Caring for young gender nonconforming children

Over the past few years, there has been growing awareness of children and adults who believe that their gender identity does not match their birth sex. In fact, publisher Merriam Webster announced that gender nonconforming was one of the new words it added to the dictionary in April 2019.

Although there is an increasing amount of research and media coverage regarding adolescents with gender dysphoria or self-identification as transgender, resources are more limited for younger (prepubertal) children with gender nonconforming (GNC) behaviors and preferences. 

Gender dysphoria occurs when there is a conflict between the sex you were assigned at birth and the gender with which you identify. Learn how we care for children with gender identity concerns.

Primary care providers are often the first professionals with whom younger GNC children and their parents discuss emerging gender identities. Parents also require guidance about how to support their children’s self-concept and to help them negotiate an often unaccepting social world. Accordingly, pediatric providers need to be knowledgeable about the care of young children who are GNC to provide them and their families with comprehensive care.

Natural history of gender nonconforming behaviors/preferences

We know very little about the underlying causes of a mismatch between genetic/anatomic sex and self-identified gender; but some very young children have clearly expressed that their gender does not match their sex.  Other children may identify themselves as having gender nonconformity or dysphoria between 5 and 10 years of age. Still other children may not identify themselves as one gender until early adolescence or adulthood. Recently, some teenagers have also been rejecting the binary definitions of gender altogether and insisting on a pan-gender (nonbinary) identity. 

Parents can be eager to know whether their child will continue to express GNC behaviors and preferences in the future. One follow-up study of children with GNC preferences found that two-thirds of children “desisted” (did not remain GNC after puberty), whereas about one-third “persisted” in their gender identity variation. In the same study, how intensely a child experienced gender dysphoria appeared to predict persistence or adult self-identification as transgender.

Mental health of GNC children

While some children may express discomfort with early gender assignment at as early as two years of age, dysphoria generally intensifies as children grow older. This may relate to a number of factors including internal confusion, familial worries, and stress related to gender dysphoria, as well as potential stigmatization in school, community, and religious settings.

Studies of adolescents with gender dysphoria or adolescents who are transgender suggest an increased risk of anxiety and mood disorders, eating disorders, and suicidality. 

Dr. Marie Reilly

There is limited data regarding the mental health of young GNC children, but a study of 120 children with gender dysphoria, ages 4-11, showed that 52 percent experienced a psychiatric condition. Additionally, studies of adolescents with gender dysphoria or adolescents who are transgender suggest an increased risk of anxiety and mood disorders, eating disorders, and suicidality. 

Associations of gender dysphoria with other conditions

Some recent studies have indicated that parents of children with attention deficit hyperactivity disorder (ADHD) and parents of children with an autism spectrum disorder (ASD) are more likely to report that their child experiences gender variance. There are also many case reports of children and adults with ASD experiencing gender dysphoria. In fact, experts recommend that given the coincidence of ASD among children who are GNC, all children and adolescents referred to a gender clinic should be screened for ASD and adolescents with ASD should be screened for gender concerns.

Recommendations for providers

In clinic, providers can make their offices more welcoming for GNC children and their families by having posters, resource listings, and books about gender diversity in waiting rooms. This lets children and families know that their gender concerns can be discussed freely. It is also important to adjust names and pronouns in a child’s medical record to match their expressed identity. All providers (including receptionists, nurses, and professional staff) should be mindful of using a child’s changed name and pronouns. Stigmatizing questions and comments should be strictly avoided.  Providers should also make an effort to review the emerging literature on children who are GNC.

Outside the clinic, it is good to remember that children who are GNC are especially vulnerable in the community, the school, and even within the family. Providers should familiarize themselves with local laws regarding the status of GNC children and should also assist families of children who are GNC in promoting and supporting diversity. Providers should also become familiar with family-oriented therapists and other community resources. If a support/discussion group for parents does not already exist in the community, providers may consider taking the lead in establishing one.

Dr. Marie Reilly is a developmental behavioral pediatrician at Boston Children’s Hospital. This blog post is derived from her in-depth article in the Journal of Developmental & Behavioral Pediatrics.