Overview of gender development and clinical presentation of gender nonconformity in children and adolescents
- Michelle Forcier, MD, MPH
Michelle Forcier, MD, MPH
- Associate Professor of Pediatrics
- Warren Alpert School of Medicine, Brown University
- Johanna Olson-Kennedy, MD
Johanna Olson-Kennedy, MD
- Assistant Professor of Clinical Pediatrics
- University of Southern California, Keck School of Medicine
- Section Editors
- Diane Blake, MD
Diane Blake, MD
- Section Editor — Adolescent Medicine
- Professor of Pediatrics
- University of Massachusetts Medical School
- David Brent, MD
David Brent, MD
- Section Editor — Childhood Mental Disorders
- Professor of Psychiatry, Pediatrics and Epidemiology
- University of Pittsburgh School of Medicine
- Mitchell E Geffner, MD
Mitchell E Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
Children generally are assigned a gender at birth based upon genital anatomy or chromosomes. For most children, gender assignment correlates with gender identity, which is the innate sense of maleness or femaleness. However, some children have a gender identity that does not correlate with assigned gender. These children are called gender-nonconforming or sometimes transgender. (See 'Terminology' below.)
The trajectory of gender nonconformity in childhood is unpredictable; some children with gender nonconformity will grow up and be transgender adults and some will grow up and be cis-gendered adults (ie, adults in whom gender identity matches genital anatomy). (See 'Trajectory' below.)
This topic will provide an overview of gender development and the clinical presentation of gender nonconformity in children and adolescents. An overview of the management of gender nonconformity in children and adolescents and issues related to gender in children with disorders of sexual development are presented separately. (See "Overview of the management of gender nonconformity in children and adolescents" and "Management of the infant with atypical genitalia (disorder of sex development)", section on 'Decisions about sex of rearing and surgery'.)
Cultural differences in concepts of gender, the language used to describe gender, and attitudes toward gender-nonconforming people may affect expressions of gender identity [1,2]. Many Western societies view gender as binary: male or female. This ideology sets an expectation that gender expression must conform to one or the other and may contribute to the pathologization of gender nonconformity . When the gender expression of a child or adolescent does not fit neatly into the societal construct of male or female in congruence with their assigned sex, the child and family may be ostracized or stigmatized.
An alternate perspective views gender as a continuum from male to female, permitting a spectrum of gender identities with varying proportions of maleness and femaleness. Societies that view gender according to this more fluid or developmental perspective may be more accepting of gender variations . Health care provider recognition and validation of the gender continuum and acceptance of individuals no matter where on the spectrum they identify may help to increase tolerance in families and communities.
- World Professional Association for Transgender Health (WPATH). WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version. Available at: www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf (Accessed on November 27, 2012).
- Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016; 388:401.
- Brown RT. Adolescent sexuality at the dawn of the 21st century. Adolesc Med 2000; 11:19.
- Perrin EC. Sexual Orientation in Child and Adolescent Health Care, Springer, New York 2002.
- Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132.
- 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; 59:321.
- Levine DA, Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013; 132:e297.
- Adelson SL, American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry 2012; 51:957.
- Vance SR Jr, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics 2014; 134:1184.
- American Psychiatric Association. Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.451.
- American Psychiatric Association. Gender identity disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 4th ed, American Psychiatric Association, Washington, DC 2000. p.576.
- Mallon GP, DeCrescenzo T. Transgender children and youth: a child welfare practice perspective. Child Welfare 2006; 85:215.
- Meyer-Bahlburg HF. From mental disorder to iatrogenic hypogonadism: dilemmas in conceptualizing gender identity variants as psychiatric conditions. Arch Sex Behav 2010; 39:461.
- Zucker KJ. The DSM diagnostic criteria for gender identity disorder in children. Arch Sex Behav 2010; 39:477.
- Shechner T. Gender identity disorder: a literature review from a developmental perspective. Isr J Psychiatry Relat Sci 2010; 47:132.
- Martin CL, Ruble D. Children's search for gender cues. CDPS 2004; 13:67.
- Zosuls KM, Ruble DN, Tamis-Lemonda CS, et al. The acquisition of gender labels in infancy: implications for gender-typed play. Dev Psychol 2009; 45:688.
- Egan SK, Perry DG. Gender identity: a multidimensional analysis with implications for psychosocial adjustment. Dev Psychol 2001; 37:451.
- Carver P. Gender identity and adjustment in middle childhood. Sex Roles 2003; 49:95.
- Maccoby EE. The Two Sexes: Growing Up Apart, Coming Together, Harvard University Press, Cambridge, MA 1998.
- Bullough VL. Children and adolescents as sexual beings: a historical overview. Child Adolesc Psychiatr Clin N Am 2004; 13:447.
- Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male, WB Saunders Co, Philadelphia 1948.
- Piper J, Mannino M. Identity formation for individuals in transition: A narrative family therapy model. J GLBT Fam Stud 2008; 4:75.
- van Beijsterveldt CE, Hudziak JJ, Boomsma DI. Genetic and environmental influences on cross-gender behavior and relation to behavior problems: a study of Dutch twins at ages 7 and 10 years. Arch Sex Behav 2006; 35:647.
- de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex 2012; 59:301.
- Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med 2011; 165:171.
- Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418.
- Meyer WJ 3rd. Gender identity disorder: an emerging problem for pediatricians. Pediatrics 2012; 129:571.
- Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016; 388:390.
- Zucker KJ. Gender identity. In: Developmental-Behavioral Pediatrics: Evidence and Practice, Wolraich ML, Crotar DD, Dworkin PH, Perrin EC (Eds), Mosby Elsevier, Philadelphia 2008. p.825.
- Steensma TD, van der Ende J, Verhulst FC, Cohen-Kettenis PT. Gender variance in childhood and sexual orientation in adulthood: a prospective study. J Sex Med 2013; 10:2723.
- Achenbach TM. Manual for Child Behavior Check List/4-18 and 1991 Profile. University of Vermont Department of Psychiatry, Burlington, VT 1991.
- Achenbach TM, Edlebrock C. Manual for the Youth Self-Report and Profile. University of Vermont Department of Psychiatry, Burlington, VT 1987
- Shields JP, Cohen R, Glassman JR, et al. Estimating population size and demographic characteristics of lesbian, gay, bisexual, and transgender youth in middle school. J Adolesc Health 2013; 52:248.
- Zucker KJ. Gender identity development and issues. Child Adolesc Psychiatr Clin N Am 2004; 13:551.
- Cohen-Kettenis PT, Owen A, Kaijser VG, et al. Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: a cross-national, cross-clinic comparative analysis. J Abnorm Child Psychol 2003; 31:41.
- Fridell SR, Owen-Anderson A, Johnson LL, et al. The playmate and play style preferences structured interview: a comparison of children with gender identity disorder and controls. Arch Sex Behav 2006; 35:729.
- Malpas J. Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families. Fam Process 2011; 50:453.
- Teurk CM, Menvielle E, de Jesus J. If you are concerned about your child’s gender behaviors. Outreach Program for Children with Gender-Variant Behaviors and their Families, Children's National Medical Center, Washington, DC. Available at: www.childrensnational.org/files/PDF/DepartmentsandPrograms/Neuroscience/Psychiatry/GenderVariantOutreachProgram/GVParentBrochure.pdf (Accessed on November 27, 2012).
- Bussey K, Bandura A. Social cognitive theory of gender development and differentiation. Psychol Rev 1999; 106:676.
- Pearson K. Personal communication. Executive Director of Transyouth Family Allies.
- Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 2008; 47:1413.
- Steensma TD, McGuire JK, Kreukels BP, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry 2013; 52:582.
- Grossman AH, D'Augelli AR. Transgender youth and life-threatening behaviors. Suicide Life Threat Behav 2007; 37:527.
- Alanko K, Santtila P, Witting K, et al. Psychiatric symptoms and same-sex sexual attraction and behavior in light of childhood gender atypical behavior and parental relationships. J Sex Res 2009; 46:494.
- Landolt MA, Bartholomew K, Saffrey C, et al. Gender nonconformity, childhood rejection, and adult attachment: a study of gay men. Arch Sex Behav 2004; 33:117.
- Plöderl M, Fartacek R. Childhood gender nonconformity and harassment as predictors of suicidality among gay, lesbian, bisexual, and heterosexual Austrians. Arch Sex Behav 2009; 38:400.
- D'Augelli AR, Grossman AH, Starks MT. Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. J Interpers Violence 2006; 21:1462.
- Rijn AB, Steensma TD, Kreukels BP, Cohen-Kettenis PT. Self-perception in a clinical sample of gender variant children. Clin Child Psychol Psychiatry 2013; 18:464.
- Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry 2011; 16:499.
- Houk CP, Lee PA. The diagnosis and care of transsexual children and adolescents: a pediatric endocrinologists' perspective. J Pediatr Endocrinol Metab 2006; 19:103.
- Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013; 132:198.
- Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatr 2014; 164:906.
- Clark TC, Lucassen MF, Bullen P, et al. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth'12). J Adolesc Health 2014; 55:93.
- Olson J, Schrager SM, Belzer M, et al. Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria. J Adolesc Health 2015; 57:374.
- Reisner SL, Biello KB, White Hughto JM, et al. Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women: Baseline Findings From Project LifeSkills. JAMA Pediatr 2016; 170:481.
- Aitken M, VanderLaan DP, Wasserman L, et al. Self-Harm and Suicidality in Children Referred for Gender Dysphoria. J Am Acad Child Adolesc Psychiatry 2016; 55:513.
- Reisner SL, Katz-Wise SL, Gordon AR, et al. Social Epidemiology of Depression and Anxiety by Gender Identity. J Adolesc Health 2016; 59:203.
- de Vries AL, Doreleijers TA, Steensma TD, Cohen-Kettenis PT. Psychiatric comorbidity in gender dysphoric adolescents. J Child Psychol Psychiatry 2011; 52:1195.
- Yunger JL, Carver PR, Perry DG. Does gender identity influence children's psychological well-being? Dev Psychol 2004; 40:572.
- Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 2009; 123:346.
- Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance - United States, 2011. MMWR Surveill Summ 2012; 61:1.
- Greytak EA, Kosciw JG, Diaz EM. Harsh Realities: The Experiences of Transgender Youth in Our Nation’s Schools. Gay, Lesbian and Straight Education Network 2009. Available at: www.glsen.org/binary-data/GLSEN_ATTACHMENTS/file/000/001/1375-1.pdf (Accessed on November 27, 2012).
- McCabe S. D.C. police investigating death, attacks on transgender people. The Examiner 2011. Available at: www.washingtonexaminer.com/d.c.-police-investigating-death-attacks-on-transgender-people/article/118236 (Accessed on February 23, 2012).
- Roberts AL, Rosario M, Corliss HL, et al. Childhood gender nonconformity: a risk indicator for childhood abuse and posttraumatic stress in youth. Pediatrics 2012; 129:410.
- Roberts AL, Rosario M, Slopen N, et al. Childhood gender nonconformity, bullying victimization, and depressive symptoms across adolescence and early adulthood: an 11-year longitudinal study. J Am Acad Child Adolesc Psychiatry 2013; 52:143.
- Roberts AL, Rosario M, Corliss HL, et al. Elevated risk of posttraumatic stress in sexual minority youths: mediation by childhood abuse and gender nonconformity. Am J Public Health 2012; 102:1587.
- Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav 2009; 13:902.
- Garofalo R, Deleon J, Osmer E, et al. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health 2006; 38:230.
- Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health 2001; 91:915.
- Spack N. Transgenderism. Med Ethics (Burlingt Mass) 2005; 12:1.
- Drescher J, Byne W. Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn. J Homosex 2012; 59:501.
- de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 2011; 8:2276.
- Möller B, Schreier H, Li A, Romer G. Gender identity disorder in children and adolescents. Curr Probl Pediatr Adolesc Health Care 2009; 39:117.
- Feldman J, Goldberg J. Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia. 2006. Available at: transhealth.vch.ca/resources/library/tcpdocs/guidelines-primcare.pdf (Accessed on October 05, 2012).
- de Vries AL, Cohen-Kettenis PT, Delemarre-Van de Waal H. Caring for transgender adolescents in BC: Suggested guidelines. Available at: transhealth.vch.ca/resources/library/tcpdocs/guidelines-adolescent.pdf (Accessed on October 05, 2012).
- Kreiss JL, Patterson DL. Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth. J Pediatr Health Care 1997; 11:266.
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and Society for Adolescent Medicine. Protecting adolescents: Ensuring access to care and reporting sexual activity and abuse. J Adolesc Health 2004; 35:420.
- Ford C, English A, Sigman G. Confidential Health Care for Adolescents: position paper for the society for adolescent medicine. J Adolesc Health 2004; 35:160.
- Association of Women's Health, Obstetric & Neonatal Nursing. Confidentiality in adolescent health care. J Obstet Gynecol Neonatal Nurs 2010; 39:127.
- Edwards-Leeper L, Spack NP. Gender identity disorder. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), 2011. p.229.
- Olson J. Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) Youth and the Internet: A Virtual Closet or Cornucopia? California Pediatrician 2011; :6.
- Perrin E, Smith N, Davis C, et al. Gender variant and gender dysphoria in two young children. J Dev Behav Pediatr 2010; 31:161.
- Bockting W, Knudson G, Goldberg JM. Counseling and mental health care for transgender adults and loved ones. International Journal of Transgenderism 2006; 9:35.
- Anton B. Proceedings of the American Psychological Association for the legislative year 2008: Minutes of the annual meeting of the Council of Representatives, February 22-24, 2008, Washington, DC, and August 13 and 17, 2008, Boston, MA, and minutes of the February, June, August, and December 2008 meetings of the Board of Directors. American Psychologist 2008; 64:372.
- Menvielle E, Gomez-Lobo V. Management of children and adolescents with gender dysphoria. J Pediatr Adolesc Gynecol 2011; 24:183.
- CULTURAL CONTEXT
- GENDER DEVELOPMENT IN CHILDHOOD
- CLINICAL PRESENTATION
- During childhood
- During adolescence
- Associated concerns
- Prepubertal children
- After puberty
- ROLE OF THE MEDICAL PROVIDER
- Education and support
- ROLE OF THE MENTAL HEALTH PROVIDER