In addition, the researcher note that the relatively small sample size in their study did not allow separate genetic analyses for males and females (Coolidge et al.). Environmentalism (social influence). A recent study by Wallien and Cohen-Kettenis (2008) analyzed psychosexual outcomes of gender-dysphoric children at 16 years and older to determine childhood characteristics related to psychosexual outcomes based on various social influences that may be experienced during the timeframes studied. In this regard, this study began with a cohort of 77 children (mean age=8.4 years, range=5-12 years); at follow-up about 3-1/2 years later, 54 of these children (mean age=18.9 years, range=16-28 years) were still available and amenable to continue participation in the study. Of the original 77 subjects, 54 subjects, or 27% (12 boys and 9 girls), were found to be gender dysphoric (the researchers defined this cohort as the "persistence group"), and 43% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric (Wallien & Cohen-Kettenis). The 21 male and female subjects in the persistence group were found to be extremely cross-gendered in both behaviors and feelings; moreover, this group was also more likely to satisfy relevant gender identity disorder (GID) criteria during their childhood years than their counterparts in the other two groups (Wallien & Cohen-Kettenis). These authors conclude that, "At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation" (p. 1413). Based on their analysis, Wallien and Cohen-Kettenis conclude that, "Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality" (Wallien & Cohen-Kettenis, p. 1423).

The findings of a study by Bartlett, Vasey and Bulkowski (2000) suggest that the level of congruence between young people's perception of their gender and the respective role assigned to that gender by society provides support for a social basis for the condition of gender dysphoria in young people. These authors evaluated a series of empirical studies to determine whether gender identity disorder in children satisfied the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV) definitional criteria for mental disorder by analyzing whether gender dysphoria in children is associated with (a) present distress; (b) present disability; - a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (Bartlett et al.). Yet another factor studied by these authors was whether the gender identity disorder was regarded as a dysfunction in the individual or was viewed as deviant behavior or a conflict between the individual and society (Bartlett et al.). The authors conclude that, "The evaluation indicates that children who experience a sense of inappropriateness in the culturally prescribed gender role of their sex but do not experience discomfort with their biological sex should not be considered to have gender identity disorder" (Bartlett et al., p. 753).

Finally, citing the results of previous studies that have found a combination of hormonal and psychosocial factors as explanations for gender dysphoria, Slijper, Drop, Molenaar, Sabine and Keizer-Schrama (1998) emphasize that there is a probable biological basis for gender dysphoria, but that socialization factors play an important role as well. In this regard, Slijper and his colleagues report that, "It is possible that the conflict between biological and psychological forces can produce stress which, in a genetically vulnerable child who grows up in a family unable to raise the child unambiguously in the assigned sex, results in GID and general psychopathology" (p. 125).

Constructivism (new ideas or concepts based on current/past knowledge). Like many of the authorities reviewed above, researchers who employ a constructivist approach to the study of gender dysphoric individuals typically acknowledge that there are likely other biological and social forces at work as well. In this regard, Sloop (2004) reports that, "For both those who discuss the case publicly from a constructivist position and those who hold that gender is primarily an expression of the body's sex, gender is seen as being successfully or unsuccessfully behaved or expressed through particular clothing,...

It is these activities that make up in large part the reiteration of gender norms" (p. 28).
The purpose of a recent study Deogracias, Johnson, Meyer-Bahlburg, Kessler, Schober and Zucker (2007) was to develop a psychometrically sound dimensional measure of gender identity (gender dysphoria) that could be used with adolescents and adults of both sexes. The authors emphasize the importance of their study of populations of patients with gender identity conflict due to the prevalence of specific comorbid psychiatric conditions, including Asperger's disorder and eating disorders (Deogracias et al.). According to these authors, gender identity and/or core gender identity have been defined as a "person's basic sense of self as a male or female"; noting that a majority of males have a male gender identity and a majority of females have a female gender identity (congruent with their original legal sex and typically founded on the physical appearance of the genitalia at birth), the authors also note that gender identity is frequently conceptualized in "a bipolar, dichotomous manner with a male gender identity at one pole and a female gender identity at the other pole" (Deogracias et al., p. 370). The authors also note, though, that males and females who are experiencing an uncertain or confused gender identity or who are in the process of transitioning from one gender to the other do not satisfy these dichotomous schemata (Deogracias et al.).

Citing the DSM-IV's nosological perspective concerning the determination of whether an individual satisfies the criteria for gender identity disorder or not, Deogracias and his colleagues advise, "Of course, one could create a dimensional measure from the DSM criteria for gender identity disorder by counting, for a particular patient, the number of indicators that are present, but this has not been common practice in either the clinical or research literature" (p. 370). In support of this rationale, the authors point out that when Fisk (1973) originally coined the term, "gender dysphoria," it was clear that this construct could be.".. conceptualized dimensionally and, if appropriately operationalized, would hold great promise in assessing the degree to which an individual is struggling with his or her gender identity (vis-a-vis one's birth sex)" (Deogracias et al., p. 371). The authors conclude that their comparison of the gender-dysphoric males who were either homosexual or heterosexual found that although these two subgroups experienced fundamentally different developmental pathways prior to their gender dysphoria in adolescence and adulthood, the similarity in the self-reported concurrent gender dysphoria by the subjects reinforces the notion of equifinality (i.e., different starting points leading to the same outcome) for these gender-dysphoric youths (Deogracias et al.).

According to Sloop (2004), "The representation of a case as an example of gender constructedness begins when John Money, the physician who carried out John / Joan's reassignment and observed the case for years, writes about it or is quoted by others in its early stages in the mid-to late 1960s" (p. 30). To his credit, the study of human beings, especially young ones, is a challenging enterprise by any measure, but it would seem that Money may have been premature in making some of his assessments concerning the extent to which the constructivist view could explain the snapshots he was glimpsing of this young person's life. For example, Money's initial comments on the case indicate that John/Joan's parents prepared their child for the sexual reassignment by changing his name, the manner in which they dressed him and even his hairstyle. As Sloop points out, "Relying on letters from the child's mother reporting success, Money notes that the effects of these changes helped feminize the child. For Money, signs of this success could be found in the child's 'clear preference for dresses over slacks' and her pride 'in her long hair' (p. 119 quoted in Sloop at p. 31). In addition, Money quotes John/Joan's mother as saying that Joan "just loves to have her hair set; she could sit under the drier all day long to have her hair set" (p. 120 quoted in Sloop at p. 31).

In retrospect, it is little wonder that this case attracted a great deal of attention from the popular press, and Money was not reluctant to share his findings with a rapt national audience. In this regard, Sloop emphasizes that, "Significantly, when Time initially reports on the case, the author employs the statements concerning John/Joan's love of having her hair set and her predilection for 'frilly' clothes as the primary and convincing evidence that the child had successfully become a girl" (quoted on Sloop at p. 31).…