Recalled gender-related play behavior and peer-group preferences in childhood and adolescence among adults applying for gender-affirming treatment

ABSTRACT

Norms are considered to influence expectations toward gender-related behavior. Deviations from these norms are often perceived negatively by the social environment. The objective of this study was to investigate adults diagnosed with a Gender Identity Disorder (GID), their recalled play behavior, and peer preferences in childhood and adolescence. Differences between individuals who applied for transition from female to male (FtMs) and those who applied for transition from male to female (MtFs) and between age-of-onset subgroups were explored. Data collection took place as part of the European Network for the Investigation of Gender Incongruence. The sample consisted of N = 634 participants (mean age = 30.6) diagnosed with GID according to DSM-IV-TR who were recruited between 2007 and 2012. Participants answered two questions regarding recalled play behavior and three questions on peer preferences. Nonconforming gender expression was more frequently recalled in FtMs than MtFs. Within gender groups, individuals who were categorized as early-onset recalled nonconforming gender expression more frequently than individuals who were categorized as late-onset. The results of the study are in line with previous findings indicating different phenomenological pathways in individuals applying for gender-affirming treatment that warrant attention. Factors that are considered to impact on gender-related differences in nonconforming gender expression are discussed.

KEYWORDS:

• Gender identity disorder
• gender dysphoria
• transgender
• childhood play behavior
• childhood peer preferences

Acknowledgments

We would like to offer our special thanks to all who made this research possible. First of all, we are most grateful to the participants of this study. We would also express our very great appreciation to the collaborating medical and psychological staff and colleagues from all four gender clinics.

Disclosure statement

The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

Notes

1. In the following description of research results, we refer to both subtyping and terminology used by the original authors. Thus, this terminology might not reflect the terminology used by the authors of the present study.

2. Blanchard proposed the existence of two subtypes of transsexual individuals based on sexual orientation related to sex assigned at birth: homosexual and non-homosexual. His typology based on data from three studies with male-to-female individuals (MtFs; Blanchard 1985, 1988, 1989). The homosexual group was more cross-gender oriented in childhood and preferred cross-gender partners. The non-homosexual group were more likely to be sexually aroused from the image of themselves as a woman, which Blanchard named autogynephilia.

3. Individuals who – in addition to the GID diagnosis – retrospectively fulfill criteria A and B of Gender Identity Disorder in Childhood (GIDC) are considered as having an early onset (EO). Those who fulfill neither criteria A nor B of GIDC were considered as having a late onset (LO). For a detailed description, see Methods section.

4. According to Rea and Parker (1992), the strength of an association between two variables is described by the following characterization: <.10 = negligible association; .10–.20 = weak association; .20–.40 = moderate association; .40–.60 = relatively strong association; .60–.80= strong association; >.80= very strong association.

Additional information

Notes on contributors

Andreas Koehler

Andreas Koehler is a master student at the University of Hamburg and graduated with a bachelor degree at the University of Osnabrueck. Since 2012, he worked as an intern at the Department of Sex Research and Forensic Psychiatry located at the University Medical Center Hamburg-Eppendorf (UKE). Currently, he is a student assistant at the Interdisciplinary Transgender Health Care Center Hamburg.

Hertha Richter-Appelt

Hertha Richter-Appelt is a psychoanalyst (IPA). She was the vice-director of the Department of Sex Research and Forensic Psychiatry at the University Medical Center Hamburg till 2014. She studied in psychology and statistics at the University of Vienna (Austria) and got training in behavior therapy at the Middlessex Hospital, London. Hertha Richter-Appelt was a research fellow and psychotherapist at the Universities Bern, Konstanz and Hamburg. Since 1997, she was a professor for sex research at the Medical Faculty of the Hamburg University. She was co-editor of the German Journal for Sex Research, principal investigator of a research project on medical experiences and quality of life of individuals with different forms of intersexuality (DSD), and co-initiator of the European multicenter study with Belgium, Netherlands and Norway on diagnostic criteria for gender dysphoria.

Susanne Cerwenka

Susanne Cerwenka, Ph.D., is a research assistant at the Department of Sex Research and Forensic Psychiatry located at the University Medical Center Hamburg-Eppendorf (UKE) and member of the European Network for the Investigation of Gender Incongruence (ENIGI). Her major research focus are experiences of discrimination, personal and social resources as well as sexual health of transgender individuals and other gender minority groups.

Baudewijntje P.C. Kreukels

Baudewijntje P.C. Kreukels, Ph.D., works as a researcher and research coordinator at the Center of Expertise on Gender Dysphoria and the Department of Medical Psychology of the VU University Medical Center, in Amsterdam, since 2006. Her research focuses on the concepts of gender incongruence and gender dysphoria, and the effects of – hormone – treatment on brain and behavior. She is a member of the steering committee of the European Network for the Investigation of Gender Incongruence. She supervises several PhD and master students in the field of gender incongruence.

Meike Watzlawik

Meike Watzlawik is a professor for Developmental Psychology at the Sigmund Freud University in Berlin. Her major research focus is identity development in adolescence. In her dissertation, she conducted a cross-cultural study on sexual identity development and has continued to work in this field since.

Peggy T. Cohen-Kettenis

Peggy T. Cohen-Kettenis is a professor emeritus of medical psychology. She participated in the development of the Standards of Care of the World Professional Association for Transgender Health (WPATH), and the Endocrine Society Clinical Practice guideline on the treatment of transsexuals. She was the chair of the American Psychiatric Association's DSM-5 sub-workgroup on Gender Identity Disorders and a member of the World Health Organization's ICD-11 working group on the classification of Sexual Disorders and Sexual Health.

Griet De Cuypere

Griet De Cuypere, M.D. Ph.D., graduated in medicine at the University Ghent in 1973 and qualified in psychiatry in 1977. She has been active in diagnostic and therapeutic work with transgendered people for nearly thirty years. As a psychiatrist-psychotherapist, she is the coordinator of the welll-known multidisciplinary gender team of the University Hospital Ghent, Belgium, collaborating with Prof. Dr. S. Monstrey, the team's plastic surgeon.

Ira. R. H. Haraldsen

Ira R. H. Haraldsen is a specialist in psychiatry and neurology, Oslo, Norway. She is qualified in medicine in Bonn in 1984, trained neurology and psychiatry in Cologne, FRG and Oslo, Norway. She has a special interest in neurobiological medicine, and is one of the founders of ENIGI.

Timo O. Nieder

Timo O. Nieder, PhD ECPS, is a mental health professional specialised in transgender care. He is head of the outpatient unit for sexual health at the Department of Sex Research and Forensic Psychiatry, deputy chairman of the Interdisciplinary Transgender Health Care Center Hamburg, both located at the University Medical Center Hamburg-Eppendorf (UKE). He is a member of the European Network for the Investigation of Gender Incongruence (ENIGI) and director of education and clinical training of the European Professional Association for Transgender Health (EPATH). He qualified in psychology in Berlin, Germany, is licensed to practise as a psychotherapist in cognitive behavioural therapy and trained in sex therapy -- he is approved as a EFS/ESSM certified psycho-sexologist (ECPS).