Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry

Darryl B. Hill,
 Concordia University,
 Christina Rozanski,
 Hobart and William Smith Colleges
 Jessica Carfagnini,
 and
 Brian Willoughby,
 Concordia University

Report Presented at American Psychiatric Association Symposium

By Darryl B. Hill, et al,  CNSNews.com Information Services, June 11, 2003

(CNSNews.com Editor's Note: The following is an extract of a report presented at a May 19, 2003, symposium sponsored by the American Psychiatric Association entitled)

Abstract

While debates continue as to whether or not a diagnosis of gender identity disorder (GID) is wanted or needed by today's adult transsexual, there is increasing concern both in academic and lay literature regarding the diagnosis of children and adolescents with GID. This paper critically evaluates the diagnosis, assessment and treatment of GID in children and adolescents in light of published controversies, evidence and arguments in social science discourse since the release of the DSM-IV. In the years since GID's first inclusion in the DSM-III, growing criticisms weigh heavily against the diagnosis of GID in children and adolescents. This analysis urges a reconsideration of GID for children and, to a lesser extent, adolescents. In the very least, since this is a highly contentious diagnosis with little established reliability and validity, and problematic assessment and treatment approaches, researchers and clinicians need to establish that GID is validly diagnosed with non-biased assessments and treated effectively in accordance with current standards. Overall, there is deepening discomfort with pathologizing children and youth for extreme gender variance.

Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry

Gender identity disorder (GID) is one of the more recent diagnoses to enter the Diagnostic and Statistical Manual of Mental Disorders (DSM), becoming a diagnosis in 1980 with the DSM-III (American Psychiatric Association, 1980). As it is currently described by the DSM-IV-TR (APA, 2000), GID is based on two main ideas: a strong and persistent cross-gender identification and discomfort about one's assigned sex or gender. In order to be diagnosed with GID, the individual must meet the four criteria listed in Table 1.

The "Diagnostic Features" section, the preamble, describes boys and girls with GID. It specifies that such boys may prefer "traditionally feminine activities," "girls' or women's clothes," and they may reject stereotypical boys' activities in favor of stereotypical girls' toys "such as Barbie" (p. 576). Boys might "insist on sitting to urinate" and insist that he is, or will grow up to be, female (p. 576). Girls diagnosed with GID shun dresses or other "feminine attire" for "boys' clothing and short hair" (p. 576-577). They usually have boys as playmates, enjoy "contact sports, rough-and-tumble play, and traditional boyhood games," and identify with "powerful male figures such as Batman or Superman" (p. 577). A girl with GID may "refuse to urinate in a sitting position," insist that she "has a penis, or will grow a penis," and that "she will grow up to be a man" (p. 577).

While debates continue as to whether or not GID is wanted or needed by today's adult transsexual (an issue not addressed by this paper), there is growing concern both in academic and lay literature regarding GID in children and adolescents. Indeed, this is not a popular diagnosis. Recent published criticisms of GID in psychiatric and psychological journals, as a well as book-length criticisms, target a wide range of problems with the conceptualization, assessment, and treatment of the diagnosis (e.g., Rottnek, 1999). These critiques build upon issues and positions that arose during a controversy in the late 1970s over using behavior modification techniques to alter gender identity in children and adolescents (e.g., Morin & Schultz, 1978; Newman, 1977; Nordyke, Baer, Etzel, & LeBlanc, 1977; Winkler, 1977; Wolfe, 1979). In the last decade, criticism against the GID diagnosis has been mounting. From within psychiatry, critics observe that GID is the only psychiatric diagnosis directly associated with the performance of gender roles (Richardson, 1996), and some even call for the complete removal of GID from the DSM (Isay, 1997).

Furthermore, lay sources have begun questioning the practice of assessing and treating gender non-conforming children and adolescents. Popular books like Gender Shock (Burke, 1996) dramatize the controversial issues involved when treating GID. Most important, this discourse has been significantly invigorated by a wide coalition of transgender activists (e.g., GenderPAC), feminists (e.g., National Organization of Women), gay and lesbian organizations (e.g., National Gay and Lesbian Task Force), and human rights organizations (e.g., Human Rights Campaign) seeking reform of the GID diagnosis (In Your Face, 1999). A webpage, GIDreform.org, dedicated to GID reform tracks developments (see http://www.transgender.org/tg/gidr/ .

This paper critically evaluates the diagnosis, assessment, and treatment of GID in children and adolescents in light of published controversies, evidence, and arguments in social science discourse since the publication of the DSM-IV. The heat has been rising on these debates in recent years, and the case against using the GID diagnosis with children and adolescents is strong. Yet, this discourse is full of twists and turns. Proponents of the diagnosis readily admit fundamental problems with the diagnosis, at least from a scientific point of view. This paper liberally cites such proponents, hopefully without misrepresentation. As responsible scientists, they openly acknowledge the limitations of research on GID. Certainly no one expects that all questions about a disorder need to be answered before any diagnostic or therapeutic efforts, yet proponents persist with the diagnosis and treatment of children and adolescents. Not surprisingly, there is often a moral tone to much of the discourse, reflecting conflicting ideologies and deeply held values, perhaps protecting vested interests or reflecting gender politics. The question facing many is whether to maintain a diagnosis in the face of critical rational scientific argument because it fits with their morals and values, many of which are increasingly out of step with quickly changing views on gender and sexuality in the Western world. And ultimately, the appeal to morals fails to support this diagnosis. For, in a culture that widely supports the equality of the genders, and even (in many jurisdictions) legislates against discrimination on the basis of gender, the best approach is to guide gender choices, but not enforce one gendered way of being on any young person solely because it violates social norms. Thus, those not swayed by the paucity of good science underlying the diagnosis of GID in children and adolescents are often moved by the humanistic arguments against it. There are many issues in this wide-ranging discourse not addressed by this review. This paper focuses on the validity of the criteria used to diagnose GID, the validity and reliability of the diagnosis in clinical practice, the nature of GID, and the rationale for treatment (including the distress of the child and adult consequences of GID).