Case: A boy who wants to be a girl

September 1, 2008

A 4-year-old boy verbally expresses his desire to be a girl, and wears female clothes. Does he meet clinical criteria for gender identity disorder?

A four-year-old boy who is saying that he wants to be a girl warrants attention. First, it is important to determine if this child meets DSM-IV criteria for gender identity disorder (GID). GID is characterized by a pervasive and persistent wish to be the opposite gender, a stated desire or insistence that one is really a member of the opposite gender, cross-dressing, preference for cross-gender roles in fantasy play, desire to participate in cross-gender games, and preference for playmates of the other gender. The onset of GID is usually between the ages of 2 and 4 years, and boys are referred for clinical evaluation more often than girls.

Although parents often want to have their child tested for chromosomal abnormalities, most children have normal genotypes. The presence of an intersex condition, which may predispose a child to cross-gender behavior patterns, is usually determined earlier.

In this case, the boy fits the clinical picture; he is voicing a wish to be a girl, chooses girls as playmates, and does the things that girls do, including dress in girls' clothes. Four-year-olds who show signs and symptoms consistent with GID are often demanding and insistent on choosing their attire and their friends, but open to negotiation and compromise on certain things such as bathing suits and standing in line. Not all are irritable and inconsolable. This case grows even more complicated as the 4-year-old is beginning to get angry and sad when reprimanded, reminded that he is a boy, and forced to comply with societal mores.

One of the most common questions asked by parents of a boy with GID has to do with future sexual orientation. In fact, boys with GID are more likely than boys without GID to demonstrate a bisexual/ homosexual orientation in adolescence or young adulthood. However, the very few follow-up studies of young children that measure the degree of persistence of active symptoms of GID into adolescence report percentages ranging from 2.2 to 11.9.1 And, most children who meet criteria for GID do not go on to have sexual reassignment surgery in young adulthood.

The "treatment" of children with GID is controversial, and dependent on whether or not the caregiver appreciates GID as a "disorder" or not. A clinician who believes that gender identity and role are biologically determined and not affected by psychosocial or other factors might be unlikely to intervene, but instead support the child in his choices and help the family and child manage the social milieu and potential for ostracism.

On the other hand, clinicians who believe that very young children who voice unhappiness with their gender should be understood against a backdrop of developmental change will suggest any of a number of psychological interventions, including psychodynamic psychotherapy, family work, and behavioral modification.

Unfortunately, there is little data to support the validity of either approach. Choice of path is often determined by the ability of the parents to tolerate the child's statements and behavior patterns, and the availability of therapists willing and able to work with very young children with gender issues of this kind.

I find that, with my own patients, I spend a lot of time exploring the various schools of thought with parents before helping them to access whatever kind of supportive or therapeutic interventions they choose for themselves and for their child. It is not possible or helpful for parents to assume that the developmental trajectory is fixed. Instead, they must be helped to tolerate both the loss of their pre-existing expectations, and a large degree of uncertainty.

Faced with this clinical scenario, the pediatrician should, if possible, refer the patient and his parents to a child psychiatrist for diagnostic evaluation, discussion of therapeutic options, and family work. Working with children with GID and their families demands fairly frequent appointments, close follow-up, and sometimes consultation with school personnel or other adults involved in the care of the child. This preschooler's additional symptoms of "depression," suggestive of an emerging mood disorder, are also potentially quite serious, and will require careful monitoring and possible treatment.

DR. PRAGER is an Assistant Professor of Psychiatry at Harvard Medical School and Director of the Child Psychiatry Emergency Service at the Massachusetts General Hospital, Boston. The author has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Reference

1. Zucker KJ: Gender Identity Disorder. In: Lewis's Child and Adolescent Psychiatry, A Comprehensive Textbook, Fourth Edition, ed. Martin A, Volkmar FR: 2007 Lippincott, Williams & Wilkins, p669