See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/23498013

On the Natural History of Gender Identity

Disorder in Children
Article in Journal of the American Academy of Child and Adolescent Psychiatry January 2009
Impact Factor: 7.26 DOI: 10.1097/CHI.0b013e31818960cf Source: PubMed

CITATIONS

READS

26

76

1 author:
Kenneth J. Zucker
University of Toronto
220 PUBLICATIONS 7,080 CITATIONS
SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate,

letting you access and read them immediately.

Available from: Kenneth J. Zucker

Retrieved on: 07 June 2016

EDITORIAL

On the BNatural History^ of Gender Identity

Disorder in Children
KENNETH J. ZUCKER, PH.D.

We are now approaching the 50th Banniversary[ of the

seminal paper on young children with gender identity
problems by Green and Money.1 Because there are not
a lot of research clinicians working in this specialty area of
developmental psychiatry and clinical psychology, advances
in knowledge have come slowly. Over time, however, we have
learned a fair bit about phenomenology, assessment and
diagnosis, identification of associated behavioral problems,
and exploration of etiological hypotheses.2,3
In the past few years, gender identity disorder (GID) in
children and adolescents has elicited remarkable attention in
the mass media. No longer confined to the clinic and the
peer-reviewed journal, GID in children and adolescents has
Bcome out of the closet.[ For example, in the 1999 film Boys
Dont Cry, Hilary Swank won an Academy Award for her role
as Brandon Teena. Teena (born Teena Brandon), a female-tomale transsexual from Nebraska, was raped and subsequently
murdered in 1993 at the age of 21 after two of his male friends
discovered that he was a biological female. There have been
articles on GID in Time,4 Saturday Night,5 and the New York
Times6 (for the outbreak, try Googling the term). On May 12,
2004, The Oprah Winfrey Show, which attracts at least
20 million daily viewers in the United States alone, featured
several Btransgendered[ children and their parents, and on
April 27, 2007, ABCs 20/20 broadcast a similar show hosted
by Barbara Walters. Talk about an Bimpact factor[! In this
new cultural context of mass media coverage, the article in this
issue of the Journal by Wallien and Cohen-Kettenis7 provides
important new information on the Bnatural history[ of GID
by providing follow-up data in adolescence on a cohort of
77 children originally assessed at a mean age of 8.4 years.

Accepted July 15, 2008.

Dr. Zucker is with the Centre for Addiction and Mental Health, Toronto,
Ontario, Canada.
Correspondence to Dr. Kenneth J. Zucker, Gender Identity Service, Child,
Youth, and Family Program, Centre for Addiction and Mental Health, 250
College Street, Toronto, Ontario M5T 1R8, Canada; e-mail: Ken_Zucker@
camh.net.
0890-8567/08/4712-13612008 by the American Academy of Child and
Adult Psychiatry.
DOI: 10.1097/CHI.0b013e31818960cf

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 47:12, DECEMBER 2008

The study by Wallien and Cohen-Kettenis7 needs to be

contextualized in this specialty areas small history. In the
1960s, when the phenomenon of transsexualism (a term that
preceded the use of the GID acronym) in adults started to
attract clinical attention, a number of medical centers in the
United States and elsewhere established specialty clinics for
these patients to provide recommendations and guidelines for
the advisability of hormonal and surgical sex reassignment. At
the time, an important part of the patients narrative history
was that the origins of their gender dysphoria (the felt sense of
incongruity between ones gender identity and birth sex) was
said to have begun in early childhood. In the 1960s, a team
led by Robert Stoller8 and Richard Green9 at the University of
CaliforniaYLos Angeles began to study prospectively a group
of behaviorally feminine boys. At the time, it was thought that
this cohort of boys was showing signs of transsexualism in
statu nascendi.
As it turns out, the story proved to be more complicated.
In Greens long-term follow-up of behaviorally feminine
boys, a transsexual outcome was rare: only 1 of the 44
feminine boys seen at a mean follow-up age of 18.9 years was
judged to be persistently gender dysphoric.10 The remainder
apparently no longer desired to be female and were, more or
less, content with a male gender identity. If these boys were
indeed gender dysphoric in childhood, for the majority, the
gender dysphoria apparently disappeared without a trace. So
much for the convergence between retrospective and
prospective data.
In terms of long-term psychosexual differentiation,
Greens follow-up study showed something else. Depending
on the metric (fantasy or behavior), 75% to 80% of the
feminine boys differentiated either a bisexual or a homosexual
sexual orientation in contrast to a 0% to 4% rate in a control
group of boys unselected for their degree of childhood
masculinity or femininity.10 Thus, the pervasive pattern of
feminine behaviors (consistent with the DSM criteria for
GID) was much more predictive of a later sexual orientation
than a cross-gender identity and, on this point, closely
matched patterns of sex-typed behavior from childhood
recalled by gay men and lesbian women.11
Since Greens follow-up study was published more than
20 years ago, some new data on long-term follow-up have

WWW.JAACAP.COM

1361

Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

ZUCKER

accumulated (for review, see Zucker and Bradley3). In one

recent study, for example, Drummond et al.12 reported data
on 25 girls with GID assessed at a mean age of 9 years (range
3Y12 years) and followed up at a mean age of 23 years (range
15Y36 years). Of these 25 girls, only 3 (12%) were judged to
have persistent gender dysphoria; the remainder were judged
to have a female-typical gender identity. Depending on the
metric (behavior or fantasy), 24% to 32% of the girls
differentiated either a bisexual or a homosexual sexual orientation; in fantasy, the remainder were either heterosexual
(60%) or asexual (8%), and in behavior, 44% were heterosexual, and 32% were asexual.
Wallien and Cohen-Kettenis7 have now provided much
needed additional follow-up data on a sample from the largest
gender clinic for children and adolescents in Western Europe.
As reported in their article, 20% of their boys and 50% of
their girls were judged to be persistently gender dysphoric at
the time of follow-up. Their persistence rate for boys was
comparable to the rate reported on by Zucker and Bradley,3
but the persistence rate for girls was clearly higher than that
reported on by Drummond et al.12
If we take stock of the collective follow-up data to date, it is
now possible to make a few cautious general statements:
persistent gender dysphoria occurs at a rate higher than
originally reported on by Green but still constitutes a
minority outcome. There is variability in long-term sexual
orientation, but for boys, a homosexual sexual orientation is
clearly the most common outcome, whereas for girls, there
seems to be a more equal distribution of homosexual and
heterosexual sexual orientation outcomes. From these data,
then, it is apparent that there is no one Bnatural history[ for
GID in children: some children show a persistence in their
gender dysphoria, whereas a large number show a clear desistance. Some children differentiate into a homosexual
orientation; and others into a heterosexual orientation.
Regarding gender dysphoria, a key empirical question (the
answer to which has important theoretical and clinical
implications) is whether we can predict which children in
the GID spectrum will be Bpersisters[ and which children will
be Bdesisters.[ Wallien and Cohen-Kettenis7 provide some
tantalizing clues: they were able to show that, at the time of
assessment in childhood, their persisters were more likely to
meet the complete DSM-IV diagnostic criteria for GID than
the desisters, and on two-dimensional measures of crossgender behavior and gender dysphoria, the persisters also had
more extreme scores. These findings are suggestive of some
kind of Bdosage[ effect.
The data provided by Wallien and Cohen-Kettenis7 will
surely add to the current conversation that is going on with
regard to Bbest practice[ in clinical management for children
with gender dysphoria.13 At present, there are three general
approaches to therapeutics: one approach actively attempts to

1362

WWW.JAACAP.COM

work with the children and their parents to lessen the gender
dysphoria, on the assumption, perhaps, that this will increase
the rate of desistance; a second approach takes an intermediate positionVthere is no active effort to lessen the
gender dysphoria or cross-gender behaviorVa sort of
Bwatchful waiting[ approach; a third new approach is
predicated on the assumption that the early appearance of
cross-gender behavior is a sign that the child is Btruly[
transgendered. Parents and therapists who adhere to this
model are taking a different interventionist approach from the
first two: both preschool- and school-age children are
encouraged to transition to a cross-gendered role and identity
(e.g., institution of a name change, attendance at school in the
cross-gender role), and if the childs cross-gender identity
persists as puberty approaches, there is the option of pubertyblocking hormonal treatment.
These three therapeutic approaches are informed by a
variety of distinct conceptual and philosophical assumptions
regarding psychosexual differentiation. An interesting and
important empirical question is whether these three
approaches will result in different long-term psychosexual
outcomes for these youngsters. For example, will the rate of
persistence be higher among those parents and therapists who
facilitate an early gender role and gender identity transition
than among those parents and therapists who attempt to
lessen the childhood expression of gender dysphoria? A
second important question is whether these different
therapeutic approaches will result in different or distinct
long-term outcomes with regard to the childs more general
psychosocial and psychiatric adjustment. At present, we do
not know the answers to these questions. To formulate best
practice guidelines for working with children with gender
dysphoria, it is urgent that clinicians and researchers collect
the requisite data.

Disclosure: The author is the chair of the DSM-V Workgroup on Sexual

and Gender Identity Disorders.

REFERENCES
1. Green R, Money J. Incongruous gender role: nongenital manifestations
in prepubertal boys. J Nerv Ment Dis. 1960;131:160Y168.
2. Cohen-Kettenis PT, Pf af f lin F. Transgenderism and Intersexuality in
Childhood and Adolescence: Making Choices. Thousand Oaks, CA: Sage
Publications; 2003.
3. Zucker KJ, Bradley SJ. Gender Identity Disorder and Psychosexual Problems
in Children and Adolescents. New York: Guilford Press; 1995.
4. Cloud J. His name is Aurora. Time. September 25, 2000:90Y91.
5. Bauer G. Gender bender. Saturday Night. 2002;117:60Y62, 64.
6. Brown PL. Supporting boys or girls when the line isnt clear. New York
Times. December 2, 2006:A1, A11.

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 47:12, DECEMBER 2008

Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

EDITORIAL

7. Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender

dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47:
1413Y1423.
8. Stoller RJ. Male childhood transsexualism. J Am Acad Child Psychiatry.
1968;7:193Y209.
9. Green R. Sexual Identity Conflict in Children and Adults. New York: Basic
Books; 1974.
10. Green R. The BSissy Boy Syndrome[ and the Development of Homosexuality.
New Haven: Yale University Press; 1987.

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 47:12, DECEMBER 2008

11. Bailey JM, Zucker KJ. Childhood sex-typed behavior and sexual
orientation: a conceptual analysis and quantitative review. Dev Psychol.
1995;31:43Y55.
12. Drummond KD, Bradley SJ, Badali-Peterson M, Zucker KJ. A followup study of girls with gender identity disorder. Dev Psychol. 2008;44:
34Y45.
13. Zucker KJ. Children with gender identity disorder: is there a best practice? [Enfants avec troubles de lidentite sexuee: y-a-t-il une pratique la
meilleure?]. Neuropsychiatr Enfance Adolesc. 2008;56:358Y364.

WWW.JAACAP.COM

1363

Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.