October 28, 2008 1 Comment
Kelley Winters, Ph.D.
GID Reform Advocates
Jazz, a beautiful seven year old girl with long brown hair and poise beyond her years, explained gender diversity from her porch swing in a YouTube video this summer:
“If someone asks me why I used to be a boy and now I’m a girl, I would say that I have a girl brain and a boy body. I think like a girl, but I just have a boy body and it’s different than you.” 
The American Psychiatric Association might learn a lot from this young girl. Last year, Jazz and her family appeared with Barbara Walters in the television news magazine 20/20. They shared how painful her assigned birth-role had been for her until her family acknowledged her feminine identity at age five and created safe space for Jazz to be herself. They shared how her distress was relieved with transition to a female social role and how she has thrived since.
It is important to note that for preadolescent children, transition refers to a change in social gender role and not medical or surgical intervention. The earliest medical treatments, if needed, would come later at initial stages of puberty. According to endocrinologist Norman Spack, hormone blockers called GnRH analogues may be prescribed to delay onset of unwanted puberty and avoid resulting emotional trauma as well as “the physically and psychologically painful procedures required to reverse puberty’s physical manifestations.” 
In the context of children, transition is not an assignment by parents or clinicians. Transition means simply creating an environment where gender variant or transcendent  children may safely define their own roles that are congruent with their inner sense of gender identity. These roles may be stereotypically masculine, feminine or uniquely in between and may include self-expression in clothing and mannerisms and identification in name and pronouns. However, the APA labels all youth who transition their social gender roles as mentally disordered in the Diagnostic and Statistical Manual of Mental Disorders, ed. IV-TR (DSM),  regardless of how happy and well they are in their new roles. Many of the barriers these youth face in school and society are exacerbated by these psychiatric labels. In the Byzantine nomenclature of the current Gender Identity Disorder in Children (GIDC) diagnosis, gender transcendent children should be closeted and not seen nor heard.
In fact, gender role transition itself is misconstrued as symptomatic of psychosexual illness in the diagnostic criteria for GIDC. Of the four criteria for diagnosis,  the first is intended to address gender identity and is the most confusing and controversial:
Criterion A for Gender Identity Disorder in Children:
A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being 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 he or she is, the other sex
2. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine 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 preferences for playmates of the other sex
Of the five characteristics of criterion A, only the first has anything to do with gender identity and it is not required for diagnosis. The remaining four are based strictly on nonconformity to social birth-sex stereotypes, and only four of the five characteristics are required. Thus, a child may be diagnosed with Gender Identity Disorder without evidence of gender identity that is incongruent with natal sex — without ever stating any desire to be the “other sex.”
The last four characteristics pathologize as mental illness and sexual disorder behaviors and self-expression that would be considered ordinary for other children. In the supporting text of the GIDC diagnosis, these are described to include playing with Barbie dolls, homemaking and nurturing role play for birth-assigned males and aversion to cars, trucks, competitive sports and so-called “rough and tumble” play. For birth-assigned females, pathology is implied by playing Batman or Superman, competitive contact sports, and aversion to dolls or wearing dresses. Criterion A serves a punitive role in enforcing these dated, narrow and sexist gender stereotypes for children, upon penalty of diagnosis of mental disorder. The fifth characteristic, a “strong preference for playmates of the other sex” seems to equate mental health with sexual discrimination. 
In criterion A, birth-assigned males are inexplicably held to a much stricter standard of conformity than birth-assigned females in their choice of clothing and activities. A simple preference for cross-dressing or “simulating” female attire meets the diagnostic criterion for the former but not for the latter, who must insist on wearing only male clothing to merit diagnosis. In modern Western culture where children’s clothing is often unisex and gender roles are as political as social, terms like “stereotypical” or “normative” clothing seem archaic. 
In criterion A, “other sex,” “cross-sex,” and “cross-dressing,” are defined with respect to assigned birth sex with no clarification regarding current affirmed gender role. This is evidenced in the criterion and supporting text, where children are always termed by birth-sex pronouns, regardless of transition status. For example, an affirmed transitioned girl, such as Jazz, is maligned as a “boy” and “he” in the DSM. There is no exit from diagnosis for her or other transitioned youth who are happy and well adjusted in their affirmed gender roles; they will permanently meet criterion A as it is currently written.
Criterion B for Gender Identity Disorder in Children:
Persistent discomfort with his or her sex or sense of inappropriateness 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 rejection 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.
The second diagnostic criterion is intended to embody gender dysphoria, coined by Dr. Norman Fisk in 1973,  but profoundly misses its mark. From a Greek root for distress, gender dysphoria is defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role.  While a dated definition of gender dysphoria remains in the DSM-IV-TR glossary,  its meaning in the current criterion B is far less clear than in previous editions.
“Discomfort” and “inappropriateness” seem euphemistic in describing the intense and often debilitating distress that many children experience with their anatomy or assigned birth-sex role. While the criterion describes elements of anatomic dysphoria,  it lacks clarity for distress with anticipated physical sex characteristics for preadolescent birth-assigned males, such as facial hair, voice change and upper body musculature. Most troubling, criterion B substitutes nonconformity to gender stereotypes for clear distress with assigned birth-sex role. The phrases following the “or” in the sentences for “boys” and “girls,” which include “rough-and-tumble play” and “normative feminine clothing,” make criterion B redundant to criterion A. For example, children who are profoundly distressed by their birth-sex assignment and corresponding names and pronouns are not clearly described in criterion B, while gender nonconforming youth with no clear evidence of anatomic dysphoria or distress with their birth-sex may be falsely implicated. Like the first criterion, there is no exit for children whose gender dysphoria has been relieved by social role transition. Transitioned youth would permanently meet criterion B as it is currently written, even more so than before transition.
Criterion C for Gender Identity Disorder in Children:
The disturbance is not concurrent with a physical intersex condition.
The DSM-IV Subcommittee on Gender Identity Disorders recommended at one point that individuals born with anatomical or chromosomal intersex conditions be included in the GID diagnoses for adults, adolescents and children,  as did previous editions of the DSM. However, the final decision was to exclude them from GID diagnosis and recommend diagnosis of Gender Identity Disorder Not Otherwise Specified. 
Criterion D for Gender Identity Disorder in Children:
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
A significant change in the 1994 DSM-IV from prior editions was the addition of a clinical significance criterion to most diagnostic categories. Its purpose was to establish a definition of mental disorder and limit false positive diagnosis of those who do not meet that definition.  This policy change was controversial within mental health professions  and was particularly opposed by some members of the DSM-IV Subcommittee on Gender Identity Disorders. In an article on the Transvestic Fetishism diagnosis, Dr. Kenneth Zucker, chair of the present DSM-V Sexual and Gender Identity Disorders work group and Dr. Raymond Blanchard, chair of the DSM-V paraphilias subcommittee, dismissed the clinical significance criterion as “muddled” and having “little import.”  This view seems to conflict with that of Dr. Darrel Regier, Vice Chair of the DSM-V Task Force:
“We do not consider something a disorder unless there is a clearly defined description of this entity and there is clearly some significant dysfunction and distress associated with it,” 
The central flaw in criterion D for the GID in Children category is that it fails to distinguish distress and impairment caused by gender dysphoria from those resulting from societal prejudice or intolerance. Dr. Zucker notes, “the standard of impairment in children with GID has been their poor same-sex peer relations, with attendant social ostracism.”  Thus, ego-syntonic or self-accepting gender variant children who are victimized by prejudice at school meet criterion D only because of hate from others. Gender variant children with healthy peer relations with children of the same gender identity also meet criterion D, because their friends are not of the same birth-assigned sex. This lack of clarity serves to promote gender-reparative psychotherapies that attempt to change gender identity and repress all gender expression not conforming to birth sex. Zucker continues,
“I hope that the vagaries of the distress/impairment criterion do not dissuade clinicians from providing early therapeutic intervention”
Moreover, Drs. Zucker and Susan Bradley, who chaired the DSM-IV GID Subcommittee, invoked circular logic to cast all children diagnosed with GID as cognitively impaired. They claimed that diagnosed children were more likely to “misclassify their own gender, which … surely must lead to confusion in their social interactions.”  In other words, children who disagree with their birth-assigned roles were presumed impaired by fiat. But are these children actually misclassifying their gender or are they certain of it? Is it more likely that their psychiatric examiners are confused about the true gender of these children?
The current diagnostic criteria for Gender Identity Disorder of Childhood are broadly over-inclusive. They encourage false-positive diagnosis of gender nonconforming children having no significant distress of gender dysphoria, and they encourage diagnosis of mental illness on the basis of victimization from prejudice and intolerance. Authors of the GIDC diagnosis in the DSM-IV acknowledged that nearly 30% of children who did not meet the DSM-III criteria would meet the current criteria in the DSM-IV, based on changes to criterion A alone, using data from the Toronto Centre for Addiction and Mental Health (CAMH), formerly the Clarke Institute of Psychiatry. 
While the American Psychiatric Association has emphasized that the DSM “does not provide treatment recommendations or guidelines,”  the GIDC diagnostic criteria are heavily biased in favor of gender-reparative therapies that attempt to change gender identity and expression differing from birth-sex assignment. Children whose gender variant expression is shamed into the closet by these treatments no longer meet criteria A,B or D, even if they continue to verbalize unhappiness and rejection of their birth-sex assignment. (Criterion C, regarding concurrent intersex conditions, would not be relevant to gender expression or transition status in this example)
Emerging alternatives to gender-reparative interventions have very recently been termed “Gender Identity Actualization” by therapist Reid Vanderburgh.  Sadly, the diagnostic criteria for Gender Identity Disorder in Children contradict these affirming treatment approaches, including social role transition to relieve distress of gender dysphoria. Youth who are happy and well adjusted after transition to affirmed gender roles and who may experience intolerance at school continue to meet criteria A, B and D, even if they are not distressed by their anatomy. In fact they are stereotyped as even more symptomatic of mental disorder, according to these criteria, than before transition.
According to the American Psychiatric Association, the purpose of the DSM includes facilitation of research and communication among clinicians and researchers.  However, the diagnostic criteria for Gender Identity Disorder in Children arguably bias research on the persistence of gender identity in youth. Follow-up studies of gender variant children commonly use GIDC diagnosis to select the study sample and evaluate gender dysphoria or transsexualism later in adolescence or adulthood. [25,26] Since children can meet the DSM-IV criteria for GIDC on the basis of gender role nonconformity with no stated anatomic dysphoria, it follows that rates of persistent dysphoria at follow-up could be under-reported. The actual impact of this error on current published literature is unclear, as follow-up studies still partially rely on data from subjects selected under the DSM-III and III-R. Drs. Zucker, Bradley and others have acknowledged concerns that the DSM-IV criteria for GID of Childhood may “’scoop in’ youngsters who show extreme cross-gender behavior but are not necessarily gender-dysphoric.” For example, Zucker has suggested that,
“Because of the putative conflation of gender identity dysphoria and gender role
behavior, particularly in the Point A criterion, one could argue that reform of the
criteria is called for.” 
With the publication of the DSM-V, there is opportunity to address very serious shortcomings in the diagnosis of Gender Identity Disorder in Children. I hope that the Sexual and Gender Identity Disorders Work Group will clarify distress with physical sex characteristics (including those anticipated at puberty) and distress with birth-sex assignment as the focus of diagnostic nomenclature. I urge the Work Group to remove all references to gender expressions that differ from birth-sex roles from the diagnostic criteria. Expressions that would be ordinary or even exemplary for all other youth do not constitute mental illness in gender variant youth.
Back on Jazz’s porch swing, the seven year old concluded,
“It’s ok to be different because it just matters who you are. It doesn’t matter if you’re different than anybody else. It just matters that you’re having a good time and you like who you are.”
We all might learn a lot from this young girl.
 Jazz, “7yr. old Jazz’s thoughts on being a Transgender Child,” http://www.youtube.com/watch?v=7S5usRgY720
 A. Goldberg and J. Adriano, “’I'm a Girl’ — Understanding Transgender Children,” ABC News 20/20, April 27, 2007, http://abcnews.go.com/2020/story?id=3088298&page=1
 N. Spack, “Transgenderism,” Lahey Clinic Medical Ethics Journal, Fall 2005, http://www.lahey.org/newspubs/publications/ethics/journalfall2005/journal_fall2005_feature.asp
 I define transgender, gender variant and gender transcendent in a broadly inclusive community sense: describing those whose inner sense of gender identity or outer gender expression transcend social gender stereotypes or differ from those associated with assigned birth sex. I use the terms roughly synonymously, although I am coming to prefer gender transcendence for its affirming shade of meaning.
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.
 DSM-IV-TR, 2000, p. 581.
 K. Winters (under pen-name K. Wilson), “The Disparate Classification of Gender and Sexual Orientation in American Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association, Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997, www.priory.com/psych/disparat.htm.
 Winters, 1998.
 Fisk, N. (1973). Gender dysphoria syndrome. (The how, what, and why of a disease). In D. Laub & P. Gandy (Eds.), Proceedings of the second interdisciplinary symposium on gender dysphoria syndrome (pp. 7–14). Palo Alto, CA: Stanford University Press.
 Working definition of Gender dysphoria by Dr. Randall Ehrbar and I following our panel presentations at the 2007 convention of the American Psychological Association.
 DSM-IV-TR, 2000, App. C, p. 823. “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.”
 K. Zucker and S. Bradley, Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, Guilford Press, 1995, pp. 21-22.
 S. Bradley, Ray Blanchard, et al., “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorder,” Archives of Sexual Behavior, Vol. 20, 4, p. 339.
 DSM-IV-TR, 2000, p. 582.
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., 1994, pp.xxi, 7.
 Spitzer R.L., Wakefield J.C. (1999). “DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem?” Am. J. Psychiatry 156:1856-64 http://ajp.psychiatryonline.org/cgi/content/abstract/156/12/1856.
 K. Zucker and R. Blanchard, “Transvestic Fetishism Psychopathology and Theory,” in D. Lays and W. O’Donohue, eds., Sexual Deviance: Theory, Assessment, and Treatment, Guilford, 1997, p. 258.
 B. Alexander, “What’s ‘normal’ sex? Shrinks seek definition,” MSNBC , May 22, 2008, http://www.msnbc.msn.com/id/24664654/.
 K. Zucker, “Commentary on Richardson’s (1996) ‘Setting Limits on Gender Health,’” Harvard Rev Psychiatry, vol 7, 1999, p. 41.
 Zucker & Bradley, 1995, p. 58.
 K. Zucker, R. Green, et al., “Gender Identity Disorder of Childhood: Diagnostic Issues,” in T. Widiger, A. Frances, et al., DSM-IV Sourcebook, Am. Psychiatric Assoc., 1998, p. 511.
 American Psychiatric Association, “APA STATEMENT ON GID AND THE DSM-V, “
 R. Vanderburgh, “Appropriate Therapeutic Care for Families with Pre-Pubescent Transgender/Gender-Dissonant Children,” to be published in Child Adolesc Soc Work J, 2008.
 DSM-IV, 1994, p. xxiii.
 K. Drummond, S. Bradley, M. Peterson-Badali, K. Zucker, “A follow-up study of girls with gender identity disorder,” Developmental Psychology, vol. 44, 1, Jan 2008, p. 34-45.
 Zucker & Bradley, 1995, p. 290-301.
 K. Zucker, “Gender Identity Disorder in Children and Adolescents,” Annu. Rev. Clin. Psychol., vol. 1, 2005. p. 17.9.
Copyright © 2008 Kelley Winters, GID Reform Advocates