expression do not develop an adolescent or adult transgender identity (Wallien and Cohen-Kettenis, 2008), and many adults with a transgender identity do not report symptoms of childhood gender identity disorder (Lawrence, 2010). More specifically, this diagnosis has been criticized for conflating gender-variant expression with gender-variant identity. At least four of the five criteria are required to qualify for the diagnosis, and only one of these explicitly refers to cross-gender identification, allowing children with gender-variant expression but without a variant gender identity to qualify for the diagnosis (see also Bockting and Ehrbar, 2006).

BOX 4-1Criteria for Diagnosis of Childhood Gender Identity Disorder

  1. 1.A strong and persistent crossgender identification, manifested in 4 or more of the following:

    1. 1.Repeatedly stated desire to be, or insistence that he or she is, the other sex;

    2. 2.In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing;

    3. 3.Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex;

    4. 4.Intense desire to participate in the stereotypical games and pastimes of the other sex;

    5. 5.Strong preference for playmates of the other sex.

  2. 2.In adolescents, it is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

  3. 3.Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex, manifested by any of the following:

    1. 1.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, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities;

    2. 2.In girls, 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 toward normative feminine clothing.

  4. 4.In adolescents, 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 or she was born the wrong sex.

  5. 5.The disturbance is not concurrent with a physical intersex condition.

  6. 6.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

SOURCE: DSM IV (American Psychiatric Association, 2000b).

The approach to treatment of gender identity disorder among children includes early therapeutic interventions with the child, and perhaps with the family, school, and/or community, to broaden the child's gender role interests and behavior and/or provide a safe environment to allow gender identity to develop while preventing rejection, ridicule, and abuse from peers (Benestad, 2009; Brill and Pepper, 2008; Menvielle and Tuerk, 2002; Meyer-Bahlburg, 2002; Rosenberg, 2002; Zucker, 2008). The approach to treatment of gender identity disorder among adolescents includes therapeutic interventions to assist the adolescent and his or her family to explore and understand gender variance and cope with the related stress and social adjustment, which may include a gender role transition (Di Ceglie, 2009; Meyer et al., 2001). In addition, early medical intervention is available for carefully selected youth who have persistent gender dysphoria that has increased with the initial stages of puberty and who have support from their parents for such intervention (Cohen-Kettenis et al., 2008; Hembree et al., 2009; Meyer et al., 2001). The intervention consists of administering puberty-delaying hormones (such as gonadotropin-releasing hormone [GnRH] analogs) as early as Tanner Stage II of puberty (a development stage marked by certain physical milestones as opposed to age) and cross-sex hormones as early as age 16. The puberty-delaying hormones allow for more time to monitor the development of the youth's gender identity while reducing the dysphoria associated with the pubertal development of incongruent sex characteristics, an approach that has been shown to be beneficial (Cohen-Kettenis and van Goozen, 1997; de Vries et al., 2010; Delemarre-van de Waal and Cohen-Kettenis, 2006; Smith et al., 2001, 2005).


American Academy of Pediatrics Bright Futures

AAP Bright Futures is a national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities.

Journal of Pediatrics - Pubertal Bloackade

Studies in the Netherlands show that pubertal blockade at Tanner 2/3 prevents unwanted sex characteristics and improves psychological functioning. Endocrine Society guidelines (2009) recommend pubertal suppression for adolescents with gender identity disorder until approximately age 16.