Journal of Abnormal Child Psychology

, Volume 25, Issue 3, pp 217–227 | Cite as

Sex Differences in Referral Rates of Children with Gender Identity Disorder: Some Hypotheses

  • Kenneth J. Zucker
  • Susan J. Bradley
  • Mohammad Sanikhani


From 1978 through 1995, a sex ratio of 6.6:1 of boys to girls (N = 275) was observed for children referred to a specialty clinic for gender identity disorder. This article attempts to evaluate several hypotheses regarding the marked sex disparity in referral rates. The sexes did not differ on four demographic variables (age at referral, IQ, and parent's social class and marital status) and on five indices of general behavior problems on the Child Behavior Checklist; in addition, there was only equivocal evidence that boys with gender identity disorder had significantly poorer peer relations than girls with gender identity disorder. Although the percentage of boys and girls who met the complete DSM-III-R criteria for gender identity disorder was comparable, other measures of sex-typed behavior showed that the girls had more extreme cross-gender behavior than the boys. Coupled with external evidence that cross-gender behavior is less tolerated in boys than in girls by both peers and adults, it is concluded that social factors partly account for the sex difference in referral rates. Girls appear to require a higher threshold than boys for cross-gender behavior before they are referred for clinical assessment.

Gender identity disorder sex differences boys girls 


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  1. Achenbach, T. M., & Edelbrock, C. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington: University of Vermont, Department of Psychiatry.Google Scholar
  2. Achenbach, T. M., & Edelbrock, C. S. (1981). Behavioral problems and competencies reported by parents of normal and disturbed children aged four through sixteen. Monographs of the Society for Research in Child Development, 46(1, Serial No. 188).Google Scholar
  3. Achenbach, T. M., Howell, C. T., Quay, H. C., & Conners, C. K. (1991). National survey of problems and competencies among four-to sixteen-year-olds. Monographs of the Society for Research in Child Development, 56(3, Serial No. 225).Google Scholar
  4. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.Google Scholar
  5. Antill, J. K. (1987). Parents' beliefs and values about sex roles, sex differences, and sexuality: Their sources and implications. In P. Shaver & C. Hendrick (Eds.), Sex and gender (pp. 294–328). Newbury Park, CA: Sage.Google Scholar
  6. Bailey, J. M., & Zucker, K. J. (1995). Childhood sex-typed behavior and sexual orientation: A conceptual analysis and quantitative review. Developmental Psychology, 31, 43–55.Google Scholar
  7. Bakker, A., van Kesteren, P. J. M., Gooren, L. J. G., & Bezemer, P. D. (1993). The prevalence of transsexualism in the Netherlands. Acta Psychiatrics Scandinavica, 87, 237–238.Google Scholar
  8. Blanchard, R. (1985). Typology of male-to-female transsexualism. Archives of Sexual Behavior, 14, 247–261.Google Scholar
  9. Blanchard, R. (1988). Nonhomosexual gender dysphoria. Journal of Sex Research, 24, 188–193.Google Scholar
  10. Blanchard, R., Clemmensen, L. H., & Steiner, B. W. (1987). Heterosexual and homosexual gender dysphoria. Archives of Sexual Behavior, 16, 139–152.Google Scholar
  11. Brown, D. G. (1956). Sex-role preference in young children. Psychological Monographs, 70(14, Whole No. 421).Google Scholar
  12. Cole, H. J., Zucker, K. J., & Bradley, S. J. (1982). Patterns of gender-role behaviour in children attending traditional and non-traditional day-care centres. Canadian Journal of Psychiatry, 27, 410–414.Google Scholar
  13. Dickey, R., & Steiner, B. W. (1990). Hormone treatment and surgery. In R. Blanchard & B. W. Steiner (Eds.), Clinical management of gender identity disorders in children and adults (pp. 137–158). Washington, DC: American Psychiatric Press.Google Scholar
  14. Doering, R. W., Zucker, K. J., Bradley, S. J., & MacIntyre, R. B. (1989). Effects of neutral toys on sex-typed play in children with gender identity disorder. Journal of Abnormal Child Psychology, 17, 563–574.Google Scholar
  15. Fagot, B. I. (1977). Consequences of moderate cross-gender behavior in preschool children. Child Development, 48, 902–907.Google Scholar
  16. Fagot, B. I. (1985). Beyond the reinforcement principle: Another step toward understanding sex role development. Developmental Psychology, 21, 1097–1104.Google Scholar
  17. Feinman, S. (1974). Approval of cross-sex-role behavior. Psychological Reports, 35, 643–648.Google Scholar
  18. Godlewski, J. (1988). Transsexualism and anatomic sex ratio reversal in Poland. Archives of Sexual Behavior, 17, 547–548.Google Scholar
  19. Gooren, L. (1980). [Letter to the editor]. Archives of Sexual Behavior, 18, 537–538.Google Scholar
  20. Green, R. (1970). Little boys who behave as girls. California Medicine, 113, 12–16.Google Scholar
  21. Green, R. (1974). Sexual identity conflict in children and adults. New York: Basic Books.Google Scholar
  22. Green, R. (1976). One-hundred ten feminine and masculine boys: Behavioral contrasts and demographic similarities. Archives of Sexual Behavior, 5, 425–446.Google Scholar
  23. Green, R. (1987). The “sissy boy syndrome” and the development of homosexuality. New Haven, CT: Yale University Press.Google Scholar
  24. Green, R. (1995). Gender identity disorder in children. In G. O. Gabbard (Ed.), Treatments of psychiatric disorders (Vol. 2) (2nd ed., pp. 2001–2014). Washington, DC: American Psychiatric Press.Google Scholar
  25. Green, R., Williams, K., & Goodman, M. (1982). Ninety-nine “tomboys” and “non-tomboys”: Behavioral contrasts and demographic similarities. Archives of Sexual Behavior, 11, 247–266.Google Scholar
  26. Green, R., Williams, K., & Harper, J. (1980). Cross-sex identity: Peer group integration and the double standard of childhood sex-typing. In J. Samson (Ed.), Childhood and sexuality (pp. 542–548). Montreal: Editions Etudes Vivantes.Google Scholar
  27. Hollingshead, A. B. (1975). Four Factor Index of Social Status. Unpublished manuscript, Department of Sociology, Yale University, New Haven, CT.Google Scholar
  28. Karim, R. B. (1996). Vaginoplasty in transsexuals. Amsterdam: VU University Press.Google Scholar
  29. Lamb, M. E., Easterbrooks, M. A., & Holden, G. A. (1980). Reinforcement and punishment among preschoolers: Characteristics, effects, and correlates. Child Development, 51, 1230–1236.Google Scholar
  30. Lamb, M. E., & Roopnarine, J. L. (1979). Peer influences on sex-role development in preschoolers. Child Development, 50, 1219–1222.Google Scholar
  31. Langlois, J. H., & Downs, A. C. (1980). Mothers, fathers, and peers as socialization agents of sex-typed play behaviors in young children. Child Development, 51, 1237–1247.Google Scholar
  32. Lord, C., Schopler, E., & Revicki, D. (1982). Sex differences in autism. Journal of Autism and Developmental Disorders, 12, 317–331.Google Scholar
  33. Martin, C. L. (1990). Attitudes and expectations about children with nontraditional and traditional gender roles. Sex Roles, 22, 151–165.Google Scholar
  34. Martin, C. L. (1995). Stereotypes about children with traditional and nontraditional gender roles. Sex Roles, 33, 727–751.Google Scholar
  35. Meyer-Bahlburg, H. F. L. (1985). Gender identity disorder of childhood: Introduction. Journal of the American Academy of Child Psychiatry, 24, 681–683.Google Scholar
  36. Ruble, D. N., & Martin, C. L. (in press). Gender development. In W. Damon (Ser. Ed.) and N. Eisenberg (Vol. Ed.), The handbook of child psychology (5th ed.). Vol. 3: Social, emotion, and personality development. New York: Wiley.Google Scholar
  37. Sandberg, D. E., Meyer-Bahlburg, H. F. L., Ehrhardt, A. A., & Yager, T. J. (1993). The prevalence of gender-atypical behavior in elementary school children. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 306–314.Google Scholar
  38. Weisz, J. R., & Weiss, B. (1991). Studying the “referability” of child clinical problems. Journal of Consulting and Clinical Psychology, 59, 266–273.Google Scholar
  39. Zahner, G. E. P., & Pauls, D. L. (1987). Epidemiological surveys of infantile autism. In D. J. Cohen & A. M. Donnellan (Eds.), Handbook of autism and pervasive developmental disorders (pp. 199–207). New York: Wiley.Google Scholar
  40. Zucker, K. J. (1982). Childhood gender disturbance: Diagnostic issues. Journal of the American Academy of Child Psychiatry, 21, 274–280.Google Scholar
  41. Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.Google Scholar
  42. Zucker, K. J., Bradley, S. J., Lowry Sullivan, C. B., Kuksis, M., Birkenfeld-Adams, A., & Mitchell, J. N. (1993). A gender identity interview for children. Journal of Personality Assessment, 61, 443–456.Google Scholar
  43. Zucker, K. J., Doering, R. W., Bradley, S. J., & Finegan, J. K. (1982). Sex-typed play in gender-disturbed children: A comparison to sibling and psychiatric controls. Archives of Sexual Behavior, 11, 309–321.Google Scholar
  44. Zucker, K. J., Finegan, J. K., Doering, R. W., & Bradley, S. J. (1983). Human figure drawings of gender-problem children: A comparison to sibling, psychiatric, and normal controls. Journal of Abnormal Child Psychology, 11, 287–298.Google Scholar
  45. Zucker, K. J., Lozinski, J. A., Bradley, S. J., & Doering, R. W. (1992). Sex-typed responses in the Rorschach protocols of children with gender identity disorder. Journal of Personality Assessment, 58, 295–310.Google Scholar
  46. Zucker, K. J., Wilson-Smith, D. N., Kurita, J. A., & Stern, A. (1995). Children's appraisals of sex-typed behavior in their peers. Sex Roles, 33, 703–725.Google Scholar

Copyright information

© Plenum Publishing Corporation 1997

Authors and Affiliations

  • Kenneth J. Zucker
    • 1
  • Susan J. Bradley
    • 1
  • Mohammad Sanikhani
    • 1
  1. 1.Clarke Institute of PsychiatryTorontoCanada

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