Gender identity disorder: an emerging problem for pediatricians.

A new pediatric problem is in town. In this issue of Pediatrics there are 2 articles concerning gender identity disorder (GID). There has been an explosion of public interest in recent years and concern about children who show an interest in changing their gender. This, of course, brings more inquiries to the pediatrician about what to do. Cross-gender behavior in children has been known for many years. Even in the Child Behavior Check List developed by Achenbach in the 1970s there are 2 gender questions for parents to complete. Mothers reported that 2% to 4% of boys and 5% to 10% of girls of a nonclinical sample between the ages of 4 and 18 behaved as the opposite gender from time to time. Less frequently, these mothers reported that their children wished to be the opposite gender. Using the Youth Self Report, 5% to 13% of teenage boys and 20% to 26% of teenage girls of a nonclinical sample reported cross-gender behavior. Two percent to 5% of boys and 15% to 16% of girls reported sometimes desiring to be the opposite gender. In spite of this relatively high rate of cross-gender behavior, very few patients have presented for evaluation and treatment even in countries such as the Netherlands where there is a wellestablished formal program for treatment. The prevalence there is of the order of 0.01% (1 in 10 000–30 000). Therefore, a lot of children seem to be experimenting with cross-gender behavior, but very few are following through to request gender change as they mature. However, combining this relatively high prevalence of cross-gender behavior with widespread information in the public domain concerning the availability of a new early treatment using puberty blocking hormones has produced a rapid increase in the number of referrals, as noted in the paper by Spack et al. His experience is not unique; I have also seen a similar increase in Texas. The more parents hear about childhood GID, the more they question if their child may need to change gender. Many of the presentations in the public media concerning childhood GID give the impression that a child with cross-gender behavior needs to change to the new gender or at least should be evaluated for such a change. Very little information in the public domain talks about the normality of gender questioning and gender role exploration and the rarity of an actual change. The burden of that education is going to fall on the pediatrician.