Gender Dysphoria in Childhood and Adolescence

The concept of gender may appear to be simple for those who have never thought about the fact that their biologic sex is congruent with their gender identity; however, it is a complex term with complex meanings. It can morph and change over time and can be expressed in an infinite number of ways. For children and adolescents, gender identity can be especially confusing. Historically, the assumption was that a child is born with a set of chromosomes that defined gender identity: XY for boys and XX for girls. These chromosomes were thought to be typically associated with the assigned gender marker, a congruent gender identity, congruent gender role/expression, and an attraction to the opposite sex. But there have always been individuals who have not had fit so neatly into this paradigm. With the recent increase in coverage of gender variance within the media, more children are exposed to the idea that gender is more complex than just boy or girl. For mental health professionals, an understanding of gender development is crucial in treating youth, particularly among those who present with gender dysphoria.

We first aim to help providers have a sense of the difference between assigned sex, gender identity, and gender role and how gender dysphoria affects children and adolescents. It is important to have a common language to discuss the differences and relationships between sex, gender identity, and gender expression. Biologic sex is defined as the set of anatomic and hormonal differences that have historically defined male and female. These are affected by the individual’s genetic makeup. This is different from an individual’s gender identity, which is an individual’s subjective sense of his/her own gender as male, female, or another gender identification. Gender variance is encompassed within gender identity, as it describes any variability in gender identity or gender role. Gender role is the behaviors and roles learned by an individual as determined by the cultural norms. Gender expression is how an individual presents his/her gender through his/her actions, dress, and demeanor, and how those presentations are based on gender norms.

Gender dysphoria is a term created by the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition ( DSM-5 ) to describe the distress that might be present in the context of incongruence between sex assigned at birth and gender identity. There is some controversy around the inclusion of gender dysphoria within the diagnostic manuals, as it may inadvertently pathologize gender variance through its inclusion in this manual. Gender variance is a healthy exploration of the gender spectrum. Although we do not believe that gender variance is pathologic, we know that individuals who experience incongruence between biologic sex and gender identity are forced to face intense minority stress, overtly and covertly, and it is unsurprising that transgender adolescents often have alarmingly high rates of mental health issues, including increased suicidal ideation and suicide attempts. Minority stress is seen systemically through the chronic violence toward transgender and gender nonconforming individuals, high rates of homelessness, underemployment, and poor medical care for these individuals. An individual presenting with gender dysphoria might have symptoms that stem from minority stress or might be independent of minority stress; however, the dysphoria is not the result of the individual’s gender identity itself. In this chapter, we seek to discuss gender variance and how gender identity develops within childhood and also to describe gender dysphoria and treatment associated with it. We will also discuss the important role of parental support as a mediator of outcomes for transgender youth with gender dysphoria.

Development of Gender Identity

The development of gender identity is complex and not the same for every individual. Kohlberg defined developmental stages of gender identity development and posited that children move through these stages and see things as more complex as they age. Through his work he identified that around 2–3 years of age, the construct gender identity becomes apparent. Children in this age have a sense of who they are, but it is not stable. Children aged 4–5 years understand the concept of gender stability that their own gender is stable. Between ages 5–7 years, children begin to understand gender constancy , the concept that everyone’s gender is stable. For some children, this period where gender constancy solidifies is when we begin to see an increase in gender dysphoria, as there is less fluidity in gender cognitively at this period. When children enter puberty, there is also an increase in questioning around gender identity. Because the body begins to change, many children are more aware of the discrepancy between their sex assigned at birth and their gender identity.

Diagnostic Criteria for Gender Dysphoria in Childhood and in Adolescence

The diagnosis of gender dysphoria has a history that is controversial in nature. Distress related to gender identity was first acknowledged in DSM-II in 1968 as sexual deviation, and in children this distress was not addressed until DSM-III . Since then, the diagnosis has morphed in its naming to gender dysphoria rather than gender identity disorder. Although the diagnosis does not fully encapsulate the concept of minority stress, it is important to give this diagnosis when appropriate. DSM-5 defines gender dysphoria in children as incongruence between assigned sex and gender identity and expression that occurs for at least 6 months. It must be accompanied by at least six symptoms (see Table 1.1 ). In adolescents, the criteria for gender dysphoria are the same as for adults and include incongruence between assigned sex and gender identity that occurs for at least 6 months and two accompanying symptoms (see Table 1.1 ).

TABLE 1.1

DSM-5 Criteria for Gender Dysphoria in Children and Adolescents

From AAP. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) . American Psychiatric Pub; 2013; with permission.

Gender Dysphoria in Children	Gender Dysphoria in Adolescents and Adults
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing 3. A strong preference for cross-gender roles in make-believe play or fantasy play 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender 5. A strong preference for playmates of the other gender 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities 7. A strong dislike of one’s sexual anatomy 8. A strong desire for the primary and/or secondary sex characteristics B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning	A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following: 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics, or a desire to prevent the development of the anticipated secondary sex characteristics 3. A strong desire for the primary and secondary sex characteristics of the other gender 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) 5. A strong desire to be treated as the other gender 6. A strong conviction that one has the typical feelings and reactions of the other gender B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Gender Dysphoria in Children

Gender Dysphoria in Adolescents and Adults

A.
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):
- 1.
  A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- 2.
  In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
- 3.
  A strong preference for cross-gender roles in make-believe play or fantasy play
- 4.
  A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
- 5.
  A strong preference for playmates of the other gender
- 6.
  In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
- 7.
  A strong dislike of one’s sexual anatomy
- 8.
  A strong desire for the primary and/or secondary sex characteristics
B.
The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning

A.
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
- 1.
  A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
- 2.
  A strong desire to be rid of one’s primary and/or secondary sex characteristics, or a desire to prevent the development of the anticipated secondary sex characteristics
- 3.
  A strong desire for the primary and secondary sex characteristics of the other gender
- 4.
  A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- 5.
  A strong desire to be treated as the other gender
- 6.
  A strong conviction that one has the typical feelings and reactions of the other gender
B.
The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Epidemiology and Etiology

There are a number of challenges associated with identifying the prevalence of gender nonconforming and transgender youth. Some of these methodological challenges include changes in diagnostic criteria, differences in defining constructs, measurement differences, and the fact that gender identity can be fluid. In Amsterdam, there have been two studies looking at older adolescents and adults identifying that approximately 3%–4.5% report an “ambivalent gender identity” and approximately 1% report an “incongruent gender identity.” In a study specifically assessing children and adolescents rated by their parents using the Child Behavior Checklist (CBCL), approximately 2.5%–5% children were identified as behaving like the other sex and 1%–2% reported “identifying as the other sex.” For adolescents in this sample, approximately 1.1%–3.1% reported an ambivalent gender identity, and 0.2%–0.4% reported a transgender identity. In the most recent samples, approximately 0.7% of adolescents aged 13–17 years identify as transgender. Although these data give us a picture about transgender youth, they do not capture the rates of gender nonconforming youth. The etiologic process of gender identity development is even less clear, and there is not enough literature at this time to understand the biologic and genetic components of gender identity clearly. Gender identity is separate from sex, gender role, and gender expression; therefore it is difficult to understand gender identity’s etiologic mechanisms fully at this time.

When addressing whether these symptoms persist into adulthood, there are a number of prospective studies that report predictors of persistence of a transgender or gender nonconforming identity into adulthood, including intensity of the incongruence between natal sex and gender identity, cognitive identification, age of presentation, and having made a social role transition. Children who persist through puberty are more likely to persist into adulthood, although it is impossible to predict with full certainty the future gender identity for an individual. Children who persist into adulthood might be more likely to say they are the other gender, rather than saying they have a wish to be the other gender, although this is not universally predictive. In addition, adolescents who identify as transgender are more likely to persist in their identity than those who identify as transgender earlier. Further research is needed to be able to determine how to better predict persistent transgender identity to tailor interventions.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here