Gender indentity disorder and related issues under the view of developmental psychopathology


                                                                                                                                                                                            Phan Thieu Xuan Giang, MD


We discuss about some different terms: Sex and gender both are used to talk about masculine or feminine following biology, aweareness of a child about his or her gender is called gender identity. In addition, society describes behaviors and feelings that are suitable for boy and girl and the children must learn these appropriate gender behaviors (Gender role). Finally, sexuality relates to sexual feeling and behavior while sexual orientation refers selection of sexual partner, this could be the same  or different gender.

Gender identity:

At the beginning of cognitive process, gender identity is defined as a recognition of a child about he or she is a member of the gender and does not belong to the other. Stoller (1946) decribed the term “ core gender identity” which refer to development of a “ basic sense of belonging to a gender” that is “ aweareness” of being male or female. At emotional level, feeling of belonging to this gender is valuable, thus the child experiences a comfortable or secure sense from being boy or girl.

Gender role:

Each society describes different behaviors that are appropriate or inappropriate with boy or girl. Children from 2-3 years of age like toys which are consistence with their gender ( eg, truck for boy, doll for girl) and prefer playing with the same gender peers (Maccoby, 1999). In school ages, parents interact  more with the same gender children, boy is encouraged to understand community and indepedency while girl is under much supervision and encouraged to be obedience. Teacher and friend are also influence on children to make them respond to social demands.


Sexualtity in young age children is subtle and difficult to  establish methodology to study. In 2000, Volbert studied about this topic in children, this was a very rare research. Volbert interviewed a sample of 147 children from 2-6 years of age. By age 5, there were no any children who shown knowlegde of sexual behaviors of adult and there were only 03 older children described sexual behaviors openly, one boy who had better knowledge said that he saw these actions in a film.

One research in Netherland in 2000, Standfort and Cohen Kettenis questioned mothers for behaviors that they observed in their children, these included: 352 boys and 319 girls from 0-11 years old.The mothers reported that 97% children touched their own genitals , 60% played “ doctor” game with peers, 50% masturbated, 33% touched the other’s genitals, 21% shown their genitals to others, 13 drawn these organs, 8% talked about sexual activities and 2% imitated sexual behaviors with dolls. Some of these behaviors increased in frequency following the ages of children, some behaviors were more in boys, for example: masturbation, some were more in girls such as: playing with dolls in sexual manners.

 Puberty is signaled  by physiologic maturation, this period lasts from 8-18 years old in girl and 9 ½ to 18 years old in boy ( Conger & Galambos, 1997).

Gender identity disorder:

Diagnosis of gender identity disorder is made when a child feels that he or she is stick in the appearance of opposite gender, the object experiences distress from this feeling. This disorder appears clearly when the child is young (APA). A boy who has this disorder likes games and activities for girl typically. He also wants to be opposite gender, he requires sitting down for urination and often hides his penis (APA,2000). Girl could refuse to wear skirt or refuse to participate in events that expect wearing skirt. She could wear and act like a boy. Girl with gender identity disorder feels that she looks like a boy, she wants to become a boy, even having an idea that she will have a penis. She prefers standing for urination (APA, 2000).

Gender identity disorder (GID) usually appear from 2-4 years of age, and come to visit professionals at school age period. Most children with GID will no longer  showing  their symptoms when they reach adolescent stage. At the last of this period, 75% boys with GID will develop homosexual or bisexual orientation. Most of them view their sexual activies with boy is with opposite sex. It is rare to understand about this process in girl because detailed research has not been performed yet ( APA, 2000). We can recognize GID by these following symptoms:

1)    The object feelings that he or she has incorrect gender in very early age

2)    With some people, it is stable in all life long

3)    It could increase much so that people with GID want to have surgery to change their body features in order to have a life that is similar to wanted gender

The rate in transexuality in male is 1/30.000 and in female is 1/100.000 (APA)

People with GID feel that they have wrong gender, what gender are they attracted to? Most of them said that they are attractive to the same biological gender but they do not admit they are gay ( with male)  because a boy with GID feels that he is girl and a girl with GID feels that she is boy.

Etiology and pathogenesis of GID:

There are many theories but it is difficult to reason all of things by one theory.

Biological mechanisms and theories:

Children with GID don’t have any different body appearance, this could help to rule out endocrine abnormality before birth.

Activity level:

Activity level of boy is higher than girl: researches shown that boys with GID have lower activity level than boys in control group ( Bates et al, 1979; Zucker & Bradley, 1995).

Games contain fighting and aggressive characteristics are more in boys than girls.

Birth weight:

Boy is usually heavier than girl ( Arbuck et at, 1993).

There are many factors that influence birth weight, one of these factors is gender difference in response to Androgen. In a study, girls with congenital adrenal hyperplasia have higher birth weight than girls without the disease (Quazi & Thompson, 1971).


Male is more left-handed than girl.

Genetic factors play a role in determining handedness.

Boys with GID have increased rate of left-handedness significantly compare to control group (Zucker et al, 2001). Male adults with GID are also  more left-handed, male adults with homosexuality are more left-handed as well (Lalumiere, 2000).

Sex ratio in siblings and birth order:

Children with GID have more brothers than sisters, these children usually are latter children. They explain this by immuno response mechanism in mother ( Blachard & Klassen, 1997; Green, 2000).

Physical appearance:

Boys with feminine features usually have beautiful face, eyes and gentle movement. Parents of boys with GID often describe their children as “ beautiful” boys and “ having feminine traits”. Probably, physical appearance contributes to parents’s behaving to their children.

Psychosocial mechanisms and theories:

Gender assignment at birth:

Most children with GID have no physical conditions like intersexuality. In some cases, external sex organs are intersex, ambiguous , gender assignment is late because parents don’t know how to call their children as boy or girl.

One gender preference from parents before birth:

It is realized that in situation of boys with GID,  parents usually dream about having girls in a family that have many boys.

Social reinforcement for cross-gender behaviors:

Mothers of boys with GID often tolerate and encourage female behaviors easily and less encourage male behaviors than mothers in control group. Excessive dreaming about having girl and being not  satisfaction, pathological regret for wanted gender could occur, we may see these following symptoms: severe depression related to having boy at birth, repeated night dream with having female baby in pregnancy, late naming, active wearing girl clothes for boy (Zucker, 1996).

Relationship between child and father:

Boy with GID is much closer to mother, father is not available.

General psychopathology:

Mothers of children with GID usually have psychopathology problems such as depression, OCD, and other psychological problems. With mental disorders, the mothers have no ability to be available, this can lead to worry and insecurity for children, then contribute to onset of the disorder. There are also another factors, for instance: temperament of the child, relationship with mother, position of father in family system.

Sexual orientation:

In the US, there are about 1-2% children in high school determines that they are gay, lesbian or bisexual.

In Vietnam, we have not had any formal research. However, there have been increased information about this topic on media and communication.

In 2001, Savin Williams interviewed the adolescents with minor sexual orientation and described 4 steps:recognition, curiosity and ambivalance, acceptance and integration. After discovering their own sexual orientation, about 20-40% children with minor sexual orientation were refused  or threaten by their family members, 5% having body injury. Many children reported that they lost their peers after opening their sexual orientation.

Minor sexual orientation and related issues:

Adolescents with minor sexual orientation could deal with more stress and other psychopathology problems such as depression and anxiety…, these influence process of personal identity as well as relationships with family and friends.

Some comments for Vietnam:

Talking about sexuality and gender are still new in Vietnam, many people are ashamed because of culture.

Knowledge and experience of working with GID or related problems lack in professionals, there are some wrong counselling for client , for example: need to have sexual hormonal measurement in children or adult with GID!

We need to distinguish between GID and minor sexual orientation, the later is not classified as a disorder in DSM-IV and ICD-10.

In clinical practice, we recognize some cases that parents worry about their young children’s gross-gender behaviors but it is not common.

To adolescent, parents usually bring them to the clinic because of suspecting homosexualiy, most of the cases are boys, parents want to bring them to return to their biological gender.

These children often have another disorders such as: depression, anxiety, sleep disorder, hair pulling (trichotillomania) , difficulty in relationships….the adolescents are also looking for homosexual information on internet , participating in peer group and they want to hide this from their parents.

Adults visit the clinic because of difficulty in relationship , anxiety and depression … They admit that they are homosexual after some therapy sessions.

In therapy, we focus on  stress, depression and anxiety to help the children to overcome these disorders. We need a lot of time to work with parents to help them to understand the children better. Treatment for GID is difficult.

Research direction for Vietnam are: understanding about culture characteristics, parent’s point of view, taboos in talking about sexuality, gender.


1)Abnormal psychology (Jefferey S.Nevid; Spencer A.Rathus; Beverly Greene, 1994)

2)Developmental psychopathology from infancy throught adolescent ( Charles Wenar, Patricia Kerig, 2003)

3)Abnormal Psychology (Micheal L. Rauline, 2003)

4)Child and Adolescent Psychiatry ( Melvin Lewis, 2002)

5)DSM-IV-TR (APA, 2000)

6)Psychodynamic Diagnostic Manual (PDM) ( Alliance of psychoanalytic organizations, 2006)

7)Psychiatry (Oxford core text, Michael Gelder, Richard Mayou, John Geddes, 2003)

8)ICD-10 (WHO, 1992)

9)DC: 0-3 casebook (Alicia Liberman, Serena Wieder, Emily Fenichl,  National Center for Infants, Toddlers and Families, 2003)

10) Current Diagnosis and Treatment in Psychiatry (Michael H. Ebert, Peter T. Loosen, Barry Nurcombe, 2000)