COMMENTARY

Gender-Questioning Kids: When Is It Gender Dysphoria?

Patty Huang, MD

Disclosures

August 08, 2016

Editorial Collaboration

Medscape &

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Hello. I'm Dr Patty Huang, a developmental and behavioral pediatrician at The Children's Hospital of Philadelphia. Today I'd like to talk about how pediatricians can best support families of youth exploring their gender identity at different ages.

Early Questioning

A crucial first step to helping families is 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, such as girls playing with dolls.

However, it is common for young children to experiment with gender expression. 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, nonchanging concept. For some children, their gender identity, or 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 nonconforming.

Most young children who explore activities and expressions, such as clothing, that are typically associated with peers of the opposite sex 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 it as children. However, for those in whom gender dysphoria increased after the onset of puberty, the feelings of gender dysphoria tended to persist.

Advice for Clinicians

There are several ways in which clinicians can advise parents and caregivers in supporting their children who may be questioning their gender. Encourage families to give their young children opportunities to explore different styles of play, as well as toys that show men and women in nonstereotypical and diverse roles. This can actually be a good recommendation for all kids. 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.

The takeaway message here is that your young patients may experiment with different forms of gender expression, but when children experience insistent, persistent, and consistent feelings of mismatch between their gender identity and the sex they were assigned at birth, you'll need to refer families to your expert colleagues.

At The Children's Hospital of Philadelphia, I am fortunate to be able to refer families with questions about gender to our Gender and Sexuality Development Clinic, which is just one of four such pediatric comprehensive programs in the country. This multidisciplinary group provides both medical and psychosocial care for children and families, and also offers training to providers. For families who do not have access to such a clinic, finding a therapist who has experience with supporting gender-nonconforming and transgender youth can be critical.

Parents may not always understand the differences between normal gender development and gender dysphoria. Pediatricians can play an important role in helping to guide patient families that may need more support. 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.

The American Academy of Pediatrics has information on gender-nonconforming and transgendered youth, as well as recommendations for office treatment of transgendered youth, available on its website.

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