A Follow-Up Study of Girls With Gender Identity Disorder

Abstract

This study provided information on the natural histories of 25 girls with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 8.88 years; range, 3-12 years) and at follow-up (mean age, 23.24 years; range, 15-36 years) were used to evaluate gender identity and sexual orientation. At the assessment in childhood, 60% of the girls met the Diagnostic and Statistical Manual of Mental Disorders criteria for GID, and 40% were subthreshold for the diagnosis. At follow-up, 3 participants (12%) were judged to have GID or gender dysphoria. Regarding sexual orientation, 8 participants (32%) were classified as bisexual/homosexual in fantasy, and 6 (24%) were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. The rates of GID persistence and bisexual/homosexual sexual orientation were substantially higher than base rates in the general female population derived from epidemiological or survey studies. There was some evidence of a "dosage" effect, with girls who were more cross-sex typed in their childhood behavior more likely to be gender dysphoric at follow-up and more likely to have been classified as bisexual/homosexual in behavior (but not in fantasy).

Full text

A Follow-Up Study of Girls With Gender Identity Disorder
Kelley D. Drummond
Ontario Institute for Studies in Education of the University of
Toronto
Susan J. Bradley
Centre for Addiction and Mental Health
Michele Peterson-Badali
Ontario Institute for Studies in Education of the University of
Toronto
Kenneth J. Zucker
Centre for Addiction and Mental Health
This study provided information on the natural histories of 25 girls with gender identity disorder (GID).
Standardized assessment data in childhood (mean age, 8.88 years; range, 3–12 years) and at follow-up
(mean age, 23.24 years; range, 15–36 years) were used to evaluate gender identity and sexual orientation.
At the assessment in childhood, 60% of the girls met the Diagnostic and Statistical Manual of Mental
Disorders criteria for GID, and 40% were subthreshold for the diagnosis. At follow-up, 3 participants
(12%) were judged to have GID or gender dysphoria. Regarding sexual orientation, 8 participants (32%)
were classified as bisexual/homosexual in fantasy, and 6 (24%) were classified as bisexual/homosexual
in behavior. The remaining participants were classified as either heterosexual or asexual. The rates of
GID persistence and bisexual/homosexual sexual orientation were substantially higher than base rates in
the general female population derived from epidemiological or survey studies. There was some evidence
of a “dosage” effect, with girls who were more cross-sex typed in their childhood behavior more likely
to be gender dysphoric at follow-up and more likely to have been classified as bisexual/homosexual in
behavior (but not in fantasy).
Keywords: gender identity disorder, gender identity, sexual orientation, girls, follow-up
Research on normative (or typical) gender development has
documented various behavioral domains in which children show,
on average, significant sex differences: gender identity self-
labeling, sex-of-playmate preference, toy and activity interests,
roles in fantasy play, parental rehearsal play, and so on (for a
review, see Ruble, Martin, & Berenbaum, 2006; Zucker, 2005c).
The determinants of this between-sex variation in sex-typed be-
havior have long been deemed by developmentalists to have im-
portant implications for other aspects of psychosocial develop-
ment, such as interpersonal relational styles (e.g., Maccoby, 1998),
cognitive skills (e.g., Liss, 1983), and vocational interests (e.g.,
Lippa, 1998), for which there are also significant sex differences.
As noted by Lippa (2002), determining within-sex individual
differences in gender-related behavior is another strategy used to
study variations with regard to other aspects of development (see,
e.g., Barrett & White, 2002; Khuri & Ruble, 2006). In the present
study, we used this approach to examine the relation, if any,
between sex-typed behavior patterns in childhood, including gen-
der identity, and subsequent gender identity and sexual orientation
in late adolescent girls and young adult women.
Several lines of evidence suggest that there are empirical rea-
sons to posit a link between sex-typed behavior in childhood and
later gender identity and sexual orientation. Like sex-typed behav-
ior in childhood, gender identity and sexual orientation in adult-
hood are also sex dimorphic: Most women have a “female” gender
identity (the subjective sense of self as a woman) and are sexually
attracted to men, whereas most men have a “male” gender identity
and are sexually attracted to women. Indeed, gender identity and
sexual orientation may be the two behavioral traits that most
strongly differentiate women from men (cf. Hyde, 2005). Using a
self-report questionnaire designed to measure gender identity di-
mensionally in adolescents and adults, for example, Deogracias et
al. (2007) obtained a between-sex effect size, using Cohen’s d,of
13.24.
Over the past several decades, the empirical literature has relied
on two methods, namely, retrospective and prospective designs
using targeted samples, to examine the relation between sex-typed
behavior in childhood and subsequent gender identity and sexual
orientation in adulthood. Retrospective designs have studied adults
with known variation in their gender identity and/or sexual orien-
tation. For example, adults who meet the Diagnostic and Statistical
Manual of Mental Disorders (DSM) criteria for gender identity dis-
order (GID; also known as transsexualism) recall engaging in more
cross-gender-typed behavior in childhood than do adults without GID
(e.g., Blanchard & Freund, 1983; Doorn, Poortinga, & Verschoor,
1994; Ehrhardt, Grisanti, & McCauley, 1979; Freund, Langevin,
Satterberg, & Steiner, 1977; see also Bartlett & Vasey, 2006).
Kelley D. Drummond and Michele Peterson-Badali, Department of
Human Development and Applied Psychology, Ontario Institute for Stud-
ies in Education of the University of Toronto, Toronto, Ontario, Canada;
Susan J. Bradley and Kenneth J. Zucker, Gender Identity Service, Child,
Youth, and Family Program, Centre for Addiction and Mental Health,
Toronto, Ontario, Canada.
Correspondence concerning this article should be addressed to Kenneth
J. Zucker, Gender Identity Service, Child, Youth, and Family Program,
Centre for Addiction and Mental Health, 250 College Street, Toronto,
Ontario M5T 1R8, Canada. E-mail: ken_zucker@camh.net
Developmental Psychology Copyright 2008 by the American Psychological Association
2008, Vol. 44, No. 1, 34–45 0012-1649/08/$12.00 DOI: 10.1037/0012-1649.44.1.34
34
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The largest body of retrospective research pertains to the within-
sex association between sex-typed behavior in childhood and
sexual orientation in adulthood. Bailey and Zucker (1995) per-
formed a meta-analysis of 41 retrospective studies that made a
quantitative comparison between heterosexual and homosexual
same-sex adults using some measure of childhood sex-typed be-
havior. These studies yielded 48 independent effect sizes: 32
compared heterosexual and homosexual men, and 16 compared
heterosexual and homosexual women. Using Cohen’s d, Bailey
and Zucker found that there were substantial differences in pat-
terns of recalled childhood sex-typed behavior between heterosex-
ual and homosexual adults. On average, both homosexual men and
women recalled more cross-sex-typed behavior in childhood than
did their heterosexual counterparts (respective ds were 1.31 and
0.96). Subsequent studies have, with no exception, continued to
replicate these findings (summarized in Zucker et al., 2006).
There are, of course, both methodological and interpretive prob-
lems with retrospective designs (for an overview, see Hardt &
Rutter, 2004). In a targeted sample of adults with GID (invariably
recruited from specialized gender identity clinics), it is possible
that the association with cross-sex-typed behavior is magnified
because not all individuals with pervasive cross-gender behavior in
childhood end up seeking out medically assisted gender change in
adulthood (e.g., because their earlier gender dysphoria had de-
sisted). In the studies comparing the recollections of heterosexual
and homosexual adults, in which there is less of a sampling bias
problem, the most common criticism has pertained to memory
distortion or selective recall. For example, it has been argued that
the greater recollection of cross-gender behavior during childhood
by homosexual than by heterosexual adults is linked to the wide-
spread “master narrative” in Western culture that presupposes that
“gender inversion” is linked to homosexual sexual orientation (see,
e.g., Cohler & Galatzer-Levy, 2000; Gottschalk, 2003; Hegarty,
1999; Kite & Deaux, 1987). As a result, it has been claimed that
the sex-typed behavior–sexual orientation association is nothing
more than participants recalling behaviors that adhere to cultural
stereotypes and expectations. Although there is evidence that
speaks against this retrospective distortion hypothesis (summa-
rized in Bailey & Zucker, 1995; Zucker, 2005a, in press; Zucker et
al., 2006), there is general agreement that the retrospective data
should be confirmed (or disconfirmed) with prospective designs.
One prospective approach has been to target a sample of chil-
dren presumed to have moderate-to-pervasive cross-gender behav-
ior. In one line of research, sampling consisted of ad-recruited girls
with parent-nominated “tomboyish” behavior, along with mea-
sures of sex-typed behavior administered to the girls themselves
(e.g., Bailey, Bechtold, & Berenbaum, 2002; Berenbaum & Bailey,
2003; Green, Williams, & Goodman, 1982), who were compared
to girls unselected for their gender behavior. Neither research team
has, as of yet, reported on longer term linkages.
A second strategy has been to study children referred to spe-
cialized gender identity clinics because there is concern about their
cross-gender behavior and gender identity status (e.g., on the part
of parents, mental health professionals, teachers, etc.). Over the
years, several research teams have studied such children, and
overviews may be found in the work of Green (1987), Zucker and
Bradley (1995), and Cohen-Kettenis and Pfa¨fflin (2003).
In one study, Green (1987) assessed the gender identity and
sexual orientation of 44 behaviorally feminine boys and 30 control
boys who were at a follow-up mean age of 18.9 years (range,
14–24 years) and who had initially been evaluated at a mean age
of 7.1 years (range, 4–12 years). Of the 44 behaviorally feminine
boys, only 1 youth, at the age of 18 years, was gender dysphoric
to the extent of considering sex-reassignment surgery. None of the
other boys were reported to have gender identity problems at
follow-up. Sexual orientation in fantasy and behavior was assessed
by means of a semistructured, face-to-face interview. Kinsey rat-
ings were made on a 7-point continuum, ranging from exclusive
heterosexuality (a Kinsey “0”) to exclusive homosexuality (a Kin-
sey “6”; Kinsey, Pomeroy, & Martin, 1948). Depending on the
measure (fantasy or behavior), 75%–80% of the previously be-
haviorally feminine boys were either bisexual or homosexual
(Kinsey ratings between 2 and 6) at follow-up versus 0%–4% of
the control boys.
Data from seven other follow-up reports on a total of 82 behav-
iorally feminine boys have been summarized in detail elsewhere
(Zucker, 2005b; Zucker & Bradley, 1995, pp. 285–286, 290–297).
Similar to Green’s (1987) case-control study, these studies also
identified an elevated rate of either a bisexual or homosexual
sexual orientation (52.4%). In contrast to Green’s (1987) study,
however, the other studies found the rate of GID persistence was
higher, with rates ranging from 12% to 20%.
From these prospective studies of behaviorally feminine boys,
two conclusions might be drawn: (a) The rate of persistent gender
dysphoria was modest but arguably higher than one estimated base
rate for gender dysphoria in the general population of biological
males: 1 in 11,000 men (Bakker, van Kesteren, Gooren, & Beze-
mer, 1993), and (b) the rate of a later bisexual or homosexual
sexual orientation was notably higher than the known base rates
for a bisexual or homosexual sexual orientation in the general
population of biological males (see, e.g., Laumann, Gagnon, Mi-
chael, & Michaels, 1994). Thus, for sexual orientation, there
appears to be a reasonable convergence between prospective and
retrospective studies but, for gender identity, there is more diver-
gence: Many boys with pervasive cross-gender behavior and co-
occurring gender dysphoria do not show persistent gender dyspho-
ria by late adolescence or young adulthood, which is at some
variance from the recollections of most gender-dysphoric adoles-
cent boys and adult men.
Over the years, it has been noted that little is known about the
longer term psychosexual outcome of girls referred to specialized
gender identity clinics (Peplau & Huppin, in press; Peplau, Spal-
ding, Conley, & Veniegas, 1999). In part, this has been a function
of the fact that boys are much more likely than girls to be referred
to gender identity clinics: 5.75:1 in one clinic and 3.07:1 in another
(see Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003;
Cohen-Kettenis et al., 2006). The present study attempted to fill
this gap by providing, to our knowledge, the first systematic
follow-up report of clinic-referred girls with GID with regard to
gender identity and sexual orientation.
Method
Participants
Between 1975 and 2004, 71 girls (age range, 3–12 years) were
referred for assessment to the Gender Identity Service, Child,
Youth, and Family Program at the Centre for Addiction and
35
SPECIAL SECTION: GENDER IDENTITY DISORDER IN GIRLS
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Mental Health in Toronto, Ontario, Canada. To participate in the
follow-up study, patients had to be at least 17 years of age. Using
this age cutoff, we identified 37 eligible girls, of whom 30 were
contacted for participation. Of the remaining 7 girls, 3 could not be
traced through previous addresses, registrars, and personal con-
tacts (e.g., the patient and/or their family had moved and a current
telephone number, mailing address, or e-mail address could not be
identified), and 4 were not available to participate within the time
requirements of the study.
Initial telephone contact was first made with the parents or legal
guardians because participants were minors at the time of assess-
ment and some may have had no recollection of their clinic
attendance.
1
Of the 30 clients contacted, 25 (83.3%) agreed to
participate; 24 came into the clinic for testing, and 1 participant
completed a telephone interview because she was too anxious to
travel to the clinic. Of the remaining 5 girls, 4 of the girls’ parents
or guardians (e.g., the Children’s Aid Society) were unwilling to
provide contact information for their children. One individual
declined to participate.
The demographic characteristics of the participants in childhood
and at follow-up are shown in Table 1. The GID diagnosis in
childhood was based on the DSM (3rd ed. [DSM–III]; 3rd ed., rev.
[DSM–III–R]; or 4th ed. [DSM–IV]; American Psychiatric Asso-
ciation [APA], 1980, 1987, and 1994, respectively) criteria appli-
cable at the time of assessment. Fifteen girls (60%) met complete
DSM criteria for GID in childhood. The remaining 40% were
subthreshold for a DSM diagnosis of GID, but all had some
indicators of GID, and some would have met the complete DSM
criteria at some point in their lives prior to their assessment in
childhood.
Four of the girls in the follow-up sample were born with a
disorder of sex development (DSD; 2 had cloacal exstrophy, 1 had
congenital micropenis syndrome of unknown etiology, and 1 had
mixed gonadal dysgenesis; Hughes, Houk, Ahmed, Lee, & Law-
son Wilkins Pediatric Endocrine Society/European Society for
Paediatric Endocrinology Consensus Group, 2006). Three of the
nonparticipants also had a DSD (partial androgen insensitivity
syndrome, congenital adrenal hyperplasia, or true hermaphrodit-
ism). There are arguments for and against the inclusion of the 4
girls with a DSD in this sample (see, e.g., Meyer-Bahlburg, 1994).
A female gender assignment was made for all 4 girls almost
immediately after birth. Also in early infancy, the 4 girls were
gonadectomized and had surgical feminization of their external
genitalia. Like the somatically intact girls, the 4 girls were referred
for concern about their gender development in relation to their
assigned gender. On the one hand, as noted by Meyer-Bahlburg
(2005), “there is every reason to assume that the processes and
psychosocial factors involved in normative gender development
also contribute to development of all aspects of gender. . .in per-
sons with intersexuality” (p. 434). On the other hand, as also noted
by Meyer-Bahlburg (2005), “additional factors. . .may come into
play in [such persons]. . .particularly the awareness of an atypical
biological condition and medical history” (pp. 434–435). As noted
in Table 3, only 1 of these girls met the complete Point A and Point
B DSM criteria for GID, and the other 3 were subthreshold.
Procedure
All participants were evaluated on a single day. Below, we
provide information on the measures used in this report (for other
measures, including parent and self-ratings of behavior problems,
psychiatric diagnoses, and experiences of stigma, see Drummond,
2006). All of the participants provided written informed consent
prior to their involvement in the follow-up assessment and were
provided a stipend for their participation and reimbursement for
travel expenses. The study was approved by the Institutional
Review Boards at the Centre for Addiction and Mental Health and
the University of Toronto.
1
It is beyond the scope of this report to describe the types of therapies
(as well as their frequency and duration) that the girls and/or their parents
may have received between the assessment in childhood and the follow-up
(e.g., by a therapist within the Gender Identity Service at the Centre for
Addiction and Mental Health or in the community). From the participants’
clinic files, 13 of the 25 girls had at least some contact with our clinic
during the interval between assessment and follow-up (e.g., as therapy
clients or for a reassessment). Of the 25 girls and/or their parents, 18 had
been in some type of therapy or counseling during the interval between
assessment and follow-up; of these, 5 were patients of staff within the
Gender Identity Service, and the remainder were seen by a professional in
the community.
Table 1
Demographic Characteristics (N ⫽ 25)
Characteristic MSD Range %
From childhood
Age (in years) 8.88 3.10 3.17–12.95
Year of assessment 1989.36 7.02 1977–2002
IQ
a, b
105.17 21.73 57–144
Social class
c
35.72 14.40 8–66
Marital status
d
Two-parent family 60.0
Other 40.0
Caucasian 80.0
At follow-up
Age (in years)
e
23.24 5.82 15.44–36.58
Year of birth 1980.52 6.06 1968–1989
Interval (in years)
f
14.34 7.03 2.99–27.12
IQ
b, g
10.20 2.71 5.00–15.75
a
Full-scale IQ was obtained with age-appropriate Wechsler intelligence
scales (the Wechsler Preschool and Primary Scale of Intelligence—Third
Edition [Wechsler, 2002], the Wechsler Intelligence Scale for Children—
Revised [Wechsler, 1974], and the Wechsler Intelligence Scale for Chil-
dren—Third Edition [Wechsler, 1991]). One participant was administered
the Stanford-Binet Intelligence Scale (Thorndike, Hagen, & Sattler,
1986).
b
IQ scores at assessment and follow-up were not available for 1
participant.
c
For social class, Hollingshead’s (1975) Four Factor Index
of Social Status was used. The absolute range was 8–66.
d
For marital
status, the category “Other” included the following family constellations:
single parent, separated, divorced, living with relatives, or in the care of the
Children’s Aid Society.
e
One participant (who was 15.44 years of age)
was below the lower bound age cutoff of 17 years but was included in the
study because her guardian had contacted the clinic for issues unrelated to
gender identity status.
f
Interval denotes the time between childhood
assessment and follow-up assessment.
g
Composite IQ ⫽ (Vocabulary ⫹
Comprehension ⫹ Block Design ⫹ Object Assembly subscale scores)/4.
The absolute range was 1–19.
36
DRUMMOND, BRADLEY, PETERSON-BADALI, AND ZUCKER
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Measures
Childhood Assessment
Cognitive functioning. IQ was assessed with the Wechsler
Adult Intelligence Scale—Third Edition (Wechsler, 1997) or the
Wechsler Intelligence Scale for Children—Third Edition (Wech-
sler, 1991) and, for one participant, with the Stanford-Binet Intel-
ligence Scale (Thorndike, Hagen, & Sattler, 1986).
Sex-typed behavior. Five child informant and three parent
informant measures were used to assess the participants’ sex-typed
behavior in childhood: (a) the Draw-a-Person test (Zucker, Fin-
egan, Doering, & Bradley, 1983); (b) a free-play task (Zucker,
Doering, Bradley, & Finegan, 1982); (c) the Playmate and Play-
style Preferences Structured Interview (Fridell, Owen-Anderson,
Johnson, Bradley, & Zucker, 2006); (d) sex-typed responses on the
Rorschach test (Zucker, Lozinski, Bradley, & Doering, 1992); (e)
the Gender Identity Interview (Zucker et al., 1993); (f) the Gender
Identity Questionnaire for Children (Johnson et al., 2004); (g) a
measure of activity level/extraversion (Zucker & Bradley, 1995);
and (h) the Games Inventory (Bates & Bentler, 1973). These child
and parent informant measures all had established discriminant
validity, that is, they significantly differentiated the clinic girls
referred for gender identity concerns from control girls (for a
review, see Zucker, 2005c; Zucker & Bradley, 1995). A Childhood
Sex-Typed Behavior Composite was computed for each partici-
pant by averaging the z-scores for these measures (which yielded
a total of 11 indices), as well as the GID DSM diagnosis (1 ⫽
threshold,2⫽ subthreshold) in childhood. Data from the total
sample of participants and nonparticipants (N ⫽ 37) were used.
Because of missing data, the mean number of indices/participant
was 9.16 (SD ⫽ 2.30).
Follow-Up Assessment
Cognitive functioning. Four subtests (Vocabulary, Compre-
hension, Block Design, and Object Assembly) of the Wechsler
Adult Intelligence Scale—Third Edition or the Wechsler Intelli-
gence Scale for Children—Third Edition were administered. The
standard scores from the subtests were averaged to form an IQ
score for cognitive functioning.
Recalled childhood gender identity and gender role behavior.
Participants completed the Recalled Childhood Gender Identity/
Gender Role Questionnaire (RCGI; Zucker et al., 2006). This
questionnaire consists of 23 items pertaining to various aspects of
sex-typed behavior, as well as to the relative closeness to the
mother and father during childhood. Individual items were rated on
a 5-point response scale. Each participant was instructed to make
ratings for her behavior as a child (“between the years 0 to 12”).
Factor analysis identified two factors, accounting for 37.4% and
7.8% of the variance, respectively (all factor loadings ⱖ.40).
Factor 1 consisted of 18 items that pertained to childhood gender
role and gender identity, and Factor 2 consisted of three items that
pertained to parent–child relations (relative closeness to one’s
mother versus one’s father). Information on normative sex differ-
ences and discriminant validity was reported in Zucker et al.
(2006). For the present study, the mean Factor 1 score was com-
puted for each participant.
Concurrent gender identity. During an audiotaped interview,
each participant was asked to describe her current feelings about
being female and then to describe positive and negative aspects
about her gender status. The examiner also asked semistructured
gender identity questions from the adolescent and adult GID
criteria outlined in the DSM–IV–TR (APA, 2000). The interviewer
asked four questions related to the Point A criteria (e.g., the stated
desire to be a man, the desire to live or to be treated as a man) and
six questions from the Point B criteria (e.g., a preoccupation with
getting rid of breasts or genitalia). Participants were asked to
respond according to the last 12 months with No, Yes,orSome-
times. Participants who answered Yes or Sometimes for one or
more of the questions from both Point A and B criteria were
classified as displaying persistent gender dysphoria.
The female version of the Gender Identity/Gender Dysphoria
Questionnaire for Adolescents and Adults (GIDQ-AA; Deogracias
et al., 2007) was also completed. This 27-item questionnaire mea-
sures gender identity and gender dysphoria in adolescents or
adults. Item content was based on prior measures, expert panels,
and clinical experience. Each item was rated on a 5-point response
scale ranging from Never to Always based on a time frame of the
past 12 months. Item examples include the following: “In the past
12 months, have you felt unhappy about being a woman?” and “In
the past 12 months, have you wished to have an operation to
change your body into a man’s (e.g., to have your breasts removed
or to have a penis made)?” Factor analysis identified a strong
one-factor solution that accounted for 61.3% of the variance. All
27 items had factor loadings ⱖ.30 (median, .86; range, .34–.96).
Psychometric evidence for discriminant validity and clinical utility
can be found in Deogracias et al. (2007). Participants’ GIDQ-AA
total scores were calculated by summing scores on the completed
items and dividing by the number of marked responses.
Sexual orientation in fantasy. Each participant’s sexual orien-
tation in fantasy was assessed with specific questions during an
audiotaped face-to-face interview and the self-report Erotic Re-
sponse and Orientation Scale (EROS; Storms, 1980). Questions
posed in the interview addressed four types of sexual fantasy: (a)
crushes on other people, (b) sexual arousal to visual stimuli (e.g.,
to strangers, acquaintances, partners, and individuals presented in
the media [video, movies, magazines, the internet]), (c) sexual
content of night dreams, and (d) sexual content of masturbation
fantasies. Using the Kinsey scale criteria, the interviewer assigned
ratings that ranged from 0 (exclusively heterosexual)to6(exclu-
sively homosexual) for each parameter. A dummy score of 7
denoted that the participant did not experience or report any
fantasies. A global fantasy score was derived on the basis of
ratings from the four questions. In the present study, only ratings
for the last 12 months are reported.
During the interview, participants were not asked directly about
the gender of the person or persons who elicited sexual arousal,
thus allowing time for the participant to provide this information
spontaneously. Directed questions were asked only if the partici-
pant did not volunteer specific information about same-sex or
opposite-sex partners. This approach was used so that, by the end
of the interview, the participant provided information about sexual
arousal to both same-sex and opposite-sex individuals.
The EROS is a 16-item self-report measure assessing sexual
orientation in fantasy over the past 12 months. Half of the ques-
tions pertained to heterosexual fantasy (e.g., “How often have you
had any sexual feelings (even the slightest) while looking at a
man?”) and the other half pertained to homosexual fantasy (e.g.,
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“How often have you had any sexual feelings (even the slightest)
while looking at a woman?”). Each item was rated on a 5-point
scale for frequency of occurrence, ranging from “none”to“almost
every day.” Mean homoerotic and heteroerotic fantasy scores were
derived for each participant. Previous use of the EROS has shown
good evidence of discriminant validity (Storms, 1980; Zucker et
al., 1996).
Sexual orientation in behavior. Each participant’s sexual ori-
entation in behavior was assessed with specific questions during
the face-to-face interview and with a modified version of the
Sexual History Questionnaire (SHQ; Langevin, 1985). In the in-
terview, questions asked about five types of sexual behavior: (a)
dating; (b) holding hands in a romantic manner; (c) kissing; (d)
genital fondling or being touched on the breasts (or, in cases of
same-sex sexual behavior, touching another woman’s breasts); and
(e) penile–vaginal intercourse, anal intercourse, or the use of
dildos. Kinsey ratings for behavior for the past 12 months were
made in the same manner as fantasy ratings.
The modified SHQ consisted of 20 questions. Ten questions
pertained to heterosexual experiences (e.g., “How many men have
you kissed on the lips in a romantic way?”), and 10 questions
pertained to homosexual experiences (e.g., “How many women
have you kissed on the lips in a romantic way?”). Each item was
rated, for the 12 month period prior to the follow-up assessment,
on a 5-point scale for frequency of occurrence, ranging from none
to 11 or more. Mean total scores for heterosexual and homosexual
experiences were derived.
Sexual identity self-labeling. Participants were asked to pro-
vide a label for their current sexual identity and were offered the
following options: (a) “straight” or “heterosexual”; (b) “lesbian,”
“homosexual,” or “queer”; (c) “bisexual”; (d) “asexual”; or (e)
“other.”
Social desirability. Social desirability can threaten the validity
of self-report scales when respondents seek social approval or try
to represent themselves in a favorable manner (King & Brunner,
2000). Participants ⱖ18 years of age completed the Marlowe–
Crowne Social Desirability Scale (M–C SDS; Crowne & Marlowe,
1960), which consists of 33 true–false items. The scale consists of
18 culturally acceptable but unlikely statements keyed in the true
direction and 15 socially undesirable but probable statements
keyed in the false direction for a maximum possible score of 33.
Participants under 18 years of age completed a shorter version of
the M–C SDS (Strahan & Gerbasi, 1972). This scale consists of 12
culturally acceptable but improbable statements keyed in the true
direction and 8 socially undesirable but probable statements keyed
in the false direction for a maximum possible score of 20. Several
studies have found that the M–C SDS is a reliable and valid
measure (Crowne & Marlowe, 1960; Holden & Fekken, 1989;
Silverthorn & Gekoski, 1995).
Results
Participants Versus Nonparticipants
A preliminary analysis compared the assessment information
from childhood of the 25 girls who participated in the study with
that of the 12 girls who did not participate. There were no signif-
icant differences between the participants and nonparticipants on
any of these variables (data not shown).
2
At least by these mea
-
sures, it appears that the participants were representative of the
total pool of available patients and thus did not constitute a
markedly biased sample at follow-up.
Sex-Typed Behavior in Childhood
Table 2 shows the mean RCGI Factor 1 score, which pertained
to the participants’ recollections of their sex-typed behavior from
childhood. This mean score can be compared with the scores of
several samples of women, unselected for their gender identity or
sexual orientation, reported on in Zucker et al. (2006) and also
shown in Table 2. By comparing the mean factor score with the
scores from the other samples (mean range, 3.43–3.80), we see it
is apparent that the women in this study recalled relatively more
cross-gender behavior in childhood (M ⫽ 2.57, SD ⫽ .67).
Table 2 also shows the mean RCGI Factor 1 score of the
participants as a function of DSM diagnostic status in childhood.
Although the threshold participants recalled, on average, more
cross-gender behavior in childhood than the subthreshold partici-
pants, the difference was not significant, t(18) ⬍ 1; the effect size
(Cohen’s d) of .32 would be considered small. We also examined
the z-composite for childhood sex-typed behavior as a function of
diagnostic status (for this analysis, the DSM metric was removed
from the composite and served as the independent variable). With
age at assessment in childhood covaried, the threshold participants
had, on average, significantly more cross-sex-typed behavior in
childhood (M ⫽ .15, SD ⫽ .54) than did the subthreshold partic-
ipants (M ⫽⫺.31, SD ⫽ .36), F(1, 21) ⫽ 23.36, p ⬍ .001, partial
␩
2
⫽ .53.
Psychosexual Differentiation at Follow-Up
A summary of the psychosexual differentiation data, including
gender identity at follow-up, sexual orientation, and sexual identity
self-labeling for each participant, is shown in Table 3.
2
These data are available in the study by Drummond (2006).
Table 2
Mean Factor 1 Score on the Recalled Childhood Gender
Identity/Gender Role Questionnaire (Zucker et al., 2006)
Group MSDdn
Total sample 2.57 .67 20
(Female university students) (3.43) (.54) (100)
(Mothers of boys with GID) (3.80) (.54) (230)
(Mothers of control boys) (3.72) (.34) (13)
(Mothers of nonreferred boys) (3.77) (.39) (24)
(Sisters/female cousins of
women with CAH) (3.70) (.43) (15)
Childhood diagnosis
GID: Threshold 2.48 .66 .32 11
GID: Subthreshold 2.70 .69 9
Note. Absolute range is 1.00–5.00. A lower score indicates more recalled
atypical gender identity and gender role behavior. Groups and values in
parentheses are from Zucker et al. (2006). GID ⫽ gender identity disorder;
CAH ⫽ congenital adrenal hyperplasia.
38
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Gender Identity at Follow-up
On the basis of their answers to the semistructured clinical
interview questions, participants were classified as either gender
dysphoric or not gender dysphoric. In answering these questions,
22 participants (88%) reported no distress with their female gender
identity at follow-up. None of the participants desired contrasex
hormones or sex reassignment surgery to masculinize their bodies,
nor did they express a desire to get rid of their female sex
characteristics.
The remaining 3 participants (12%) were classified as gender
dysphoric at follow-up (none of these 3 girls had a co-occurring
DSD). Among these 3 participants, 1 had been living as a boy
since early adolescence (i.e., was known to others as a boy) and
was in the process of legally changing his name on official doc-
uments. The other 2 participants were living as girls, although both
were often perceived of as boys by naı¨ve others (e.g., new ac-
quaintances, strangers, etc.), which they preferred. All 3 gender
dysphoric participants wished they had been born a boy and
wondered whether they would have been happier as a boy. Two of
these individuals indicated a desire to have surgery to masculinize
their bodies. The other participant classified as gender dysphoric
reported indifference with regard to altering her physical appear-
ance but felt that “it was better to be neutral.” On the basis of this
information, 2 of the participants met DSM–IV–TR criteria for
GID. Although the other participant did not meet full criteria for
GID, information from the clinical interview and semistruc-
tured GID interview indicated that she was gender dysphoric at
follow-up.
In the Deogracias et al. (2007) study, a cutoff score of ⱕ3.00
was used to indicate “caseness” for gender dysphoria on the
GIDQ-AA. The 2 participants classified as gender dysphoric (and
who completed the GIDQ-AA) had scores lower than 3.00 (means
of 2.19 and 2.26, respectively), whereas the 18 participants clas-
sified as not gender dysphoric (and who completed the GIDQ-AA)
all had scores 3.00 (M ⫽ 4.78, SD ⫽ .20; range, 4.30–5.00). There
was a significant difference between these two subgroups, t(18) ⫽
17.81, p ⬍ .001, d ⫽ 13.27, which supports the classification of
the participants on the basis of the clinical interview.
Bakker et al. (1993) estimated that 1 in 30,400 genetically
female adults in the general population have GID. Using this
baseline prevalence value, the odds of persistent gender dysphoria
(12%) in the present sample was 4,084 times the odds of gender
dysphoria in the general population of biological females.
Sexual Orientation
On the basis of the Kinsey interview ratings, participants were
classified into the following three sexual orientation groups for
fantasy and behavior: (a) heterosexual (Kinsey ratings of 0–1), (b)
bisexual/homosexual (Kinsey ratings of 4–6), and (c) no sexual
fantasy or behavior. For the fantasy ratings (see Table 3), 15
Table 3
Summary of Gender Identity and Sexual Orientation Results at Follow-Up
Participant
ID
Age at
assessment
(years)
Age at
follow-up
(years)
Global Kinsey ratings Sexual
identity
label Gender identity DSMFantasy Behavior
1 9.74 36.58 6 6 HS WNL ⫹
2 8.88 36.61 6 6 HS WNL ⫹
3 5.85 32.41 0 0 HT WNL ⫹
4 3.17 28.78 0 — HT WNL ⫹
5 4.92 26.61 4 0 BS WNL ⫹
6
a
5.75 26.58 0 0 HT WNL ⫹
7 12.67 17.09 — — AS Dysphoric
8 12.95 28.72 6 — HS WNL
9 8.41 23.34 6 6 HT Dysphoric ⫹
10 8.29 24.12 4 6 BS WNL ⫹
11 4.10 20.04 0 0 HT WNL ⫹
12 4.72 19.73 0 — HT WNL ⫹
13 6.70 21.53 0 0 HT WNL ⫹
14 6.81 18.73 0 0 HT WNL ⫹
15 12.62 23.57 6 6 HS WNL
16 12.16 21.10 6 6 HT Dysphoric ⫹
17 7.32 17.51 0 0 HT WNL ⫹
18 8.51 17.34 0 — HT WNL
19
a
12.88 21.58 0 — HT WNL
20 9.20 17.81 0 0 HT WNL
21 11.26 19.27 0 0 HT WNL ⫹
22
a
12.18 17.35 — — HT WNL
23 12.45 15.44 0 — HT WNL
24
a
11.89 27.74 0 0 HT WNL
25 8.79 23.12 0 0 HT WNL
Note. For Kinsey ratings (last 12 months), 0 ⫽ exclusively heterosexual and 6 ⫽ exclusively homosexual. In the DSM column, a plus sign indicates the
participant met complete DSM-III, DSM-III-R, or DSM-IV symptom criteria for gender identity disorder at initial assessment. Dashes indicate the participant
did not report fantasy or behavior. ID ⫽ identification label; HS ⫽ homosexual (lesbian); HT ⫽ heterosexual or straight; BS ⫽ bisexual; AS ⫽ asexual;
WNL ⫽ within normal limits (i.e., the participant did not report any distress about being a female).
a
Participant with a disorder of sex development.
39
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participants (60%) were classified as exclusively heterosexual, 8
(32%) were classified as bisexual/homosexual, and the remaining
2 (8%) were classified as having no sexual fantasies. Of the 3
participants classified as gender dysphoric, 2 were exclusively
homosexual in fantasy (i.e., sexually attracted to members of their
own birth sex). The other gender dysphoric participant reported no
sexual fantasies and described herself as being “dead sexually.”
(Of the 4 participants with a DSD, 3 were classified as exclusively
heterosexual in fantasy, and 1 reported no sexual fantasies; 2 were
classified as exclusively heterosexual in behavior, and 2 reported
no sexual behavior.)
For the EROS, we compared the participants classified as ex-
clusively heterosexual with those classified as bisexual/
homosexual on the basis of their Kinsey ratings. With age at
follow-up covaried, a 2 (sexual orientation: heterosexual vs. bi-
sexual/homosexual) ⫻ 2 (EROS: attraction to men vs. attraction to
women) analysis of covariance (ANCOVA) revealed a significant
Sexual Orientation ⫻ EROS interaction, F(1, 20) ⫽ 25.67, p ⬍
.001, partial ␩
2
⫽ .56.
Independent t tests showed that participants classified as het-
erosexual in fantasy had, on average, a higher heteroerotic EROS
score (M ⫽ 2.03, SD ⫽ .87) than participants classified as bisex-
ual/homosexual in fantasy (M ⫽ 1.84, SD ⫽ 1.34), but the differ-
ence was not significant, t(20) ⬍ 1, d ⫽ .19; however, participants
classified as bisexual/homosexual reported, on average, a signifi-
cantly higher EROS homoerotic score (M ⫽ 3.32, SD ⫽ 1.25) than
participants classified as heterosexual (M ⫽ 1.02, SD ⫽ .07),
t(20) ⫽⫺7.28, p ⬍ .001, d ⫽⫺3.33. A paired-samples t test was
conducted to evaluate whether participants classified as heterosex-
ual reported higher heteroerotic fantasies than homoerotic fanta-
sies. The results indicated that the mean heteroerotic score was
significantly greater than the mean homoerotic score, t(14) ⫽ 4.75,
p ⬍ .001, with a large effect size of 1.23. Conversely, participants
classified as bisexual/homosexual reported significantly higher
homoerotic fantasies then heteroerotic fantasies, t(6) ⫽⫺2.61,
p ⬍ .04, with a large effect size of ⫺.99.
Regarding Kinsey ratings of sexual orientation in behavior (see
Table 3), 11 participants (44%) were classified as exclusively
heterosexual, 6 (24%) were classified as bisexual/homosexual, and
the remaining 8 (32%) were classified as having no sexual expe-
riences. Of the 3 participants classified as gender dysphoric, 2
were exclusively homosexual in behavior (i.e., had sexual experi-
ences with members of their own birth sex). The other gender
dysphoric participant reported no sexual behaviors.
For the SHQ ratings, we compared the participants classified as
exclusively heterosexual with those classified as bisexual/
homosexual on the basis of their Kinsey ratings. A 2 (sexual
orientation: heterosexual vs. bisexual/homosexual) ⫻ 2 (SHQ:
with men vs. with women) analysis of variance (ANOVA) re-
vealed a significant Sexual Orientation ⫻ SHQ interaction, F(1,
13) ⫽ 70.41, p ⬍ .001, partial ␩
2
⫽ .84. Independent t tests for the
SHQ scores showed that participants classified as heterosexual in
behavior reported, on average, significantly more heterosexual
sexual experiences (M ⫽ 2.15, SD ⫽ .54) than participants clas-
sified as bisexual/homosexual (M ⫽ 1.00, SD ⫽ .00), t(13) ⫽ 4.12,
p ⫽ .001, d ⫽ 2.42. In fact, participants classified as bisexual/
homosexual reported no sexual experiences with men over the past
12 months. Participants classified as bisexual/homosexual re-
ported, on average, significantly more homosexual sexual experi-
ences (M ⫽ 2.48, SD ⫽ .40) than did participants classified as
heterosexual (M ⫽ 1.04, SD ⫽ .12), t(13) ⫽⫺11.17, p ⬍ .001,
d ⫽⫺6.56.
For participants classified as having a “typical” (i.e., non-
gender-dysphoric) gender identity at follow-up, there were no
substantive disjunctions between Kinsey ratings and sexual iden-
tity self-labeling (see Table 3). One exception was a participant
who self-labeled as heterosexual, although she did not report any
sexual fantasies or behaviors in the 12 months prior to the inter-
view. For the 3 participants classified as gender dysphoric at
follow-up, 2 self-labeled as heterosexual; however, it should be
noted that their sexual orientation in relation to their birth sex was
homosexual. As noted earlier, the remaining gender-dysphoric
participant felt that she was “dead sexually” and labeled herself as
asexual.
One participant (ID 5 in Table 3) was classified as bisexual/
homosexual in fantasy but heterosexual in behavior. Her self-
labeled sexual identity was bisexual. For the 17 participants who
could be assigned a Kinsey rating between 0 and 6 for both
behavior and fantasy (i.e., excluding the 8 individuals who did not
report any sexual behavior [n ⫽ 6] or any sexual fantasy and
behavior [n ⫽ 2]; see Table 3), the correlation between Kinsey
fantasy and behavior ratings was .93 (df ⫽ 15), p ⬍ .001.
Odds Ratios for Bisexual/Homosexual Sexual Orientation
in Fantasy and Behavior
Odds ratios were calculated for bisexual/homosexual sexual
orientation in fantasy and behavior using prevalence estimates
from several major survey studies of sexual orientation in adoles-
cent girls and young women (Dickson, Paul, & Herbison, 2003;
Fergusson, Horwood, Ridder, & Beautrais, 2005; McCabe,
Hughes, Bostwick, & Boyd, 2005; Narring, Stronski, & Michaud,
2003; Remafedi, Resnick, Blum, & Harris, 1992; Russell & Seif,
2002). From these studies, base rates for bisexual/homosexual
sexual orientation in fantasy and behavior were estimated to range
from 2.0% to 5.0% in the female general population. The odds of
reporting bisexual/homosexual sexual orientation in fantasy in the
present sample was 8.9–23.1 times higher, and the odds of report-
ing bisexual/homosexual sexual orientation in behavior in the
present sample was 6.0–15.5 times higher than it is in women in
the general population.
Relation Between Age and Sexual Orientation
Table 4 shows the means and standard deviations of ages at
assessment and at follow-up as a function of Kinsey groups in
fantasy and behavior, respectively. For the Kinsey fantasy ratings,
a one-way ANOVA for age at follow-up was significant, F(2,
22) ⫽ 4.91, p ⫽ .017, while the ANOVA for age at assessment in
childhood approached statistical significance, F(2, 22) ⫽ 2.58, p ⫽
.098. At follow-up, participants classified as bisexual/homosexual
were, on average, significantly older than participants classified as
heterosexual or asexual, t(21) ⫽⫺2.54, p ⫽ .019, and t(8) ⫽
⫺2.37, p ⫽ .046, respectively. There was no significant difference
in the mean age at follow-up between participants classified as
heterosexual and those classified as asexual, t(15) ⫽⫺1.30, p ⫽
.211. For the Kinsey behavior ratings, the one-way ANOVAs for
40
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age at assessment and follow-up were nonsignificant, F(2, 22) ⫽
2.14, p ⫽ .142, and F(2, 22) ⫽ 2.73, p ⫽ .087, respectively.
Social Desirability
One-way ANCOVAs (age at follow-up covaried) were con-
ducted to evaluate the proportion of socially desirable responses on
the M–C SDS for participants classified as heterosexual, bisexual/
homosexual, and asexual in fantasy and behavior. There were no
significant differences in the proportion of socially desirable re-
sponses on the M–C SDS as a function of Kinsey ratings in either
fantasy or behavior, F(2, 20) ⫽ 1.00, ns, and F(2, 20) ⬍ 1,
respectively (data not shown; see footnote 2).
Relation Between Sex-Typed Child Behavior and Sexual
Orientation
To evaluate whether degree of cross-sex-typed behavior in
childhood was related to sexual orientation at follow-up, we used
the z-composite of sex-typed behavior as a function of Kinsey
classification in fantasy (heterosexual, bisexual/homosexual, asex-
ual). With age at follow-up covaried, there was no significant
difference in participants’ cross-sex-typed behavior in childhood
as a function of sexual orientation in fantasy, F(2, 21) ⫽ 1.06,
partial ␩
2
⫽ .09 (data not shown; see footnote 2). For Kinsey
ratings in behavior, however, a one-way ANCOVA was signifi-
cant, F(2, 21) ⫽ 6.45, p ⫽ .006, the strength of which was large,
as assessed by partial ␩
2
, with the Kinsey ratings accounting for
37% of the variance of participants’ cross-sex-typed behavior in
childhood. Participants classified as bisexual/homosexual (M ⫽
.52, SD ⫽ .49) had significantly more cross-sex-typed behavior in
childhood than participants classified as heterosexual (M ⫽⫺.04,
SD ⫽ .45) or asexual (M ⫽⫺.33, SD ⫽ .39), both ps ⬍ .05. There
was no significant difference in the mean z-composite of sex-typed
child behavior between participants classified as heterosexual and
those classified as asexual (see footnote 2).
For the Kinsey ratings in behavior, we reran this analysis with
the 3 gender-dysphoric participants removed (2 were classified as
bisexual/homosexual and 1 was classified as asexual). For the
z-composite, the main effect for Kinsey ratings in behavior re-
mained statistically significant, F(2, 18) ⫽ 3.58, p ⬍ .05, partial
␩
2
⫽ .29.
Relation Between Recalled Childhood Cross-Gender
Behavior and Gender Identity at Follow-Up
We conducted an evaluation of recalled cross-gender behavior
between gender-dysphoric and non-gender-dysphoric participants.
Table 5 shows the means and standard deviations of the RCGI
Factor 1 score. Participants classified as gender dysphoric at
follow-up (n ⫽ 2; Ms ⫽ 1.29 and 1.81, respectively) recalled
significantly more cross-gender identity and role behavior in child-
hood than participants classified as having no gender dysphoria
Table 4
Means and Standard Deviations of Age (in Years) as a Function of Kinsey Ratings in Fantasy
and Behavior
Age
None
Exclusively
heterosexual Bisexual/homosexual
pM SD M SD M SD
By Kinsey fantasy ratings
a
At assessment 12.42 .35 7.96 3.10 9.75 2.73 .098
At follow-up 17.22 .18 21.76 4.78 27.50 5.88
.017
By Kinsey behavior ratings
b
At assessment 9.94 3.99 7.51 2.51 10.02 1.91 .142
At follow-up 20.66 5.11 22.81 4.79 27.45 6.93 .087
a
For participants grouped by Kinsey fantasy ratings, n ⫽ 2, n ⫽ 15, and n ⫽ 8 for participants with no fantasies,
exclusively heterosexual fantasies, and bisexual/homosexual fantasies, respectively.
b
For participants grouped
by Kinsey behavior ratings, n ⫽ 8, n ⫽ 11, and n ⫽ 6 for participants with no behaviors, exclusively heterosexual
behaviors, and bisexual/homosexual behaviors, respectively.
Table 5
Mean Factor Scores and Standard Deviations on the Recalled
Childhood Gender Identity/Gender Role Questionnaire (Zucker
et al., 2006) for Gender Identity Status and Sexual Orientation
at Follow-Up
Group MSD d n
Gender identity status
Gender dysphoric 1.55 .36 ⫺1.96 2
No gender dysphoria 2.69 .59 18
(Adolescent girls with GID) (2.15) (.58) (25)
Sexual orientation
a
Heterosexual 2.82 .54 1.88 15
(Heterosexual comparison sample) (3.34) (.53) (30)
Bisexual/homosexual 1.84 .44 5
(Homosexual comparison sample) (2.68) (.72) (21)
Note. The absolute range was 1.00–5.00. A lower score indicates more
recalled atypical gender identity and gender role behavior. Twenty partic-
ipants completed the questionnaire because the RCGI was not yet part of
the follow-up protocol for 5 participants. Groups and values in parentheses
are from Zucker et al. (2006); the factor scores were from a sample of
heterosexual and homosexual female university students unselected for
gender identity. GID ⫽ gender identity disorder.
a
Sexual orientation was determined on the basis of Kinsey ratings for
fantasy and behavior.
41
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(n ⫽ 18; M ⫽ 2.69; range, 1.56–3.87), t(18) ⫽⫺2.62, p ⫽ .017.
As shown in Table 5, the mean Factor 1 score on the RCGI for the
participants with persistent gender dysphoria was more extreme
than it was for a sample of clinic-referred adolescent girls (n ⫽ 25)
with GID reported on by Zucker et al. (2006), whereas the mean
score of the participants without gender dysphoria was somewhat
less extreme.
Further analyses on the RCGI Factor 1 score by sexual orien-
tation revealed that participants classified as bisexual/homosexual
recalled significantly more cross-gender identity and gender role
behavior in childhood than did participants classified as hetero-
sexual or asexual, t(18) ⫽ 3.65, p ⫽ .002.
Discussion
The data reported in this article represent the first systematic
psychosexual follow-up into late adolescence and young adulthood
of clinic-referred girls with potential problems in their gender
identity development. The two key findings were as follows: (a)
the percentage of girls with persistent gender dysphoria was mod-
est but arguably higher than the base rate of GID in the general
population of biological females, and (b) the percentage of girls
who differentiated a later bisexual/homosexual sexual orientation
was moderate but clearly higher than the base rates of bisexual/
homosexual sexual orientation in general survey and epidemiolog-
ical studies of adolescent girls and young adult women in which
sexual orientation (in fantasy and/or behavior) was assessed with
at least some gradation in response options (as opposed to simple
dichotomous items).
Before providing an analysis of these findings, we note two
limitations of the study. First, the sample size was small, but this
is, at least in part, understandable because the number of referred
girls to specialized gender identity clinics is notably lower than
that of referred boys (e.g., Cohen-Kettenis et al., 2003, 2006).
Second, the present study did not have a concurrent control group
(e.g., a group of girls referred for other kinds of clinical concerns
or a group of nonreferred girls). Accordingly, some of our com-
parative analyses relied on epidemiological or survey data.
Regarding the persistence of gender dysphoria from the child-
hood assessment to the follow-up, the present study found that the
vast majority of the girls showed desistance: 88% of the girls did
not report distress about their gender identity at follow-up. The
high rate of desistance appears to differ quite markedly from the
findings of other follow-up studies of adolescent girls and adult
women with GID (in which the baseline assessment is in adoles-
cence or adulthood). In these studies, the rate of GID persistence
appears to be, at minimum, around 70% (Cohen-Kettenis & van
Goozen, 1997; Smith, van Goozen, Kuiper, & Cohen-Kettenis,
2005). In a comparative developmental perspective, then, there
appears to be important variation in GID persistence between
childhood and adolescence/young adulthood.
How might this disjunction be understood? One possibility
pertains to the differences in the DSM criteria for GID that are used
for children versus those that are used for adolescents/adults. The
criteria for GID in girlhood place relatively greater weight on
surface behaviors of cross-gender identification, whereas the cri-
teria in adolescence and adulthood rely more strongly on behaviors
and feelings pertaining to the disjunction between gender subjec-
tivity and somatic sex. Thus, it is conceivable that the childhood
criteria for GID may “scoop in” girls who are at relatively low risk
for adolescent/adult gender dysphoria, which revolves so much
around somatic indicators (e.g., distress regarding breast develop-
ment or other markers of physical femaleness, etc.).
It should, however, be noted that adolescent girls and adult
women with GID typically recall the same kinds of cross-gender
behavior patterns in girlhood that correspond to the DSM criteria
for GID in childhood (e.g., Blanchard & Freund, 1983; Pearlman,
2006; Zucker et al., 2006), which are then augmented and exac-
erbated by the external physical markers of biological femaleness
at puberty. Indeed, in the present study, the recalled sex-typed
behavior from childhood of our participants was reasonably sim-
ilar to the childhood recollections of girls with GID assessed for
the first time in adolescence (see Table 5).
In the present study, 40% of the girls were not judged to have
met the complete DSM criteria for GID at the time of childhood
assessment (although some of these girls likely had met the com-
plete criteria at some earlier point in their development). Thus, on
the one hand, it could be argued that if some of the girls were
subthreshold for GID in childhood, then one might assume that
they would not be at risk for GID in adolescence or adulthood. On
the other hand, it could be argued that cross-gender identification
in girlhood (including subthreshold GID) is a risk factor for later
GID; that is, under some conditions, there is an intensification of
cross-gender identification that results in the development of gen-
der dysphoria (see Green, 2003). Indeed, clinical experience with
adolescent girls with GID indicates that not all of them would have
met the complete criteria for GID in girlhood. Indeed, it is not
uncommon for the parents of these girls to recall that their daugh-
ters identified as “tomboys” during childhood and that they did not
remember them voicing the desire to want to become a boy, but
that their gender dysphoria emerged only around the time of
puberty (see, e.g., Pearlman, 2006; Zucker, 2006, Case 1).
If one accepts the argument that girlhood cross-gender identifi-
cation is a risk factor for gender dysphoria in adolescence and
adulthood, the relatively high rate of desistance in the current study
(in comparison with the relatively high rate of persistence seen in
gender-dysphoric girls and women assessed for the first time in
adolescence or adulthood) suggests that there is some type of
plasticity in gender identity differentiation that operates early in
development but then narrows considerably by adolescence. Thus,
at least among the girls in the present sample, some factor or set of
factors may have operated to lessen the likelihood that their gender
dysphoria or cross-gender identification would persist or intensify
in adolescence and adulthood. Of course, such factors could in-
clude both biological and psychosocial influences, but the system-
atic identification of such factors was beyond the scope of the
present investigation.
To our knowledge, the results of the present study represent the
first prospective data set that shows that girlhood cross-gender
identification is associated with a relatively high rate of bisexual/
homosexual sexual orientation in adolescence and adulthood. Us-
ing survey data on sexual orientation in young women as a com-
parative metric, we estimated that the odds of reporting a bisexual/
homosexual sexual orientation in fantasy was 8.9–23.1 times
higher in the present sample and that the odds of reporting a
bisexual/homosexual sexual orientation in behavior was 6.7–15.5
times higher. In this respect, the data show at least some conver-
42
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gence with data from retrospective studies (Bailey & Zucker,
1995).
A strength of the present study was that the assessment of sexual
orientation was based on a multiparameter, face-to-face interview
from which Kinsey global ratings were derived and that was
complemented by self-report on psychometrically sound question-
naires (cf. Savin-Williams, 2006). Although one has to be cautious
about the possibility that our participants underreported a minority
sexual orientation, it should be recalled that we found no signifi-
cant relation between our Kinsey classifications and the propensity
to give socially desirable responses on the M–C SDS.
Our classification of participants’ sexual orientation was based
on fantasy and behavior ratings for the 12-month period prior to
follow-up. In the literature on women’s sexual orientation, there
has been a lot of recent discussion regarding its stability versus its
fluidity (see, e.g., Baumeister, 2000; Peplau et al., 1999). Diamond
(2005b), for example, followed 79 self-labeled lesbian, bisexual,
and “unlabeled” sexual minority women over an 8-year period
(mean age at baseline, 19 years). At the 8-year follow-up, 92.4%
of the women continued to self-label as lesbian, bisexual, or
unlabeled, although there was considerable fluctuation within
these three categories over time (e.g., lesbian to bisexual or unla-
beled to lesbian). The remaining 7.5% of the women self-labeled
as heterosexual at the follow-up. In our view, Diamond’s (2005b)
data suggest considerable stability of a minority sexual orientation
despite the evidence of greater fluidity within the subcategories of
lesbian, bisexual, and unlabeled.
One limitation of Diamond’s study was that it did not include a
group of self-labeled heterosexual women at baseline; thus, com-
parative evidence on the stability or fluidity of a majority sexual
orientation was not available. Using data from the National Lon-
gitudinal Survey of Adolescent Health, however, Savin-Williams
and Ream (2007) provided data on the stability of a heterosexual
sexual orientation (attraction and behavior) of several thousand
girls and women between the ages of 15 and 26 years in a
three-wave assessment. In their study, there was considerable
evidence for a stable heterosexual sexual orientation. For example,
only 3.1% of girls who reported exclusive heterosexual attractions
at Wave 1 reported bisexual or lesbian attractions at Wave 3, and
only 3.5% of girls who reported exclusive heterosexual behavior at
Wave 1 reported bisexual or lesbian behavior at the Wave 3. Given
these findings, the case could be made that our participants’ sexual
orientations will remain relatively stable over time but, on this
point, only continued follow-up can test this conjecture empiri-
cally.
Because there was considerable variability in sexual orientation
at follow-up, we made some relatively crude efforts at predicting
such variation (compromised, of course, by the small sample size).
There were hints in the data that younger age at assessment in
childhood was associated with a later heterosexual sexual orien-
tation (Table 4), but the effects were weak. The composite index of
sex-typed behavior in childhood was not significantly associated
with sexual orientation in fantasy, but it was with sexual orienta-
tion in behavior, with those participants classified as bisexual/
homosexual exhibiting more cross-gender behavior). We also
found that participants classified as bisexual/homosexual recalled
having engaged in more cross-gender behavior during childhood
than those classified as heterosexual or asexual (Table 5). These
data are suggestive, therefore, of a “dosage” effect, that is, that
degree of girlhood cross-gender identification is associated with a
greater likelihood of a later minority sexual orientation. Of course,
these preliminary findings need to be confirmed in much larger
clinical samples; in addition, it would be desirable to examine
whether or not variation in degree of girlhood cross-sex-typed
behavior is related to sexual orientation in epidemiological sam-
ples drawn from nonclinical populations.
How do the results of the present study compare with those of
follow-up studies of boys with GID? In Zucker (2005b), a
follow-up on 40 boys with GID from the same clinic, using the
same methods as in the present study, showed a persistence rate of
20%, only modestly higher than the rate of 12% for the girls in the
present study. In Zucker (2005b), 42.5% of the boys were classi-
fied as bisexual/homosexual in fantasy, which is again only mod-
estly higher than the rate of 32% for the girls in the present study;
however, the rate of a bisexual/homosexual sexual orientation in
fantasy was considerably lower than the 75% found by Green
(1987) in his study of feminine boys. In comparison with the boys
followed up by Green (1987) and by Zucker (2005b), it is impor-
tant to note that the girls in the present study were, on average,
several years older at follow-up, which, if anything, would suggest
that the likelihood of underreporting a minority sexual orientation
would be lower for this sample than for the samples of boys.
If it proves to be the case that cross-sex-typed behavior is,
indeed, less closely linked to a later bisexual/homosexual sexual
orientation in girls than it is in boys, this would be consistent with
a prediction made by Bailey and Zucker (1995) in their meta
analytic retrospective study. It would also be consistent with recent
theorizing on the greater flexibility of sexual orientation in women,
in which it has been argued that relational factors during adoles-
cence and adulthood play a more important role in sexual partner
preference than it does in men (Diamond, 2003, 2005a; Peplau et
al., 1999). It is apparent from the present study that there is
considerable within-sex variation to be explained in the long-term
psychosexual differentiation of behaviorally masculine girls, with
regard to both gender identity and sexual orientation. These find-
ings suggest that any reductionist account of psychosexual differ-
entiation will likely be unable to capture this variation. Multivar-
iate models are clearly required in order to identify the best
predictors of such within-sex variation. On this point, the field will
hopefully move forward as larger samples are collated, including
prospective, epidemiologically based cohorts that incorporate the-
oretically based predictor variables.
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Received September 27, 2006
Revision received July 24, 2007
Accepted July 31, 2007 䡲
45
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