Young Children With Gender Nonconforming Behaviors and Preferences

Abstract

Background: There is growing awareness and exposure in both the medical community and the lay media about the characteristics and complex needs of individuals who believe that their gender identity does not match their birth sex. Despite research and lay publications about teens with gender dysphoria and those who identify as transgender, little guidance is available regarding young (prepubertal) children with questions about their gender identity. Although many terms are used to describe these children, we have chosen to describe them as “gender nonconforming” (GNC). Objective: Primary care and developmental-behavioral pediatric providers are often the first professionals with whom young gender nonconforming children and their families discuss their concerns about their emerging gender identity. It is important, therefore, that pediatric providers be knowledgeable about the dilemmas, conflicts, and choices that are typical of these children and their families to guide them appropriately. Overview: In this special article, we present observations, informed by clinical experience, an emerging body of research, and a developmental-behavioral pediatric framework, of the complex needs of prepubertal gender nonconforming children and their families and an approach to their care. The article begins by outlining the cognitive and biological bases for gender identity development, as well as the natural history of gender nonconforming preferences and behaviors. It then sets the context for understanding the care of GNC children as an area in which developmentally sophisticated providers can play a crucial role in support of the complex developmental patterns and need for advocacy in multiple settings among these children.

Trends in Referrals to a Pediatric Transgender Clinic

“…Our findings support those of previous studies that highlight the importance of providing mental health services to TGNC youth. 2,5,15,16 We were unable to collect data on comorbid psychiatric conditions, but others have documented a high prevalence of psychopathology in this population. Studies have found that TGNC youth often have higher rates of depression, anxiety, self-harm, and substance use compared with their cisgender counterparts.…”

“…The burden of this dysphoria may be decreased by delaying puberty. 5,15,16 Providers in our clinic initiate hormone blockers and cross-sex hormones when patients have started puberty, which is determined by either a score of 2 on the Tanner Scale during physical examination or laboratory confirmation. Decisions surrounding when to initiate blockers and/or cross-sex hormone therapy are made by the health care team on an individualized, patient-directed basis.…”

“…27,28 When children and adolescents are supported in their identity, mental health outcomes significantly improve. 3,5,6,16,[27][28][29][30][31] Some patients seek phenotypic transition through gender-affirming surgery. The majority of the of the procedures were for mastectomy, many of which were completed before patients turned 18.…”

“…Transgender persons have higher rates of psychopathology such as depression, anxiety, suicidality, and self-harm compared with the general population. [2][3][4][5][6] In addition, transgender persons often have poorer health outcomes that stem from social and structural factors such as homelessness, poverty, discrimination, and negative health care experiences. [7][8][9] A weakness of transgender research is that studies have predominantly focused on the adult population.…”

Is Research on Transgender Children What It Seems? Comments on Recent Research on Transgender Children with High Levels of Parental Support

“…Some articles repeated what the two articles claimed—that there are no differences in depression or self-worth between transgender children and control children with only slight or minimal differences in anxiety. Turban (2017, 101) stated clearly that “Transgender youth in this study showed only mildly increased levels of anxiety (below the subclinical range)” and that “child-report levels of self-worth were similar to those of matched non-transgender controls.” Chen et al (2018, 76) noted that “Results show that transgender children did not differ from either control group on depression scores and had only marginally higher anxiety scores” and the two groups did not differ “on ratings of depression or self-worth and had marginally higher anxiety scores.” Other studies came to similar conclusions regarding either or both of the two articles (Alberse et al 2019, 389; Alegria 2018, 132; Bonifacio et al 2019, e72; Campo-Engelstein 2019, 85; Cartaya and Lopez 2018, 47; Chen, Hidalgo, and Garofalo 2017, 342; Deardorff et al 2019, 143; Janicka and Forcier 2016, 33; Oswalt and Lederer 2017, 7; Reilly et al 2019; Saleem and Rizvi 2017, 3; Shumer 2018, 1; Toomey, Syvertsen, and Shramko 2018, 7; Valdiserri et al 2019, 579; Wanta and Unger 2017, 126).…”