To be fluent in discussions around gender and sexuality, pediatric clinicians need to be well-informed regarding the appropriate associated definitions and vocabulary. Gender refers to the characteristics (masculine and feminine) associated with the sex a person was assigned at birth, based exclusively on their reproductive anatomy. Gender in no way implies anything about sexual orientation or sexual preference. Gender identity describes how people relate to their gender. The term cisgender is used to describe a person whose gender identity and gender expression are in agreement with the sex they were assigned at birth, as is the term gender conforming. Gender nonconforming, genderqueer, gender expansive, or gender variant are all terms used to describe people whose gender identity and/or gender expression are not in agreement with the sex they were assigned at birth. Gender dysphoria implies distress over the gender that one was assigned at birth. Gender expression is the way in which a person chooses to demonstrate or express his or her assigned gender, such as wearing certain clothes, colors, or participating in activities typically associated with a certain gender.
Physicians should also be aware as to how gender variant people view themselves and how they prefer to be addressed. Various pronouns have been introduced into language for use when referring to gender nonconforming persons (Table 1). It is imperative to ask patients what their preferred pronoun is and to attempt to use it in all encounters and documentation. It is important to appreciate that terminology is constantly evolving and expanding as we continue to strive to better address the needs of the lesbian, gay, bisexual, trans, and queer (LGBTQ) community.
Gender Neutral Pronouns
Gender Identification: It Can Be Fluid
To fully appreciate the often fluid concept of gender identity, one must have an understanding of various stages of gender identification a child passes through as he or she matures. Most preschoolers are able to identify as male or female and begin using pronouns when referring to others. They tend to play with same-sex peers and prefer toys or roles that are traditionally associated with their gender assignment. As a child ages, he or she may begin to explore activities and clothing that are gender nonconforming while not overtly expressing any conflict or distress over his or her anatomic gender. Most of these children also seek out same-sex playmates.
The majority of children with gender nonconformity do not develop gender dysphoria that persists past puberty.1 However, the prepubertal and pubertal child with gender incongruence is at risk for many health and social struggles and needs a provider who is well-informed and able to guide him or her through this potentially difficult stage.
Gender dysphoria that worsens or intensifies as puberty approaches is much less likely to subside than earlier presentations.2 These same children were also more likely to have exhibited distress over their anatomic gender or asked for genitals of the opposite sex as younger children. On occasion, a child will present with gender dysphoria for the first time as puberty approaches. The physical and emotional changes that occur during puberty may be the first realization that their body is not what they wished it would be. Feelings of betrayal and alienation by one's own physical self may ensue. Difficulties in social and academic settings may mount as the growing child may no longer be given leeway in gender expression, being forced to conform to either male or female roles. Sports participation, clubs, friendships, and peer groups that were sources of pleasure or comfort for the child may now be limited or inaccessible as secondary sexual characteristics develop. The primary care provider may be the first person outside of the child's immediate family to be aware of gender dysphoria and therefore able to facilitate obtaining the medical, emotional, and social support needed by the child and family.
It may be difficult for the physician to broach the subject of gender nonconformity with a patient who has not chosen to confide in them on previous occasions. However, it is essential that a set of questions, both sensitive and open-ended, be asked of any prepubertal or pubertal child that appears uncomfortable about his or her changing body. Asking such things as “are you comfortable in the body you're in?” or “are you unsure of or questioning your gender identity?” are examples of ways to open a meaningful discussion with a child or young adult struggling with this issue. Reassurance that such difficulties can be a normal part of this stage of life is essential.
Parents of preschool children who voice concern regarding cross-gender dress or play should be counseled that such behavior is a normal part of this stage of development and extremely common. Curiosity and conversation regarding anatomy and genitals are also common among preschool-age children. Caretakers should encourage gender nonconforming play that is voluntary and joyful for the child and use great caution in any attempts to restrict such activities. Informing parents that the majority of preschoolers participating in cross-gender play do not become transgender adults may be helpful in their understanding and acceptance of such activities.3 Educating parents that an open dialogue will result in an enhanced level of trust between them and their growing children is paramount.
As a child enters the school-age years, the concept of gender becomes more solidified in a child's sense of self. Children that continue to be gender expansive in this stage of life may face many hurdles, as alluded to above. They are likely to be bullied or ostracized by their peers and by nonfamilial adults as well as face possible rejection by their parents or other family members. Involvement of mental health professionals, school officials, and primary care physicians may be necessary to provide them with a safe and secure school environment. Parents who are having a difficult time with the choice of their child should be informed as to how they can best support the child in what may or may not be a permanent decision. This may be best accomplished through a social transition.
Social transitioning is the process of allowing the child to conform to the affirmed or desired gender in some or all aspects of his life. She may want to change her name and/or be called by a new pronoun and dress in a manner now more comfortably aligned with her identity. The ramifications of a transition are far-reaching and need the support of both parents and school officials. Mental health providers should be intimately involved in guiding the process. Although a social transition can be a reversible process, it should be reserved for those children who are exhibiting dysphoria that interferes with their well-being on a daily basis. Backlash from peers and other adults must be presented as a likely consequence, and safeguards to protect the child need to be in place in advance of the transition.
Although a large number of gender nonconforming school-age children go on to be cisgendered adults, the decision to go through a social transition should be made on a case-by-case basis.
Gender expansive youth who are at the age of puberty and beyond are unlikely to re-identify with the gender they were assigned at birth. This can be a tumultuous time for such adolescents, who are beginning to experience the emotional, physical, and biochemical effects of puberty. This may also be a time when it's realized by those at home and at school that what may have been thought of as a “phase” by others is here to stay.
The role of the pediatrician at this stage is not just to offer support but to provide the child and family with appropriate referrals that offer mental health, endocrinologic, and community interventions.
Multidisciplinary clinics designed for the gender dysphoric pediatric patient are now available at some children's medical centers and can offer the array of services outlined above for the pubertal child.4 One of most difficult decisions to be made at this juncture is whether or not the pubertal process is allowed to continue or whether the process should be halted by hormonal intervention. Gonadotropin-releasing hormone agonists, such as leuprolide, can be used to stop puberty and the development of secondary sexual characteristics.5 This allows the adolescent time to further transition socially as well as time to decide if a full transition with opposite sex hormones is appropriate for them. Most authorities agree that pubertal suppression should be started around Tanner stage 2.1 Hormonal intervention after Tanner stage 2 may not fully halt the development of secondary sexual characteristics and future surgical corrections may still be required if desired by the patient. Therapy before the initiation of puberty has not been shown to change the outcome as compared to starting at Tanner stage 2 and therefore is not cost-effective. Once pubertal suppression has begun, all adolescents must be carefully followed for potential side effects and mental health changes. This is best accomplished by an endocrinologist or multidisciplinary clinic with assistance from the primary care provider.
In addition to offering support to the patient and family coping with gender identity issues, the pediatrician must be well-versed in the health needs of the child in question as well as in anticipatory guidance. The office environment should be welcoming to the needs of LGTBQ children and their families by offering such things as gender neutral restrooms and the use of preferred pronouns. All staff, including physicians, should be trained to offer a “safe space” if such a program is available to them nearby. Children and adolescents who are gender expansive are facing many of the same struggles as their cisgendered peers as well as their own unique ones. There are numerous studies documenting the challenges faced by LGTBQ youth, including but not limited to family strife, bullying at school, and being ignored or isolated by peers. Risk-taking acts such as drug and alcohol use, sexual promiscuity, and self-harm are more likely to occur in these children as is homelessness.6,7 The physician must be able to provide a confidential and comfortable office environment in which to screen for these behaviors and offer appropriate medical and mental health intervention. Counseling for prevention of pregnancy and sexually transmitted infections is paramount. Teens coping with gender identity issues may be experimenting with sexual activity with those with the same anatomic or genital sexual organs or with people of the opposite sexual anatomy. They are also more likely to be involved in violent or abusive relationships than gender conforming heterosexual adolescents. Careful questioning regarding these issues as well as the offering of sound medical advice and anticipatory guidance is essential. When potential legal issues arise such as bullying, victimization, or possible infringement of civil rights, the physician may need to employ the help of local authorities, child welfare agencies, or advocacy groups (Table 2). Any interventions need to be done with confidentiality in mind.
As society continues to progress in how it views and accepts gender expansive people, so must the practice of medicine. The primary care physician must evolve as the world begins to welcome gender-variant citizens. Physicians must be educated in the specific health care needs of this patient population as well as provide the support for patients and their loved ones. Only then can the hurdles that these children face be overcome.
- Sherer I, Baum J, Ehrensaft D, Rosenthal SM. Affirming gender: caring for gender atypical children and adolescents. Contemporary Pediatrics. 2015;32(1):16–19.
- Forcier M, Olson-Kennedy J. Overview of gender development and clinical presentation of gender nonconformity in children and adolescents. http://www.uptodate.com/contents/overview-of-gender-development-and-clinical-presentation-of-gender-nonconformity-in-children-and-adolescents?source=search_result&search=overview+of+the+gender+development+and+clinical+presentation+of+gender+nonconforming+in+children+and+adolescents&selectedTitle=1~150. Accessed April 18, 2016.
- Levine DACommittee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):e297–313. doi:10.1542/peds.2013-1283 [CrossRef]
- Spack NP, Edwards-Leeper L, Feldman S, et al. Children and adolescents with gender dysphoria referred to a pediatric medical center. Pediatrics. 2012;129(3)418–425. doi:10.1542/peds.2011-0907 [CrossRef]
- Olson-Kennedy J, Forcier M. Overview of the management of gender nonconformity in children and adolescents. www.uptodate.com/contents/overview-of-the-management-of-gender-nonconformity-in-children-and-adolescents. Accessed April 18, 2016.
- Vance SR, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;136(6):1184–1192. doi:10.1542/peds.2014-0772 [CrossRef]
- Lopez X. Gender dysphoria associated with mental health concerns. AAP News. 2015;36(3):16.
- Bennett J. She? Ze? They? What's in a gender pronoun. The New York Times. http://www.nytimes.com/2016/01/31/fashion/pronoun-confusion-sexual-fluidity.html. Accessed April 8, 2016.
Gender Neutral Pronounsa
|Gay, Lesbian & Straight Education Network: GLSEN.org
|Human Rights Campaign: HRC.org
|National LGBTQ Task Force: Thetaskforce.org
|World Professional Association for Transgender Health: wpath.org