It’s a boy! It’s a girl! Gender is often defined by the external sex organs of an individual and is assigned at birth. But gender identity comes from the brain. It’s an individual’s psychological sense of their own maleness, femaleness or nonbinary-ness and it cannot be determined by another person.
The traditional model of gender identity was binary, meaning there were only the two choices: male or female, but there are many individuals who don’t feel they fit into either category or report that their gender identity doesn’t match their body. Learning about the terms currently used to describe gender can increase our understanding of what a child may be experiencing in this regard. This can can also promote acceptance, which is so important, as acceptance, especially from family members, protects these youth from depression, suicidal thoughts and other risk factors.
Rather than the traditional binary model, I describe a spectrum model to the children and families I work with. This spectrum has male at one end, female at the other end and many points in-between. Some specific terms that may help with understanding these points include the following:
Non-binary is a term used to denote a gender identity that is neither fully male nor female, but in between the two, or experienced as altogether different. What each individual experiences varies greatly so an exact definition can be difficult to pin down, but as an example, some of my patients have used terms such as “not she” or “off center female” to describe their gender identities. Gender queer or queer are other words used to describe a gender identity that isn’t binary.
When a person’s identity or behavior doesn’t fit into the common gender stereotypes - rules or expectations society has for each gender - we use the term gender expansive. A simple example is a girl being a “tom boy.” Kids may also feel their gender identity fluctuates between two or more genders. This is described as being gender fluid. Again, I want to emphasize that gender identity is a personal experience and we are all unique individuals with unique experiences. No one can tell another person what their gender identity is.
Biological gender or sex is usually defined by the external reproductive organs and defined as male or female. However, individuals may be born with genitals that aren’t clearly male or female. Most often, these individuals are diagnosed with conditions that alter the usual development of the reproductive organs known as disorders of sexual development. These disorders have multiple causes including alterations in chromosomes that determine an individual's characteristics before birth or in the enzymes and hormones that control what's happening in the body.
Gender roles are society’s views on what behaviors are appropriate for each gender. Throughout history these roles have been expanding. Consider female soldiers or stay-at-home dads.
Sexual orientation is entirely separate from gender identity and refers to feelings of romantic or sexual attraction to others. Heterosexual refers to opposite-gender attraction, homosexual denotes same-gender attraction, bisexual defines attraction to both male and female genders, and pansexual describes an individual who is attracted to all genders. Some people may describe themselves as asexual, or not experiencing sexual attraction to others.
However, the term LGBTQ+, which is often used when talking about this community, is meant to be inclusive and does mix sexual orientation and gender. Lesbian, gay and bisexual describe attraction, and transgender and queer describe gender identities. The Q can also describe “questioning” as in considering one’s gender identity or sexual orientation. The + sign includes other sexual orientations and gender identities not completely described by LGBTQ.
Gender dysphoria is essentially a mismatch between a person's gender identity and their biological body, which results in psychological distress or impairment in functioning. This is considered a diagnosable medical disorder based not on the mismatch, but on the distress the child experiences. When an individual is dysphoric because they identify as the opposite gender from their biological body, the term transgender describes this situation. Individuals may also express gender dysphoria because their body doesn’t match with their non-binary gender identity. Research supports that the brains of transgender individuals are more similar to the gender they identify with than their biological gender in both structure and function.
An 11-year-old child I work with recently said to me “I have a 'boy' brain but a 'girl' body.” Children with gender dysphoria may insist on the stereotypical toys, activities, clothes and friendships of their identified gender and express dissatisfaction or discomfort with their biological body. Teens with gender dysphoria also may express dissatisfaction with their biological body and express they want the body characteristics of their identified gender. This age group is capable of deeper and more complex thinking and may even report they have the usual thoughts and feelings associated with their identified gender. The best predictor we have of a stable transgender identity is the worsening of distress once the biological changes of puberty begin. Many children will experience an alignment of their gender identity with their biological body once puberty begins and feel more comfortable with their body, but those with worsening dysphoria are much more likely to remain in a transgender identity.
Kids may strongly express they ARE the identified gender at a very young age, or they may not tell anyone until their teen years. Coming out describes sharing your gender identity or sexual orientation with others. Many children and teens I’ve worked with have told me they “tried really hard” to identify with and act like their gender assigned at birth but then later came out as transgender. Some teens have first told their parents they were gay to “test the waters” and see if their parents would still accept them before actually revealing they were transgender. I often say that everyone has their own unique “gender journey” and there is no “right” way to identify as transgender.
Family acceptance is highly important because research has demonstrated it protects against depression, suicidal thoughts, suicide attempts, self-harm, drug abuse and risky sexual behavior. Family rejection is associated with all of these problems in transgender youth. When parents state they cannot be 100 percent accepting of a child's gender identity, I encourage them to be at least neutral instead of rejecting. However, what's best for a child, and what we recommend, is recognizing that individuals know their gender identity and need to be accepted for who they are. In other words: having a gender-affirming perspective. This acceptance and support from family, friends and peers is so important for mental health and for helping children and teens develop to their fullest potential.
The first step a parent can take to support a transgender child is to accept their gender identity and allow them to explore it. A child adopting the hairstyles, dress and sometimes a name associated with their identified gender is known as a social transition. This can take place at any stage of life and is reversible. Many kids first begin a transition in their home, by wearing their preferred clothes after school or during a vacation. These are chances to practice living in their identified gender and see how it feels to them. Later, they may socially transition at school. Don’t insist a child adhere to gender stereotypes when they're indicating they aren’t comfortable with those or want to explore different gender roles or behavior. Refusing to allow your child to express their gender identity can give them the message there is something wrong with them.
As a society, we can support children by incorporating flexibility in our traditional views of gender roles and stereotypes. Encourage your children to accept individuals with different identities, cultures, races and sexual orientations. Don’t make negative comments about LGBTQ+ individuals and praise leaders who are supportive of the LGBTQ+ community.
In Central Virginia, we are lucky our children can attend support groups for LGBTQ+ middle and high schoolers coordinated by Side by Side, a Richmond-based non-profit which supports these youth in multiple ways. They also offer support groups for parents.
Many hospitals are expanding programming and care in this area. At CHoR, we offer a multidisciplinary clinic for the evaluation of gender-expansive children and teens and the treatment of gender dysphoria. Our team includes experts in endocrinology and psychiatry who work together to provide a gender-friendly atmosphere, family support, and services dedicated to helping those we serve become who they were meant to be.
It is often difficult to speak up about your gender identity when you may be bullied or rejected for it. One of my goals is to increase understanding and acceptance for these youth so they can experience their lives in an accepting and affirming community. I love working with these kids and I really admire their bravery.
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