Rudolph's Pediatrics, 22nd Ed.

CHAPTER 90. Gender Identity and Sexual Behavior

Kenneth J. Zucker


Gender identity has both a cognitive component and an affective component. There is now considerable evidence that by the age of 2 to 4 years, children have a rudimentary cognitive understanding of their gender identity. They are, for example, able to self-label as a boy or as a girl. Although it is normative for children in this age range to self-label correctly, a more sophisticated cognitive understanding of gender is lacking. A girl, for example, who can correctly self-label as a girl might readily declare that she will be a daddy (or even a giraffe) when she grows up. With cognitive maturity, however, children eventually master the notion that gender is an invariant part of the self. Coinciding with a cognitive-developmental understanding of gender, there is a corresponding affective pride in gender identity self-labeling in that children appear to value themselves as being a boy or being a girl, and there is a tendency to overvalue other members of one’s sex and devalue members of the other sex—a type of “in-group vs out-group bias.”1,2

Early in development, it is common for children to hold rather stereotyped views about behaviors that are “appropriate” for boys and for girls. Some theorists argue that this is related to the tight connection that children make between subjective gender identity and surface-related gender role behaviors. Thus, young children will adhere to the notion that “only girls” can wear dresses (dubbed the “pink frilly dresses” phase3) or that “only boys” can become doctors. Over time, greater cognitive flexibility in gender role attributions emerge, although affective behavior preferences might remain strong for culturally defined gender role behaviors.1

The pediatrician is often the first professional that parents might consult regarding the child whose behavior departs from conventional patterns of sex-typed behavior. Developmentally related sexual behaviors emerge at various ages in young boys and girls (Table 90-1). Issues surrounding gender often cause intense anxiety for parents. Are the behaviors in question “only a phase” that the child will outgrow? Or, are the behaviors in question prognostic of longer-term developmental issues? Regarding gender development, parents often want to know if the behaviors of their young child are prognostic of a later homosexual sexual orientation or of transsexualism, the desire to receive contrasex hormonal treatment and physical sex change (eg, in males, penectomy/castration and the surgical creation of a neovagina; in females, mastectomy and the surgical creation of a neophallus). Parents also often worry about the stigma that their child’s pervasive cross-gender behavior might elicit within the peer group and in society at large.

Table 90-1. Developmentally Related Sexual Behaviors

These kinds of questions require a familiarity about the basic mechanisms that underline gender development, which allows the pediatrician to make decisions about differential diagnosis and to consider therapeutic options. A guiding principle is that typical and atypical development are two sides of the same coin: Understanding one side informs an understanding of the other.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains the diagnosis gender identity disorder (GID), with distinct criteria sets for children vs. adolescents/adults (Table 90-2).4 The use of the DSM diagnosis for GID can be helpful in differentiating a gender identity problem from more transient cross-gender behavior patterns, what some clinicians term “gender variance” or “gender nonconforming” behaviors.

The DSM criteria emphasize a pattern of pervasive cross-gender behavior and associated distress with being a boy or being a girl. In a clinical practice with young children, it is probably best to first review with parents (in the child’s absence) the indicators of the GID diagnosis. If warranted, the primary care clinician can refer the parents and child for a more comprehensive psychologic/psychiatric evaluation.5To assist pediatricians in this process, the brief Gender Identity Interview (GII) for Children (Table 90-3) is useful, especially if good rapport can be established with the child.6 The information revealed in this interview may be followed by a consultation with a specialist.

In terms of a differential diagnostic workup, parents commonly ask if there are physical or laboratory tests that can detect an underlying biologic or somatic abnormality. For children who meet the diagnostic criteria for GID, it is rarely the case that there is a co-occurring disorder of sex development (a physical intersex condition): Disorder of sex development is almost always identified during the neonatal or infancy period.7 Thus, it would be highly uncommon to detect abnormal sex chromosomes, and hormonal testing is likely to be noncontributory because circulating sex hormones are so low during early childhood prior to the onset of puberty.

Psychoeducation is an important part of the assessment process. Follow-up studies of children with gender identity disorder (GID) show that a minority will persist into adolescence or adulthood, but for the majority, GID will remit over time.8-10 The most common long-term outcome for boys with GID is the development of a homosexual or gay sexual orientation without co-occurring gender dysphoria (the subjective sense of unhappiness in being a male or a female). For girls with GID, follow-up studies suggest a more variable picture with regard to sexual orientation, but again without co-occurring gender dysphoria.

Table 90-2. DSM-IV-TR Diagnostic Criteria for Gender Identity Disorder

A. 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 4 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 preference for playmates of the other sex

In adolescents, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. 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.

In adolescents, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (eg, request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if (for sexually mature individuals):

Sexually attracted to males

Sexually attracted to females

Sexually attracted to both

Sexually attracted to neither

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000. Reprinted with permission.

Therapeutic approaches to GID in childhood are currently receiving a great deal of debate. Some therapists take an active approach in trying to help the child resolve his or her gender dysphoria, with a variety of interventions, including individual therapy with the child and parent counseling with an emphasis on changes in the day-to-day environment (eg, increased exposure to same-sex playmates, encouragement of alternative activities as replacements for pervasive cross-gender behaviors). Other therapists take an approach that might be characterized as “watchful waiting”: monitoring the child for continued cross-gender behavior, explaining to the child that surface gender-related behaviors can be engaged in by anyone without having to “change” sex, and so on. More recently, some therapists take the position that a young child with a cross-gender identity should be allowed to make a social gender role change on the assumption that the child’s gender identity is fixed, and the child therefore should be allowed to be “who he really is.” These different approaches reflect variation in underlying conceptual and philosophical positions, so it is important for pediatricians to be aware of these different perspectives.11-14


From a developmental perspective, there are two opposing “worldviews” of childhood sexuality. The first view casts the child as an “asexual rookie” to be protected from the sexual disinhibitions of adulthood. This assumption has likely been one of the underlying factors that fueled interest in the topic of sexual abuse or even child-to-child sexual interactions (“sex play”), namely, that premature exposure to sexual experiences (or too much exposure) would abnormally accelerate a child’s sexual development. The other view casts the child as a “sexual veteran” to be protected from the sexual inhibitions of adulthood. This assumption has contributed to interest in those variables that will promote, over time, a more sex-positive developmental outcome. Surely, both views, at least in their extreme, are incorrect, and the developmental approach would argue for some kind of intermediate position; that is, childhood sexuality (knowledge, attitudes, feelings, behaviors) has some kind of developmental form to it, with specific mature end-states to be reached.15,16

Table 90-3. Gender Identity Interview (GII) for Children: An 8-Year Old Boy

Interviewer (I): Are you a boy or a girl?

Child C: A boy.

I: Are you a girl?

C: Boy.

I: When you grow up, will you be a daddy or a mommy?

C: A dad.

I: Could you ever grow up to be a mom?

C: No.

I: Are there any good things about being a boy?

C: Yes.

I: Tell me some of the good things about being a boy.

C: It’s fun. That’s it . . . that’s all I know about boys.

I: Are there any things that you don’t like about being a boy?

C: Yes.

I: Tell me some of the things you don’t like about being a boy.

C: I don’t like the penis. It’s disgusting for me. I don’t like how boys react . . . I don’t like how they play, like they mess up a lot.

I: Do you think it is better to be a boy or a girl?

C: Girl.

I: Why?

C: Because they’re cute. They don’t mess up.

I: In your mind, do you ever think you would like to be a girl?

C: Yes.

I: Can you tell me why?

C: Because they don’t mess up.

I: In your mind, do you ever get mixed up and you’re not really sure if you are a boy or a girl?

C: Yes.

I: Tell me more about that.

C: I don’t like it when I just mess up and stuff.

I: Do you ever feel more like a girl than like a boy?

C: Yes.

I: Tell me more about that.

C: Well, I don’t like how boys react.

I: You know what dreams are, right? Well, when you dream at night, are you ever in the dream?

C: Yes.

I: In your dreams, are you a boy, a girl, or sometimes a boy and sometimes a girl.

C: Girl.

I: Tell me about the dreams in which you’re a girl.

C: Once I was a robber girl . . . it was a nightmare. It was so scary.

I: Do you ever think that you really are a girl?

C: Yes.

I: Tell me more about that.

C: I don’t know . . . always.

An understanding of normal sexual behavior in children must take into account important demographic variables, such as the child’s cultural background, ethnicity, and social class. These variables are likely related to how much exposure children receive regarding basic information about sexuality, including both bodily attributes and behavioral expression.

Body image development includes learning about sexual anatomy and sexual function. Some children learn earlier than others about some of these parameters (eg, genital differences, procreational behavior). Children also develop an interest in learning about the sexual anatomy of other people and develop a gradual understanding of the meaning of physical intimacy. Learning about sexual “structure” and “function” constitutes normative aspects of development, and an interest in sexual conduct should not be considered abnormal or problematic.17-19

For pediatricians, the most important developmental issue concerns the line between normative sexual behavior and sexual behavior associated with adverse psychosocial experiences or difficulties with self-regulation. In this regard, it is important to have a reference about normative sexual behavior during childhood. The Child Sexual Behavior Inventory is a parent-report questionnaire that provides useful guidelines for normative sexual behavior in children.20-25 From this well-normed questionnaire, it is possible to identify behaviors that are age-typical from those that are unusual. Moreover, studies using the CSBI have been successful in establishing its discriminant validity (eg, in showing that sexually abused children have higher scores than clinical control children, who in turn have higher scores than nonclinical controls).26,27 From an assessment point of view, it is important not to view any single “sexualized” behavior as prima facie evidence that a child has, for example, been sexually abused. As an example, although depiction of genitalia in human figure drawings has been shown to be associated with sexual abuse, there are both false positives and false negatives,28,29 so such single markers should be used only as a starting point for a more thorough evaluation.

For children who show markedly sexualized behavior, it is important from an assessment standpoint to understand what drives the behavior; it is likely that multiple factors are involved. Although sexual abuse may be one factor or exposure to adult erotica may be another, it is also likely that other independent factors may be involved, including general problems in self-regulation.30 Psychoeducational or therapeutic interventions can be tailored to address these underlying issues (eg, in the case of sexual abuse, protection of the child; in the case of deficits in behavioral self-regulation, social skills training and perhaps medication targeted at the more general behavioral disinhibition, such as stimulant medication or the class of atypical antipsychotics, such as respiridone.