Psychiatric News

Remove Gender Identity Disorder From DSM

By Richard A. Isay, M.D.

APA removed homosexuality from DSM-III in 1973; with the 1987 publication of DSM-III-R, ego-dystonic homosexuality was deleted as well. Thus, homosexuality is no longer considered an illness. But a vestige of those earlier diagnoses remains in DSM-IV in the category of psychiatric illness known as "gender identity disorder" (GID) in children, which implicitly labels homosexual boys as mentally disordered.

Since many young boys generally considered to be feminine are sent by their parents for psychiatric treatment that, at times, may itself cause emotional damage by injuring the self-esteem of a child who has no mental disorder, I urge that GID be removed from the next edition of DSM.

Every one of the several hundred adult gay men I have seen in my practice over the past 30 years has reported that as a child he had some "feminine" traits and interests that made him feel "different." Many of these traits disappeared during adolescence, but as children most of my gay male patients had little interest in rough-and-tumble activities, were atypically emotional and cried easily, and preferred playing with girls more than with other boys. Many occasionally dressed in their sisterís or motherís clothes. Most formed a strong bond with their mothers, with whom they shared so many of these traits. Many occasionally wished that they had been born girls rather than boys because "life would have been easier," while a few had the sustained wish throughout childhood to be a girl.

Such observations are in accord with the findings of a 1995 review of the studies of homosexuals in which Bailey and Zucker concluded that there is "clear evidence of a relation between patterns of childhood sex-typed behavior and later sexual orientation."

Many investigators now believe that homosexuality in men is associated with a variety of gender-variant traits whose genesis they attribute to the in-utero development of the brain. In 1989 one nucleus in the hypothalamus, INAH3, was found to be two to three times larger in men than in women; Simon LeVay demonstrated in 1991 that INAH3 was also two to three times larger in heterosexual than in homosexual males. Allen and her colleagues discovered that the anterior commissure was larger in women than men. Subsequently they found that the anterior commissure was larger in homosexual men than in heterosexuals, and that the size differential was about the same as that found earlier between women and heterosexual men.

The interest of psychoanalysts in gender identity disorders of children started with attempts to understand the origin of homosexuality, which analysts attributed to the feminization of the boy by his binding mother. The observation of a close bond between the homosexual boy and his mother was correct, but the cause of this bond was ascribed to poor or misguided parenting rather than to the natural closeness that forms between a boy with mixed-gender traits and the parent with whom he has more in common.

Adult gay men report that parental pressure to alter their "feminine" behavior usually began when they started elementary school, most likely because the parents felt their son would be rejected or that his behavior would reflect badly on their parenting and the fatherís masculinity. Several of my patients were sent for psychiatric treatment.

Parental admonitions about traits and behavior experienced by these boys as part of their nature and the psychiatric interventions aimed at modifying this behavior often deleteriously affect these boysí self-regard. To placate their parents, many of these children cease showing the excitability and emotionality that have been labeled "feminine." As adults, they frequently appear emotionally constricted and restrained, have lost contact with their emotions, find feelings "uncomfortable," and attempt to disown aspects of their nature they now unconsciously regard as "feminine" and therefore unacceptable.

APA acknowledges in DSM-IV, "By late adolescence or adulthood, about three-quarters of boys who had a childhood history of Gender Identity Disorder report a homosexual or bisexual orientation, but without concurrent Gender Identity Disorder" (page 536). Why, then, continue to label this aspect of the normal development of homosexual boys disordered, neglecting the fact that their unusual mix of gender traits results in a rich variety of interests and, for some, their choice of vocations?

It would be in the interest of the homosexual boyís development for parents to be supportive of his gender-atypical traits. For far more than learning to be "like other boys," it is the love and support of his parents that promote the self-regard that best insulates the child from peer rejection and social prejudice and helps him develop into a loving adult.