Gender dysphoria in children
|Gender dysphoria in children|
|Synonyms||Gender identity disorder in children, gender incongruence of childhood|
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Gender dysphoria in children, also known as gender identity disorder in children or gender incongruence of childhood, is a formal diagnosis used by psychologists and physicians to describe children who experience significant discontent (gender dysphoria) with their biological sex, assigned gender, or both.
GIDC was formalized in the third revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 and primarily referenced gender non-conforming behaviors. GIDC remained in the DSM from 1980 to 2013, when it was replaced with the diagnosis of "gender dysphoria" in the fifth revision (DSM-5), in an effort to diminish the stigma attached to gender variance while maintaining a diagnostic route to gender affirming medical interventions such as hormone therapy and surgery.
Controversy surrounding the pathologization and treatment of cross-gender identity and behaviors, particularly in children, has been evident in the literature since the 1980s. Proponents of more widespread GIDC diagnoses argue that therapeutic intervention helps children be more comfortable in their bodies and can prevent adult gender identity disorder. Opponents say that the equivalent therapeutic interventions with gays and lesbians (titled conversion or reparative therapy) have been strongly questioned or declared unethical by the American Psychological Association, American Psychiatric Association, American Association of Social Workers and American Academy of Pediatrics. The World Professional Association for Transgender Health (WPATH) states that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical." Critics also argue that the GIDC diagnosis and associated therapeutic interventions rely on the assumption that an adult transsexual identity is undesirable, challenging this assumption along with the lack of clinical data to support outcomes and efficacy.
Gender dysphoria in children is more heavily linked with adult homosexuality than adult transsexualism. According to limited studies, the majority of children diagnosed with gender dysphoria cease to desire to be the other sex by puberty, with most growing up to identify as gay or lesbian with or without therapeutic intervention.
Children with persistent gender dysphoria are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. Some (but not all) gender diverse / gender independent / gender fluid youth will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormonal and surgical intervention). Treatment may take the form of puberty blockers such as leuprorelin, or cross-sex hormones (i.e., administering estrogen to an assigned male at birth or testosterone to an assigned female at birth), or surgery (i.e., mastectomies, salphingo-oophorectomies/hysterectomy, the creation of a neophallus in female-to-male transsexuals, orchiectomies, breast augmentation, facial feminization surgery, the creation of a neovagina in male-to-female transsexuals), with the aim of bringing one’s physical body in line with their felt gender. The ability to transition (socially and medically) are sometimes needed in the treatment of gender dysphoria.
The Endocrine Society does not recommend endocrine treatment of prepubertal children because clinical experience suggests that GID can be reliably assessed only after the first signs of puberty. It recommends treating transsexual adolescents by suppressing puberty with puberty blockers until age 16 years old, after which cross-sex hormones may be given.
The University of Washington is leading the largest study of transgender youth ever conducted. The study, known as the Transgender Youth Project, looks at 300 transgender kids between the ages of 3 and 12. Researchers hope to follow the children for 20 years.
DSM-IV TR (2000)
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV (TR)) makes a differential diagnosis coding based on current age:
- 302.6 Gender Identity Disorder in Children
- 302.85 Gender Identity Disorder in Adolescents or Adults
The current edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) has five different diagnoses for gender identity disorder, including one for when it manifests during childhood. It is important to note that the diagnoses of gender identity disorder is not given to intersex individuals (those born with "ambiguous" genitalia). Additionally, it is important to note that, as with all psychological disorders, these symptoms must cause direct distress and an impairment of functioning of the individual exhibiting the symptoms (Bradley, Zucker, 1997).
F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.0.
In the DSM of mental disorders used by psychologists in the United States, gender identity disorder is given two sets of criteria. Criterion A indicates that a child identifies as a member of the opposite sex. The child needs to demonstrate four of the five[clarification needed][discuss] following symptoms: dressing as a member of the opposite sex, primarily befriending members of the opposite sex, demonstrating a desire to engage in play activities characteristic of the opposite sex, and actively stating that they wish to be the opposite sex. Criterion B, on the other hand, indicates that the child does not identify with the sex they were born. This could manifest itself as a dislike of styles of dress characteristic of the sex they were born, avoidance of association with members of their born sex, and distress towards the aspects of their physiology which indicate their born gender (Bradley, Zucker, 1997).
DSM-5 (2013) diagnosis of gender dysphoria
In May 2013, the American Psychiatric Association published the DSM-5 in which the GIDC diagnosis was removed and replaced with gender dysphoria, for the first time in its own distinct chapter. Lev states that gender dysphoria places the focus on distress with one's body rather than conformity with societal gender norms, and that this change was accompanied by changes to sexist language and a reduced reliance on binary gender categories. Gender dysphoria reframes the diagnosis as a time-limited distress of the body which is potentially rectified with access to gender transition procedures, rather than a lifetime disorder of the identity.
Therapeutic approaches for GIDC differ from those used on adults and have included behavior therapy, psychodynamic therapy, group therapy, and parent counseling. Proponents of this intervention seek to reduce gender dysphoria, make children more comfortable with their bodies, lessen ostracism, and reduce the child's psychiatric comorbidity. The majority of therapists currently employ these techniques. "Two short term goals have been discussed in the literature: the reduction or elimination of social ostracism and conflict, and the alleviation of underlying or associated psychopathology. Longer term goals have focused on the prevention of transsexualism and/or homosexuality."
Individual therapy with the child seeks to identify and resolve underlying factors, including familial factors; encourage identification by sex assigned at birth; and encourage same-sex friendships. Parent counseling involves setting limits on the child's cross-gender behavior; encouraging gender-neutral or sex-typical activities; examining familial factors; and examining parental factors such as psychopathology. Longtime researchers of gender identity disorder, Kenneth Zucker and Susan Bradley, state that it has been found that boys with gender identity disorder often have mothers who to an extent reinforced behavior more stereotypical of young girls. They also note that children with gender identity disorder tend to come from families where cross-gender role behavior was not explicitly discouraged. However, they also acknowledge that one could view these findings as merely indicative of the fact that parents who were more accepting of their child's cross-gender role behavior are also more likely to bring their children to a clinical psychiatrist as opposed to parents who are less accepting of cross-gender role behavior in their children (Bradley, Zucker, 1997). " Proponents acknowledge limited data on GIDC: "apart from a series of intrasubject behaviour therapy case reports from the 1970s, one will find not a single randomized controlled treatment trial in the literature" (Zucker 2001). Psychiatrist Domenico Di Ceglie opines that for therapeutic intervention, "efficacy is unclear," and psychologist Bernadette Wren says, "There is little evidence, however, that any psychological treatments have much effect in changing gender identity although some treatment centres continue to promote this as an aim (e.g. Zucker, & Bradley, 1995)." Zucker has stated that "the therapist must rely on the 'clinical wisdom' that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions."
The consensus of the World Professional Association for Transgender Health is that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical." Clinicians have called Zucker and Bradley's therapeutic intervention "something disturbingly close to reparative therapy for homosexuals"  and have noted that the goal is preventing transsexualism: "Reparative therapy is believed to reduce the chances of adult GID (i.e., transsexualism) which Zucker and Bradley characterize as undesirable." Edgardo Menvielle, a child-adolescent psychiatrist at the Children's National Medical Center in Washington states, "Therapists who advocate changing gender variant behaviours should be avoided." Developmental and clinical psychologist Diane Ehrensaft told the Psychiatric Times, "The mental health profession has been consistently doing harm to children who are not 'gender normal,' and they need to retrain,"
Author Phyllis Burke wrote, "The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse."  Zucker dismisses Burke's book as "simplistic" and "not particularly illuminating;" and journalist Stephanie Wilkinson said Zucker characterized Burke's book as "the work of a journalist whose views shouldn't be put into the same camp as those of scientists like Richard Green or himself."
Critics argue GIDC was a backdoor maneuver to replace homosexuality in the DSM, and Zucker and Robert Spitzer counter that GIDC inclusion was based on "expert consensus," which is "the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published." Katherine Wilson of GID Reform Advocates stated:
In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier revisions, to the concern of many civil libertarians. A child may be diagnosed with Gender Identity Disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls. Most psychologists who specialize in gender identity disorder in children note a higher level of male patients brought to them, rather than female patients. A possible explanation would be that cross-sex behavior is less acceptable and therefore more noticeable and more likely to be viewed by problematic by the child’s parents (Bradley, Zucker, 1997). preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical" clothing, toys and activities of the other sex are imprecise in an American culture where much children's' clothing is unisex and appropriate sex role is the subject of political debate. Equally puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination and segregation.
Clinicians argue that GIDC "has served to pressurize boys to conform to traditional gender and heterosexual roles." Feder notes that the diagnosis is based on the reactions of others to the child, not the behavior itself. Langer et al. state "Gender atypicality is a social construction that varies over time according to culture and social class and therefore should not be pathologized." Zucker refuted their claims in a response. Critics "contend that it is a precursor of homosexuality, that parents should simply accept it, and that the very diagnosis is based on sexist assumptions."
Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-5 committee on GIDC. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." Zucker is accused by LGBT activists of promoting "gender-conforming therapies in children" and "treating children with GID with an eye toward preventing adult homosexuality or transsexuality." Zucker "rejects the junk-science charge, saying that there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'" However, opponents continue to argue that the diagnosis "harms the very children it purports to help".
The DSM-5 change to "gender dysphoria" was endorsed by transgender activists and allies as a way to lessen stigma but maintain a diagnostic route to trans-specific medical care. However, Lev states that the diagnosis of gender dysphoria continues to pathologize transgender experiences.
The existence of two-spirit people (those understood to be connected to both the masculine and feminine spirit) has been documented in over 130 pre-colonial Indigenous nations in North America including the Zuni lhamana and the Lakota winkte. In some of these nations, the identification of a two-spirit child was regarded as a blessing for the family and the community. While the roles which two-spirit people held in their communities varied widely from nation to nation, in some cases they were held in high regard, for example We'wha who was the cultural ambassador for the Zuni people during the late 19th century. The historical and contemporary existence of alternative gender roles has also been documented worldwide, for example: the kathoey in Thailand and Laos, the hijra of India, the muxe of the Zapotec people in Mexico, the mukhannathun of what is now Saudi Arabia, the māhū in Hawaii, the fakaleiti in Tonga and the fa'afafine in Samoa. Though the historical meaning of these roles is often disputed, their existence is not.
Referencing contemporary Western views on gender diversity, psychologist Diane Ehrensaft states: "I am witnessing a shake-up in the mental health community as training sessions, workshops and conferences are proliferating all over this country and around the world, demanding that we reevaluate the binary system of gender, throw out the idea that gender nonconformity is a disorder, and establish new guidelines for facilitating the healthy development of gender-creative children." Child-adolescent psychiatrist Edgardo Menvielle and psychotherapist Catherine Tuerck offer a support group for parents of gender non-conforming children at the Children's National Medical Centre in Washington D.C., aimed "not at changing children's behaviours but at helping parents to be supportive". Other publications are beginning to call for a similar approach, to support parents to help their child become their authentic self. Community organizations established to support these families have begun to develop, such as Gender Spectrum, Trans Youth Family Allies, Gender Creative Kids Canada, and Trans Kids Purple Rainbow, as well as conferences such as Gender Odyssey Family Conference and summer camps such as Camp Aranu'tiq, all with the goal of supporting healthy families with gender non conforming or transgender children. Popular media accounts of parents assisting their children to live in their felt gender role have recently begun to emerge. These stories demonstrate that children and their parents face substantial stigma; however, Menvielle maintains that "the therapist should focus on helping the child and family cope with intolerance and social prejudice, not on the child's behaviours, interests or choice of playmates". A host of new terms being applied to these children (such as gender variant), gender non-conforming, gender-creative and gender-independent) indicates that many are beginning to reject the label of Gender Identity Disorder in Children.
The introduction of the GIDC diagnosis into the DSM-III in 1980 was preceded by numerous US studies and treatments on feminine boys beginning as early as the 1950s and 1960s, most prominently by John Money and Richard Green at the Johns Hopkins Hospital and the University of California, Los Angeles (UCLA). The prevention of transsexuality and / or homosexuality was explicitly stated as the goal of many of these studies: "My focus will be what we might consider the prevention of transsexualism." Bryant notes that feminine boys were not a new phenomenon at this time; however, the public emergence of adult transsexual women (male to female) in the 1950s was new and created a number of problems for psychologists, motivating some to undertake efforts at preventing their further emergence. Meyerowitz chronicles the deep disagreements which erupted between psychologists and physicians after Christine Jorgensen's public gender transition, namely over whether transsexuals should be permitted to align their bodies with their inner identities or whether their inner identities must be brought in line with their bodies. At the time, transsexual women were beginning to publish first-person narratives which highlighted their awareness of their femininity at a young age and Bryant notes that some clinicians and researchers thus turned their attention to feminine boys, constructing sissies as a new "medicalized patient and research population."
One early researcher was George Alan Rekers who focused his 1972 doctoral research on the treatment of feminine boys. In this work, Rekers describes a litany of feminine behaviours which he catalogues including: feminine posture, gait, arm and hand gestures, feminine inflection in speech, as well as interest in feminine clothing, games and conversation topics. Using classical behaviour modification techniques he and a team of research assistants set about extinguishing 'problem' feminine behaviours in three boys in particular, enlisting the help of parents and occasionally teachers to provide rewards and punishments corresponding to behaviours identified as wanted or unwanted. Rekers' dissertation describes in detail, the case of Kraig (a pseudonym for Kirk Andrew Murphy) whose mother was instructed over earphones to alternately praise or ignore him depending on whether he played with a table of toys deemed to be feminine (typically dolls) or masculine (typically weapons). She was also trained to monitor his behaviour at home, with research assistants visiting weekly to ensure she was correctly completing her four times daily observations of Kraig's gendered behaviour. Physical punishment from Kraig's father is named as one of the primary consequences for feminine behaviour at home. Throughout Rekers future work, he cites his treatments with Kraig as a success, claiming that "Kraig's feminine behaviours have apparently ceased entirely […]."
In contrast to this, a number of facts about Kraig have become public information, including: that he was a gay man; that according to his family, he never recovered from these treatments; and that in 2003, at the age of 38, he committed suicide. Even without confirmed knowledge of such outcomes, by the mid 1970s Rekers' publications on his treatment modality were already attracting harsh criticism from scholarly and popular media sources and Bryant speculates that this is one possible explanation for why many clinicians do not publish on their treatment techniques, focusing instead on less controversial aspects of GIDC, such as diagnostic criteria. At present, the nature of current treatments administered on children diagnosed with GIDC are poorly explained in the work of prominent clinicians such as Kenneth Zucker; however, first-person accounts of treatment in popular media sources would seem to indicate that feminine behaviours in boys continue to be identified and selected for elimination, hence the mounting opposition to this practice.
The majority of children diagnosed with gender dysphoria cease to desire to be the other sex by puberty, with most growing up to identify as gay or lesbian with or without therapeutic intervention. If the dysphoria persists into puberty, it is usually or likely to be permanent. Gay and lesbian adults also report having exhibited more opposite-sex gender role behavior than heterosexual adults.
- Bartlett, NH; Vasey, PL; Bukowski, WM (2000). "Is Gender Identity Disorder in Children a Mental Disorder?". Sex Roles. 43 (11/12): 753–785.
- Moran, Mark (5 April 2013). "New Gender Dysphoria Criteria Replace GID". Psychiatric News. 48 (7): 9. doi:10.1176/appi.pn.2013.4a19 – via psychnews.psychiatryonline.org.
- Advancing Science Serving Society. (December 14, 1998). "American Psychiatric Association Rebukes Reparative Therapy".
- World Professional Association for Transgender Health (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7. Archived 2012-03-03 at the Wayback Machine.
- Jameson L, de Kretser DM, Marshall JC, De Groot LJ (2013). Endocrinology Adult and Pediatric: Reproductive Endocrinology. Elsevier Health Sciences. p. 483. ISBN 0323221521. Retrieved August 4, 2018.
- Marcdante K, Kliegman RM (2014). Nelson Essentials of Pediatrics E-Book. Elsevier Health Sciences. p. 75. ISBN 0323226981. Retrieved August 4, 2018.
- Wallien, M. S. C.; Cohen-Kettenis, P. T. (2008). "Psychosexual Outcome of Gender-Dysphoric Children". Journal of the American Academy of Child and Adolescent Psychiatry. 47 (12): 1413–1423. doi:10.1097/chi.0b013e31818956b9.
- Steensma TD; McGuire JK; Kreukels BP; Beekman AJ; Cohen-Kettenis PT (2013). "Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study". Journal of the American Academy of Child and Adolescent Psychiatry. 52 (6): 582–90. doi:10.1016/j.jaac.2013.03.016. PMID 23702447.
- Wylie C. Hembree; Peggy Cohen-Kettenis; Henriette A. Delemarre-van de Waal; Louis J. Gooren; Walter J. Meyer III; Norman P. Spack; Vin Tangpricha; Victor M. Montori (2011). "Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. doi:10.1210/jc.2009-0345#sthash.Tq83TQ4U.dpuf.
- World Health Organization (May 1990). Disorders of adult personality and behaviour F60-F69 .
- Bradley, Susan J.; Zucker, Kenneth J. (1997). "Gender Identity Disorder: A Review of the Past 10 Years". Journal of the American Academy of Child & Adolescent Psychiatry. 36 (7): 872–80. doi:10.1097/00004583-199707000-00008. PMID 9204664.
- American Psychiatric Association. (2013). "Diagnostic and statistical manual of mental disorders" (5th ed.). Washington, DC.,
- Lev, A (2013). "Gender Dysphoria: Two steps forward, one step back". Clinical Social Work Journal. 41 (3): 288–296. doi:10.1007/s10615-013-0447-0.
- Spiegel Alix (May 7, 2008). Two families grapple with sons' gender preferences. All Things Considered, National Public Radio
- Bradley, SJ; Zucker, KJ (1990). "Gender Identity Disorder and psychosexual problems in children and adolescents". Canadian Journal of Psychiatry. 35 (6): 477–86. PMID 2207982.
- Zucker, Ken J. (2002). Gender Identity Disorder. In Michael Rutter, Eric A. Taylor (Eds). Child and adolescent psychiatry: modern approaches. Blackwell Publishing. ISBN 0-86542-880-8
- Di Ceglie, D (1995). "Gender identity disorders in children and adolescents". British Journal of Hospital Medicine. 53 (6): 251–6. PMID 7767569.
- Wren (2000). "Early Physical Intervention for Young People with Atypical Gender Identity Development". Clinical Child Psychology and Psychiatry. 5 (2): 220–231. doi:10.1177/1359104500005002007.
- Zukcer, KJ (2008). "Children with gender identity disorder: Is there a best practice?". Neuropsychiatrie de l'Enfance et de l'Adolescence. 56 (6): 358–364. doi:10.1016/j.neurenf.2008.06.003.
- Pickstone-Taylor, Simon D (2003). "Children with gender nonconformity". Journal of the American Academy of Child and Adolescent Psychiatry. 42 (3): 266. doi:10.1097/00004583-200303000-00005.
- Hill DB, Rozanski C, Carfagnini J, Willoughby B (2006). Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry. pp. 7-34. In Karasic D, Drescher J (Eds.) Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation. Haworth Press ISBN 0-7890-3214-7
- Menvielle, E.; Tuerk, C.; Perrin, E. (2005). "To the best of a different drummer: The gender-variant child". Contemporary Pediatrics. 22 (2): 38–45.
- Wingerson, L. (2009, May 19). /display/article/10168/1415037 Gender identity disorder: Has accepted practice caused harm? "Psychiatric Times".
- Burke, Phyllis (1996). Gender Shock. Anchor. ISBN 978-0-385-47718-5
- Wilkinson, Stephanie (2001). Drop the Barbie! Archived July 8, 2011, at the Wayback Machine. Brain, Child
- Zucker KJ, Spitzer R (2005). Was the Gender Identity Disorder of Childhood Diagnosis Introduced into DSM-III as a Backdoor Maneuver to Replace Homosexuality? A Historical Note. Journal of Sex and Marital Therapy, Volume 31, Number 1, January–February 2005, pp. 31-42(12)
- Wilson K (1998). The Disparate Classification of Gender and Sexual Orientation in American Psychiatry 1998 annual meeting of the American Psychiatric Association, Workshop IW57, Transgender Issues, Toronto Canada, June.
- Wilson, I; Griffith, C; Wren, B (2002). "The Validity of the Diagnosis of Gender Identity Disorder (Child and Adolescent Criteria)". Clinical Child Psychology and Psychiatry. 7 (3): 335–351. doi:10.1177/1359104502007003003.
- Feder, EK (1997). "Disciplining the family: The case of gender identity disorder". Philosophical Studies. 85 (2–3): 195. doi:10.1023/a:1004275024875.
- Langer, SJ; Martin, JI (2004). "How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children". Child and Adolescent Social Work Journal. 21 (1): 5–23. doi:10.1023/b:casw.0000012346.80025.f7.
- Zucker, KJ (2006). "Commentary on Langer and Martin's (2004) "How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children". Child and Adolescent Social Work Journal. 23 (5/6): 533–555. doi:10.1007/s10560-006-0074-5.
- Goleman, Daniel (March 22, 1994). The 'Wrong' Sex: A New Definition Of Childhood Pain. New York Times
- Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality. New Haven: Yale University Press.
- Lou Chibbaro, Jr. (2008-05-30). "Activists alarmed over APA: Head of psychiatry panel favors 'change' therapy for some trans teens". Washington Blade.
- Alexander, Brian (2008-05-22). "What's 'normal' sex? Shrinks seek definition: Controversy erupts over creation of psychiatric rule book's new edition". MSNBC. Retrieved 2008-06-14.
- Szymanski, Zak (July 3, 2008). Trans March rallies around inclusion. Archived October 11, 2008, at the Wayback Machine. Bay Area Reporter
- Osborne, Duncan (2008-05-15). "Flap Flares Over Gender Diagnosis". Gay City News. Archived from the original on 2008-10-24. Retrieved 2008-06-14.
- Bryant, K (2006). "Making gender identity disorder of childhood: Historical lessons for contemporary debates". Sexuality Research & Social Policy. 3 (3): 23–39. doi:10.1525/srsp.2006.3.3.23.
- Winters, K. (2008). "Gender Madness in American Psychiatry: Essays from the struggle for dignity". Dillon, Colorado: GID Reform Advocates
- Roscoe, W. (1991) "The Zuni Man-Woman." University of New Mexico Press.
- Williams, W. (1986). "The spirit and the flesh: Sexual diversity in American Indian culture." Boston: Beacon Press.
- Roscoe, W. (1991) "The Zuni Man-Woman". University of New Mexico Press.
- Feinberg, L. (1996). "Transgender warriors: Making history from Joan of Arc to Dennis Rodman." Beacon Press.
- Ehrensaft, D. (2011). "Gender Born, Gender Made". New York, NY: The Experiment.
- Menvielle, E.; Tuerk, C. (2002). "A support group for parents of gender-nonconforming boys. (clinical perspectives)". Journal of the American Academy of Child and Adolescent Psychiatry. 41 (8): 1010–1014. doi:10.1097/00004583-200208000-00021.
- Brill, S., & Pepper, R. (2008). The transgender child. San Francisco: Cleis Press.
- "TransYouth Family Allies". imatyfa.org.
- "Welcome to GenderCreativeKids.ca! - Gender Creative Kids". Gender Creative Kids.
- "TransKids Purple Rainbow Foundation". TransKids Purple Rainbow Foundation.
- "Gender Odyssey Seattle: August 9-12, 2018, WA State Convention Center".
- "Camp Aranu'tiq of Harbor Camps for Transgender Youth". Camp Aranu'tiq of Harbor Camps.
- Park, M. (2011, September 2011).  "Transgender kids: Painful quest to be who they are." CNN.
- "The New Face of Transgender Youth".
- The 519 Community Centre. (2011).  "Gender Independent Children and Family Support Survey"
- American Psychiatric Association. (1980). "Diagnostic and statistical manual of mental disorders" (3rd ed.). Washington, DC.,
- Green, R.; Money, J. (1960). "Incongruous gender role: Nongenital manifestations in prepubertal boys". Journal of Nervous Disorders. 131 (2): 160–168. doi:10.1097/00005053-196008000-00009.
- Green, R (1971). "Diagnosis and treatment of gender identity disorders during childhood". Archives of Sexual Behavior. 1 (2): 167–173. doi:10.1007/bf01541061.
- Meyerowitz, J. (2004). "How sex changed: A history of transsexuality in the United States". Harvard University Press.
- Star, Hedy Jo (1955). "I changed my sex." Chicago, Illinois: Novel Books.
- Rekers, G. A. (1972). Pathological sex-role development in boys: Behavioral treatment and assessment. Unpublished dissertation, University of California, Los Angeles.
- CNN, By Scott Bronstein and Jessi Joseph,. "Therapy to change 'feminine' boy created a troubled man, family says".
- Rekers, G. A.; Lovaas, O. I. (1974). "Behavioral treatment of deviant sex-role behaviors in a male child". Journal of Applied Behavior Analysis. 7 (2): 173–190. doi:10.1901/jaba.1974.7-173. PMC . PMID 4436165.
- Nordyke, N. S.; Baer, D. M.; Etzel, B. C.; LeBlanc, J. M. (1977). "Implications of the stereotyping and modification of sex role". Journal of Applied Behavior Analysis. 10 (3): 553–557. doi:10.1901/jaba.1977.10-553. PMC . PMID 924924.
- Rorvik, David Michael. (October 9, 1975) "The gender enforcers: Seeing to it the boys will be boys." Rolling Stone
- Spiegel, A. (May 7, 2008) "Two families grapple with sons' gender preferences: Psychologists take radically different approaches in therapy." National Public Radio.
- Cohen-Kettennis, PT; Gooren, LJ (April 1999), "Transsexualism: a review of diagnosis, etiology, and treatment.", Journal of Psychosomatic Research, 46 (4): 315–33, doi:10.1016/s0022-3999(98)00085-3, PMID 10340231
- Gender Identity Disorder and Transsexualism via Merck Manual
- Issues of Psychiatric Diagnosis for Gender Nonconforming Youth via GIDreform.org
- More Children Seek Help for Gender Dysphoria via WebMD.com
- Health Effects Of Transitioning In Teen Years Remain Unknown via NPR
- When Transgender Kids Transition, Medical Risks are Both Known and Unknown via Frontline PBS
- Parents of transgender children are faced with a difficult decision via NYMag.com
- The boy who was raised a girl via BBC
- Led by the child who simply knew The twin boys were identical in every way but one. via Boston.com
- A nonprofit program serving transgender and gender-variant youth and their families. via Camp Aranutiq
- As Attention Grows, Transgender Children’s Numbers Are Elusive via The New York Times
- First U.S. Study of Transgender Youth Funded by NIH via University of California, San Francisco