“A child who finds himself rejected and attacked on all sides is not likely to develop dignity and poise as his outstanding traits. On the contrary, he develops defenses. Like a dwarf in a world of menacing giants he cannot fight on equal terms. He is forced to listen to their derision and laughter and submit to their abuse” [1]

I recall wanting to have a doll when I was a prepubescent boy. My parents were concerned that this was not a good sign because, as we all know, dolls are “girl’s toys.” My parents eventually buckled under my persistent requests, and so I received my first doll. It was a girl doll, and although I remember I really wanted a boy, I enjoyed my doll as my sisters had earlier enjoyed theirs. Later as a young teenager, I received a GI Joe doll for Christmas one year, and that toy brought smiles to my face for many playful hours. I always wished it had been anatomically correct, but alas, I needed to wait many more years until I one day discovered a Billy doll – but that is another story.

I am not a transsexual, but I did eventually arrive at defining as gay. As it turns out, this is not an unusual outcome for boys who have cross-gender interests (also know that most gay men do not present as feminine in either appearance or behaviour). Before I review findings in this area, let me provide you some important history and terminology. The term transsexual entered the professional and public lingo in the 1950s. Transsexualism became a diagnosis in the American manual of mental disorders (DSM), third-edition, in 1980, and this term was later changed in DSM-IV (1994) to gender identity disorder (GID). [2]

Most children diagnosed with GID go on to become homosexual adults. In one sample of feminine boys with GID, 75-80% of them were either bisexual or homosexual at follow-up versus 0-4% of the boys in the control group. From six other studies, follow-up reports (13 to 26 years later) of 55 boys with GID, 21 were homosexual, 5 were transsexual, 1 was a transvestite, 15 were heterosexual, and 13 could not be rated for unspecified reasons. [3]

Only a small percentage of children with GID progress to developing transsexualism, which is defined primarily by a persistent desire to be the opposite sex. [4] Part of the reason that explains this finding is that the criteria for diagnosing childhood GID is somewhat different than for diagnosing it in an adolescent or adult. Children receive the diagnosis of GID if they behaviorally present a persistent affinity toward cross-gender interests (e.g., cross-gender play and dress) whereas adolescents or adults need to persistently express a desire to get rid of their biological sex characteristics or to persistently believe that they were born the wrong sex. Nonetheless, it is also true that most boys and girls who also want to change their sex and gender will outgrow this desire. [5]

Interestingly, while homosexuality was being removed from the DSM system (this officially occurred in 1973), gender identity disorder was added. Some researchers have argued that this occurred in response to the removal of homosexuality – in other words, it was a way that clinicians could still give gender-inappropriate children a label and begin treating them as disordered. [6] It is impossible to know if there was indeed conspiracy around this. Regardless, these same researchers suggested DSM should be revised to use the term Atypical Identity Organization instead of GID because of (a) its focus on identity instead of gender-atypical behaviour and (b) because it does not result in a pathological diagnosis. [7]

Far more boys than girls receive a GID diagnosis, ranging from a ratio of 5:1 to 6:1. [8] The cause of this condition is unknown, and researchers – as is typical when they don’t know the cause of something – have suggested it is likely caused by a combination of biological, psychological, and social factors. [9] We also do not know the prevalence of this condition in children, although DSM-IV suggests that the proportion of adult transsexuals might be around 1 in 30,000 males and 1 in 100,000 females. Children with GID often have behavioral problems, difficulties in relationships with peers and parents, and they frequently also suffer from separation anxiety disorder (i.e., a disorder where children become very anxious when not in the presence of their primary caregiver). [10]

Transgendered individuals are not seen as having a mental disorder worldwide. Even in present day Hawaii, the Mahu population reportedly accepts men and women who express the opposite gender identity. Another example includes the Hijras of India, where transgendered individuals are revered by some but tolerated with derision by others. [11]

Children and adolescents experiencing GID are frequently misunderstood by family members, peers, and professionals alike. There are only three specialized child and adolescent gender identity clinics worldwide: one in Amsterdam (recently relocated from Utrecht); one in London, England; and one in Toronto. [12] The rareness of the condition means finding a competent mental health therapist or physician is sometimes difficult. Practitioners and transsexual individuals are well advised to read and study the International Standards of Care. [13]

A great deal of caution is expressed in the published literature about proceeding therapeutically with adolescent transsexuals, despite the deep psychological pain that most experience. Most published articles recommend a four-step process for adolescent transsexuals: (a) a very thorough assessment, possibly followed by psychotherapy if this is indicated; (b) first level of hormone therapy, which is reversible; (c) second level of hormone therapy (many of the changes are not reversible) along with living as the desired gender for a year or more; and (d) sex reassignment surgery (SRS). The international standard is not to embark on SRS until the individual is at least 18 years of age. [14] However, these standards also allow for the first level of hormone therapy to occur as soon as puberty changes begin. The second level of hormone therapy can commence as early as age 16, and those embarking on it should be aware that the maximum physical effect from these hormones may take up to two years of regular administration. [15]

Many transsexual individuals decide not to embark on the full array of surgeries available to them. Some male-to-female transsexuals (MFTs) do not have their genitalia removed, for example, while some female-to-male transsexuals (FMTs) elect not to have male genitalia constructed. In a follow-up study after breast removal in FMTs, 40% were satisfied with the results, 50% were moderately satisfied, and 10% were dissatisfied. The disappointment experienced by some was due to the visibility of scars. Of the MFTs who had vaginoplasty, 60% expressed satisfaction with the look and function of their vaginas. [16]

Dutch researchers followed-up 33 transsexual adolescents, only 22 of whom went on to receive SRS after successfully going through the necessary steps. Twelve of the 22 had started hormone treatment between 16 and 18 years of age. One to five years after surgery, all 22 were functioning well psychologically and socially, and none of them expressed regret in their decision to undergo SRS. [17] These same researchers also argue that unfavorable postoperative outcomes seem mostly related to a late rather than an early start of the SRS procedure. Furthermore, they cite research suggesting that even after years of intensive psychotherapy aimed at altering GID, “permanent gender identity change is, even in the ‘milder’ cases, not always achieved.” [18]

One of the world experts and his colleagues have indicated that a youngster’s struggle with gender identity often increases as homoerotic feelings emerge (most transsexuals are primarily attracted to members of their biological sex). They suggest that internalized homophobia and familial homophobic feelings may increase the desire to change one’s sex. Consequently, they suggest that therapists may assist some GID adolescents by helping them “consider homosexuality as a viable lifestyle,” and that this “may result in the lessening of the desire to change sex.” [19] Research is clearly needed to ascertain whether this makes one iota of difference.

In the meantime, children and adolescents who experience GID continue to be misunderstood and poorly accepted by their peers and often by their families alike. While the gay and lesbian movement has accomplished tremendous advances in the past 35 years or so, the transsexual community – probably because of their small numbers – has not garnered much political clout. Many transsexuals, particularly those in rural regions, end up feeling very isolated and alone.

We must all remember that regardless of etiology, transsexual individuals do not chose to feel the way they do. They deserve our deepest care, concern, and respect. I cannot think of anything more difficult than perpetually feeling that your body betrays how you feel inside. For those of you out there who relate to these words, you have my greatest admiration. It takes great courage to act and to be who you really are.

Dr. Alderson is an assistant professor of counselling psychology at the University of Calgary who specializes in gay and lesbian studies. He also maintains a private practice. He can be contacted by confidential email at alderson@ucalgary.ca, or by confidential voice mail at 605-5234.

1 Allport, 1954, as cited in Wilson, I., Griffin, C., & Wren, B. (2002). The validity of the diagnosis of gender identity disorder (child and adolescent criteria). Clinical Child Psychology and Psychiatry, 7, 335 351 (quote on 343-343).
2 Harry Benjamin International Gender Dysphoria Association. (2001). Standards of care for gender identity disorders (6th ed.). Retrieved November 25, 2005 from http://www.hbigda.org/Documents2/sosv6.pdf
3 Zucker, K. J. (2005). Gender identity disorder in children and adolescents. Annual Review of Clinical Psychology, 1, 467 492.
4 Wilson, Griffin, & Wren (2002).
5 Harry Benjamin International Gender Dysphoria Association (2001).
6 Wilson, Griffin, & Wren (2002).
7 Ibid
8 Di Ceglie, D., Freedman, D., McPherson, S., & Richardson, P. (2002). Children and adolescents referred to a specialist gender identity development service: Clinical features and demographic characteristics. International Journal of Transgenderism, 6, 1 17.
9 Ibid
10 Ibid
11 Wilson, Griffin, & Wren (2002).
12 Zucker (2005).
13 Harry Benjamin International Gender Dysphoria Association (2001).
14 Ibid
15 Ibid
16 Cohen Ketteinis, P. T., & Van Goozen, S. H. M. (1997). Sex reassignment of adolescent transsexuals: A follow up study. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 263 271.
17 Ibid
18 Ibid
19 Zucker, K. J., Owen, A., Bradley, S. J., & Ameeriar, L. (2002). Gender dysphoric children and adolescents: A comparative analysis of demographic characteristics and behavioral problems. Clinical Child Psychology and Psychiatry, 7, 398 411.