Gender Identity Disorders In Childhood And Adolescence: A Critical Inquiry And Review Of The Kenneth Zucker Research

Gender Identity Disorders In Childhood And Adolescence:
A Critical Inquiry And Review O f The Kenneth Zucker Research
By the NARTH Scientific Advisory Committee
Published March 2007
The debate continues as to whether or not a diagnosis of gender identity disorder (GID) is
wanted or needed today, especially for children. Indeed, some are calling for the
complete removal of GID from the DSM (Isay, 1997), with the reasoning that GID is
used to pathologize gender-variant children. Others suggest that GID has the potential to
derail biological priming and places children at risk for distress. While arguments from
both sides of the scientific and political spectrum are likely to persist for some time, this
paper seeks to review the work of perhaps one of the m ore prominent researchers in this
area: Dr. Kenneth J. Zucker. Dr. Zucker is Psychologist -in-Chief, Centre for Addiction
and Mental Health, Head, Child and Adolescent Gender Identity Clinic, Child, Youth and
Family Program—Clarke Division, Toronto, Canada.
Recent Literature on Gender Identity Disorder: A Compilation of Reviews
I. Gender Identity Disorder Overview
Zucker (2005) presented the principal findings of research on children and adolescents
manifesting the “sex-typed behavioral patterns that co rrespond to the diagnosis of Gender
Identity Disorder (GID).” This review summarizes three topics in the research literature:
diagnosis and assessment, associated psychopathology, and developmental trajectories.
Diagnosis and assessment. Zucker attends to the questions of whether GID can be
diagnosed with reliability and validity. Concerning children, the clinical research
literature has scarcely addressed the issue of reliability except for a single study (Zucker
et al., 1984) which demonstrated that the diagnosis can be reliably made. In addition, the
author cites many studies that provide strong evidence for the discriminant validity of
GID.
To support this contention of discriminant validity, Zucker describes factor analyses of
two psychometric instruments: the 11-item Gender Identity Interview for Children, which
was administered to child subjects, and the 16-item Gender Identity Questionnaire for
Children, which utilized parent reports. The mean factor scores significantly
differentiated subjects from controls, with the factors accounting for approximately 48%
and 44%, respectively, of the variance for the two instruments.
In contrast to children, there are relatively few st udies investigating adolescents, and none
dealing with reliability. The auth or points out that this dearth of research likely reflects
the low numbers of adolescents who are treated for GID.
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Zucker contends that the diagnostic criteria effectively differentiate both children and
adolescents with GID from “subthreshold cases” bec ause mild gender dysphoria is very
uncommon. However, this article also includes a summary of several studies that
addressed the question of whether the DSM IV criteria distinguish GID patients from
those who merely exhibited “extreme gender nonconforming behavior.” The results cited
demonstrate that the criteria consistently separate the threshold from the subthreshold
cases even when the latter group’s effect sizes on gender nonconformity are substantial.
Nevertheless, the author acknowledges that render ing some revisions to the DSM could
reduce the future risk of diagnostic error. First, the criteria could be strengthened by
mandating that “the repeated stated desire to be, or insistence that he or she is, the other
sex” be applied to all patients in ord er to qualify as GID. Currently, this criterion is listed
under a heading in a group of five with subjects needing only to meet four of these in
order to achieve a diagnosis. Second, he posits that adding the descriptors of “persistent”
and “intense” to some of the criteria listed under cross -gender identification would
further screen out those whose gender dysphoria is merely episodic.
Finally, the essential question is addressed of whether GID comprises a true mental
disorder or is simply a normal varia nt that is the object of unnecessary social disapproval.
In defending the appropriateness of preserving GID as a diagnosis, Zucker quotes the
DSM-III as saying that “there is no satisfactory definition that specifies precise
boundaries for the concept of ‘mental disorder.’”
In addition, he states that the disjunction of somatic sex from gender identity inherently
indicates that a condition of psychological distress is occurring. This is especially the
case when one considers the ultimate outcomes of GID as either sex-reassignment
surgery or contrasex hormone treatment. Furthermore, he suggests that the desire of
certain patients to have a limb amputated because it is experienced as alien to the body,
described by some as Body Integrity Identity Disorder, pe rhaps parallels the sensation in
GID patients that their genitals are eg o-alien.
Associated psychopathologies . Associated psychopathologies comprise the second topic
covered in this review. Here, Zucker points out that several case studies provide evidenc e
of GID’s co-occurrence with Pervasive Developmental Disorder. He theorizes from these
descriptions that behavioral rigidity and obsessiveness are traits that appear to be
common to both disorders, with GID patients particularly manifesting obsessions wit h
issues surrounding gender.
Normative studies present additional evidence about co -morbidity. For example, parent
report data reveal that GID children have, on average, more behavioral problems that
either their non-referred siblings or other children. O ther studies demonstrate that boys
with GID have a clear pattern of internalizing behavior problems, such as schizoid traits
and withdrawal, and both boys and girls have low ratings of global self -worth and self-
perceived social competence.
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Behavioral problems in boys with GID increase with age. This is likely at least partly due
to the effects of peer ostracism , although research data also indicate these difficulties are
associated with a composite index of maternal psychopathology. Thus the tendency of
GID boys to internalize may also reflect general familial risk for other mental disorders
such as depressive conditions.
Developmental trajectories. In this third section, Zucker makes a distinction between the
retrospective and prospective studies of GID as these lead to somewhat differing but
complementary interpretations. The author points out that a considerable amount of
developmental research has been completed although significant gaps still exist.
The retrospective studies indicate that adults and adolescents with GID almost
universally recall patterns of cross -sex identification in childhood. Thus the case for
childhood onset is clearly demonstrated.
A particularly important retrospective finding involves adult homosexuals. Here, a meta -
analysis of 48 studies in addition to 14 subsequent studies found that both male
homosexuals and lesbians were far more likely than heterosexuals to recall cross -gender
identification during childhood.
Four prospective studies assessed GID male children, or those with prominent
characteristics associated with GID, and evaluated them again at one or more follow up
points. Results indicate relatively low rates of GID persistenc e into adolescence or
adulthood, ranging from 2.9% to 20%. The differing figures may be ex plained by the
nature of the respective subject pools, with the lowest figure involving youngsters drawn
from a general population, while the remaining studies examined clinic-referred children
who likely exhibited more extreme cross -gender traits. With large clinic samples now
available, Zucker postulates that it should be feasible to conduct within -group analyses
which will lead to the identification of predictor variables discriminating between the
persistent and desistent cases of GID.
A noteworthy finding involved the high proportion of subjects reporting a homosexual or
bisexual orientation at follow -up. Figures varied from 42.5% to nearly 80%, all far above
both those of the control groups as well as the population base rates. Although gender
dysphoria did not continue past childhood in the great majority of these cases, adolescent
and adult males known to have GID traits as children appear to have strong inclinations
toward homosexual or bisexual attractions. With reasons for this correlation unknown ,
the author recommends this as a major focus of future research.
In contrast to boys, relatively little study has been completed with GID girls. This dearth
of research reflects the low incidence of clinic referrals of girls, possibly because GID
seems to be the object of less ostracism with girls than is the case with boys.
Nevertheless, published investigations report rates of GID persistence and homosexuality
at follow up that are higher than those found with male subjects. Adolescent patients have
extremely high GID persistence rates. Three investigations concluded that 43.2% to 66%
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of the teens (subjects’ genders were not identified) had gender dysphoria that persisted in
such a manner as to qualify them to receive either sexual reassignment surgery or a
further evaluation that could lead to the scheduling of that procedure.
The consistency of the studies’ results is remarkable; GID typically remits when
identified in childhood, but most often is persistent when identified in adolescence. The
cause for this difference is unknown, but may involve one or both of two possible
explanations. One might be referral bias with the children belonging to families showing
more concern for the psychological well being of their offspring, compared to the
adolescents, who typically received no professional care for GID during childhood.
Alternatively, gender dysphoria may be characterized by more plasticity and malleability
during childhood than is the case later on. With adolescence, these traits apparently
become more refractory and less amenable to change. Therefore, the evidence suggests
that treatment begun during childhood is far more likely to be successful than that
conducted during the teen years.
In conclusion, the research conducted to date provides sig nificant evidence that GID can
be diagnosed with reasonable certainty, being distinct from less extreme forms of gender
dysphoria. GID is associated with psychological problems, particularly in boys, such as
internalizing behaviors, and is possibly correlated to maternal mental health problems.
Whether they received treatment or not, GID patients are shown to have a high
probability of developing a homosexual or bisexual orientation after childhood. If treated
during childhood, however, the condition is lik ely to desist. If untreated, significant
distress occurs with patients experiencing their genitals as something akin to being ego -
alien and typically seeking drastic measures such as sexual reassignment surgery.
II. Summary Comments about Zucker’s (2006) GID in Children and Adolescents
Overview of clinical and research literature on gender identity disorder (GID) for
adolescent males and females with limited attention given to transvestic fetishism (TF)
for adolescent males (Zucker, 2006).
Terms defined: Sex (biological male/femaleness); Gender (psychological or behavioral
characteristics associated with biological males and females); Gender Identity (basic
discrimination of males from females and a sense of belonging to one sex); Gender Role
(behaviors, attitudes and personality traits that a given cultural/historical society
designate as more appropriate to masculine/feminine); Sexual Orientation (sex- and age-
of the persons to whom one is attracted sexually); Sexual Identity (who/how one regards
oneself to be as a sexual being vs. one’s actual attractions and/or behaviors).
Historical Context of GID: From 19th century recognition of adults who suffered
profound discomfort with gender identity; to the use in 1923 of “transsexual”; to “gender
dysphoria”- “a sense of awkwardness or discomfort in the anatomically congruent gender
role and the desire to possess the boy of the opposite sex”; clinically, any experience of
being sufficiently uncomfortable with one’s “biological sex to form the wish for sex
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reassignment.” Original focus on males has expanded to research and treat gender
dysphoria in females. Relatively new development “is the availability of hormonal and
surgical techniques for transforming aspects of biological sex to conform to the felt
psychological state.” Research on adolescents with GID lags behind research on children
and adults.
Developmental Psychopathology Framework : “Adaptational failure must be defined
with respect to normative developmental tasks” (Sroufe); “In the general populat ion of
males and females…most females have a female gender identity;…a feminine gender
role behavioral pattern; and …are erotically attracted to males.” The reverse for males.
Description of GID in Adolescents : Strong psychological identification with th e
opposite sex, verbalization of strong desire to become a member of the opposite sex, and
expression of extreme unhappiness about being one’s own sex.
Core Symptoms:
1) Frequently stated desire to be a member of opposite sex.
2) Verbal or behavioral expressions of anatomic dysphoria (wanting to masculinize
their bodies if female, or feminize them if male).
3) Strong desire to pass socially as member of opposite sex (e.g., changing one’s hair,
clothing, name).
Diagnostic Criteria (DSM-IV-TR): Criteria for adolescents were differentiated from
those for children as thought to be more closely related to indicators seen in adults.
Point A possible indicators of “strong and persistent cross -gender identification”:
(1) stated desired to be the other sex.
(2) frequent passing as the other sex.
(3) desire to live or be treated as the other sex.
(4) conviction that s/he has the typical feelings and reactions of the other sex.
Point B possible indicators of “persistent discom fort with [one’s own] sex or sense of
inappropriateness in the gender role of that sex”:
(1) preoccupation with getting rid of primary and secondary sex characteristics.
(2) belief that one was born the wrong sex.
Reliability and Validity of Dx: There have been no formal studies of adolescents (vs.
children). It is clinically “uncommon…to encounter an adolescent who has o nly very
mild gender dysphoria.” Normative data and base rates suggest that “the frequent wish to
be of the opposite sex …appears to be extremely low ,” and “even a periodic desire to
become a member of the opposite sex is quite atypical.” It was suggested that when DSM
is revised, Point A indicators should have specific referents made for “persistence or
intensity” of cross-gender identification (vs. transient feelings). Point B indicators should
differentiate whether “partial” or total sex reassignment is sought.
Special Dx Considerations : DSM allows specification about sexual
attraction/orientation for “sexually mature individuals”. Most adolescents - and adults-
with GID who have a childhood onset are sexually attracted to birth sex; while most
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adolescents whose GID started in adolescence – e.g., youth with TF- are attracted to
opposite sex.
Prevalence and related demographics: GID in adolescents is considered rare, although
not well studied. It is not true that GID in childhood necessarily persists into adulthood.
During childhood boys tend to be referred more frequently, and at an earlier age (roughly
10 months), than girls, but the referral ratio lessens during adolescence (for various
suggested reasons -- including the fact that girls are more likely to engage in “masculine”
behaviors than boys are “feminine” ones.) “Children with GID are represented in all
socioeconomic groups.” “GID occurs in both Western and non -Western cultures.” In
Canada, child patients with GID tended to be proportionately more Caucasian, to speak
English as a first language, and to be born in Canada than were adolescents. Age of onset
for most adolescents with GID was the toddler/preschool years, during which “multiple
indicators of cross-gender behavior including the wish to be of the opposite sex” were
reported retrospectively. In general, adolescents diagnosed with GID have “a long
history of pervasive cross-gender behavior.” Exceptions are adolescents with TF and
gender dysphoria and those with “an obsession with gender identity in the context of
either a preexisting obsessive -compulsive disorder or Asperger’s disorder.”
Associated Behavior and Emotional Problems: According to studies using parent and
teacher versions of the Child Behavior Check List (CBCL) , compared with gender-
referred children, “gender-referred adolescents had significantly higher lev els of
behavioral disturbance.” When compared with other adolescents who were either not
referred for gender related issues or not referred at all, “GID adolescents had…levels of
behavioral disturbance comparable to” the adolescents who were referred for other
problems, “and considerably highe r levels of behavioral disturbance when compared to
the non-referred adolescents.” This suggests “that the persistence of GID is a risk factor
for the intensification of general behavior problems” in adolescence. “It is likely that
multiple factors contribute to their difficulties, including risk factors common to many
referred youth.
Developmental Course and Outcome : “Regarding psychosexual differentiation [the
persistence and desistance of GID], three outcomes have been identified: (1) persistence
of GID with a co-occurring homosexual sexual orientation; (2) desistance of GID, with a
co-occurring homosexual sexual orientation; and (3) desistance of GID, with a co -
occurring homosexual sexual orientation. Outcome (2) has been the most common among
boys- with girls not well studied. “From a developmental perspective, this suggests that
gender identity, at least among children with GID, is malleable and likely influenced by
psychosocial experiences, such as therapeutic interventions ” (emphasis added here and
for subsequent quotes).
Etiology:
Biological: The review of research on the “possible” effects of prenatal hormones, etc.,
offers lots of conjecture but little substance. And interesting finding, with a poor
explanation as to how/why it matters, is that: “Males with GID have an excess of brothers
to sisters (sibling sex ratio) and a later birth order. …Males with GID are born late
primarily in relation to the number of older brothers, but not sisters.
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Psychosocial: with respect to “predisposing, precipi tating and perpetuating (or
maintaining) factors…Given the early behavioral onset of GID, psychosocial
mechanisms that are operative during adolescence are most likely perpetuating or
maintaining factors.” For example, an intensification of cross -gender identification
following “the emerging awareness of homoerotic attractions” probably results from an
existing “significant vulnerability in the adolescent’s sense of self as a male or female,
which is further compounded by having to address sexual orientatio n issues.” Many
adolescents with GID grew up in families in which, at least for a time, “cross -gender
behavior was tolerated or encouraged, often being viewed as ‘only a phase.’” It is
hypothesized for adolescents - but so far demonstrated only for children - that “family
psychopathology” is a perpetuating factor (e.g., so stressed and burdened by psychiatric
difficulties that are less able to address the therapeutic needs of their GID children).
Adolescents with GID already are burdened with significantly m ore general behavioral
difficulties than their child counterparts which may make it harder for the adolescents to
deal specifically with their gender identity difficulties. “In fact for many adolescents, the
desire to change sex is seen as a way of solving many of their problems in living, which is
unrealistic.”
Assessment: While “the development of reliable and valid assessment techniques for
adolescents has lagged behind” techniques to assess children, the several which exist
“can be used to establish t he degree of current gender dysphoria, the extent of both
current and childhood cross -behavior, and characterize the adolescent’s sexual
orientation.”
Treatment:
Ethical Considerations: “The politics of sex and gender in postmodern Western culture”
raise “complex social and ethical issues” such as is GID “just a ‘normal’ variant of
gendered behavior,” and are marked cross-gender behaviors inherently or only
relatively/socially harmful. After raising many ethical questions, Zucker advises: “These
and other questions force the clinician to think long and hard about theoretical, ethical,
and treatment issues.
Developmental Considerations: Since “GID is less responsive to psychosocial
interventions during adolescence (and, certainly by young adulthood) than it is during
childhood...the lessening of malleability and plasticity over time in gender identity
differentiation is an important clinical consideration. ”
“Therapeutic” Approaches: When GID in adolescence does not respond to “psychosocial
treatment” (unspecified how that would be attempted), Zucker suggests either that efforts
may be taken (e.g., group therapy) to help an adolescent explore and come to make “a
homosexual adaptation,” or that the otherwise reluctant clinicians may wish to consider
offering the persistently dysphoric adolescent the hormonal and surgical interventions
used for adults, though these are highly controversial interventions .
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Summary Thoughts (by Zucker): Since GID first appeared as a diagnosis in DSM -III in
1980, “the phenomenology of GID is now well-described and extant assessment
procedures are available to conduct a thorough and competent diagnostic evaluation .
…Like other psychiatric disorders that affect adolescents, it is apparent that
complexity,
not simplicity, is the guiding rule of thumb in any effort to make sense of the origins of
GID.” Very little research has been done - relative to children or even adults - to identify
the “genesis and maintenance” of GID for adolescents. “ The current state of the art
suggests a rather poor prognosis for the resolution of GID if it persists into
adolescence.”
III. Measurement of Psychosexual Differentiation: Summary with Reflection
The issues of gender identity, gender role and sexual orientation have been in the
forefront of the discussion of human development for some time. Beginning with the
work of Money (1957) it was asserted that although biological factors play a role in the
development of a gender identity, sociological factors seem to play an even larger role.
Diamond (1965) asserted that newborns were psychosexually “neutral” with regard to
gender identity differentiation. Implicit in this hypothesis is that malleability in the short
run implies adaptation in the long run. It has been demonstrated in the 40 years sin ce that
this is not the case- malleability does have a bearin g on adaptation in the long run --
namely, that gender atypical behavior and identity is associated with a number of
negative outcomes.
The notion of malleability perhaps naively informed physic ians that psychosexual
surgery, when properly applied, would have positive outcomes for ambiguously
appearing children. Money’s assertion, particularly with his most famous client, cannot
be so simplistically understood and applied as he would wish. Zuck er (2005), in his
article, argues strongly that clinicians should engage in a formal assessment of children
with ambiguous genitalia or gender atypical behavior or identity. The informed clinician
(through psychometrics) can better assist other profession als, the parent and the child
than merely relying on the assumption of malleability and adaptability.
There are several assumptions that one makes when using psychometrics to assess
psychosexual differentiation , and Zucker wishes his reader to be aware of them.
1. Psychometrics should be able to demonstrate differences between a normative and
clinical population. These differences should be demonstrable in the three areas
associated with
a. Males and females having a Gender Identity consistent with their gender .
b. Males and females having a Gender Role consistent with typical gender
behavior.
c. Males and females being erotically attracted to their opposite gender.
2. A second assumption is that even animals on the evolutionary ladder below
primates demonstrate that soc iological factors play a significant role in the
acquisition of gender-typical behaviors. This is used as justification for applying
what others might assert are “transient, oppressive, cultural mores” as indicators
of either typical or atypical gendered behavior. If animals socialize their young
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along certain patterns for the betterment and survival of the species, it is not
oppressive, arbitrary or coercive to assess and encourage the socialization of
children along those same lines.
3. A third assumption is that psychometric measures should be tied to cultural
definitions of the two genders, unless the trait being measured is so demonstrably
transient or arbitrary as to be meaningless.
Zucker then begins to list for the reader a variety of instruments whi ch can either be
administered to the child or to the parent which have moderate to large Effect Sizes. In
this regard they are powerful (they properly reject the null hypothesis that there is no
difference between gender-identity disordered children/physi cally intersex condition and
normals). These measurements occur in all three areas of assessment: gender role,
gender identity and temperament. This makes the assessment and validity of a GID
diagnosis all the more powerful as it occurs in multiple meas ures across multiple
attributes:
“…all of the measures listed in Table 1 met one or more of the following
psychometric requirements: (1) there was evidence for a significant normative
gender difference; (2) there was evidence for discriminant validity in c omparing
children with GID versus controls; (3) there was evidence for discriminant
validity in comparing children with physical intersex conditions…versus same -
sex controls.”
The power of these assessment tools is all the more compelling when one looks closely at
the statistical analyses used in these instruments. Each instrument demonstrates moder ate
to large Effect Sizes (.50 and larger). This is especially true of parent report measures.
Even more importantly these effect sizes are larger for GID c hildren than for CAH
children (girls with congenital adrenal hyperplasia).
These moderate-to-large effect sizes are present in 11 studies of free play, such that
normative children play with gender -typical toys at a much higher rate that either GID
boy and girls or CAH girls. Free play that includes both gender typical toys and the
opportunity for dress-up seems to be an even more useful tool at discriminating behaviors
typical of girls and boys (Rekers and Yates, 1976).
The next question to be addressed in research is the assessment of adults and adolescents
along the same three dimensional paradigm (gender identity, gender role, sexual
orientation). The concept of how gender identity effects gender role and sexual
orientation over time has not been ope rationally assessed. This leads clinicians to speak
to parents, doctors and clients from a vacuum. Although there are a number of
assessment tools which are said to address these factors in these age groups, they are
inadequate by comparison to the preci sion of tools which exist to assess children.
Consequently, a lack of empirical data leads to much guessing and assertions based upon
religion, politics and other subjective systems which may or may not serve the client. In
this regard it leads me to the following set of questions:
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1. What percentage of GID diagnosed children later identify as homosexual in
orientation?
2. What percentage of GID diagnosed children later continue gender -atypical
behavior, but identify with their gender role and do not identify with a
homosexual orientation?
3. What percentage of GID diagnos ed children later report gender -typical behavior
and identification with their gender role and report opposite -sex attraction?
4. How does the ethical clinician navigate this process, not with only children who
are GID, but with adults who later report symptoms consistent with a prior
diagnosis of GID?
a. Is gay affirmative therapy likely to help or harm (does it share some
similarities to Money’s poorly conceived malleability hypothesis)?
b. Is reorientation therapy likely to help or harm (is emphasizing masculine
interests and friends really sufficient in understanding and helping men
who have gender atypical interests who wish to live as heterosexuals)?
IV. Zucker Defends the Diagnosis and Treatment of GID
The diagnosis of GID is under attack these days. In separate articles responding directly
to critics, Zucker and Spitzer (2005) and Zucker ( in press) address differing but related
aspects of the controversy. Zucker and Spitzer respond to the accusat ion that GID was
introduced into the DSM-III in 1980 as a backdoor method of replacing homosexuality as
a diagnostic category, which had been deleted from the DSM -II in 1973. This claim has
been based on the connection between GID in childhood and later h omosexuality, as a
homosexual sexual orientation without co -occurring GID is the most common outcome
for children diagnosed with GID. The authors challenge the assertion of a
homosexuality-GID diagnostic swap on a number of grounds, arguing that the GID
diagnosis had shown clear clinical utility and met the test of expert consensus. Moreover,
they assert that there was no need for another diagnosis to replace homosexuality, as the
DSM-III contained the diagnosis of ego -dystonic homosexuality, and subsequent DSM
versions have retained the residual diagnosis of sexual disorder not otherwise specified,
which includes distress about homosexual orientation as one of its examples. For Zucker
and Spitzer, GID is a credible and valid diagnosis that deserves furth er study rather than
inaccurate historical characterizations.
In a separate response to an article by Langer and Martin (2004) in the Child and
Adolescent Social Work Journal , Zucker (in press) defends the GID diagnosis against a
slew of criticisms. Zucker begins by noting that since the mid -1970s he and his
colleagues have assessed about 475 children and 300 adolescents referred for concerns
about their gender-identity development. Zucker challenges the view of GID as simply a
social construction, which has been asserted based on the higher referral rates for boys as
opposed to girls. He contends instead that while social factors influence referral rates,
one could equally argue that social factors result in a dismissal of gender conflict in girls,
whereby greater tolerance for cross -gender behavior in girls results in parents and
therapists not taking seriously the possibility of a girl experiencing substantial distress
about her gender identity.
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