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Gender Identity

by George R. Brown, MD

Gender identity is how people see themselves, whether masculine, feminine, or somewhere in-between. Gender role is how people present themselves in public in terms of gender. It includes the way people dress, speak, wear their hair, in fact everything that people say and do that indicates masculinity or femininity. For most people, gender identity is consistent with their anatomic sex and their gender role (as when a man has an inner sense of masculinity and publicly acts in masculine ways).

Did You Know...

  • Many young boys go through a phase of playing with girls' toys.

Gender identity is well established by early childhood (18 to 24 months of age). During childhood, boys come to know they are boys, and girls come to know they are girls. Children sometimes prefer activities considered to be more appropriate for the other sex. However, this preference does not mean that a young girl who, for example, likes to play baseball and wrestle has a gender identity problem, as long as she sees herself as and is content with being female. Similarly, a boy who plays with dolls and prefers cooking to sports or to rough types of play does not have a gender identity problem as long as he identifies himself as and is comfortable with being male. Young boys often pass through phases where they play with girls' toys or clothes, but few of them have problems with gender identity as adults.

Children born with genitals that are not clearly male or female (see Genital Defects) usually do not have a gender identity problem if they are decisively reared as one sex or the other, even if they are raised in the gender role that is opposite to their biologic sex pattern. There have been some highly publicized cases, however, in which this approach has failed.

Gender Identity Disorders and Transsexualism

Gender identity disorders involve a significant discrepancy between a person's anatomic sex and the inner sense of self as masculine, feminine, mixed, or neutral. Transsexualism is the most extreme form of gender identity disorder.

  • Children focus on activities typically associated with the other sex and have negative feelings about their genitals.

  • Doctors base the diagnosis on symptoms indicating a strong preference to be the other sex.

  • People who feel a strong need to live as the other sex may be helped by counseling, hormone therapy, and sometimes irreversible genital surgery.

People with a gender identity disorder believe that they are victims of a biologic accident and that they are cruelly imprisoned in a body incompatible with their gender identity. That is, people who are biologically male feel like women trapped in a man's body, and vice versa. For transsexuals, the incompatibility felt is complete, severe, disturbing, and long-standing. Transsexualism appears to occur in about 1 of 11,900 male and 1 of 30,000 female births.

Most transsexuals are biologic males who identify themselves as females, sometimes early in childhood, and regard their genitals and masculine features with repugnance. However, most children with gender identity problems do not become transsexual adults.

Rarely, transsexuals are people who were born with genitals that are not clearly male or female (ambiguous genitals) or who have a genetic abnormality, such as Turner’s syndrome or Klinefelter’s syndrome. However, when children are clearly and consistently considered and reared as either boys or girls, even when genitals are ambiguous, most of them have a clear sense of their gender identity.


Problems with gender identity usually develop by age 2. Children who have these problems may do the following:

  • Prefer cross-dressing

  • Insist that they are of the other sex

  • Intensely and persistently desire to participate in games and activities associated with the other sex

  • Have negative feelings toward their genitals

For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may sit to urinate and wish to be rid of his penis and testes. For boys with a gender identity disorder, distress at the physical changes of puberty is often followed by a request for treatment that will make their body more like a woman’s.

Although most transsexuals began having gender identity problems in early childhood, sometimes gender identity disorders first become apparent during adulthood. People, usually men, may be cross-dressers first and not acknowledge their identification with the other sex until later in life. Some of these men marry or join the military as a way to escape or deny their feelings of wanting to be the other sex. Once they accept these feelings, many publicly adopt a convincing feminine gender role. Others experience problems, such as depression and suicidal behavior.

Most boys with a gender identity disorder do not grow up to have the disorder as adults, but many are homosexual or bisexual in their sexual orientation.


Most children with a gender identity disorder are not evaluated until they are 6 to 9 years old.

With children, a doctor bases the diagnosis on whether they have the following:

  • A strong, persistent desire to be or insistence that they are the other sex

  • A strong, persistent sense of discomfort about their sex or belief that they were born the wrong sex

  • Significant distress or problems functioning caused by these feelings

With adolescents and adults, a doctor bases the diagnosis on whether they do the following:

  • Express a desire to be the other sex frequently

  • Try to pass as the other sex

  • Want to live or be treated as the other sex

  • Believe that they feel and react like the other sex


Cross-gender behavior in adults, such as cross-dressing, may not require treatment if people do not have psychologic distress or trouble functioning in society.

Transsexuals may seek psychologic help, either to assist them in coping with the difficulties of living in a body that they do not feel comfortable with or to help them through a gender transition. Many transsexuals appear to be helped most by a combination of counseling, hormone therapy, electrolysis, and sometimes genital surgery (which is irreversible).

Some transsexuals with a milder form of gender identity disorder are satisfied with changing their gender role by working, living, and dressing in society as a member of the opposite sex. This approach may include obtaining identification (such as a driver's license) that helps them work and live in society as the opposite sex. They may never seek to alter their anatomy in any way. Many of these people, who are sometimes referred to as “transgenderists,” meet no criteria for a mental health disorder.

Did You Know...

  • Children with a gender identity disorder may insist that they are the opposite sex.

Other transsexuals, in addition to adopting the behavior, dress, and mannerisms of the opposite sex, appropriately receive hormone treatments to change their secondary sex characteristics. In biologic males, use of the female hormone estrogen causes breast growth and other body changes, such as wasting of the genitals (genital atrophy) and the inability to maintain an erection. In biologic females, use of the male hormone testosterone causes such changes as growth of facial hair, deepening of the voice, and changes in body odor and distribution of body fat.

Still other transsexuals request sex reassignment surgery. For biologic males, surgery involves removal of the penis and testes and creation of an artificial vagina. For biologic females, surgery involves removal of the breasts and the internal reproductive organs (uterus and ovaries), closure of the vagina, and creation of an artificial penis. For both sexes, surgery is preceded by use of the appropriate sex hormone ( estrogen in male-to-female transformation and testosterone in female-to-male transformation), and a real-life experience living in the opposite gender role for at least 1 year.

Although transsexuals who have sex reassignment surgery cannot procreate, many are able to have satisfactory sexual relations. The ability to achieve orgasm is often retained after surgery, and some people report feeling comfortable sexually for the first time. However, few transsexuals endure the sex reassignment process for the sole purpose of being able to function sexually as the opposite sex. Confirmation of their inner sense of gender identity is the usual motivation.

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