This article looks at the diagnosis of gender identity disorder (child and adolescent criteria) as used in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). It considers how gender identity disorder came to be in the fourth edition, and explores some of the problematic aspects of the DSM-IV criteria. The authors argue that research has focused on cross-gender behaviours and gender role, and consequently muddled issues of pathology. In particular, that this has served to pressurize boys to conform to traditional gender and heterosexual roles. The authors suggest that the pathology accompanying gender identity dysphoria should be the focus of the clinical work rather than treating gender role behaviour. It is proposed that the model of atypical gender identity organization, is able to account for the diverse factors that may be contributing to a discordant gender identity, without labelling what may be a normal developmental pathway as pathological.