sexuality. The reported changes and consolidation in gender identity shortly before or in the early stages of puberty in this study corre- spond with the impression of some clinicians that, before puberty, gender identity is more malleable than later in adolescence or in adult- hood (e.g.,
Byne et al., 2012). It may be that pubertal hormones only steer the process. However, as the adolescents themselves indicate that the perception of others and their sexual feelings (and perhaps even related factors, such as body image)
also play a role, it is more like- ly that in the process of consolidation of their experienced gender all these elements had to be experienced, explored, and weighed, particu- larly when gender identity was not yet firmly established in childhood. Adult gender dysphoria is not a homogeneous condition and there are various ways of classifying gender dysphoric individuals (see Lawrence, 2010, for an overview). In a significant number of natal males with gender identity problems (little is known about females), gender dysphoria only develops during or after puberty. In the early stages of puberty, these adolescents discover that they find wearing female
clothing sexually exciting (Zucker et al., 2012). According to themselves and their parents, they often have not been particularly feminine in childhood. During ado- lescence, or much later, the role of sexual arousal diminishes or vanishes, and the desire to live permanently in the female role becomes so strong that they apply for gender reassignment. This late onset gender dysphoria thus seems to be erotically motivated (at least initially) and is denoted in the literature as
autogynephilia, because
Blanchard (1985) stated that the sexual arousal in these men is accompanied with the thought or image of one-self as a female. Therefore this form of gender dysphoria could be conceptualized as a paraphilia. Because they are usually
sexually attracted to women, gender dysphoric individuals should, according to Blanchard, be classified on the basis of their sexual orientation:
homosexual – in rela- tion to their natal sex – or
non-
homosexual. Blanchard's conceptualization has created much debate (e.g. Nuttbrock et al., 2011) and onset age has been proposed as a valid classification criterion as well (e.g. Nieder et al., 2011). Although sexuality certainly plays a role in late onset gender dysphoria, autogynephilic fantasies may not be the only reason why ado- lescents start cross-dressing. For instance, clinically some report that they
started cross-dressing as some form of comfort-seeking.
Irrespective
of the underlying mechanism, in both the late and early onset routes, adolescence seems to serves as a crucial period, either because it consolidates an already existing development or because it initiates a development that eventually leads to a full blown gender dysphoria.
Factors related to gender variant identity development
Because gender identity generally develops in accordance with one's natal sex it is virtually impossible to assess the separate contri- bution of biological and psychosocial factors in normative developing individuals. Studies focusing on the development of gender identity in individuals with DSD and individuals with gender dysphoria or GID offer more possibilities to determine the relative contribution of these factors to the development of gender identity.
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