GID is characterized by intense and persistent cross-gender identification and discomfort with one’s own sex. In children these feelings may be manifested by behaviors such as cross-dressing, stating that one wants to be or is the opposite sex, and a strong and almost exclusive preference for cross-sex roles, games, and playmates. The onset of these behaviors often can be traced back to the preschool period. However referral for evaluation typically occurs at school age or later, when it becomes clear that the behaviors do not represent a transient phase, and the behaviors may begin to interfere with social relationships. Forty to 80% of children with GID will have a bisexual or homosexual sexual orientation as adults. However there is no reliable way to predict adult sexual orientation, and there is no evidence that parental behavior would alter the developmental pathway toward homosexual or heterosexual behavior.
In adults GID may be characterized by a belief that one was born the wrong sex and by a persistent desire to live and be treated as the opposite sex. Adults may request hormones or surgical procedures to alter sexual characteristics to simulate the other sex, but, when these procedures are done in individuals who have completed puberty, they often fail to fully achieve the appearance of the desired gender. Long-term follow-up studies of children with GID suggest that only 2% to 20% have GID as adults, but gender dysphoria that intensifies with the onset of puberty is likely to persist. In 2009 the Endocrine Society published guidelines that recommended considering reversible suppression of puberty using gonadotropin releasing hormone analogs at Tanner stages 2 through 3 for individuals with GID because this allows the adolescent more time to decide whether to begin cross-sex hormone treatment.
Identical twins (even twins raised in separate families) show a higher concordance rate for sexual orientation than would be expected by chance alone, but nowhere near 100%, as would be expected if genetics alone determined sexual orientation. Some studies have found differences in the size of certain brain regions in homosexual individuals, but the findings are inconsistent. The levels of androgens and estrogens have not been found to differ in homosexual and heterosexual adults. Although it is well documented that parents tend to treat boys and girls differently, if, or how, these interactions affect sexual orientation is unknown.
It is currently estimated that about 1% to 4% of adults identify themselves as homosexual. Given the prevalent negative societal attitudes toward homosexuality, these children are at high risk for having a negative self-esteem, being isolated, being verbally harassed, and often being physically assaulted. Although sexual behaviors, not sexual orientation, determine risk of sexually transmitted infections, homosexual male adolescents engage in high-risk behaviors despite the threat of infection from the human immunodeficiency virus (HIV). For medical and psychosocial reasons, health care providers need to provide an environment in which adolescents feel comfortable discussing their sexual orientation (Table 23-2).
Acknowledging that one is homosexual and disclosing it to one’s parents is often extremely stressful. Although many parents come to accept their child’s homosexuality, some parents, particularly those who view this behavior as immoral, may reject their child. Homosexual youth are at a high risk for homelessness. Adolescents need to be made aware that even parents who eventually come to accept their child’s homosexuality initially may be shocked, fearful about their child’s well-being, or upset about the loss of the adulthood they had expected for their child. Parents may need to be reassured that they did not cause their child to have a homosexual orientation. Likewise they may need to be informed that therapies designed to change sexual orientation not only are language (e.g., partner as opposed to husband/wife)
Ensure that one uses gender-neutral questions when asking about dating or sexual behaviors Display posters, brochures, and information that show concern for issues important to homosexual youth and their families Provide information about support groups and other resources for homosexual youth and their families
Adapted from Perrin EC: Sexual Orientation in Child and Adolescent Health Care, New York, 2002, Kluwer Academic/Plenum Publishers.