EDITORIAL

JOURNAL

VOLUM

Gender Identity: On Being Versus WishingPeter T. Daniolos, M.D.

ender evokes strong images in most ofus, because it is deeply rooted in our

G experience of being male or female and

our assumptions of what each of those categoriesentails. Pink is for girls, blue is for boys. How-ever, in the early part of the 20th century, boysroutinely wore the “stronger” color pink andgirls wore the “dainty” color blue.1 As MarjorieGarber noted,1 gender often provokes strong re-actions when the bearer of a gender “dares” tocross the line into another gendered expressiondiffering from the natal phenotype. Our angst isonly amplified when the individual in questionhappens to be a child.

It takes articles such as the one by Steensmaet al. in this issue of the Journal to help shed light onbiases when it comes to gender-nonconformingyouth—including youth who aim to transition tothe other gender and children who simply reso-nate with aspects of the other gender rather than“being” the other gender.2 The authors definegender dysphoria (GD) as “a sense of discomfortfrom incongruence between their gender iden-tity and assigned sex.” This article provides aresearch-based clinical foundation so that pro-viders are better poised to facilitate gender tran-sitioning when appropriate or help a child bettersettle into his or her experience of gender withoutforeclosing exploration or erroneously presumingthat the child is transgendered. This study doesmuch to further our state of knowledge when itcomes to GD youth by looking more carefully atfactors differentiating those whose struggle withaspects of gender is less rooted in their core genderidentity and who in time are able to “settle” intotheir natal gender (known as gender “desisters”)from those who truly are “transgendered” and ona life course of transitioning from their natalgender (“persisters” in gendered language).

The authors illuminate core issues that pre-dict the persistence of GD, including a linkbetween the intensity of GD in childhood anda higher probability of persistence for natal

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girls. Psychological functioning was not foundto be linked. Among the most fascinatingfindings of this article was the association ofcognitive and/or affective cross-gender identi-fication and social role transition with thepersistence of childhood GD and how thesefactors varied between boys and girls.

This article is user-friendly and transparent,facilitated by the authors’ careful review of thestudy aims and the process of their investigation,including possible confounding variables such asthe strongly supportive climate in Amsterdamregarding gender-nonconforming youth poten-tially biasing the sample by shifting their studypatient population to one with more acute GD,because milder cases likely would not be re-ferred to a specialty center. The study design isstrengthened by the use of in-depth psychodiag-nostic individual and combined child and parentinterviews to determine whether the criteria forGD are met and to evaluate the functioning of thechild and family, rather then simply relying onquestionnaires. The quality and range of ques-tionnaire instruments are impressive, providinga triangulation of data. One possible issue is thatthe authors “assumed that for the 80 adolescents. who did not return to the clinic, that theirgender dysphoric feelings had desisted, and thatthey no longer had a desire for gender reassign-ment. .” They based this on the fact that theirclinic is the only specialized gender identityservice in the country. They did, however, getback 46 questionnaires from the presumed 80desister adolescents, with an additional 6 allow-ing their parent to fill out the questionnaires,leaving 28 as nonresponders.

The authors astutely advise the reader thatmost children with GD eventually settle into theirnatal sex and do not experience GD into adoles-cence or adulthood. However, the authors notethat a substantial minority will continue to reportGD (often in conjunction with a pattern of sexualattraction to the same natal gender), hence the

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value of this study in best identifying predictorsof persistence and desistence of GD to betterfacilitate interventions. The authors offer a con-cise and thorough review of seminal studiesrelated to the desistance and persistence ofchildhood GD and comment on similarities withthis study. They highlight that prior research hassuggested that gender outcomes are most closelylinked to the intensity of GD in childhood, theamount of cross-gendered behaviors, and pos-sible differences in the way each youth experi-ences his or her gender, i.e., persisters believingthat they were the other sex versus desisterswishing that they were the other sex linked toa desired gender role, with the latter identifyingas a “girlish boy or boyish girl.”2 The authors ofthis prior study3 explored bodily discomfort,finding that “persisters indicated that their dis-comfort originated from the felt incongruencebetween their bodies and their gender identity,whereas the desisters indicated that the discom-fort was more likely to be a result of the wish foranother body in order to fulfill the desired socialgender role.” The authors do wonder if thereports of greater cognitive cross-gender identi-fication in persisters in this study are evidence ofSteensma et al.’s previous finding of persistersbelieving that they were the other sex.3 Theauthors astutely advise clinicians to explicitly askchildren with GD with which sex they identifyas a helpful tool in predicting future genderoutcomes.

Most demographic and developmental char-acteristics were not associated with the persis-tence of GD, thus helping put to rest assumptionsthat early adversity and psychopathology lead tolater gender identity confusion. Age and natal sexemerged as the only significant demographicpredictors, with older children with GD beingmore likely to be persisters (in keeping with priorstudies) and the unique finding of girls beingmore likely to be persisters than younger childrenand boys. Another fascinating and significantfinding was that boys and girls seem to followdistinct paths toward gender consolidationowing to previously unstudied factors of cogni-tive and/or affective cross-gender identificationand a social role transition. I would have appre-ciated an expanded discussion of hypotheses asto why the cognitive gender identity confusionresponses to the Gender Identity Interview forChildren were the strongest predictor for natalmale and female children, whereas the affectiveresponses to the Gender Identity Interview for

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Children were significant predictors only for thenatal female children. The authors do later elab-orate that, for natal girls especially, it is crucial tointerview them directly about their gender expe-rience rather than relying on parent interviews,because parent reports are of less value in pre-dicting future persistence of GD in girls versusboys. I wonder if there could be a connectionbetween this and the affect-based factors thatappear to play a larger role in a natal girl’s genderdevelopment, which may be less apparent toa parent than cognitive factors.

Another finding was the impact of childhoodgender social role transition on GD and genderoutcomes. The authors engage in an examinationand discussion of this increasingly commonphenomenon of children transitioning into thedesired gender, sometimes before seeking evalu-ation in a gender program. Boys in this studywho had undergone early social role transitionpresented as having higher levels of GD. In fact,social role transition accounted for the largestportion of the variability in the persistence of GDin boys. A chicken-and-egg discussion ensues asto whether this simply reflects greater innateearly GD leading to the early gender transitionversus the more ominous possibility that thetransition process itself may heighten GD,leading to later complications if the child desiresto return to the natal gender. This is a highlythought-provoking question with deep clinicalramifications, because prior studies have foundthat most gender-nonconforming and GD chil-dren eventually settle into their natal gender witha homosexual or bisexual orientation, with theGD subsiding.3

In summary, this study supports the linkbetween the intensity of GD in childhood andthe persistence of GD and the higher likelihoodof natal GD persisting in girls versus boys, witha complex interaction between cognitive andaffective gender identity variables. The authors’multivariate model found that factors linked topresentation and persistence of GD were dif-ferent between natal sexes, highlighting theimportance of paying special attention to girls’own affective experience of gender rather thanrelying on parent interviews, which tended tonot be predictive of gender course, at least forgirls. Likewise, this study reminds clinicians ofthe wisdom of determining each child’s cogni-tive and/or affective experience of his or hergender by teasing out whether the child believesversus wishes that he or she were the other sex

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EDITORIAL

as helpful tools for predicting future genderoutcomes and guiding interventions. Theauthors appropriately remind us that our clin-ical recommendations need to be different fornatal boys versus girls and tailor made to thelife course of each child. Clinicians need toattend to family dynamics, because a family’sresponse to a child’s GD may shape that child’scognitive and/or affective representation of hisor her gender. This study also sheds light on thepossible impact of early childhood gender roletransition on GD persistence, especially in boys,including potential influences on the develop-ment of identity. Such a social transition mayshape future persistence of GD by affecting thecognitive self-representation of gender identityand making persistence more likely. Theauthors point out that a consequence of thisincreasingly common outcome could be a largerproportion of youth needing to transition backto their natal gender role owing to desisting

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GD. The authors call for future studies toaddress this unexamined domain and supportcurrent World Professional Association forTransgender Health guidelines that call forcautious and thoughtful approaches when work-ing with children and their families strugglingwith gender, because of the potential impact ofearly childhood transitioning on ultimate genderidentity outcomes. &

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Accepted March 27, 2013.

Dr. Daniolos is with the University of Iowa Children’s Hospital.

Disclosure: Dr. Daniolos reports no biomedical financial interests orpotential conflicts of interest.

Correspondence to Peter T. Daniolos, M.D., Associate Professor,Child and Adolescent Psychiatry, University of Iowa Children’sHospital, 200 Hawkins Drive, 1882 John Pappajohn Pavillion, IowaCity, IA 52242; e-mail: peter-daniolos@uiowa.edu

0890-8567/$36.00/ª2013 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2013.03.014

REFERENCES

1. Garber M. Vested Interests: Cross Dressing and Cultural Anxiety.

New York: Harper Perennial; 1997.2. Steensma TD, McGuire J, Kreukels B, Beekman A, Cohen-

Kettenis PT. Factors associated with desistence and persistenceof childhood gender dysphoria: a quantitative follow-up

study. J Am Acad Child Adolesc Psychiatry. 2013;52:582-590.

3. Steensma TD, Biemond R, De Boer F, Cohen-Kettenis PT. Desistingand persisting gender dysphoria after childhood: a qualitativefollow-up study. Clin Child Psychol Psychiatry. 2011;16:499-516.

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