Boys will be girls

What do you do when your child wants to be the opposite sex?

The phrase "boys will be boys" is often used by parents as a throwaway comment to excuse rough-and-tumble games. Delve deeper and you might question why a girl barely out of nappies can't help but rifle through your make-up bag and why your small son insists on brandishing plastic swords and toy guns around the house. But at what stage in childhood does our gender identity become fixed - and what if there is a mismatch with the biological sex we are given?

The fact is that most people conform to the body they are born with, but for a small minority of children, this acceptance can be a daily battle.

Gender identity disorder (GID) is when the biological sex of a person does not match their gender identity, but those with GID often describe it as "feeling trapped inside the body of the wrong sex". According to science, our biological sex is determined by our chromosomes and hormones, but accepting the gender we are given is not always so simple.

Dr Domenico Di Ceglie, a child psychiatrist and founder of Britain's only NHS gender identity development service, at London's Portman Clinic, explains that people with GID have a strong sense of conviction or a wish to belong to the opposite sex.

"Nobody knows for sure what determines this profound sense of perception," he explains. "It could be a whole range of factors working together, involving responses to traumatic events, hormonal influences or different life experiences at critical points of brain development. But what we do know, is that in some children it becomes a permanent feature of their personality that stays with them into adulthood."

It could be argued that it is commonplace for children to have gender issues while they are growing up. Plenty of women recall childhood memories of adopting stereotypically boyish traits such as cutting their hair short or climbing trees.

But, explains clinical psychologist Dr Chris Williams, "girls who are tomboys are demonstrating distinct patterns of behaviour, which is very different to identifying themselves as boys and struggling emotionally to be a girl.

"Our society is much more accepting of girls being tomboys, which involves dressing like boys and engaging in boyish activities," says paediatrician Ilona Bendefy. "As a result, parents may pick up differences in their son's sexual behaviour much sooner than they would for a daughter." Experts tend to agree that the incidence of GID for both sexes may be the same, but the prevalence among girls is less, because society is far more tolerant of male behaviour in females. Perhaps, it is not surprising then, that most children referred to gender clinics are boys. According to research, six times more boys than girls seek guidance on how to overcome such problems.

So how can you tell if your child has a gender identity disorder? Most children develop a clear sense of whether they are boys or girls between the ages of 18 and 30 months. After this age, a period of gender stability occurs and children adopt stereotypical behaviour - starting to dress and play in ways appropriate to their gender identity.

However, children with GID may well show different kinds of behaviour. He or she may insist they belong to the opposite sex. Boys may show a preference for cross-dressing or playing the female role, while girls may adopt masculine clothing and be drawn towards rough-and-tumble games.

They may also show a strong preference for friends of the opposite sex and show signs of discomfort with their own body. For example, boys might be disgusted with their penis and want it to disappear as they grow older, and girls may want to hide away their breasts and vagina.

Although GID is a rare condition, doctors have noticed an increase in referrals to gender clinics.

"Society now has a better recognition of gender issues", says Di Ceglie. "In the past, ideas of identity were less clear or stigmatised, but now children and parents have a framework of naming things and know how to ask for help if such gender questions arise." Although there are no follow-up studies, it has been suggested that in a minority of children, the gender identity disorder will persist and manifest itself as transsexualism in adulthood. Referrals to clinics show that around one in 30,000 adult males and one in 100,000 adult females seek gender reassignment surgery. The remaining children who show signs of GID will develop a homosexual, bisexual or heterosexual orientation as adults.

Although it is still not known what causes GID, it is regarded as a medical condition and one study shows that amniocentesis, which tests for spina bifida in pregnancy, can cause a surge of hormones to the foetus, which in turn, can trigger a hormonal imbalance in the child resulting in GID.

Indeed, Dr Glenn Wilson, from London's Institute of Psychiatry, believes that hormones play a big part in gender identity. "If there is maternal stress during pregnancy, this can block the effect of emasculating or feminising hormones at the point when the foetal brain development is establishing gender identity."

But Dr Di Ceglie is not convinced that GID in childhood can be explained by a simple causal model, but rather by a combination of factors. He cites one case where an eight-year-old boy lived with his aunt from the age of six months and encouraged him to help her with cooking and tidying up the house.

After her sudden death, the little boy developed GID. He played with dolls and fantasised that he was a mother breastfeeding his dolls. At school he wanted to play with girls and avoided rough-and-tumble play.

He could not talk about the death of his aunt for several months, but therapy revealed that his make-believe play was his way of dealing with his loss. Eventually the features of his GID disappeared.

Paul Shaw, whose son is now seven, first noticed signs of GID when Josh was three. "Josh seemed to prefer playing with dolls and make-up rather than cars and planes like his brother, but we put it down to the influence of his younger sister - behaviour we now know are typical signs of GID.

"As Josh got older, we explained the boundaries to him. For school, we encourage him to wear neutral clothes, but at weekends he has free reign and can put on whatever he likes, which is often his favourite floral jeans and make-up."

Finding out what people will accept within your social network and getting advice on how to cope with prejudice is one of the solutions offered by Mermaids, a support group for children and teenagers with GID, which has seen a tenfold increase in inquiries since its formation in 1993. "Just speaking the same language and recognising that there is a particular issue can bring great relief to the child," says Margaret Griffiths, who founded the group when her daughter developed signs of GID.

One of the most common problems reported by parents contacting Mermaids, is that their child is unhappy at school - often because of bullying or feelings of alienation. "Kids are quick to pick up on anything different: a simple hand gesture or even a type of walk can be a dead giveaway," says Griffiths, who remembers when Boy George was asked how he first knew he was different - and he replied, "when other kids told me".

This rings true with Shaw who believes that greater awareness at school is vital to the wellbeing of children like Josh. "People are aware of transsexual adults, but most of us don't make the connection that those adults were once children too," he says. "Teachers and other parents can be unkind to problems they don't understand - after all gender is one of the last taboos."