[Gender identity disorder and related sexual behavior problems in children and adolescents: from the perspective of development and child psychiatry].

The present paper reviews the theoretical and empirical literature on children and adolescents with gender identity disorder. The organizational framework underlying this review is one that presents gender behavior in children and adolescents as a continuum rather than as a dichotomy of normal versus abnormal categories. Theories of normative gender development, prevalence, assessment, developmental trajectories, and comorbidity were investigated. There is a greater fluidity and likelihood of change in the pre-pubertal period. It was reported that the majority of affected children had been eventually developing a homosexual orientation. As an approach to determine the prevalence of GID in clinical samples in our child psychiatry clinic, screening instruments that include items on cross-gender or cross-sex identification were used. We applied the Child Behavior Checklist (CBCL). Of the 113 items in the Japanese version of the CBCL, there are two measures of cross-gender identification: "behaves like opposite sex" and "wishes to be opposite sex." Like the other items, they are scored on a 3-point scale of: 0-not true, 1- somewhat true, and 2-very true. Our study of 323 clinically-referred children aged 4-15 years reported that, among the boys, 9.6% assigned a score of 1 (somewhat true) or a score of 2 (very true) to the two items. The corresponding rates for the clinically-referred girls were 24.5%. The item of diagnosis of GID in our clinical sample was significantly higher than in non-referred children, reported as 2-5% using the same method. Two clinical case histories of screened children are also presented. Both of them were diagnosed with PDDNOS. Together with the literature review, most of the gender-related symptoms in autistic spectrum disorders (ASD) could be related to the behavioral and psychological characteristics of autism as shown in case histories. ASD subjects in adolescence can sometimes develop a unique confusion of identity that occasionally exaggerates to gender-related problems. However, these views do not explain all cases; true comorbidity of ASD and GID should be considered. A full assessment including evaluation of the family, school, and social environment is essential as other emotional and behavioral problems are very common and unresolved issues in the child's environment are often present e. g., loss. Separation problems are particularly common in the younger group. Intervention should aim to assist development, particularly that of gender identity. It should focus on ameliorating the comorbid problems and difficulties in the child's life and reducing the distress experienced by the child.