Kenneth J. Zucker

A review of the long-term effects of child sexual abuse

The existing literature on the long-term sequelae of child sexual abuse is reviewed. The evidence suggests that sexual abuse is an important problem with serious long-term sequelae; but the specific effects of sexual abuse, independent of force, threat of force, or such family variables as parental psychopathology, are still to be clarified. Adult women with a history of childhood sexual abuse show greater evidence of sexual disturbance or dysfunction, homosexual experiences in adolescence or adulthood, depression, and are more likely than nonabused women to be revictimized. Anxiety, fear, and suicidal ideas and behavior have also been associated with a history of childhood sexual abuse but force and threat of force may be a necessary concomitant. As yet, there is insufficient evidence to confirm a relation between a history of childhood sexual abuse and a postsexual abuse syndrome and multiple or borderline personality disorder. Male victims of child sexual abuse show disturbed adult sexual functioning. The relation between age of onset of abuse and outcome is still equivocal. Greater long-term harm is associated with abuse involving a father or stepfather and abuse involving penetration. Longer duration is associated with greater impact, and the use of force or threat of force is associated with greater harm.

Childhood sex-typed behavior and sexual orientation: A conceptual analysis and quantitative review.

This article reviewed research examining the association between childhood sex-typed behavior and sexual orientation. Prospective studies suggest that childhood cross-sex-typed behavior is strongly predictive of adult homosexual orientation for men; analogous studies for women have not been performed. Though methodologically more problematic, retrospective studies are useful in determining how many homosexual individuals displayed cross-sex behavior in childhood. The relatively large body of retrospective studies comparing childhood sex-typed behavior in homosexual and heterosexual men and women was reviewed quantitatively. Effect sizes were large for both men and women, with mens significantly larger. Future research should elaborate the causes of the association between childhood sex-typed behavior and sexual orientation and to identify correlates of within-orientation differences in childhood sex-typed behavior. Psychosexual differentiation has been a topic of long-standing interest in developmental psychology. Both classical psychoanalytic theory and learning theory were particularly influential in guiding the first wave of empirical research conducted by developmentalists (see, e.g., ). Sexologists have also made seminal theoretical and empirical contributions. For example, introduced the term to refer to “all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It includes, but is not restricted to, sexuality in the sense of eroticism” (p. 254). Mischel, 1966 Money (1955) gender role Over the next two decades, gender role was decomposed into three conceptually distinct parts (see, e.g., ). First, was distinguished from gender role. For example, , p. 453) used the slightly different term to describe a young childs developing “fundamental sense of belonging to one sex.” Cognitive–developmental psychologists (e.g., ) have used the term gender identity to indicate primarily that a child can accurately discriminate male from female individuals and identify correctly his or her own gender—a task considered by some to be the first stage in gender constancy development. Fagot & Leinbach, 1985 gender identity Stoller (1964 core gender identity Kohlberg, 1966 Compared with original definition, the term gender role is now defined more narrowly. Many scholars have used the term to refer to behaviors, attitudes, and personality traits that a society designates as masculine or feminine, that is, more “appropriate” or typical for the male or female social role (cf. ; ). In young children, the measurement of gender role behavior includes several easily observable phenomena, including affiliative preference for same versus opposite sex peers, interest in rough-and-tumble play, fantasy roles, toy interests, and dress-up play (see ). In this article, we use the term to refer to those behaviors that have been typically studied as markers of childhood gender identity and gender role. Moneys (1955) Huston, 1983 Unger, 1979 Zucker, 1985 sex-typed 5/14/03 7:25 AM Ovid: Bailey: Dev Psychol, Volume 31(1).January 1995.43–55 Page 2 of 23 https://snap.it.northwestern.edu/p/p.cgi/ovidcom/gateway1:80/ovidweb.cgi The third, erotic, component of original definition of gender role has also been operationalized more narrowly, most commonly under the rubric of the term . In contemporary sexology, sexual orientation refers to whether a person is more strongly aroused sexually by members of his or her own sex, the opposite sex, or both sexes (homosexual, heterosexual, and bisexual, respectively). Moneys (1955) sexual orientation The behavioral markers of gender identity and gender role emerge early, typically by ages 2–4 years, and become “consolidated” thereafter (e.g., ; ). In contrast, sexual orientation appears to be more readily assessed after puberty, as a persons sexual interests and desires become more salient (cf. ). At least three models have been proposed about the relation between childhood sex-typed behavior and later sexual orientation. One model hypothesizes a developmental sequence in which gender identity develops before gender role, which, in turn, develops before sexual orientation (e.g., ; ). In this model, adult sexual orientation is conceptualized as an of psychosexual differentiation, analogous, for example, to as an end state of cognitive development. Another model reverses this developmental sequence, positing that sexual orientation is apparent early enough in development to influence the expression of sex-typed behavior (e.g., ). A third model gives less attention to the temporal sequence between these two variables and instead emphasizes the possibility that sex-typed behavior and sexual orientation are both influenced by the same factors, such as prenatal sex hormones (see ; , pp. 12–15). Fagot, 1985 Huston, 1983 Meyer-Bahlburg, 1980 Green, 1974, 1987 Meyer-Bahlburg, 1980 end state formal operations

Gender identity disorder.

Because gender identity disorder (GID) in children is relatively uncommon, most child clinicians and researchers are likely to have had very little direct experience with it. In this chapter, I provide a selective overview of our knowledge about children with GID. In keeping with the general mission of this volume, where appropriate, I focus on the interface between typical and atypical development in my consideration of children with GID.

The DSM Diagnostic Criteria for Gender Identity Disorder in Children

In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as “disorder,” as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.

Gender Identity Disorder in Twins: A Review of the Case Report Literature

INTRODUCTION The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables. AIM To review the current literature on case studies of twins concordant or discordant for GID. METHODS A systematic, comprehensive literature review. RESULTS Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P=0.005). Of the seven opposite-sex twins, all were discordant for GID. CONCLUSIONS These findings suggest a role for genetic factors in the development of GID.

Cross-Gender-Identified Children

It may come as a surprise to some that this well-known retrospective researcher was sensitive to the method’s limitations. Despite their shortcomings, retrospective methods have made important contributions to the domains of developmental psychology and psychopathology. Their widespread use may be largely attributable to the acceptance by most students of development of the view that early experiences affect later behavior. Retrospective methods, for better or for worse, have played a major role in appraising the idea of continuity in development.

A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder

This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto. The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provide clinical examples of how the model is used in the treatment.

Gender Identity Disorders

The gender identity disorders (GID) are defined as disorders in which an individual exhibits marked and persistent identification with the opposite sex and persistent discomfort (dysphoria) with his or her own sex or sense of inappropriateness in the gender role of that sex. Other terms, such as transsexual, transgendered and transvestite, are explained, as are gender role, sexual orientation and sexual identity. Prevalence estimates of GID are between 110,000 to 1:30,000. Sex ratios in adults are roughly equal but in childhood are 6 (males) to 1 (female). A brief description of the historical background and recent political challenges to the diagnosis of GID are provided. Based on current theory and research there is some support for a biological predisposition, which may reflect a general vulnerability to psychopathology, and psychosocial factors which shape that predisposition. Management includes child and family interventions, psychotherapy, and surgical and hormonal interventions. Outcome is variable, with relinquishment of GID for those children seen early with cooperative parents, and greater stability of GID in children seen later in childhood or adolescence. Surgical and hormonal reassignment in adults who meet criteria is generally successful. Evaluation of the various interventions, especially in childhood, is needed.

Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism.

This study provided a descriptive and quantitative comparative analysis of data from an assessment protocol for adolescents referred clinically for gender identity disorder (n = 192; 105 boys, 87 girls) or transvestic fetishism (n = 137, all boys). The protocol included information on demographics, behavior problems, and psychosexual measures. Gender identity disorder and transvestic fetishism youth had high rates of general behavior problems and poor peer relations. On the psychosexual measures, gender identity disorder patients had considerably greater cross-gender behavior and gender dysphoria than did transvestic fetishism youth and other control youth. Male gender identity disorder patients classified as having a nonhomosexual sexual orientation (in relation to birth sex) reported more indicators of transvestic fetishism than did male gender identity disorder patients classified as having a homosexual sexual orientation (in relation to birth sex). The percentage of transvestic fetishism youth and male gender identity disorder patients with a nonhomosexual sexual orientation self-reported similar degrees of behaviors pertaining to transvestic fetishism. Last, male and female gender identity disorder patients with a homosexual sexual orientation had more recalled cross-gender behavior during childhood and more concurrent cross-gender behavior and gender dysphoria than did patients with a nonhomosexual sexual orientation. The authors discuss the clinical utility of their assessment protocol.

Fraternal birth order and birth weight in probably prehomosexual feminine boys

The purpose of this study was to confirm a previous finding that homosexual males with older brothers weigh less at birth than do heterosexual males with older brothers. The subjects comprised 250 feminine boys referred to a child psychiatry service because of extreme cross-gender wishes or behavior and assumed, on the basis of previous research, to be prehomosexual, plus 739 control boys and 261 control girls referred to the same service for reasons unrelated to sexual orientation or gender identity disorder and assumed, from base-rate probabilities, to be preheterosexual. The feminine boys with two or more older brothers weighed 385 g less at birth than did the control boys with two or more older brothers (P = 0.005). In contrast, the feminine and control boys with fewer than two older brothers did not differ in birth weight. This finding suggests that the mechanism by which older brothers increase the odds of homosexuality in later-born males operates prior to the individuals birth. We hypothesize that this mechanism may be immunologic, that antimale antibodies produced by human mothers in response to immunization by male fetuses could decrease the birth weight of subsequent male fetuses as well as increase their odds of homosexuality.