Is Gender Identity Disorder in Children a Mental Disorder?

Is Gender Identity Disorder in Children a Mental Disorder?

by Nancy H. Bartlett , Paul L. Vasey , William M. Bukowski
Paul L. Vasey [1]
Empirical studies were evaluated to determine whether Gender Identity Disorder (GID)
in children meets the Diagnostic and Statistical Manual of Mental Disorders-4th Edition
(DSM-IV, American Psychiatric Association, 1994) definitional criteria of mental
disorder. Specifically, we examined whether GID in children is associated with (a)
present distress; (b) present disability; (c) a significantly increased risk of suffering death,
pain, disability, or an important loss of freedom; and if (d) GID represents dysfunction in
the individual or is simply deviant behavior or a conflict between the individual and
society. The evaluation indicates that children who experience a sense of
inappropriateness in the culturally prescribed gender role of their sex but do not
experience discomfort with their biological sex should not be considered to have GID.
Because of flaws in the DSM-IV definition of mental disorder, and limitations of the
current research base, there is insufficient evidence to make any conclusive statement
regarding children who experience discomfort with their biological sex. The concluding
recommendation is that, given current knowledge, the diagnostic category of GID in
children in its current form should not appear in future editions of the DSM.
Controversy surrounding the pathologization and treatment of cross-gender [2] identity
and behaviors, particularly in children, has been evident in the literature for over 20 years
(Bem, 1993; Fagot, 1992; Menvielle, 1998; Morin & Schultz, 1978; Neisen, 1992;
Nordyke, Baer, Etzel, & LeBlanc, 1977; Richardson, 1996, 1999; Winkler, 1977; Zucker,
1999). This paper addresses that controversy by asking the question: "Is Gender Identity
Disorder (GID) in children a mental disorder?" To this end, our intention is not to provide
a comprehensive review of the literature on GID, but rather an evaluation of the literature
as it pertains to the question of whether GID in children is a mental disorder. Children
with GID have (a) a strong and persistent identification with the other sex or with the
culture-specific gender role associated with the other sex or with both and (b) discomfort
with their own biological sex or the culture-specific gender role of that sex or with both.
Estimates of the prevalence of the disorder range from .003% to 3% for boys, and .001%
to 1.5% for girls (American Psychiatric Association [APA], 1994; Green, 1995; Zucker,
1990). The referral ratio of boys to girls has been reported to be as high as 7:1 (Bradley &
Zucker, 1997). This paper begins with a brief historical overview of cross-gender
identification and behaviors as mental illness, followed by an outline of the current
definition of mental disorder, and then an evaluation of the relevant GID outcome
literature. Then the central question of whether GID in children is a mental disorder is
addressed using the DSM-IV definition of mental disorder as a comparison point. Our
strategy in this comparison is to simply determine whether the extant literature regarding
GID in children indicates that it constitutes a mental disorder. Finally, suggestions are
made regarding the future of GID in children as a DSM disorder.
A HISTORICAL OVERVIEW
With a concept such as gender, a historical perspective can be useful in demonstrating
that what is "deviant" behavior within a particular culture is far from stable across time.
The labelling of "gender-deviant" individuals as mentally ill is not a new phenomenon. In
late nineteenth century medical literature, accounts began to appear of individuals who

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deviated from the culture-specific social role expected for their biological sex (i.e., their
gender role). Such individuals were considered to suffer from "sexual inversion," a
reversal of gender identity (of which homosexual behavior may or may not have been one
aspect; D'Emilio & Freedman, 1988). In 1884, George Beard, an American physician,
wrote of sexual inverts: when "the sex is perverted, they hate the opposite sex and love
their own; men become women and women men, in their tastes, conduct, character,
feelings, and behavior" (as cited in Chauncey, 1989). Female inverts were described in
the literature as possessing "masculine straightforwardness and sense of honor" (Ellis,
1942, p. 250), having "a dislike and sometimes incapacity for needlework" as well as "an
inclination and taste for the sciences" (Krafft-Ebing, 1893, p. 280), being demanding of
voting rights, and skilful at whistling (Browne, 1923; Claiborne, 1914; Ellis, 1942).
Accounts of male inverts include such descriptors as, "sentimental," "something of a
chatterbox" (Carpenter, 1911, p. 132), "never smoked," "entirely averse to outdoor
games," and having a "fondness for cats" (Rivers, 1920, p. 22). Krafft-Ebing (1893) noted
that this "abnormality of feeling and of development of the character [was] often apparent
in childhood" (p. 279). On one such case, he wrote that "the boy likes to spend his time
with girls, play with dolls, and help his mother around the house" (Krafft-Ebing, 1893, p.
279).
For several decades, little attention was paid in the literature to "pathologies" related to
gender role, until Christine Jorgensen's widely-publicized sex-change operation in 1952.
By the late 1960s and early 1970s, such operations were a sought-after and popular
treatment for what was then known as transsexualism (and would later be termed GID).
In an effort to try to prevent this condition, a number of psychiatrists in the 1970s
designed programs to identify, study, and treat children "at risk" for developing adult
transsexualism. The targeted children were those who displayed unusual amounts of
cross-gender behavior (Bem, 1993). The treatments, as well as the very notion that
children's cross-gender identification and behaviors warranted treatment, were renounced
by several authors, including those from gay rights groups, as unethical (Morin &
Schultz, 1978; Nordyke et al., 1977; Winkler, 1977). GID in children was first officially
recognized by the APA as a disorder with the 1980 publication of DSM-III. Recently,
there has been a resurgence of concern about its status as a disorder, both in published
literature on the topic and among members of feminist and gay and lesbian organizations,
who are calling for the depathologization of "gender-variant" youth (Bem, 1993; Burke,
1996; Conaty & Lobel, 1998; Neisen, 1992; Wilson & Hammond, 1996).
CONCEPT OF MENTAL DISORDERS IN DSM-IV
The definition of mental disorder used by the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders has remained essentially
unchanged since the publication of DSM-III (APA, 1980). This definition is basically a
simplified derivative (Wakefield, 1993) of a definition proposed by the editor of DSM-III
and DSM-III-R, Robert Spitzer, and his colleagues, who were involved with the
American Psychiatric Association's Task Force on Nomenclature and Statistics (Spitzer
& Endicott, 1978). Remarkably, the DSM-III was the first edition of the DSM for which
there was an official definition of mental disorder. The initial impetus for defining mental
disorder, according to Spitzer and Endicott, was the controversy surrounding the removal
of homosexuality from the psychiatric nomenclature. The associated debate apparently
highlighted the need for the boundaries of the concept of mental disorder to be

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delineated, to make explicit a set of guiding principles for determining which conditions
should be included in or excluded from the nomenclature, as well as how conditions
should be defined.
The current DSM-IV definition of mental disorder is as follows (each sentence is
numbered to facilitate later reference to the definition):
[1] In DSM-IV, each of the mental disorders is conceptualized as a clinically significant
behavioral or psychological syndrome or pattern that occurs in an individual and that is
associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in
one or more important areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom. [2] In addition, this
syndrome or pattern must not be merely an expectable and culturally sanctioned response
to a particular event, for example, the death of a loved one. [3] Whatever its original
cause, it must currently be considered a manifestation of a behavioral, psychological, or
biological dysfunction in the individual. [4] Neither deviant behavior (e.g., political,
religious, or sexual) nor conflicts that are primarily between the individual and society
are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the
individual, as described above" (DSM-IV, pp. xxi, xxii).
Throughout this paper, the DSM-IV definitional criteria of mental disorder serve as the
reference points for determining whether GID in children satisfies the manual's definition
of "disorder."
DIAGNOSTIC CRITERIA FOR GID IN CHILDREN
Prior to beginning the discussion of whether GID satisfies the DSM IV criteria for mental
disorder, it is important to consider the diagnostic criteria for GID as outlined in the
DSM-IV. These criteria are shown in the Appendix. Each of the four diagnostic criteria
for GID serves a different function. The items that comprise Criterion A are intended to
refer to cross-gender identification but also include one item referring to cross-sex
identification. The items in Criterion B refer to the child's discomfort with his/her
biological sex or with the culturally prescribed gender role for that sex or both of these.
Criterion C is intended to rule out a physical intersex condition, and Criterion D states
that distress and impairment must derive from the "disturbance" implied in Criteria A and
B. Criteria A, B, and D are problematic for the following reasons. In regard to Criterion
A, the diagnostic significance of widely disparate items is treated as if it were equivalent
for each. In this way, having a preference for other-sex playmates is equated with a stated
desire to be a member of the other sex. Moreover, because it is necessary to meet only
four of the five criteria, Criterion A can be met without the child stating he or she wishes
to be the other sex. Importantly though, as specified in the Diagnostic Features of GID
subsection in the DSM-IV, to make a diagnosis of GID, "There must be evidence of a
strong and persistent cross-gender identification, which is the desire to be, or the
insistence that one is, of the other sex" (p. 532). That a mental disorder can be diagnosed
when a core feature of that disorder is absent is alarming, as well as scientifically invalid.
The items in Criterion B are similarly problematic because of the confusion of sex and
gender. Discomfort with one's biological sex and discomfort with the gender roles
ascribed to this category are very different phenomena; equating them confuses, rather
than clarifies, the distinction between them. This confusion seriously challenges the
validity of this set of items as a diagnostic criterion. An additional problem with Criterion
B, which was highlighted by Richardson (1999) as well, is the similarity in diagnostic

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significance that is ascribed to being uncomfortable with one's biological sex and
discomfort with one's assigned gender role. In so far as GID is meant to represent a
"profound disturbance of the individual's sense of identity with regard to maleness or
femaleness" (DSM-IV, p. 536), it is unclear why this symptom, for example, considering
one's genitals disgusting, is given the same diagnostic weight as having a preference for
particular play or clothing styles. Moreover, discomfort with one's biological sex is not
even necessary for Criterion B to be met. Once again, it is disconcerting that a diagnosis
of GID can be made in the absence of evidence that a child is uncomfortable with his/her
biological sex, whether this discomfort is verbally expressed or not.
The possibility that two populations are subsumed under one diagnostic category is thus
raised. One population could consist of those children who present solely with
dissatisfaction with the culture-specific gender role prescribed for their sex and the other
could consist of children who present with persistent discomfort with their biological sex,
perhaps with accompanying gender role discomfort. Attempts have been made to
determine whether two populations indeed exist. Bentler, Rekers, and Rosen (1979)
reported a correlation of .71 between "cross-gender identification," as judged partly by
verbalized cross-sex wishes, and "gender behavior disturbance," indicating an overlap of
approximately 50% in these symptoms. These authors concluded that their data provided
a basis for a distinction between the two phenomena. Zucker et al. (1998) conducted
factor analyses of Green's prospective study (Green, 1987) of 66 feminine boys to
determine whether the wish to be the other sex should be a distinct criterion in DSM-IV.
Their conclusion was that the expressed wish to be the other sex should not be considered
a distinct criterion, as it was "just one of several behavioral markers of cross-gender
identification" (factor loading = .611), along with behaviors such as wearing girls'
clothing and playing with dolls. Given the conceptual distinctiveness of expressing cross-
sex wishes, which represent a statement of identity rather than a behavior, a more
conservative conclusion might be warranted; that is, the data might better be viewed as
reflective of a common cooccurrence of cross-sex wishes and cross-gender behaviors, but
not a complete overlap. For example, perhaps those children who express cross-sex
wishes may be expected to also exhibit cross-gender behaviors, though children who
exhibit cross-gender behaviors may not necessarily be expected to also experience the
desire to be the other sex. Given the lack of any irrefutable evidence to the contrary, the
importance of remaining open to considering the existence of two populations--those
with and without discomfort with their biological sex--cannot be overstated.
Finally, in regard to Criterion D, it is stated in the diagnostic criteria for GID that the
"disturbance causes" distress or impairment, though in the definition of mental disorder,
there is no causation implied, but simply an association. Thus, there is some
inconsistency regarding whether a child's distress needs to derive directly from the
"disturbance" per se, or can be associated in an indirect manner, through sources such as
possible social ostracism. In these ways, the diagnostic criteria for GID cannot be treated
as being problem free.
OUTCOME LITERATURE ON CHILDREN WITH GID
To address the question of whether GID in children meets DSM-IV criteria for mental
disorder, outcome literature relevant to each criterion is reviewed. The criterion posited in
Sentence [2] of the DSM-IV definition is not relevant to the present discussion, as it is
clear that GID in Western cultures is not merely "an expectable or culturally sanctioned

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response to a particular event." [3] With respect to the remainder of the definition, the
following questions are asked: (a) Is GID associated with present distress (Sentence [1])?
(b) Is GID associated with present disability (Sentence [1])? (c) Is GID associated with a
significantly increased risk of suffering death, pain, disability, or an important loss of
freedom (Sentence [1])? and (d) Does GID represent a behavioral, psychological, or
biological dysfunction in the individual (Sentence [3]) or is it simply deviant behavior or
a conflict between the individual and society (Sentence [4])? It is important to mention a
problem in interpreting the literature on children with GID, namely, the lack of
consistency in the samples used. In some studies, samples are referred to as "effeminate
boys" and "masculine girls," in others, the children are "gender-disturbed" or "gender-
referred" (children referred clinically for gender-related problems), or they are children
who meet DSM-III or DSM-III-R diagnostic criteria for GID. With such a lack of
uniformity in the samples studied, it is difficult to compare data from one study to the
next, and consequently to make general statements about children with GID.
Is GID Associated With Present Distress (Sentence [1])?
According to the DSM-IV definition of mental disorder, a condition that is associated
with "present distress" (e.g., a painful symptom) meets the criteria delineated in Sentence
[1]. In the criteria set for GID, as with other disorders, there exists a criterion (in the case
of GID, this is Criterion D) which specifically states that "the disturbance causes
clinically significant distress or impairment." As noted previously, from the distress
criterion in the definition of mental disorder though, it is not evident whether the distress
must be experienced as a direct result of a condition, or can be caused by situations that
are secondary to the condition, such as social disapproval or rejection due to one's
nonconformity to societal norms. As Wakefield (1992a) notes, not all conditions that are
simply associated with distress can be considered disorders. Whether distress must be
directly caused by a particular condition or can simply be associated with it is a crucial
matter in determining whether a particular condition should be judged to be a disorder,
and should be clarified in future editions of DSM-IV. In the present paper, "distress" will
be interpreted according to the more conservative "direct causation" criterion, and the
examination of the extant literature is conducted with the above issues in mind. The very
concept of clinically significant distress presents another problem. Assessing its presence,
as noted in the DSM-IV, is an "inherently difficult clinical judgement," and "reliance on
information from family members and other third parties (in addition to the individual) ...
is often necessary" (DSM-IV, p. 7). When the identified patient is a child, it is almost
invariably the case that assessing the presence of distress involves a subjective judgement
by individuals other than the identified patient.
There is a lack of empirical evidence to support the notion of distress caused directly by
GID as opposed to simply being associated with it. Certainly, child distress does not seem
to be a common reason for referral of children with GID. Rather, the basis for clinical
referral is more often parents' or teachers' concern regarding the child's "intense
involvement in overt cross-gender play" or the parents' desire to prevent homosexuality
in their child (Doering, Zucker, Bradley, & MacIntrye, 1989; Scientific proceedings--
Panel reports, 1993). As such, the validity of a subjective judgement of child distress is
called into question.
In the literature, it is often reported that children referred for gender "problems" or
diagnosed with GID express the wish to be the other sex or feel that they are the other sex

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(Babinski & Reyes, 1994; Bleiberg, Jackson, & Ross, 1986; Chazan, 1995; Di Ceglie,
1995; Dowrick, 1983; Gilmore, 1995; Green, 1974, 1987; Green, Newman, & Stoller,
1972; Haber, 1991; Herman, 1983; Loeb, 1992; Newman, 1976; Pruett & Dahl, 1982;
Rekers & Lovaas, 1974; Rekers, Lovaas, & Low, 1974; Rekers & Mead, 1979; Sack,
1985), though this symptom has been found to be present in only a minority of cases.
Zucker (2000) reported that between 17% and 36% of gender-referred boys in his sample
expressed cross-sex wishes, though data on the associated distress experienced by these
children was not reported. It is important to note that children beyond the age of 6 or 7
tend not to verbalize cross-sex wishes. Zucker and Bradley (1995) suggest that children's
tendency to not voice cross-sex wishes is perhaps because of social reactions and not to
the fact that the child does not have such wishes. The extent to which "feminine" boys
expressed cross-sex wishes or beliefs was noted, by Green (1987), to subside with age.
Thus the possibility certainly exists that many children "grow out of" their cross-sex
wishes, and do not voice them simply because they do not have them. Although reported
cases of children who are distressed as a direct result of their GID are not common,
examples of such distress do exist in the literature, for children who present with
discomfort with their biological sex. In case descriptions, children have been reported to
make statements such as "I hate being a boy" (Zucker & Bradley, 1995, p. 57), "I don't
want to be me. I want to be a girl" (Coates & Person, 1985, p. 707). In some cases,
children are reported to dislike their genitals, wishing to have them removed if they are
boys and wishing to acquire a penis if they are girls (see Loeb & Shane, 1982; Lothstein,
1992; Zucker & Bradley, 1995; Zucker & Green, 1992). From the literature, it is difficult
to ascertain the rate of occurrence of such a disavowal of one's genitals. It has variously
been reported that the symptom of "anatomic" or "genital dysphoria" is experienced by
"virtually all" children with GID; is, compared to other symptoms, "less consistently
present" among gender-disturbed children, is a "rare" occurrence among boys; but is "one
of the most common first signs of GID" in girls (APA, 1994; Bradley & Zucker, 1990;
Coates, 1990; Zucker, 1982). Thus, evidence indicating the frequency with which
children with GID present with a persistent discomfort with their biological sex (as in
Criterion B for GID) is equivocal. It does, however, appear that in those cases where
distress is associated with this symptom, it may be in a direct manner.
Evidence from published case studies does not appear to support distress caused by
"gender role disturbances." When child distress is reported at all in these cases, the
distress is most often in the form of general unhappiness or unhappiness about poor peer
relationships, or anxiety, frequently about separations (Coates, 1990; Hay, Barlow, &
Hay, 1981; Herman, 1983; Meyer & Dupkin, 1985; Rekers, 1979; Rekers et al., 1974;
Sack, 1985), and does not seem to pertain to any direct distress on the child's part about
his/her gender identity or accompanying behaviors. Indeed, considering the minimal
amount of attention in the literature devoted to the child's distress in comparison to that
devoted to the child's tendencies to engage in cross-gender behaviors, one might infer
that the child's own feelings of contentment or distress are treated as secondary to the
distress felt by others as a result of the child's cross-gender behaviors. It is possible that
this lack of attention to child distress in the literature is reflective of the actual state of
affairs, that is, a lack of distress on the part of the child.
It has been proposed that distress among at least some children with GID is simply a
response to having their desired manner of behaving thwarted (Di Ceglie, 1995; Meyer &

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Dupkin, 1985; Stoller, 1975; Sugar, 1995; Zucker, 2000). In the literature there are
numerous accounts to sup port such a supposition. That is, many of these children are
reported to be happiest when their preferred behaviors are permitted without restriction.
Meyer and Dupkin (1985) reported on a "gender-disturbed" boy who, according to his
mother "gets very mad at me when I won't let him dress in my dresses," "obvious[ly] ...
feels like a million dollars when he has on high heels" and "seemed content and happy"
when dressed as a girl (pp. 254,255). One mother reported regarding her son's "gender-
disturbed" behavior: "He was very excited about [putting on a blouse of mine] and leaped
and danced around the room. I didn't like it and I just told him to take it off and I put it
away. He kept asking for it. He wanted to wear that blouse again" (Green 1987, p. 2).
Where is the evidence in these examples that the gender role "disturbance causes
clinically significant distress" to the identified patient? Rather, it appears that, like Stoller
proposed, the distress, in cases of children whose discomfort lies with the culturally
sanctioned gender role of their sex, is linked to the child's not being permitted to act in
the gender-atypical manner he or she desires.
Additional support that distress, in many cases, is associated in an indirect, rather than a
direct manner, can be found in what has been called a "chronicity effect." The existence
of a chronicity effect has been noted among children with GID, in the sense that their
associated psychopathology has been found to increase with age (Zucker, 1990). It has
been proposed that this positive relation between age and psychopathology could be a
function of the harmful additive influence of being exposed to peer ostracism over time.
Moreover, it may be directly related to the children's experience of receiving constant
censure for their behaviors. Research has indicated that cross-gender behaviors seem to
diminish among children with GID as they get older (Green, 1975,1987; Zucker, 1982;
Zuger, 1978). It has been suggested that this reduction occurs because of the social
pressures felt by the child to conceal his or her nonconforming behaviors (e.g., Bates,
Skilbeck, Smith, & Bentler, 1974). Former GID-diagnosed individuals who have spoken
out concerning their treatment offer first-hand evidence of the ill-effects of social
disapproval. They recall feelings of extreme shame about their gender-atypical behaviors;
they were not accepted as they were (Burke, 1996). Daphne Scholinski (1998, p. x), a
lesbian who was treated for GID as a child, writes of being "so false your own skin is
your enemy." It is unreasonable to expect that an enforced repudiation of one's gender
identity and accompanying behaviors would cause anything but a great deal of distress.
In summary, it appears that a minority of children diagnosed with GID have a sense of
discomfort with their biological sex. For those who experience this symptom, some seem
to experience distress as a direct result of their discomfort, and as an indirect result of
social ostracism. In the majority of cases, in which children do not express discomfort
with their biological sex, the evidence seems to point to distress being associated with
their GID in an indirect manner.
Is GID Associated with Present Disability (Sentence [1])?
According to the DSM-IV definition of mental disorder, a condition that is associated
with present disability meets the criteria in Sentence [1]. To meet the criterion for
"disability" it must be shown that children with GID are impaired in one or more
important areas of functioning. To this end, the social and school functioning as well as
the general mental health of children with GID will be discussed. The data from studies
in this area are not specifically reported separately for children who do and do not

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experience a sense of discomfort with their biological sex; however, this distinction is
made here where the literature allows.
Social and School Competence
CBCL Data. Few studies exist in which social competence in children with GID has been
systematically assessed. Those that do exist have relied heavily on the Child Behavior
Checklist (CBCL; Achenbach & Edelbrock, 1981). The CBCL scales assessing social
competence in activities, social, and school domains were used in a comprehensive study
by Zucker and Bradley (1995) to assess the level of functioning in gender-referred
children. They compared CBCL data from gender-referred children to that of nonreferred
and clinic-referred controls, as well as siblings of gender-referred children. It should be
noted that not all the gender-referred children in their study met complete DSM criteria
for GID. In brief, their results showed that gender-referred boys had lower maternal
ratings in areas of total social competence and school competence compared to
nonreferred boys, but did not differ from a group of clinic-referred controls on those
scales. There were no differences across groups on the Activities or Social scales.
Though Zucker and Bradley did not report the percentage of gender-referred children
whose social competence scores fell in the clinical range, an examination of their data
reveals that on none of the scales did the mean scores of gender-referred boys approach
the clinical range. Thus, in terms of total social competence and school competence,
gender-referred boys, including those with GID, may differ from the norm but not to a
degree that would indicate serious maladjustment or clinical significance. It is important
to note that, though gender-referred children, including those diagnosed with GID, appear
to have lower competence in the school domain, their IQs have generally been found to
be either average or above average (Coates & Person, 1985; Finegan, Zucker, Bradley, &
Doering, 1982; Tuber & Coates, 1985, 1989; Zucker, Finegan, Doering, & Bradley,
1984), suggesting that any school difficulties do not stem from a lack of intellectual
abilities on the part of the gender-referred child.
Among GID-diagnosed boys in a study by Coates and Person (1985), 24% of the sample
scored in the clinical range on the Activities scale, 48% scored in the clinical range on the
Social scale, and 43% scored in the clinical range on the School scale of the CBCL. A
high percentage (64%) of the boys had a total score in the clinical range. Caution must be
taken in interpreting the results of the Coates and Person study, however, as the sample of
interest included boys from the ages of 4 to 14, and some of the analyses are not reported
according to age. When the authors analysed the School scale scores separately for boys
aged 6-11 and 12-14, substantial differences were found. Of the younger boys, 22%
scored in the clinical range, compared to 80% of the older boys, suggestive again of a
chronicity effect. The other competence scale scores were not reported separately by age.
Thus, the findings of Coates and Person may paint a more disturbed picture compared to
those reported by Zucker and Bradley (1995). This discrepancy may also be, in part,
because of the fact that all the boys in the Coates and Person sample met DSM-III criteria
for GID, whereas Zucker and Bradley stated that, in their sample, some met DSM criteria
and some did not. It is unclear in the latter study which edition of the DSM was used for
diagnosis. This point is not an insignificant one; in DSM-III, for a child to receive a
diagnosis of GID, the child was required to have stated cross-sex wishes or insisted he or
she was the other sex. Thus all the boys in the Coates and Person study expressed

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discomfort with their biological sex, whereas those in the Zucker and Bradley study did
not necessarily meet this criterion.
With respect to the gender-referred girls in the Zucker and Bradley sample, total social
competence scores as well as scores on the Social scale were lower than that of a sample
of female siblings. No comparison was made, though, to nonreferred or clinic-referred
control subjects, and again, none of their scores approached the clinical range. The
evidence seems to point to the existence of disability only among those children who
experience discomfort with their biological sex.
A difficulty exists with the interpretation of disability, namely, against what standard
should scores be compared to determine the existence of disability? In the Zucker and
Bradley (1995) study, gender-referred children differed from nonreferred samples, but
did not fall in the clinical range of disturbance. Whether disability exists when a child
exhibits some impairment, but not at a clinical level is an open issue, as there exist no
general guide lines for making such decisions. It is the opinion of the present authors that,
especially with disorders such as GID, which are entrenched in controversy, the criterion
should be a conservative one. That is, it is perhaps more valid and ethical to require
scores in the clinical range before determining that impairment exists. An additional
difficulty exists in interpreting "disability," namely, that of subjective judgement. It is
glaringly evident that children's own ratings of disability or impairment are not
considered in the published literature. Rather, the emphasis is on parental report in
determining disability, a limitation that will be discussed.
Peer Relations. No published research exists to date that provides an empirical
examination of the peer relations of children with GID. Anecdotal evidence and clinical
experience suggest that feminine boys have a great deal of difficulty in their peer
relations, often experiencing teasing, rejection, and social ostracism because of their
gender nonconformity (e.g., Coates & Person, 1985; Green, 1974; Rofes, 1993-94).
Children's reactions to same-and cross-gender behavior in their peers has received some
research attention in the form of analogue studies (Albers, 1998; Carter & McCloskey,
1984; Connor, Serbin, & Ender, 1978; Langlois & Downs, 1980; Zucker, Wilson-Smith,
Kurita, & Stern, 1995) as well as naturalistic observations and peer assessment studies
(Fagot, 1977; Hemmer & Kleiber, 1981; Lamb, Easterbrooks, & Holden, 1980; Sroufe,
Bennett, Englund, & Urban, 1993), which may provide some information that can be
extrapolated to children with GID. In general, the results of such studies indicate that
cross-gender behaviors (not GID per se) are punished by peers and seem to have a
negative effect on a child's peer acceptance. In the majority of studies, boys are found to
receive more censure than do girls for their "gender transgressions," and it is generally
accepted in the literature that the cross-gender behaviors of girls are better tolerated than
are those of boys (e.g., Hemmer & Kleiber, 1981; Money & Lehne, 1993; Zucker, 1985).
This is especially relevant in light of the much higher gender-referral rates for boys. A
recent study demonstrated that significantly fewer cross-gender behaviors are required for
boys, in comparison to girls, to receive a gender-related referral (Zucker, Bradley, &
Sanikhani, 1997).
Based on maternal judgements, Green (1976) concluded that the feminine boys in his
study were more likely than were control group boys to be rejected by male peers or to be
voluntary loners. In a female sample, masculine girls were less likely than feminine boys
to be rejected by same-sex peers, though the girls seemed to "mix" less well in female

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peer groups than did their more feminine counterparts (Green, Williams, & Goodman,
1982). Similarly, gender-referred children in a study by Zucker et al. (1997) received
lower maternal ratings than their siblings did on CBCL items pertaining to peer relations,
and this was especially true for boys. The vast majority of feminine boys have a strong
affiliation with girls as playmates. Indeed, some have genuinely close friendships with
girls, and only a minority have no close friendships with children of either sex (Coates,
1990; Zucker & Bradley, 1995). In general, children who engage only or primarily in
cross-sex friendships have been found to be less popular and socially competent than
those who have same-sex friendships. Importantly, though, they tend to be more popular
and socially competent than are those with no friends at all (Kovacs, Parker, & Hoffman,
1996; Sroufe et al., 1993).
Many gay and lesbian adults recall childhood gender-nonconforming behaviors (e.g.,
Harry, 1982). A common peer problem among youth who do not conform to the gender
norms expected for their sex is victimization. During adolescence, up to 71% of lesbians
and 83% of gay males have reported experiencing high rates of verbal abuse from peers,
and as many as 30% report having been physically assaulted (Pilkington & D'Augelli,
1995; Remafedi, 1987). These rates are considerably higher than the rates of
victimization for boys and girls in the general population in North America, between 10%
and 15% of whom report being victimized by peers (Bartlett, 2000; O'Connell et al.,
1997; Perry, Kusel, & Perry, 1988).
Several researchers have reported a number of characteristics typical of children who
experience peer victimization. In general, victims, particularly boys, tend to be physically
weaker than their peers, poor at sports, and afraid of getting hurt (Boulton & Smith, 1994;
Lagerspetz, Bjorkqvist, Berts, & King, 1982; Olweus, 1993). Both male and female
victims tend to be anxious, sensitive, withdrawn, and are often unhappy or depressed
(Boivin, Hymel, & Bukowski, 1995; Craig, 1996; Olweus, 1993; Slee, 1995).
Interestingly, this characterization of a typical victim is similar to that of a child with
GID. Children, particularly boys, with GID, tend to be less athletically competent than
their peers, and are often afraid of being hurt, therefore avoiding rough and tumble play
(Bates, Bentler, & Thompson, 1979; Green, 1976; Zucker, 1990). Additionally, as will be
discussed, they may display internalizing problems, such as anxiety and depressive
symptomatology (Coates & Person, 1985; Zucker, Bradley, & Lowry Sullivan, 1996).
The overall characterization of children with GID seems, then, with the exception of the
gender identity issue itself, to be strikingly consistent with the profile of other children
who experience peer rejection and victimization. It would be of empirical interest to
determine the extent to which children with GID experience victimization compared to
children who are victimized because of other types of "nonconformity." Research has
shown that, in general, children's nonconformity to group norms is associated with peer
rejection (Boivin, Dodge, & Coie, 1995; Wright, Giammarino, & Parad, 1986). Some
types of nonconformity also appear to be associated with victimization by peers. Higher
than usual rates of victimization have been found among children who, compared to
controls, are considered less attractive, have more odd mannerisms (Lowenstein, 1978),
and higher body weight (Lagerspetz et al., 1982; Williams, 1999), as well as those who
have learning difficulties (Andison & LeMare, 1999; Martlew & Hodson, 1991;
Thompson, Whitney, & Smith, 1994) and physical disabilities (Lowenstein, 1978; Yude,
Goodman, & McConachie, 1998). Thus, it appears that, like children with GID, children

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