Gender and Sexuality: Gender Dysphoria

Gender and Sexuality: Gender Dysphoria in Children

Gender Dysphoria in Children

Gender is not an absolute or guaranteed condition in the human experience, and even young children can experience some confusion concerning their perceptions of what gender they should be based on powerful family, cultural and social influences. This confused sense of whether "I am a boy" or "I am a girl" can result in subjective distress that is known as gender dysphoria regarding their gender identity. While most adolescents tend to "grow out of" their gender dysphoric state, some continue to experience this dichotomy between their anatomical and mental sense of their gender. This study provides a review of the relevant peer-reviewed, scholarly and reliable online literature to provide an overview of transgendered children in general and gender dysphoric children through puberty in particular. An analysis of three each studies from the varying perspectives of essentialism, environmentalism and constructivism together with an explanation concerning the rationale used by the respective researchers for selecting this theoretical basis is followed by a summary of the research and salient findings in the conclusion. An annotated reference page is also provided.

Review and Analysis

Transgendered Children.

Most social researchers would likely agree that human experience their worlds in unique ways, but almost everyone is influenced by both nature and nurture as they develop over the life course. When some young people experience a gender identity that is at odds with their anatomical sex, it is little wonder that these same researchers would seek to explain such reactions in terms of these influences whether in isolation of each other or in combination with each other. In this regard, Segal (2006) reports that, "Both biological and social explanations of transsexualism are available. Some studies have linked specific physical and psychological characteristics to transsexualism and to other atypical gender identity behaviors" (p. 347). Based on her critical review of the extant body of evidence, Segal concludes that, "Transsexualism is unlikely to be associated with a major gene, but is likely to be associated with multiple genetic, epigenetic, developmental, and experiential influences" (p. 348).

Of those studies that have relied on the strictly biological basis to understand transgendered children, a study by Roughgarden (2004) found that, "Transgender experience begins with the earliest moments of consciousness. Transgender expression emerges early in childhood, along with other indicators of personality, temperament, and inclination. These narratives show that transsexualism begins with gender identity, not sex drive" (p. 265). Societal and family reactions to these young people who appear to be born with this condition, though, are typically less than compassionate. For instance, based on her empirical observations and study of homosexual and transgendered children, the director of the Family Acceptance Project at San Francisco State University, Caitlin Ryan, reports that some of the common reactions of families to children who are identified lesbian, gay or transgendered suggest that the latter condition can evoke the most severe responses on the parts of other family members and peers as well. In a recent interview with Barbara Walters (2007), Ryan and her associates reported the results of their research that found "transgender adolescents are more likely than lesbian, gay and bisexual youth to be rejected by their parents and caregivers, which increases their risk for negative health and mental health outcomes" (Adriano, p. 3).

While some transgendered youths experience verbal abuse and bullying, some are even subjected to outright physical torture and death as a result of their transgendered nature, with some high-profile cases including the 1993 murder of Brandon Teena (the account of which was made into the motion picture, "Boys Don't Cry"), and the murder of 17-year-old Gwen Araujo in 2002 who "was hogtied, strangled and then buried in a shallow grave by a group of teens. Araujo was killed after her attackers learned that she had been born a boy" (Adriano, p. 4). While transgendered children are therefore at risk of experiencing more violent encounters with their peers, many such children also experience rejection by their own family members. In this regard, Adriano quotes Ryan who emphasizes that, "Families reject their transgender children because of deeply held religious beliefs, cultural norms or pressure from other family members. Some forms of rejection, like physical violence, verbal humiliation or throwing your child out on the street, are obvious" (quoted in Adriano at p. 4).

Over time, some transgendered children experience some profound psychosocial reactions to such treatment and frequently seek to live a life of lies in order to avoid such persecution. "In response to pressure for gender conformity, transgendered children put enormous energy into trying to conform to expectations, into being the good son or the perfect daughter, often believing they'll eventually get it right" (p. 264). Likewise, Roughgarden also confirms that, "Transgendered children report violence from other children" (p. 265). Not surprisingly, some transgendered children tend to process these collective experiences in ways that do not provide them with the healthy outcomes they need to live their lives in a fashion that is congruent with their perceived gender, which can result in gender dysphoria and its associated comorbidities, including Asperger's syndrome, eating disorders, depression and even suicide (Cole, O'Boyle, Emory & Meyer, 1997) and these issues are discussed further below.

Essentialism (biological). Many researchers have assumed an essentialist approach to understanding and describing gender dysphoria in recent years, with an increasing number of studies citing the clear indication of the condition's biological origins. In this regard, Ekins and King (1996) describe the origins of the term in the mid-20th century as follows: "The concept of the transsexual and its seemingly clear differentiation from transvestism and other 'conditions' in the 1950s and 1960s began to lose ground somewhat. Early in the decade the term 'gender dysphoria' appeared in the literature and quickly established itself as the dominant term, although transsexualism has continued to be used" (p. 95). Unlike other definitions that change over time as new symptoms are described and treatments identified, Ekins and King suggest that the designation of the condition in this fashion was an important step in emphasizing the biological nature of gender dysphoria. As these authors point out, "This was not just a case of one term beginning to replace another, however. Gender dysphoria was introduced according to its originator, Fisk (1973), to reflect the fact that applications for sex-reassignment came from a variety of persons, by no means all of whom fitted the classic picture of the transsexual" (p. 95). The rationale cited by these researchers for using an essentialist theoretical basis for their study was that "they all shared the fact that they 'were intensely and abidingly uncomfortable in their anatomic and genetic sex and their assigned gender'" (Fisk, 1973, p. 10 quoted in Ekins & King at p. 95).

More recently, Green (2000) studied ten sets of siblings or parent-child pairs concordant for gender identity disorder (e.g., transsexualism) or gender identity disorder and transvestitism to identify possible genetic bases for these conditions. Based on his analyses, Green concludes that there is growing evidence for the genetic basis of gender dysphoria and encourages healthcare professionals to collect genetic samples of such patients to help develop a database that can provide important clues concerning the specific genetic markers that may be involved. In this regard, Green emphasizes that, "Clinicians evaluating and treating gender-identity patients with a positive family history should, with patient's consent, collect and store blood samples for future genetic analyses. Clinicians seeing patients in whose families gender dysphoria cooccurs should contribute to a family research database" (p. 499). Notwithstanding the growing body of evidence in support of and Green's reasoning for the use of a biological basis for his study of gender dysphoria, this researcher also emphasizes the need for additional research to determine any salient environmental factors that may play a role. For instance, the author notes that, "This brief report is intended to stimulate study of families with cooccurring gender dysphoria, transsexualism, or transvestism.... The vignettes do not detail potential social learning or psychodynamic influences on these persons' atypical development. Rather, their reporting here suggests promise for sophisticated genetic studies of such families with the newly emergent techniques of genetic science" (p. 499). Finally, Green suggests the establishment of a universal database can facilitate this research. According to Green, "These cases must be reported in scholarly publications. In consequence of the rarity of transsexualism, a pooling from the various centers worldwide is required to take this attempt to understand the origins of this vexing disorder to the next level" (p. 499).

A study by Coolidge, Thede, and Young (2002) examined the degree to which genetic factors might play a role in gender identification disorder, as well as the prevalence and heritability of the condition. Based on the survey responses from parents of 314 twin pairs, aged 7 to 14 years, these researchers identified a 2.3% prevalence and 62% heritability rate for gender identification disorder in their sample of twins, but identified nonshared environmental effects explained 38% of the variance (Coolidge et al.). These researchers qualified their findings, though, but emphasizing the limited size and highly educated nature of the sample as a delimiter to the generalizability of their findings. In addition, the researcher note that the relatively small sample size in their study did not allow separate genetic analyses for males and females (Coolidge et al.).

Environmentalism (social influence). A recent study by Wallien and Cohen-Kettenis (2008) analyzed psychosexual outcomes of gender-dysphoric children at 16 years and older to determine childhood characteristics related to psychosexual outcomes based on various social influences that may be experienced during the timeframes studied. In this regard, this study began with a cohort of 77 children (mean age=8.4 years, range=5-12 years); at follow-up about 3-1/2 years later, 54 of these children (mean age=18.9 years, range=16-28 years) were still available and amenable to continue participation in the study. Of the original 77 subjects, 54 subjects, or 27% (12 boys and 9 girls), were found to be gender dysphoric (the researchers defined this cohort as the "persistence group"), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric (Wallien & Cohen-Kettenis). The 21 male and female subjects in the persistence group were found to be extremely cross-gendered in both behaviors and feelings; moreover, this group was also more likely to satisfy relevant gender identity disorder (GID) criteria during their childhood years than their counterparts in the other two groups (Wallien & Cohen-Kettenis). These authors conclude that, "At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation" (p. 1413). Based on their analysis, Wallien and Cohen-Kettenis conclude that, "Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality" (Wallien & Cohen-Kettenis, p. 1423).

The findings of a study by Bartlett, Vasey and Bulkowski (2000) suggest that the level of congruence between young people's perception of their gender and the respective role assigned to that gender by society provides support for a social basis for the condition of gender dysphoria in young people. These authors evaluated a series of empirical studies to determine whether gender identity disorder in children satisfied the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV) definitional criteria for mental disorder by analyzing whether gender dysphoria in children is associated with (a) present distress; (b) present disability; - a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (Bartlett et al.). Yet another factor studied by these authors was whether the gender identity disorder was regarded as a dysfunction in the individual or was viewed as deviant behavior or a conflict between the individual and society (Bartlett et al.). The authors conclude that, "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 gender identity disorder" (Bartlett et al., p. 753).

Finally, citing the results of previous studies that have found a combination of hormonal and psychosocial factors as explanations for gender dysphoria, Slijper, Drop, Molenaar, Sabine and Keizer-Schrama (1998) emphasize that there is a probable biological basis for gender dysphoria, but that socialization factors play an important role as well. In this regard, Slijper and his colleagues report that, "It is possible that the conflict between biological and psychological forces can produce stress which, in a genetically vulnerable child who grows up in a family unable to raise the child unambiguously in the assigned sex, results in GID and general psychopathology" (p. 125).

Constructivism (new ideas or concepts based on current/past knowledge). Like many of the authorities reviewed above, researchers who employ a constructivist approach to the study of gender dysphoric individuals typically acknowledge that there are likely other biological and social forces at work as well. In this regard, Sloop (2004) reports that, "For both those who discuss the case publicly from a constructivist position and those who hold that gender is primarily an expression of the body's sex, gender is seen as being successfully or unsuccessfully behaved or expressed through particular clothing, hairstyles, body orientation (notably during urination), and physical activities. It is these activities that make up in large part the reiteration of gender norms" (p. 28).

The purpose of a recent study Deogracias, Johnson, Meyer-Bahlburg, Kessler, Schober and Zucker (2007) was to develop a psychometrically sound dimensional measure of gender identity (gender dysphoria) that could be used with adolescents and adults of both sexes. The authors emphasize the importance of their study of populations of patients with gender identity conflict due to the prevalence of specific comorbid psychiatric conditions, including Asperger's disorder and eating disorders (Deogracias et al.). According to these authors, gender identity and/or core gender identity have been defined as a "person's basic sense of self as a male or female"; noting that a majority of males have a male gender identity and a majority of females have a female gender identity (congruent with their original legal sex and typically founded on the physical appearance of the genitalia at birth), the authors also note that gender identity is frequently conceptualized in "a bipolar, dichotomous manner with a male gender identity at one pole and a female gender identity at the other pole" (Deogracias et al., p. 370). The authors also note, though, that males and females who are experiencing an uncertain or confused gender identity or who are in the process of transitioning from one gender to the other do not satisfy these dichotomous schemata (Deogracias et al.).

Citing the DSM-IV's nosological perspective concerning the determination of whether an individual satisfies the criteria for gender identity disorder or not, Deogracias and his colleagues advise, "Of course, one could create a dimensional measure from the DSM criteria for gender identity disorder by counting, for a particular patient, the number of indicators that are present, but this has not been common practice in either the clinical or research literature" (p. 370). In support of this rationale, the authors point out that when Fisk (1973) originally coined the term, "gender dysphoria," it was clear that this construct could be.".. conceptualized dimensionally and, if appropriately operationalized, would hold great promise in assessing the degree to which an individual is struggling with his or her gender identity (vis-a-vis one's birth sex)" (Deogracias et al., p. 371). The authors conclude that their comparison of the gender-dysphoric males who were either homosexual or heterosexual found that although these two subgroups experienced fundamentally different developmental pathways prior to their gender dysphoria in adolescence and adulthood, the similarity in the self-reported concurrent gender dysphoria by the subjects reinforces the notion of equifinality (i.e., different starting points leading to the same outcome) for these gender-dysphoric youths (Deogracias et al.).

According to Sloop (2004), "The representation of a case as an example of gender constructedness begins when John Money, the physician who carried out John / Joan's reassignment and observed the case for years, writes about it or is quoted by others in its early stages in the mid-to late 1960s" (p. 30). To his credit, the study of human beings, especially young ones, is a challenging enterprise by any measure, but it would seem that Money may have been premature in making some of his assessments concerning the extent to which the constructivist view could explain the snapshots he was glimpsing of this young person's life. For example, Money's initial comments on the case indicate that John/Joan's parents prepared their child for the sexual reassignment by changing his name, the manner in which they dressed him and even his hairstyle. As Sloop points out, "Relying on letters from the child's mother reporting success, Money notes that the effects of these changes helped feminize the child. For Money, signs of this success could be found in the child's 'clear preference for dresses over slacks' and her pride 'in her long hair' (p. 119 quoted in Sloop at p. 31). In addition, Money quotes John/Joan's mother as saying that Joan "just loves to have her hair set; she could sit under the drier all day long to have her hair set" (p. 120 quoted in Sloop at p. 31).

In retrospect, it is little wonder that this case attracted a great deal of attention from the popular press, and Money was not reluctant to share his findings with a rapt national audience. In this regard, Sloop emphasizes that, "Significantly, when Time initially reports on the case, the author employs the statements concerning John/Joan's love of having her hair set and her predilection for 'frilly' clothes as the primary and convincing evidence that the child had successfully become a girl" (quoted on Sloop at p. 31). Over time, Money continued this blow-by-blow account of the successful manner in which John/Joan was making the transformation from a biological male to a female in ways that could be taught, and continues to rely on the child's seeming preference for one type of clothing or hairstyle as proof positive of the success of the gender change. According to Sloop, "When John/Joan reached age five, Money notes, the child preferred 'dresses to pants, enjoyed wearing her hair ribbons, bracelets and frilly blouses, and loved being her daddy's little sweetheart' (p. 97 quoted in Sloop at p. 31). This author suggests that the use of such spurious indicators fails to take into account the wider range of factors and forces at play in gender identification, and points to the strict socialization processes involved as outweighing all others. For instance, Sloop adds that, "In short, taking constructivist positions on gender, Money and those who write about the case from Money's position present the child's use of common gender signifiers as evidence that gender is purely a matter of how one is socialized (in short, 'Because John/Joan likes dresses, she acts/is female')" (quoted in Sloop at p. 31).