Gender Variance in Children
Exploration and experimentation with gender is a normal part of the process of gender identity development; a process by which a child refines the ability to discriminate genders and achieves the cognitive capability to understand that gender also has stability across time and constancy across situations.
Gender non-conformity in children
A notable percentage of pre-school and school aged children exhibit some cross gender behaviors as a normal part of their process of gender identity development. Exhibiting cross gender behavior without any stated wish to be, identification of feelings of being, or stated identification as the other gender is simply understood as a variation in gender expression compared to that expected given cultural norms.
Introduction of the concepts of gender variant, gender non-conforming, gender dysphoric
I conceptualize degrees of gender variance, non-conformity, and dysphoria as five concentric rings. The outer ring encompasses all children. The children in the next ring exhibit cross gender behavior. The next two rings include children who also think they are and feel that they are the other gender. The distinction between these two groups has to do with whether the child states they "want" to be the other gender or that they "are' the other gender. Those children represented by the last and smallest of the five concentric circles claim a cross gender identity and are unhappy about their gender incongruence.
The children described by the inner four of the five rings could all be said to be gender variant. Only those children in the inner three rings who exhibit (external) cross gender behavior and report (internal) thoughts or feelings about being the other gender would be considered gender non-conforming. Finally, only those children who inhabit the very inner most ring; who claim an identity and are unhappy about their gender incongruence, are considered gender dysphoric.
Possible outcomes: dosage and duration
Young gender variant children have four possible eventual outcomes: a transgender identification; a gender-queer identification; an identification as homosexual or bisexual; or a cisgender heteronormative identity. Most pre-school children who exhibit gender non-conforming behavior do not persist in that behavior. The best predictors of persistence are said to be the “dosage” and “duration” of the gender non-conformity, not age of onset.
Dosage is greatest among children in the inner most ring; they exhibit cross gender behavior, claim a transgender identity, and are unhappy with their assigned gender. These children are persistent, consistent, and insistent about being the other gender. Research suggests that this is the sub-group of children most likely to continue to have a transgender identification into adulthood.
Duration is measured by how close to the onset of puberty the gender non-conformity occurs, not necessarily how long it lasts. As stated earlier, gender variant behavior among pre-school age children is normal and for most it will not persist. For this reason, unlike other phenomena, there is no significance to “early onset” as it relates to gender non-conformity. Furthermore, some children will not be gender non-conforming or gender dysphoric until adolescence.
Considering the interaction then between dosage and duration, even among gender non-conforming and gender dysphoric school aged children, the least likely outcome is a transgender identification in adulthood.; the most likely adult outcome for pre-school aged children who are gender non-conforming or gender dysphoric may likely be a homosexual affectional orientation.
What about my pre-school and school aged child?
So, if your pre-school aged child exhibits cross gender behavior this may be normal. If your pre-school aged child also consistently and persistently insists that they are the other gender then they may be considered gender variant and, depending on the intensity and duration of this claim, possibly transgender. In all instances, for children under age six, given the rates of desistence over time, a “wait and see” approach to your child’s gender (and sexual) orientation is generally the best advice.
Because society values all things male and because there is greater acceptance of gender fluidity among females, gender variant and gender non-conforming females rarely come to the attention of parents and clinicians during pre-school years and even childhood. By default then, a naturally occurring "wait and see" approach is common for female children, unless they are extremely gender dysphoric. For school aged males or females who are consistently, persistently and insistently gender dysphoric, there may be some benefit to shifting from a “wait and see” to a more supportive approach.
What about my pre-teen and adolescent?
Puberty is a time of great clarity when it comes to gender identity in youth. For those who were gender variant, gender non-conforming , or even gender dysphoric in childhood (and for many who were not gender variant in childhood) puberty is a time of significant desistence, persistence or even initial occurrence of varying degrees of gender dysphoria.
For those who will persist in being gender dysphoric, irreversible bodily changes associated with puberty can be devastating and create an unnecessary sense of urgency about the need to decide whether to commit to being affirming rather than just supportive. In these cases of pre-pubertal gender dysphoric youth, the use of a medication to temporarily delay the onset of puberty can allow time to remain supportive of the process of clarifying the gender identity.
Likewise, for some pre-teens a social transition can often provide some relief from the incongruence between their sense of self and other's sense of them. The closer a child is to puberty, the more reasonable it is to shift from a supportive to an affirming approach.
Therapy as part of the process of clarifying gender identity; corrective, supportive, or affirming
Therapists working with gender dysphoric youth approach treatment from one of three basic stances corresponding with the theoretical framework through which they understand gender dysphoria in youth. These three approaches can be classified as corrective, supportive and affirming.
Three corrective approaches
Therapists utilizing a corrective approach may have various reasons for their stance. Within this group there are three sub-groups: reparative, discouraging, preventative. The reparative sub-group is the smallest and most conservative of the group committed to the corrective approach. They view gender dysphoria as pathological and gender conformity as the only normative identity. Those aligned with this sub-group often cite religious doctrine and not clinical or research data. Despite numerous professional organizations declaring reparative therapy as abusive, there may be some therapists who still utilize this unethical approach.
Another sub-set of therapists who may utilize a corrective approach view gender identity as malleable in childhood and would discourage a social transition. Clinicians with this understanding base their formulation on research data which shows high rates of desistence among children and pre-pubescent youth. Because they view gender identity as malleable, these clinicians believe that any support of gender non-conformity could encourage gender dysphoria which might otherwise desist. These therapists therefore discourage affirming or even supporting a young child’s cross-gender identifications. Data does not support the idea that social pressure can change one's gender identity.
The third sub-group of clinicians implementing the corrective approach site data on psychological comorbidity among gender dysphoric youth. This research data shows higher rates of emotional, behavioral, and social difficulties among youth who are gender dysphoric. Even if they view the relationship between gender dysphoria and psychiatric difficulties as correlational rather than causal, these clinicians believe that (if) gender expression is malleable, gender conformity is a reasonable and expedient means to prevent emotional and social conflicts for gender dysphoric youth. (Another option would be to help make society more accepting and thereby reduce the social stigma and emotional sequelae that gender minorities experience.)
Corrective approaches are contraindicated; There is no clinical evidence to support the idea that parental influence or any type of therapy can have a lasting impact on a child's gender identity. We cannot create a transgender identity nor guarantee a cisgender identity. Attempting to change a child's gender can however be psychologically damaging.
The supportive approach
The second approach used by clinicians can be described as a supportive stance. These clinicians would not discourage a young person from identifying as gender dysphoric, nor would they encourage the identification. Citing the data on puberty as a time of significant desistence or persistence, these therapists may take a wait and see attitude with gender non-conforming or dysphoric children. Accordingly, they would likely discourage any social transition prior to puberty unless that dysphoria has been insistent, consistent, persistent and the distress places the youngster at risk of some sort of harm.
The affirming approach
The third approach is best described as affirming of gender dysphoric youth. These clinicians focus on developmental psychology findings which state that gender identity is solidified between the ages of four to seven and research data which suggests that there is some ability to discern those pre-pubescent youth who will persist in their dysphoria. Clinicians utilizing and affirming approach may be viewed as aligned with advocates because they may be seen as encouraging social transition.
Those clinicians who take and affirming approach often note two factors which contribute to their interpretation of the doctrine: “above all else, do no harm”. These advocates and clinicians may be willing to “err” on the side of affirming due to the research on the extreme negative outcomes among youth who do not have a supportive environment. They also note research which finds better outcomes for those who transition early rather than later.
Furthermore, it is noted that even when there is lack of support or attempts at a corrective approach, for many youth, gender dysphoria persists. Therefore, in response to the criticism that an affirming approach may be encouraging dysphoria which might otherwise persist, it is noted that, given the lack of success in discouraging a transgender identity there is likely little success in encouraging a transgender identity (especially in a culture which expects heteronormativity); One’s gender identity is not easily influenced one way or the other by external efforts to determine the outcome.
Choosing an approach
The corrective approach is a type of reparative therapy and is never an option. This type of treatment is ineffective and psychologically damaging. Many professional organizations and states have strong bans against reparative therapy.
Though it may be tempting to consider the different approaches and choose one as the best “one size fits all” model, this is not prudent given the complex population of gender creative, dysphoric, and transgender youth and families coming to consultation. Neither ‘social transition for all’ nor ‘wait and see for all’ work for the spectrum of gender-diverse children in therapy. While some children are consumed with gender dysphoria and need to be affirmed and socially transition early in childhood, other children can benefit more from a prolonged positive and supportive exploration outside of a permanent binary decision and social transition.
It is the task of a savvy clinician to help each family find the approach that is best for their child. The more insistent, consistent, and persistent the gender dysphoria and the closer to puberty, the more likely a therapist is to help the family consider moving from a supportive to an affirming approach.