As a developmental and behavioral pediatrician, I sometimes face questions such as, “My 5-year-old son much more strongly prefers ‘girl’ toys, like dolls and princesses. What does this mean?” I’m sure many other clinicians also face the same types of questions from time to time. How can we help parents to understand whether these symptoms are part of common exploration, or whether it is a sign of something else? This is important because without a supportive environment, children exploring their gender are at risk for a host of mental and behavioral concerns, bullying, physical abuse, and self- harm.
Understanding the Development of Gender Identity
To start, it is helpful to consider how children learn about gender. Children as young as 2 years old can start to identify faces as male or female. Preschoolers are usually able to identify their own gender and may prefer to use toys that typically correspond to their gender (e.g., girls playing with dolls). However, it is common for young children to experiment with gender expression. I remember frequently seeing boys in the young toddler room of my child’s daycare arguing over who could wear the tutu and princess hats. By the time children reach 4-6 years of age, they tend to segregate themselves by gender during play, and view gender as a constant, non-changing concept. On a kindergarten playground, you might see games where it is “the boys versus the girls”.
For some children, their gender identity (the gender they experience) does not match their birth assigned sex. When these feelings are persistent, insistent, and consistent, a child may have gender dysphoria, or be considered to be gender non-conforming. The formal clinical definition of gender dysphoria can be found here.
Most young children with gender dysphoria do not grow into adolescents or adults with gender dysphoria. In one study, gender dysphoria persisted into adulthood for less than a third of individuals who reported gender dysphoria as children. However, for those in whom gender dysphoria increased after the onset of puberty, the feelings of gender dysphoria tended to persist. Estimates might be limited by underreporting, but at least one population-based study revealed the incidence of middle schoolers with gender dysphoria to be roughly 0.5 - 1.5 percent.
How To Support Gender Non-Conforming Youth
When asked questions about gender in the clinic, I try to encourage families to give their young children opportunities to explore different styles of play, as well as toys which show men and women in non-stereotypical and diverse roles, as recommended by the American Academy of Pediatrics. This can be a good recommendation for all kids, in fact. I also encourage parents to allow children to pursue sports and activities of their choosing, even if they don’t conform to society’s traditional expectations for their birth-assigned gender.
Be aware that puberty can be a particularly difficult time for gender nonconforming teens, as physical changes in the body may be unwanted and do not reflect the teen’s desire. Lack of acceptance, understanding, and support from family and peers (which may include bullying) can lead to anxiety, depression, dangerous sexual behaviors, drug use, and self-harm. It is critical that clinicians and parents be on the lookout for mood changes.
Many of my young patients experiment with different forms of gender expression, but when children experience insistent, persistent, and consistent feelings of mismatch between their gender identity and their birth assigned gender, I will refer families to my expert colleagues. At CHOP, I am fortunate to be able to refer families with questions about gender to our Gender and Sexuality Development Clinic, just one of four pediatric formal programs in the country. This multidisciplinary group provides both medical and psychosocial care for children and families, and also provides training to providers. For families who do not have access to such a clinic, finding a therapist who has experience with supporting gender non-conforming and transgender youth can be critical.
Click here for more information from the American Academy of Pediatrics (AAP) on gender non-conforming and transgender children.
Click here for AAP recommendations for office treatment of transgender youth.
Gender dysphoria in children is defined by the Diagnostic and Statistical Manual of Mental Disorders 5th edition as a marked incongruence between one’s experienced/expressed gender and birth-assigned gender for at least 6 months in duration and with 6 or more of the following symptoms:
- repeatedly stated desire to be, or insistence that he or she is, the other sex
- in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
- strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
- a strong rejection of typical toys/games typically played by one’s sex
- intense desire to participate in the stereotypical games and pastimes of the other sex
- strong preference for playmates of the other sex
- a strong dislike of one’s sexual anatomy
- a strong desire for the primary (e.g., penis, vagina) or secondary (e.g., menstruation) sex characteristics of the other gender
This incongruence must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender dysphoria in adolescents and adults is defined as a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months in duration, as manifested by 2 or more of the above symptoms.
Forcier, M and Olson-Kennedy, J. Overview of gender development and clinical presentation of gender nonconformity in children and adolescents. In: UpToDate, Torchia, MM (Ed), UpToDate, Waltham, MA. (Accessed on March 15, 2016.)
American Psychiatric Association. Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.451.
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