An 8-year-old boy is brought to see a child and adolescent psychiatrist because of his mother’s complaint that he repeatedly states that he wants to be a girl. She also notes that he has always seemed to prefer girls’ clothes and frequently gets upset in the mornings when his mother dresses him in typical boy clothes for school. His play activities are characterized by games more frequently enjoyed by girls, and he prefers to play with girls. When his mother reminds him that he is a boy and should act like a boy, he frequently gets upset and sometimes has a temper tantrum. The boy has no significant past medical history, and physical examination is within normal limits. Into which of the following areas is this boy’s difficulty best classified?
A. Gender identity
B. Intellectual development
C. Sexual aversion
D. Sexual identity
E. Sexual orientation
Explanation: The correct answer is A. Gender identity is a person’s sense of maleness or femaleness. The formation of gender identity is based on many cultural influences, physical characteristics, and parental attitudes. The standard and healthy outcome in the development of gender identity is a relatively secure sense of identification with one’s biological sex. Individuals may be diagnosed with gender identity disorder when the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Intellectual development (choice B) is the process of maturation of normal cognitive functions. There is no evidence of an intellectual impairment in this case. Sexual aversion (choice C) refers to a persistent or recurrent extreme aversion to, and avoidance of all, or almost all, genital sexual contact with a sexual partner. Sexual aversion disorder is an adult sexual desire disorder, along with hypoactive sexual desire disorder. Sexual identity (choice D) refers to a person’s biological sexual characteristics: chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, and secondary sexual characteristics. In this case, there is no evidence of a disturbance in sexual identity-it is clear that the patient has a male phenotype, and presumably a male genotype (XY). Sexual orientation (choice E) describes the object of a person’s sexual impulses (heterosexuality, homosexuality, bisexuality). In this case, we have no information on the direction of the boy’s sexual impulses, or that he experiences conscious sexual impulses at this stage at all. The development of a homosexual orientation is rarely accompanied by a disturbance in gender identity, as these two developmental processes are quite distinct.