Parents with gender non-conforming children may not know where to turn to express their feelings. Many parents accept their child’s behavior, but are more concerned about the overall well being of their child.
Regardless of the stance a parent decides to take on gender non-conformity, it will affect the child and the child’s relationship with the family. Parents who recognize that they have gender non-conforming children sometimes experience a feeling of loss, shock, denial, anger, and despair. These feelings typically subside as a parent learns more about gender nonconformity.
A clinician may suggest that the parent be attentive, listen, and encourage an environment for the child to explore and express their identified gender identity, which may be termed the true gender.
This can remove the stigma associated with their dysphoria, as well as the pressure to conform to a gender identity or role they do not identify with, which may be termed the false gender self. WPATH Standards of Care also recommend assessing and treating any co-existing mental health issues.
1. Key Terms
Biological sex: As male or female (typically with reference to chromosomes, gonads, sex hormones, and internal reproductive anatomy and external genitalia).
Primary sex characteristics: Features that are directly part of the reproductive system, such as testes, penis and scrotum in males, and ovaries, uterus and vagina in females.
Secondary sex characteristics: Have no direct reproductive function, for example, facial hair in males and enlarged breasts in females.
Gender: The psychological, social and cultural aspects of being male or female.
Gender identity: How you experience yourself (or think of yourself) as male or female, including how masculine or feminine a person feels.
Gender role: Adoptions of cultural expectations for maleness or femaleness.
Gender dysphoria: The experience of distress associated with the incongruence wherein one’s psychological and emotional gender identity does not match one’s biological sex.
Transgender: An umbrella term for the many ways in which people might experience and/or present and express (or live out) their gender identities differently from people whose sense of gender identity is congruent with their biological sex.
Cisgender: A word to contrast with transgender and to signify that one’s psychological and emotional experience of gender identity is congruent with one’s biological sex.
Gender bending: Intentionally crossing or “bending” gender roles.
Cross-dressing: Dressing in the clothing or adopting the presentation of the other sex. Motivations for cross-dressing vary significantly.
Third sex or third gender: A term used to describe persons who are neither man nor woman, which could reference an intermediate state or another sex or gender or having qualities of both man/woman in oneself.
Transsexual: A person who believes he or she was born in the “wrong” body (of the other sex) and wishes to transition (or has transitioned) through hormonal treatment and sex reassignment surgery.
Male-to-Female (MtF): A person who is identified as male at birth but experiences a female gender identity and has or is in the process of adopting a female presentation.
Female-to-Male (FtM): A person who is identified as female at birth but experiences a male gender identity and has or is in the process of adopting a male presentation.
Genderfluid: A term used when a person wants to convey that their experience of gender is not fixed as either male/ female but may either fluctuate along a continuum or encompass qualities of both gender identities.
Genderqueer: An umbrella term for ways in which people experience their gender identity outside of or in between a male-female binary (e.g., no gender, genderfluid). Some people prefer a gender-neutral pronoun (e.g., “one”).
Drag queen: A biological male who dresses as a female (typically flamboyant dress and appearance) for the purposes of entertaining others. Such a person may not experience gender dysphoria and does not tend to identify as transgender.
Drag king: A biological female who dresses as a male (stereotypic dress and appearance) for the purposes of entertaining others. As with drag queens, such a person may not experience gender dysphoria and does not tend to identify as transgender.
Transvestite: Dressing or adopting the presentation of the other sex, typically for the purpose of sexual arousal (and may reflect a fetish quality). Such a person may not experience gender dysphoria and may not identify as transgender. Most transgender persons do not cross-dress for arousal and see transvestism as a different phenomenon than what they experience.
Intersex: A term to describe conditions (e.g., congenital adrenal hyperplasia) in which a person is born with sex characteristics or anatomy that does not allow clear identification as male or female. The causes of an intersex condition can be chromosomal, gonadal or genital.
For more Gender Diversity & Transgender Terminology see: https://www.glaad.org/reference/transgender
2. What is Gender Dysphoria
Gender dysphoria (GD) in children, also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent (gender dysphoria) due to a mismatch between their assigned sex and gender identity.
According to prospective studies, the majority of children diagnosed with gender dysphoria cease to desire to be the other sex by puberty, with most growing up to identify as gay, lesbian, or bisexual, with or without therapeutic intervention. If the dysphoria persists during puberty, it is very likely permanent.
The World Professional Association for Transgender Health (WPATH) states that treatment aimed at trying to change a person’s gender identity and gender expression to become more congruent with sex assigned at birth “is no longer considered ethical”.
The WPATH Standards of Care and other therapeutic interventions do not seek to change a child’s gender identity.
Instead, clinicians advise children and their parents to avoid goals based on gender identity and to instead cope with the child’s distress by embracing psychoeducation and to be supportive of their gender variant identity and behavior as it develops.
Gender nonconformity is not the same thing as gender dysphoria. According to the American Psychiatric Association, the critical element of gender dysphoria is “clinically significant distress”. Children and adults with gender dysphoria are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide.
☆ Early-Onset & Late-Onset Gender Dysphoria
Gender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset.
Early-onset gender dysphoria is behaviorally visible in childhood. In some cases, children or adolescents — sometimes even those as young as three or four years old — believe that they have been trapped in a body of the wrong sex.
Late-onset gender dysphoria does not include visible signs in early childhood, but some report having had wishes to be the opposite sex in childhood that they did not report to others.
In those assigned female at birth, early-onset gender dysphoria is the most common course.
☆Cautionary Note on The Rapid Onset Gender Dysphoria Controversy
“The term ‘Rapid Onset Gender Dysphoria (ROGD)’ is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD).”8https://www.verywellhealth.com/rapid-onset-gender-dysphoria-4685597
In August of 2018, a researcher from the Brown University School of Public Health published an article titled “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports” in the highly respected journal PLoS One. The author was Lisa Littman, MD, MPH at Brown University.
The article suggested that there was a growing concern about young, natal females developing gender dysphoria suddenly, or quickly, during or after puberty. It also suggested that social media might play a role in the development of gender dysphoria in this population.
The publication of this article led to an almost immediate outcry from the community of gender diverse individuals and their family members as well as researchers in transgender health. There was a substantial concern that this article was scientifically unsound and motivated by anti-transgender beliefs.
Over the next six months, criticisms of the article led to the journal initiating a formal review process that eventually led to the article being republished.
Approximately one month after the publication of the original article, WPATH published a position paper stating significant concerns about the proposed diagnosis of rapid onset gender dysphoria: WPATH POSITION ON “Rapid-Onset Gender Dysphoria (ROGD)”
The statement acknowledged the importance of research in understanding the development of gender identity in adolescents. However, it also cautioned against any term used “to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options.”
3. Signs & Symptoms
Children with persistent gender dysphoria are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria.
Some (but not all) gender variant youth will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormone therapy or surgery).
Signs and symptoms, as outlined by the DSM-5, include a marked incongruence between experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least six of the following (one of which must be criterion A1):
A strong desire to be of the other gender or an insistence that one is the other gender.
A strong preference for wearing clothes typical of the opposite gender.
A strong preference for cross-gender roles in make-believe play or fantasy play.
A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.
A strong preference for playmates of the other gender.
A strong rejection of toys, games and activities typical of one’s assigned gender.
A strong dislike of one’s sexual anatomy.
A strong desire for the physical sex characteristics that match one’s experienced gender.
B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
4. Clinical Treatments
Today, treatment is generally driven by the patient’s desired outcome.
It may include psychological counseling to target lifestyle changes (such as changing one’s name and/or gender on legal identity documents, or adopting dress/ mannerisms of another gender); it may also include medical interventions such as hormonal treatment, puberty suppression, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries involved in gender reassignment.
The goal of treatment may simply be to reduce problems resulting from the person’s gender identity; for example, counseling may focus on reducing internalized guilt or shame resulting from society’s lack of acceptance.
Family counseling is often helpful and necessary to help parents, partners, or other family members adjust to the person’s gender identity and any related transition.
Guidelines have been established to aid clinicians. The World Professional Association for Transgender Health (WPATH) Standards of Care are used by some clinicians as treatment guidelines.
It is important for clinicians to identify children whose gender dysphoria will persist into adolescence and those who outgrow their gender dysphoria diagnosis.
In instances where the child’s distress and discomfort continues clinicians will sometimes prescribe gonadotropin-releasing hormone (GnRH) to delay puberty.
Identifying stable and persistent cases of gender dysphoria reduce the number of surgeries and hormonal interventions individuals undergo in adolescence and adulthood. Gender dysphoria persist into adolescence in about 27%.
Diagnosis and treatment of gender dysphoria in children can be distressing for the parents, which can further exacerbate distress in their child. Parents had difficulties accepting their child’s desire to be the opposite sex, and are resistant to children wanting to alter their bodies.
☆What Is Gender Transitioning
Gender Transitioning is the process to begin living as one’s desired gender.
There are many ways to do this. An individual may go through social transition by changing their name and pronouns or medical transition by changing their body through hormone therapy or surgery. People who wish to transition may undertake one, all, or none of these steps.
○Social Transitioning
Transgender people may transition socially, which may include coming out to friends and family as transgender and changing their name to one that expresses their true gender and makes them feel comfortable. They may also ask people to use pronouns that match their desired gender.
They may want to change how they publicly express their gender, which is known as gender expression. This could mean changing their appearance, mannerisms, hairstyle, and the way they dress to express the gender they identify with.
○Medical Transitioning
Health care for transgender individuals starts with the same basics as cisgender individuals: annual physical exams, STI testing, and reproductive health care.
Those who are considering medical transitioning may need hormone therapy or surgery, which will require additional medical appointments and screenings.
Puberty blockers, hormone treatment, and surgery:
▪︎Puberty Blockers
Treatment may take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery with the aim of bringing one’s physical body in line with their identified gender.
Delaying puberty allows for the child to mentally mature while preventing them from developing a body they may not want, so that they may hopefully make a more informed decision about their gender identity once they are an adolescent. It can also help reduce anxiety and depression.
For adolescents, WPATH says that physical interventions such as puberty blockers, hormone therapy, or surgery may be appropriate.
Before any physical interventions are initiated, however, a psychiatric assessment exploring the psychological, family, and social issues around the adolescent’s gender dysphoria should be undertaken.
Some medical professionals disagree that adolescents are cognitively mature enough to make a decision with regard to hormone therapy or surgery, and advise that irreversible genital procedures should not be performed on individuals under the age of legal consent in their respective country.
Other professionals, typified by Dr. Kenneth Zucker, the Head of the Gender Identity Service, Child, Youth, and Family Program and Psychologist-in-Chief at the Centre for Addiction and Mental Health in Toronto has been criticized for statements suggesting that children with nonnormative gender might be autistic and hyperfocusing on gender.
▪︎Hormone Therapy
Hormone therapy helps people look physically more like the gender they identify as.
Transmasculine individuals will take androgens that will deepen their voice, enhance their muscles, promote body hair, and enlarge their clitoris.
Transfeminine people will take estrogen that will redistribute body fat, increase breast tissue, slow the growth of body hair, and lower testosterone. Physical changes, like breast enlargement, may take up to five years.
▪︎Gender Affirming Surgery
Sex reassignment surgery is a procedure by which a transgender person’s physical appearance and functional abilities are changed to those of the gender they identify as. The procedure is now known as gender affirmation surgery because a person’s gender identity prompts the desire for these medical procedures.
Many hospitals offer gender-affirming surgery through a department or center for transgender medicine.
Gender-affirming medical procedures include:
Breast augmentation: Insertion of a silicone or saline implant inside or beneath the breast to increase breast size.
Chest masculinization: Removal of breast tissues and contouring of the chest.
Facial surgery such as facial feminization surgery: Reshaping of the nose, brow, forehead, chin, cheek, and jaw. An Adam’s apple can be reduced as well.
Metoidioplasty and Phalloplasty: Formation of a penis.
Scrotoplasty: Creation of a scrotum.
Vaginoplasty: Using skin and tissue from a penis to create a vulva and vaginal canal.
Vulvoplasty: Using skin and tissue from a penis to create all of the outside parts of a vagina, except for the vaginal canal.
Orchiectomy: Removal of the testicles.
5. Parental Reactions
Dr. Diane Ehrensaft cites that there are three family types that can affect the outcome of a child’s gender nonconformity: transformers, transphobics, and transporters.
☆Transformers:
Transformers are parents that are comfortable in supporting their child in their gender-variant journey and can easily identify their child as a separate person.
Ehrensaft states, “These parents will stand a good chance of overcoming whatever transphobic reactions may reside within them to evolve into parents who both meet their child where he or she is and become an advocate for their gender-nonconforming child in the outside world.”
☆Transphobics:
Transphobic parents are not comfortable in their own gender, and may not understand that gender is fluid.
Transphobic parents may feel their child is an extension of themselves and respond negatively when their child is faced with his or her own adversity.
Ehrensaft believes these parents deny their child with an excess of negativity and transphobic “reactivity” this allows the child no room for nonconformity and undermines the love the parent claims to have for the child.’
☆Transporters:
Transporters are parents that appear to be completely accepting of their child’s gender nonconformity but on the inside have doubts about whether or not it is an authentic conformity.
Transporter parents may say things like, “It’s just a phase,” or “he or she will grow out of it.”
6. Neurodiversity & Gender Diversity
People who do not identify with the sex they were assigned at birth are three to six times as likely to be autistic as cisgender people are, according to the largest study yet to examine the connection.
Gender-diverse people are also more likely to report autism traits and to suspect they have undiagnosed autism.
Researchers often use ‘gender diverse’ as an umbrella term to describe people whose gender identities — such as transgender, nonbinary or gender-queer — differ from the sex they were assigned at birth. Cisgender, or cis, refers to people whose gender identity and assigned sex match.
Autistic people are more likely than neurotypical people to be gender diverse, several studies show, and gender-diverse people are more likely to have autism than are cisgender people.
The field is beginning to get a clear picture of the extent to which the two spectrums overlap: Gender identity and sexuality are more varied among autistic people than in the general population, and autism is more common among people who do not identify as their assigned sex than it is in the population at large — three to six times as common, according to an August study1.
Researchers are also making gains on how best to support autistic people who identify outside conventional genders.
Gender nonconformity is substantially elevated in the autistic population, but the reasons for this are currently unclear.
Research has shown that autistic adults present significantly more gender dysphoric feelings than people from the general population (George and Stokes 2018), are more likely to express the wish to be the gender opposite to their biological sex/birth-assigned gender (van der Miesen et al. 2018), and to report gender nonconforming identities (Cooper et al. 2018; George and Stokes 2018; Walsh et al. 2018).
In the mid-1990s, researchers had puzzled over a series of case reports made on individuals who had been diagnosed with autism spectrum disorder (ASD) also showing classic traits of gender dysphoria. The condition of having a psychological identity with a gender other than the one they were born with.
Both disorders are relatively rare, affecting less than one percent of the population. So the number of reports was striking, but it wasn’t until a study was performed in Holland in 2010 that scientists were able to make a solid connection between the two: nearly 8 percent of the more than 200 children and adolescents referred to a clinic for gender dysphoria also came up positive on an assessment for ASD.
A 2002 study on gender dysphoria shows that it may have genetic underpinnings, just as ASD does.
The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data.
There is a growing clinical recognition that a significant proportion of patients with gender dysphoria have concurrent autism spectrum disorder (ASD).
Young people with gender dysphoria have an elevated rate of Asperger syndrome, according to a new study. Individuals with gender dysphoria feel distress because there is a mismatch between their physical gender and their perceived gender.
Daniel Shumer and colleagues conducted a retrospective review of patient chart data from 39 consecutive patients between 8 and 20 years of age seen at a gender clinic. Of this group, 22 were biologically male and 17 were biologically female. The researchers report, “Overall, 23.1% of patients (9 of 39) presenting with gender dysphoria had possible, likely, or very likely Asperger syndrome as measured by the Asperger Syndrome Diagnostic Scale (ASDS).”
The researchers say their findings “are consistent with growing evidence supporting increased prevalence of ASD [autism spectrum disorders] in gender dysphoric children.”
The researchers say the cause of the association between Asperger syndrome and gender dysphoria is unknown. However, they note that genetic factors and differences in exposure to androgens (hormones that influence the development of male characteristics) have been implicated in both autism spectrum disorders and gender dysphoria.
Those with Asperger/Autism may be less susceptible to buying into the prevailing binary gender identities and instead more readily identify or know that they are non-binary or transgender. [knowledge that one is the opposite of the gender assigned at birth – Male to Female (MtF), Female to Male, (FtM)] Less constrained by the strong societal messages and more inclined to be oneself, individuals with Asperger/Autism may more readily identify as Transgender than their non-autistic counterparts who may be more susceptible to strong societal messages about remaining their gender assigned at birth.
7. Support for Gender Diverse Families
There is still controversy regarding the best approach for gender nonconforming children, but as gender nonconformity becomes more widely accepted many parents and professionals have identified things that gender variant or gender nonconforming children need to easily adjust to their transformation.
Parents have suggested that their children need the ability to discuss their gender non-conformity freely with their parents, to be loved throughout their transformation, and to be permitted to make choices regarding their gender on their own.
They have also suggested a peer support team and supportive counseling in addition to support from their school and schools administrators and authorities.
Parents must be mindful of a child’s need for parent expressions of acceptance and validation. If not validated a child may begin sharing less with their parent and more with friends, this could lead to the parent thinking the gender nonconformity was just a brief phase.
Disclosure is also very important to a family when raising a gender non-conforming child. Parents need to consider whom to talk to about their child and what type of information they decide to share. Other members of the family must also be prepared to make decisions regarding what to say and whom to say it to.
Regarding their own needs, parents have suggested that they need information regarding gender nonconforming children that can better assist them and their child in making their transition.
Additionally, parents have stated they need increased education on gender-nonconforming children, and support from surrounding friends and family to help build parental confidence.
Parents have also suggested they need counseling to help provide direction, support from medical professionals and peers, and access to transgender people to help provide them with a positive portrayal of transgender communities.
From my own lived experience as an neurodivergent (AuDD) parent with neurodivergent (Autism, ADD, Dyscalculia, Alexithymia, with co-occurring mental health conditions like Anxiety, Depression, Clinical Gender Dysphoria) kids (one transgender child and one cisgender child) – I know how absolutely crucial it is to find a safe space and safe people for your family and to have access to neurodiversity-affirming and gender-affirming psycho-education and support.
☆ Resources for Allies
See this National Geographic Documentary by Katie Couric: Gender Revolution: A Journey with Katie Couric
See this video by South African Psychologist, Chris McChlaghlan: https://youtu.be/G2-SRBfAjOw
See this video by South African medical doctor, Dr. Muller: https://youtu.be/kTtbzQ8q2ao
See this online training, “Understanding Transgender” from psychiatrist dr. Simon Pickstone-Taylor and The Neurodiversity Center: Transgender and Gender Diversity in Neurotypical and Neurodiverse Individuals
See The Trevor Project: https://www.thetrevorproject.org/resources
Comments