Despite the risks inherent in the label, parents of children who are confused about their place in the gender scale are glad to be able to give a name to gender identity disorder, discovers Kendra Sone

At the age of eight, John Smith asked his mother how much pocket money he would need in order to pay for a sex-change operation. Smith was born a boy, but grew up feeling like a girl. He hated wearing boys' clothes and acted like a girl in every way, says his mother.

'When he said he wanted to kill himself, I was desperate.' Group members nod sympathetically. As parents of children with gender identity problems they have all seen their children suffer as they struggle to come to terms with who they are. Some are certain they were 'born in the wrong body'. Others find themselves identifying with the opposite sex as they grow older.

The 13 people gathered in a room in north London are all members of Mermaids, a support group for children and teenagers with gender identity problems, and their families. They were originally brought together by Domenico Di Ceglie, a consultant child psychiatrist who runs the gender identity development unit at the Portman Clinic in London.

To date he has seen about 110 children, some as young as four. Studies of children who have these problems have shown that only a minority will become transsexual. Most will grow up to be homosexual or bisexual, while others will eventually define themselves as heterosexual¬ . Research indicates the problem is more common in boys.

Gender identity problems in children are rare, and Di Ceglie's clinic is the only multidisciplinary one specialising in them. His own interest in the condition began in the early 1980s with a teenage girl who had made repeated suicide attempts and 'who felt she was a boy inside'. The fact that his client's problems began in childhood gave him the idea for a service for children.

Children who have gender identity problems often have emotional and behavioural difficulties, including separation anxiety and depression, says Di Ceglie. He emphasises that these problems must be taken seriously because suicide attempts are common in adolescence.

While no one questions that the children are distressed and unhappy, practitioners have voiced concerns about the wisdom of labelling the children's condition as a gender identity disorder. The American psychiatrist's bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM) gives a list of diagnostic criteria for gender identity disorder­ .

But critics argue that a DSM classification turns the definition of behaviour which is considered unusual or anti-social into that of a mental disorder. DSM criteria are used as a way of policing people who deviate from the norm, says one child care professional.

Peter Wilson, director of Young Minds, agrees: 'To label the condition a disorder suggests that there is something wrong about the way they feel. To an extent they are distressed because society will not tolerate them as they are.'

The Royal College of Psychiatrists is in the process of producing guidelines on gender identity disorder in children. These children show a desire to be the opposite sex; cross-dress; play with games, toys and objects usually associated with the opposite sex; avoid play normally associated with their sex; and dislike bodily sexual characteristics and functions, say the guidelines.

It is difficult to make a case for helping the child without a formal diagnosis, says Di Ceglie. Health authorities may be reluctant to fund treatment. And having your child's problems officially diagnosed may be the only way of getting support from the school, adds one of the Mermaids parents.

Jenny Willmot, policy officer at mental health charity MIND, also takes the view that the only way to get resources may be to attach a label to the condition, since this practice then brings it into the category of 'serious mental illness' and it is here that funds are concentrated.

Di Ceglie argues that it is possible to read too much into diagnostic definitions. 'But at least we can say this child has these problems and it is a well-recognised condition. It is important to make it clear that there is a difficulty and that this child needs to be taken seriously,' he says.

Grouping young people into categories can help practitioners monitor the prevalence of certain problems and measure the success of particular approaches, as Peter Wilson admits, while pointing to the danger that labelling children condemns them.

However, it is usually true that children with gender identity problems have many characteristics in common. They often want to dress and adopt the name of a member of the opposite sex, a need which leads to a host of problems at school. Those girls who feel like boys want to use the boys' toilets and vice versa and, if the school refuses, the children will avoid going to the toilet, perhaps even soiling themselves and adding to their misery. Bullying and teasing can escalate until the child digs in his or her heels and refuses to go to school at all. 'They call me a lesbian to get on my nerves. I wouldn't mind if they called me gay,' says 11-year-old Robert Jones.

Joan Davis remembers her son's (she now refers to her as a daughter) school days with a wry smile. 'The first two years of secondary school were dotted with psychosomatic illnesses. She read about symptoms in books and acted them out. She would limp around convincingly in the hope I would produce a note.' Eventually, an education social worker threatened to take the family to court for non-attendance.

'I had two kids refusing school at the time. I had had the water and their blood and urine tested, to find out what was wrong. I was going demented with worry and then they said they'd take me to court.'

When the child was referred to the clinic, Di Ceglie and Mary Lightfoot, the clinic's social worker, visited the school and explained how they could best help the child. They helped develop a plan to get her back into school. With their support she gained seven GCSEs, an achievement which Davis says would not have been possible without Di Ceglie.

Mermaids wants to increase awareness of gender identity problems among professionals. Many of the families who attend the clinic have struggled to get social workers, doctors and psychologists to take the matter up.

Gender identity disorders in children are different from those in adults because children are still developing physically, sexually and psychologically. This makes it harder to predict the long-term consequences of their disposition, or of any intervention, creating an ethical quagmire for practitioners so that work with the young people has to proceed with caution.

Children who believe themselves to be born in the wrong body need non-judgmental and non-directional skilled support and counselling. 'We should never dismiss what they say - but we should talk through other possibilities,' says Willmot.

Di Ceglie is anxious to point out that the clinic's prime aim is not to alter the child's identity. Instead, he says, it encourages recognition and non-judgmental acceptance of the problem, and gives the children emotional security. Talking therapies are the clinic's main tool, working with the family and the child's social network to explore the origin of the problems.

'Our approach has been fairly well accepted because we have stuck to the view that what we want to do is promote their development,' he emphasises, though he admits that some parents come to the clinic hoping that professionals will make their child 'normal'.

'Part of our work is to prepare them for the possibility that things may not be like that. The issues are very complicated and we aim to give them the space to explore it. Our approach would be to try and keep an open mind.'

Seeing your child change sex before your eyes can be a traumatic experience and some parents talk about it as if it is a bereavement. 'Our son was dying and he hadn't been replaced by anyone else,' says Davis, while Jones blamed herself for what happened: 'I've never really believed that it wasn't my fault. When I found out I cried all weekend. It was the worst couple of days of my life.'

The clinic works with young people up to the age of 18, at which point they move on to the adult service for assessment. If clients are determined to move towards a sex-change, treatment comes first in the shape of drugs and then surgery. But surgery should not be attempted until the patient is well into adulthood, say the RCP's draft guidelines. However, the young people who spoke to Community Care feel strongly that their bodies are the wrong sex and are eager to begin hormone treatment - the first step on the road to gender reassignment.

The parents have mixed feelings. Medical research has shown giving treatment too early can lead to bone problems in later life for females who become males. But on the other hand, Jones argues, 'it seems criminal to me to allow Robert to grow breasts only to have a mastectomy later'.

The clinic hopes to 'help them to be neutral until puberty', says Di Ceglie. The doctor is right to be cautious. The boy who wanted to buy a sex change with his pocket money is now nearly 14 and has changed his mind.CC

¬ K J Zucker,'Cross-gender identified children', Gender Dysphoria, Plenum Press, 1985

­ Diagnostic and Statistical Manual of Mental Disorders-IV, American Psychiatric Association, 1994

· The names of clients and their parents have all been changed.

Children who have gender identity problems often have emotional and behavioural difficulties, including separation anxiety and depression