Sex is comprised of physical attributes of maleness or femaleness, including chromosomes, gonads, and genitalia. For most children, sex is assigned at birth as either female or male, based on external genitalia. Differences in sex development (DSDs) occur as frequently as 1 in 1,500 births, demonstrating that sex is not binary but rather a continuum with genotypic and/or phenotypic variations.1 Although frequently confounded, gender is different from sex. Gender develops throughout childhood with complex psychologic, physiologic, social, and cultural influences.2,3 Cognitive development influences how children understand their own and others' genders.
Facets of gender include identity, expression, and social/cultural role. Gender identity is a person's internal understanding of their own gender. Gender expression is comprised of the outward messages we send about our gender, including those based on clothing or behaviors. Gender roles are socially, environmentally, and culturally determined behaviors, attitudes, and aptitudes attributed to gender. Despite sex and gender being different constructs, children are typically assigned a binary female or male gender derived from sex assigned at birth. In most cultures within the United States, a child is expected to develop a gender identity aligning with the sex/gender assigned at birth. The child is also expected to develop in accordance with culturally sanctioned gender behaviors and roles. However, some cultures in the United States and worldwide allow for nonbinary gender developmental outcomes.4
Children developing in congruence with their sex assigned at birth are referred to as cisgender. Transgender and gender nonconforming (TGNC) children display differences in gender development. Differences occur in development of gender behaviors and/or gender identities. TGNC children express their gender differently from what is culturally expected for their sex assigned at birth. There are many different gender identities, including female, male, genderqueer, agender, bigender, and multigender. Gender expression and identity are related but separate concepts and do not always align. Not all transgender children display gender variant behaviors and not all gender nonconforming children have gender identities that differ from their sex assigned at birth.5
Some TGNC children experience distress with physical characteristics that do not align with their affirmed gender and/or distress over not being socially recognized as their identified gender. Gender dysphoria (GD) is the psychologic distress experienced over incongruence between one's affirmed gender and sex assigned at birth, leading to functional impairments in peer, family, and community settings. GD, as defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),6 includes the symptom of GD as well as a persistent desire to change physiologic and social gender presentation.
Not all TGNC children experience GD or have a desire to change sexual characteristics or social gender presentation. Frequently, TGNC children experience distress over lack of social and cultural acceptance of gender difference in our dominant binary-gendered culture. For TGNC children with GD, there can be added distress from internal discomfort of gender incongruence and socially based discrimination. This burden increases with added minority stressors such as social class and ethnicity.7
Gender Developmental Outcomes for TGNC Children
Self-awareness of gender identity typically emerges around ages 18 to 24 months, and TGNC children often begin to express differences in gender development around this time.8,9 Research on gender cognition in transgender children shows TGNC children are as capable of reporting their identified gender as cisgender peers.10 Previous gender development theories focused on the constancy and consistency of gender identity and introduced the notion that gender identity becomes crystalized at ages 6 to 7 years.11 Although differences in gender development occur as early as age 2 years, there is no definitive age of onset or time-frame for self-realization of one's differing gender identity. Differences in gender identity have been reported at all ages of childhood and adolescence.12 There does not appear to be a singular pathway for gender development in TGNC children.
One study13 following prepubertal TGNC children diagnosed with gender identity disorder (GID) per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition14 found the majority of these children did not continue to experience GD in adolescence or adulthood. Most of the adolescents studied no longer met criteria for GID, and instead endorsed gay, bisexual, or lesbian identities. Those who continued to endorse GD in adolescence displayed extreme gender nonconforming behaviors and persistent identification with a gender that differed from their sex assigned at birth.15 Data on the persistence of GD have been called into question because the GID diagnosis did not require children to endorse an incongruent gender identity. Hence, children with atypical or nonconforming gender behaviors without GD were given the diagnosis, which was misleading. DSM-56 criteria for GD now require children to have a strong desire to be another gender or insistence on a gender identity different from sex assigned at birth to avoid diagnosing solely based on cross-gender behaviors.16 To date, no studies have examined gender development outcomes of children diagnosed with GD and compared them to outcome data from prior diagnoses of GID.
There are no reliable national data to determine the prevalence of TGNC children or GD in childhood and adolescence. Reasons include lack of consistent definitions of GD and difficulty in defining combinations of gender identity and expressions. A survey of middle school students in San Francisco, CA, showed that 1.3% identified as transgender.17 Rates of TGNC children presenting to gender clinics have increased over the years. Proposed theories for these increased rates include expanding social and cultural acceptance of gender difference and improved information on available interventions for TGNC children with GD.18 Populations of TGNC children raised in validating environments or who do not experience distress are not accounted for as they typically do not present for care.
TGNC children engage with behavioral health services for a variety of reasons. Clinicians should not assume these children are presenting to address GD or other gender-related difficulties. Similar to their cisgender peers, TGNC children may be seeking treatment for primary mental health problems unrelated to gender identity. However, higher rates of depression, anxiety, self-injurious behaviors, suicide attempts, trauma, and posttraumatic stress disorder have been reported in TGNC children presenting for care at gender clinics. These increased rates are postulated to be the effects of prolonged discrimination and high levels of abuse that TGNC youth experience.19
TGNC children and their families may also present specifically to address gender-related developmental concerns. Gender-related distress can be psychologically based, environmentally based, or both. Determining the source(s) of distress is vital to delineating an appropriate treatment plan for successful interventions. Diagnosing GD in a child experiencing distress because of invalidating social environments or incongruent cultural gender expectations leads to misappropriated interventions and pathologization of gender difference that can further harm the child. Conversely, attributing distress to purely environmental factors risks missing GD. Distress related to gender development difference is not always initially revealed and should be screened for at all levels of psychiatric care. Often, gender-related distress has not been assessed for, and children are misdiagnosed with primary mental health problems that do not address their contributing gender-related factors. Addressing gender concerns helps to significantly reduce comorbid psychiatric problems.20
Creating an affirming environment for all genders is critical to ensuring TGNC patients feel safe enough to discuss gender-related topics. Affirming care includes use of patient-identified name and pronouns, staff trained in gender competencies, gender-affirming intake forms, and gender-inclusive restroom facilities and reading materials. Many TGNC children are remiss to disclose their gender identity for many years due to social and medical stigma, but may be more willing to communicate gender issues relevant to care when the environment is gender inclusive.
DSM-56 outlines criteria for diagnosis of GD with separate criteria for GD in childhood (GDC) and GD in adolescents and adults (GDA). Criterion A requires persistent experience of incongruence between assigned gender and identified gender, and Criterion B requires clinically significant distress or functional impairment to be present. For GDC, additional diagnostic criteria include atypical gender behaviors and distress, whereas for adolescents and adults criteria focus on discomfort related to physiologic markers of gender and a desire to change them.
Formal measurements to assess gender identity and behaviors in children are the Recalled Childhood Gender Identity/Gender Role Questionnaire, the Utrecht Gender Dysphoria Scale, the Body Image Scale, and the Gender Identity Interview for Adolescents. A clinical interview with the child and caregivers is critical to understanding the gender development history and current identity, family gender roles and expectations, and community gender norms.21 Open-ended questions about gender should not assume that there is distress about their gender, and should explore possibilities of nonbinary gender identities and behaviors. Treatment goals for the child and caregivers should be explored to see if they are in alignment or diverging. Finding a common goal between the child and caregivers is essential to engagement in care. Evaluation of family and community supports is critical to determine protective factors for positive health outcomes in the treatment plan. For peripubertal and pubertal children, assessing the degree of distress over pending or developing incongruent sex characteristics helps to determine the need for medical interventions to reduce distress.
Competency in Care
The World Professional Association for Transgender Health (WPATH) outlines required competencies of mental health professionals who care for TGNC children.22 Key competencies include knowledge of normative gender differences in development, ability to assess for GD, knowledge of available interventions, and ability to assess for and treat coexisting mental health concerns separate from gender dysphoria. Continuing education in gender-related topics is recommended as cultural understandings of gender evolve and research in the field progresses. Inexperience working with TGNC children should not be a reason to decline providing care, and the onus of education lies with the provider rather than patient. Clinicians are urged to seek consultation when needed.
Gender-Affirming Role in Care
Provision of affirming care for TGNC children reduces the impact of negative environmental factors that contribute to poor mental and physical health outcomes, and bolsters a person's strengths.23 Affirming care includes supporting the family in creating a nurturing environment for the youth's gender difference, providing psychoeducation regarding possible gender and sexual developmental outcomes, referring to community and national support and peer groups, and informing the child and family about interventions to promote healthy gender development. Advocacy and education within community systems (schools, places of worship) help reduce environmental stressors. Individual therapy goals of increasing adaptive resilience, problem solving, and emotional regulation support a child facing extreme environmental challenges. A fixed goal for gender development should not be mandated for the child, and approach to care should be centered on the patient's own experience, identity, and values.
Environmental and Social Interventions
Providers can discuss the option of social transition to affirm a child's identified gender at any age. Social transition is a term used to describe changing one's gender role, expression, name, and/or pronouns to better reflect affirmed gender identity. This process may involve coming out as a different gender to peers, family members, schools, and community settings such as places of worship and athletic organizations. Due to a variety of factors, children may socially transition in some environments but not others (eg, at home, but not school). During this time, many children choose to change their name and gender on legal documents. Legal assistance can be helpful for families to navigate name and gender marker changes on documents. Social transition in schools is often the most difficult for children to navigate. Schools in Transition24 is an excellent guideline to assist school administrators and staff, and serves as a template for social transition in other organizations.
Although social transition can help to relieve GD, it may place the child at increased risk of ostracism and discrimination. These risks must be discussed with the child and family prior to embarking on social transition to prepare them for unanticipated social sequelae. Engagement in therapy during social transition is helpful for children to build skill sets to face these challenges. Caregivers typically go through their own reactions and experiences relative to their child changing genders and may benefit from individual and/or family therapy. Clinically, providers report benefits from social transition for prepubertal children, as it often reduces distress over experienced gender incongruence and allows the child autonomy in gender development.25 A recent study26 compared transgender children who had socially transitioned to cisgender controls and found transgender children were as psychologically healthy as cisgender children.
Medical interventions for GD have been shown to result in positive psychologic outcomes for TGNC children.27 These interventions are considered once the child has reached puberty stage of Tanner II or age 12 years. WPATH and the Endocrine Society provide guidelines on how to initiate and monitor treatments.28 Although medical care is not indicated for peripubertal children, these children should be monitored for increasing distress about pending pubertal changes. Exploration of available options before puberty starts provides relief to the child anticipating incongruent physiologic changes. Many TGNC children can experience severe distress, depression, and anxiety with pubertal changes that do not reflect their affirmed gender identity. Self-injurious behaviors, suicidal ideation, and increased risky behaviors are often observed if no interventions are planned for or made.
Puberty blockers are used at puberty stages Tanner II and up and serve to stop pubertal changes. Puberty blockers have been shown to have low associated medical and psychological risks. They are also the most conservative intervention, as the effects are completely reversible once discontinued. Blockers can be considered when there is distress over the onset of puberty or to afford a youth more time prior to considering more permanent interventions. Sometimes caregivers are also hesitant to approve of cross-sex hormones (CSH), and use of blockers is a conservative “first-step” they can more easily agree on. Typical options for puberty blockade include the gonadotropin-releasing hormone agonists, but other options can be considered such as finasteride or spironolactone.
For adolescents who continue to have persistent GD and desire to alter physiologic sex characteristics to better reflect their affirmed gender, CSH can be used. CSH include estrogen and testosterone formulations to induce either feminizing or masculinizing effects on the body. They are considered partially reversible interventions, as some of the effects will reverse with cessation of therapy whereas some remain permanent. Use of puberty blockers with CSH may allow lower doses of CSH to be used. CSH are currently not recommended until age 16 years, although developmental considerations for the child can prompt an earlier start of hormone therapies. Risks and benefits of withholding CSH until age 16 years should be considered with the entire treatment team. Psychiatrists should be advocates for patients who may be good candidates to start CSH prior to age 16 years.
Surgical interventions are permanent interventions and historically have not been recommended for minors. Guidelines do allow for masculine-identified teens to pursue removal of breast tissue, but genital surgical interventions are not approved for minors younger than age 18 years in the United States. Surgical options can be discussed and planned for before the adolescent reaches age 18 years.
Prior to pursuing medical treatments for GD, an adolescent must be assessed by a mental health provider. This includes documentation of persistent GD or gender nonconformity and increased distress with pubertal changes. Mental health disorders should be controlled to the point of not interfering with engagement in appropriate medical care or with the child's ability to understand treatments and outcomes. Having a mental health disorder is not a contraindication to starting medical interventions and, in some cases, medical interventions may contribute to the resolution of coexisting mental health concerns. Historically, WPATH and the Endocrine Society have recommended children live as their affirmed gender prior to pursuing medical interventions.26 This can pose many safety concerns for children prior to medical transition. “Real-life experience” is not required for children unless it seems clinically helpful for a child who is questioning his or her gender. Children should have the capacity to provide assent to the treatments being considered. This includes not only the medical implications of treatment, but also the social implications. Caregivers must be able to provide informed consent for treatments and should be involved in the planning process. Exceptions include minors in state custody or emancipated minors.
Collaboration with medical providers, including endocrinologists and pediatricians, is essential to care planning, including discussions of feasibility and timing of interventions. Continued mental health care is recommended, although not necessary, throughout the process to assess response to treatment and bolster ego strength and protective factors when facing social challenges during medical transition. Although medical interventions are broken down into stages of puberty, the developmental abilities of the child should always be considered. Chronologic age may not be indicative of the youth's social, sexual, and cognitive developmental stage, and every case should be considered on an individual basis.
Conversion therapies for TGNC children are not advised, are potentially harmful, and even illegal in several states. Evidence shows TGNC children face increased risk of depression, suicide, trauma, and homelessness when family and community systems are not supportive of their gender development. In October 2015, a report by the Substance Abuse and Mental Health Services Administration (SAMHSA)27 declared that conversion therapies to alter or change a child's gender identity or behaviors are “coercive, can be harmful and should not be part of behavioral health treatment.” The report emphasizes that variations in gender identities and expressions are normal development pathways and not pathologic.29
TGNC children face many challenges, contributing to increased rates of mental health problems and long-term negative health outcomes. However, when given gender-affirming support and interventions for GD, they thrive and develop into healthy adults. Appropriate assessment and interventions reduce the plethora of risks these youth face, leading to healthier psychologic and physical developmental trajectories. A nonpathologizing approach to differences in gender development without a priori treatment goals or reparative techniques is vital to providing safe and affirming care for TGNC children.
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- Diamond LM, Butterworth M. Questioning gender and sexual identity: dynamic links over time. Sex Roles. 2008;59(5–6):365–376. doi:10.1007/s11199-008-9425-3 [CrossRef]
- Karasic DH. Transgender and gender nonconforming patients. In: Lim RF, ed. Clinical Manual of Cultural Psychiatry. 2nd ed. Washington, DC: American Psychiatric Association; 2015:397–410.
- Steensma TD, Kreukels B, de Vries A, Cohen-Kettenis P. Gender identity development in adolescence. Horm Behav. 2013;64(2):288–297. doi:10.1016/j.yhbeh.2013.02.020 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Arlington, VA: American Psychiatric Association; 2013.
- Shields SA. Gender: an intersectionality perspective. Sex Roles. 2008;59:301–311. doi:10.1007/s11199-008-9501-8 [CrossRef]
- Kohlberg L. A Cognitive-Developmental Analysis of Children's Sex-Role Concepts and Attitudes. Stanford, CA: Stanford University; 1966.
- Cohen-Kettenis P. Gender Identity Disorders. Cambridge, MA: Cambridge University Press; 2005.
- Olson K, Key AC, Eeaton NR. Gender cognition in transgender children. Psychol Sci. 2015;26(4):467–474. doi:10.1177/0956797614568156 [CrossRef]
- Siegal M, Robinson J. Order effects in children's gender-constancy responses. Dev Psychol. 1987;23:283–286. doi:10.1037/0012-16220.127.116.113 [CrossRef]
- Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “gender management service” (GEMS) in a major pediatric center. J Homosex. 2012;59(3):321–336. doi:10.1080/00918369.2012.653302 [CrossRef]
- Steensma T, Biemond R, de Boer F, Cohen-Kettenis P. Desisting and persisting dysphoria after childhood: a qualitative follow up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516. doi:10.1177/1359104510378303 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC. American Psychiatric Association; 1994.
- Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1413–1423. doi:10.1097/CHI.0b013e31818956b9 [CrossRef]
- Bryant K. Making gender identity disorder of childhood: historical lessons for contemporary debates. Sex Res Social Policy. 2006;3(3):23–39. doi:10.1525/srsp.2006.3.3.23 [CrossRef]
- Shields JP, Cohen R, Glassman JR, Whitaker K, Franks H, Bertolini I. Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school. J Adolesc Health. 2013;52(2):248–250. doi:10.1016/j.jadohealth.2012.06.016 [CrossRef]
- deVries A, Cohen-Kettenis P. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosexuality. 2012;59:301–320. doi:10.1080/00918369.2012.653300 [CrossRef]
- Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374–380. doi:10.1016/j.jadohealth.2015.04.027 [CrossRef]
- Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129(3):418–425. doi:10.1542/peds.2011-0907 [CrossRef]
- Leibowitz S, Telingator C. Assessing gender identity concerns in children and adolescents: evaluation, treatments, and outcomes. Curr Psychiatry Rep. 2012;14:111–120. doi:10.1007/s11920-012-0259-x [CrossRef]
- Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2011;13:165–232. doi:10.1080/15532739.2011.700873 [CrossRef]
- Bonifacio HJ, Rosenthal SM. Gender variance and dysphoria in children and adolescents. Pediatr Clin North Am. 2015;62(4):1001–1016. doi:10.1016/j.pcl.2015.04.013 [CrossRef]
- Orr A, Baum J, Brown J, Gill E, Kahn E, Salem A. Schools in Transition: A Guide for Supporting Transgender Students in K-12 Schools. San Francisco, CA: National Center for Lesbian Rights; 2015. http://www.nclrights.org/legal-help-resources/resource/schools-in-transition/. Accessed April 25, 2016.
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- Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3):1–8. doi:10.1542/peds.2015-3223 [CrossRef]
- de Vries A, McGuire JK, Steensma TD, Wagenaar E, Doreleijers T, Cohen-Kettenis P. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134:696–704. doi:10.1542/peds.2013-2958 [CrossRef]
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- Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.