Gender and Sexual Disorders 475
What Is Gender Identity Disorder?
Like Sam, a small percentage of people who are born one sex (either a biological
female or a biological male) do not feel comfortable with their corresponding gender
identity. Gender identity is the subjective sense of being male or female, as these cat-
egories are defi ned by the person’s culture. For instance, there are people like Sam,
who have normal male sexual anatomy but feel as if they are female. Conversely,
there are people with normal female anatomy who feel as if they are male. For people
with these feelings, their sense of their gender identity does not correspond to their
biological sex, a condition known as cross-gender identifi cation. Such individuals are
said to have a gender identity disorder, a cross-gender identifi cation that leads them
to be chronically uncomfortable with their biological sex. People with
gender identity disorder are sometimes referred to as transsexuals.
People with gender identity disorder usually identify with the oppo-site biological sex in childhood, preferring to dress or play with toys in
ways that are typical of children of the other gender. That is, they wish to
behave in accordance with the gender role of the other sex;gender role
refers to the outward behaviors, attitudes, and traits that a culture deems
masculine or feminine. For instance, gender roles for females often allow
a wider variety of emotions (anger, tears, and fear) to be displayed in
public than do gender roles for males; in contrast, gender roles for males
often allow more overtly aggressive or assertive behaviors than do gen-
der roles for females. An individual with gender identity disorder desires
to adopt the gender role of the opposite sex not because of perceived
cultural advantages of becoming the other sex, but because the opposite
gender role is consistent with the person’s sense of self.
In children, gender identity disorder is not simply “tomboyish-ness” in girls or “sissy” behavior in boys. Rather, gender identity dis-
order refl ects a profound sense of identifying with the other sex, to
the point of denying one’s own sexual organs; moreover, girls with
gender identity disorder report that they don’t want to develop breasts
or menstruate. Most children diagnosed with gender identity disor-
der, however, do not continue to have the disorder into adulthood,
although a sizable number may identify themselves as homosexual
when adults (American Psychiatric Association, 2000; Drummond et
al., 2008; Green, 1987; Zucker, 2005; Zucker & Bradley, 1995). For
instance, studies of boys with gender identity disorder have found that
only 2–12% had gender identity disorder as adults. However, 40–80%
of boys with gender identity disorder reported being bisexual or homo-
sexual in adulthood (the wide range noted here is due, in part, to the
fact that different studies defi ne adult sexuality in different ways); the
number of girls with gender identity disorder in childhood who have
been followed into adulthood is too small to obtain reliable statistics
(Zucker, 2005). Thus, having a diagnosis of gender identity disorder in
childhood is generally a poor predictor of the disorder persisting into
adulthood. Some have criticized the childhood diagnosis as a way to
pathologize early homosexual behavior or interest or a way to label
with a mental illness those who don’t conform to cultural norms of
sex-appropriate behaviors (Hill et al., 2005; Langer & Martin, 2004).
Table 11.1 lists the criteria for gender identity disorder. Amongadolescents and adults, symptoms may include discomfort from liv-
ing publicly as their biological sex. In fact, these individuals may be
preoccupied by the wish to be the other sex. They may take that wish
further and live, at least some of the time, as someone of the other
sex—dressing and behaving accordingly, whether at home or in public.
Some adults with gender identity disorder have medical and surgical
treatments to assume the appearance of the other sex.
Table 11.1 • DSM-IV-TR Diagnostic Criteria
for Gender Identity DisorderA. A strong and persistent cross-gender identifi cation (not merely
a desire for any perceived cultural advantages of being the other
sex). In adolescents and adults, the disturbance is manifested by
symptoms such as a stated desire to be the other sex, frequent
passing as the other sex, desire to live or be treated as the other
sex, or the conviction that he or she has the typical feelings and
reactions of the other sex.
In children, the disturbance is manifested by four (or more) of
the following:
(1) repeatedly stated desire to be, or insistence that the person
is, the other sex
(2) in boys, preference for cross-dressing or simulating female
attire; in girls, insistence on wearing only stereotypical mas-
culine clothing
(3) strong and persistent preferences for cross-sex roles in make-
believe play or persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games and
pastimes of the other sex
(5) strong preference for playmates of the other sex.B. Persistent discomfort with his or her sex or sense of inap-
propriateness in the gender role of that sex. In children, the
disturbance is manifested by any of the following:- In boys, assertion that his penis or testes are disgusting or
will disappear or assertion that it would be better not to have
a penis, or aversion toward rough-and-tumble play and rejec-
tion of male stereotypical toys, games, and activities; - In girls, rejection of urinating in a sitting position, assertion
that she has or will grow a penis, or assertion that she does
not want to grow breasts or menstruate, or marked aversion
toward normative feminine clothing.
In adolescents and adults, the disturbance is manifested
by symptoms such as preoccupation with getting rid of
primary and secondary sex characteristics (such as request for
hormones, surgery, or other procedures to physically alter sexual
characteristics to simulate the other sex) or belief that he or she
was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex
condition [that is, a condition in which the individual has both
male and female physical sexual characteristics].D. The disturbance causes clinically signifi cant distress or
impairment.Source: Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders, Text Revision, Fourth Edition, (Copyright 2000) American
Psychiatric Association.