Understanding Gender Variance in Children and Adolescents

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Article in Pediatric Annals · June 2014 Impact Factor: 0.61 · DOI: 10.3928/00904481-20140522-07 · Source: PubMed

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Lisa K. Simons, MD; Scott F. Leibowitz, MD; and Marco A. Hidalgo, PhD

Abstract Lisa K. Simons, MD, is Physician, Division Gender variance is an umbrella term used to describe gender identity, expression, or of Adolescent Medicine, Ann & Robert H. behavior that falls outside of culturally defined norms associated with a specific gender. Lurie Children’s Hospital of Chicago; and In recent years, growing media coverage has heightened public awareness about gen- Instructor of Pediatrics, Northwestern Uni- der variance in childhood and adolescence, and an increasing number of referrals to clin- versity Feinberg School of Medicine. Scott ics specializing in care for gender-variant youth have been reported in the United States. F. Leibowitz, MD, is Psychiatrist, Department Gender-variant expression, behavior, and identity may present in childhood and adoles- of Child and Adolescent Psychiatry, Ann & cence in a number of ways, and youth with gender variance have unique health needs. Robert H. Lurie Children’s Hospital of Chi- For those experiencing gender dysphoria, or distress encountered by the discordance cago; and Assistant Professor, Northwest- between biological sex and gender identity, puberty is often an exceptionally challeng- ern University Feinberg School of Medicine. ing time. Pediatric primary care providers may be families’ first resource for education Marco A. Hidalgo, PhD, is Psychologist, Divi- and support, and they play a critical role in supporting the health of youth with gender sion of Adolescent Medicine, Ann & Robert variance by screening for psychosocial problems and health risks, referring for gender- H. Lurie Children’s Hospital of Chicago. Address correspondence to: Lisa K. specific mental health and medical care, and providing ongoing advocacy and support. Simons, MD, Division of Adolescent Medi- [Pediatr Ann. 2014; 43(6):e126–e131.] cine, Ann & Robert H. Lurie Children’s Hos- pital of Chicago, 225 E. Chicago Avenue, Box 161, Chicago, IL 60611; email: lsimons@ luriechildrens.org. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00904481-20140522-07 © Shutterstock

e126 Copyright © SLACK Incorporated CME Copyright 2014 Pediatric Annals hildren are assigned a gender at TERMINOLOGY living in their desired gender role. Tran- birth, often based on a clinician’s Gender-related terminology can sitioning may or may not include hor- C examination of external genital sometimes be used differently by health monal and/or surgical procedures.1 anatomy and sometimes using chro- care professionals, patients, and com- Sexual orientation: The tendency to mosomes. For the majority of children munity members. When working with be romantically or physically attracted and adolescents, birth-assigned gender patients and families, it is important to to persons of the same sex, opposite sex, corresponds with gender identity, or an be sensitive and respectful regarding both sexes, or neither sex. Sexual ori- individual’s innate sense of self as male, the use of preferred names, gender pro- entation is distinct from gender identity female, or an alternate gender;1 howev- nouns, and gender-related vocabulary. and gender expression.2 er, a minority of individuals experience Biological sex: Attributes that char- discordance between their assigned gen- acterize biological maleness and female- EPIDEMIOLOGY der and internal gender identity. Some ness (eg, sex-determining genes, chro- The prevalence of gender variance in children’s gender expression, or way of mosomes, gonads, hormones, internal childhood and adolescence is largely un- communicating gender within a given and external reproductive structures).2 known. Potential attempts to determine culture, falls outside of stereotypical Gender identity (affirmed gender): worldwide prevalence are complicated norms.2 Gender variance is an umbrella An individual’s personal sense of self as by a number of factors, including a lack term used to describe behaviors, appear- male, female, or an alternate gender.1 of population-based studies as well as ance, or identity of people who do not Gender expression: The way in international and cross-cultural varia- conform to culturally defined norms for which an individual acts to communicate tion in gender identity and expression.1,7 their birth-assigned gender.2 gender within a given culture—exam- Prevalence estimates in adults have In recent years, growing media cov- ples include clothing, haircut, and com- largely been based on clinical samples erage has heightened public awareness munication patterns. Gender expression seeking gender-related medical and/or about gender variance in childhood and does not always correlate with gender surgical care primarily in Western Eu- adolescence. An increasing number of identity or biological (ie, assigned) sex.2 rope.8 referrals to clinics specializing in care Gender role: Behaviors, attitudes, Studies to date have adhered to mea- for gender-variant youth have been re- and personality traits that a society in suring the prevalence of gender identity ported in Europe, Canada, and the Unit- a given historical period designates as disorder (GID), a psychiatric diagnosis ed States.3-5 Although the prevalence of “masculine” or “feminine.”1 that was replaced by gender dysphoria gender variance in the United States is Gender variance: Behaviors, ap- (GD) in the May 2013 release of the Di- largely unknown, there appears to be a pearance, or identity of people who do agnostic and Statistical Manual of Men- significant need for expert health care not conform to culturally defined norms tal Disorders, Fifth Edition (DSM-5).9 services in this area. for their assigned gender.2 The criteria for GD, which is marked Parents may react to their child’s gen- Transgender: Individuals with an by clinically significant distress en- der variance in many different ways, and affirmed gender identity different than countered by the discordance between in some cases, may feel conflicted or un- their biological sex.6 Transgender can biological sex and gender identity that sure of how to respond. Families who are also be used to describe people whose disrupts social or school functioning, are concerned or seeking information about gender identity, expression, or behaviors listed in Table 1. The shift from GID to their child’s gender expression, behav- falls outside of culturally defined norms GD resulted from a complex and ongo- iors, or identity often turn to primary care for their biological sex.2 ing discourse between American men- providers first. It is essential that pediatri- Cis-gender: Individuals whose af- tal health researchers and practitioners. cians are familiar with phenomenology firmed gender matches their biological Although detailing the nuances of this related to gender (identity, expression, sex. discourse is beyond the scope of this ar- and behavior) and recognize when refer- Gender dysphoria: Internal distress ticle, it should be noted that consensus ral to a mental health or medical provider caused by a discrepancy between a per- to abandon GID in DSM-5 represents a with gender-related expertise is indicated. son’s gender identity and biological sex. paradigmatic shift that de-emphasizes This article reviews gender-related termi- Not all gender-variant individuals expe- gender variant identity as pathologi- nology, describes common presentations rience gender dysphoria.1 cal and focuses instead on the potential of gender variance, and offers an over- Transitioning: Process by which psychosocial challenges associated with view of a multidisciplinary model of care individuals change social, physical, or gender variance. Given this recent refor- for gender-variant youth. legal characteristics for the purpose of mulation of gender-related phenomenol-

PEDIATRIC ANNALS • Vol. 43, No. 6, 2014 e127 CME Copyright 2014 Pediatric Annals ogy, no studies have examined GD prev- TABLE 1. alence (per DSM-5 criteria) in children DSM-5 Diagnostic Criteria for or adolescents. Gender Dysphoria ETIOLOGY The etiology of gender variance is Gender Dysphoria in Children poorly understood. No singular factor A marked incongruence between one’s experienced/expressed gender and assigned gender, of has been identified, and the etiology is at least 6 months’ duration, as manifested by at least six of the following (one of which must be likely multifactorial. To date, research Criterion A1): has examined psychosocial and bio- • A strong desire to be of the other gender or an insistence that one is the other gender (or logical factors, including parent-child some alternative gender different from one’s assigned gender). relationship characteristics, in utero sex • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or hormone exposure, brain anatomy and in girls (assigned gender), a strong preference for wearing only typical masculine clothing and activation patterns, and genetic varia- a strong resistance to the wearing of typical feminine clothing. tions. A recent review of gender identity • A strong preference for cross-gender roles in make-believe play or fantasy play. development in adolescence provides • A strong preference for the toys, games, or activities stereotypically used or engaged in by the a thorough description of previous re- other gender. search.10 • A strong preference for playmates of the other gender. • In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities GENDER IDENTITY and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejec- DEVELOPMENT tion of typically feminine toys, games, and activities. Research on childhood gender de- • A strong dislike of one’s sexual anatomy. velopment proposes that by age 3 years, • A strong desire for the primary and/or secondary sex characteristics that match one’s experi- most children have a sense of what it enced gender. means to be male or female and by age • The condition is associated with clinically significant distress or impairment in social, school, or 5 to 6 years, most children will declare other areas of functioning. a gender identity of male or female, that this identity will be consistent with Gender Dysphoria in Adolescents their birth-assigned sex, and that it will remain constant across the life span.11 A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: It has been suggested that the majority of children with gender variance more • A marked incongruence between one’s experienced/expressed gender and primary/and or secondary sex characteristics (or in young adolescents, the anticipated secondary sex charac- commonly express gender-nonconform- teristics). ing behavior than a desire to be a gender 8 • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of an different from the one assigned at birth. incongruence between one’s experienced/expressed gender (or in young adolescents, a desire Until future studies incorporate GD di- to prevent the development of anticipated secondary sex characteristics). agnostic criteria, previous research us- • A strong desire for the primary and/or secondary sex characteristics of the other gender. ing GID criteria inform current concep- • A strong desire to be of the other gender (or some alternative gender different from one’s tualizations of gender development and assigned gender). are reported here. These studies suggest that without treatment, GD does not • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). persist through late childhood or early adolescence in the majority of young • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). children who meet diagnostic criteria for GD.8,12,13 In cases where GD subsides, • The condition is associated with clinically significant distress or impairment in social, school, or other areas of functioning. the majority of children will proceed to later identify as gay or lesbian, where- DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. as fewer may identify as heterosexu- From the DSM-5.9 al.11,13-16 In contrast to prepubertal children with GD, postpubertal adolescents

e128 Copyright © SLACK Incorporated CME Copyright 2014 Pediatric Annals with GD are more likely to continue ex- tion occurs solely at the social level (ie, asking about breast growth with increas- periencing GD through adolescence and without medical intervention), these ing worry about her own body. She re- adulthood.3 For some adolescents, GD children can fully revert to their birth- cently had a tantrum, refusing to leave emerges during adolescence. assigned gender should GD desist.18 the house until she could wear her older Gender-variant youth can, therefore, Opponents of social transitioning in brother’s clothing. be considered to comprise at least two pre-pubertal children argue that it can different subgroups of youth—what de- contribute to GD persistence, thereby A Peripubertal Natal Male who Is velopmental/clinical psychologist Diane increasing one’s likelihood to be trans- Transgender (ie, a Transgender Ehrensaft, PhD, refers to as “apples and gender in adolescence,19 and that given Female) oranges.”17 The “apples” refer to chil- the high desistance of childhood GD in Tommy is a 14-year-old natal male dren with gender variance who may ac- adolescence, it is likely that children presenting for a physical. He has always tually be transgender, and the “oranges” may undergo premature or entirely con- been a quiet child, never interested in being children with gender variance traindicated social transitioning.20 sports or roughhousing with other boys. who develop to be cis-gender gay, les- When the pediatrician enters the room, bian, or heterosexual individuals. A lack CLINICAL PRESENTATIONS Tommy avoids eye contact. He is wear- of empirical research on gender-variant Presentations of gender-variant ex- ing a sweater with a collar exposing one children has limited the degree to which pression, behavior, and identity differ shoulder, his hair is shoulder-length, and these subgroups of gender-variant chil- according to developmental stage. The his fingernails are painted silver. Tommy dren can be reliably distinguished from following vignettes illustrate how these remains quiet while Mom reports that each other in childhood. However, recent different cohorts may present to their since last year, Tommy’s grades have findings from a clinic-referred sample pediatrician. dropped, he “announced that he might of youth in the Netherlands has begun be gay,” and he has started dressing “an- to shed empirical light on the develop- A Prepubertal Natal Male with drogynously.” The pediatrician meets mental characteristics of “apples” versus Gender-Variant Behavior with Tommy alone. During a sexual be- “oranges,” suggesting that the likelihood Andy is a 5-year-old natal male pre- havior screen, Tommy states that he is of transgender identity in adolescence senting for a well-checkup visit. The pe- attracted to boys but that he has not been may be predicted by several factors, in- diatrician notices that Andy has long hair sexually active. He tells the pediatri- cluding a high severity of childhood GD, and is wearing a pink shirt with sequins. cian that he “might be feeling like a girl GD persistence into adolescence, and a He could easily be confused for a girl. inside” and that he might be transgen- proclivity in children to assert their gen- Mom reports that Andy will “only play der. He is distressed about his changing der cognitively versus affectively (ie, “I with girls” and “prefers toys that are ste- voice, body hair, and waking up in the am a girl” versus “I feel like a girl.”).14,16 reotypically feminine, such as dolls.” On morning with erections, and all he can Additional research is needed to further a few occasions, he has stated, “I wish I focus on is “not getting taller.” elucidate the characteristics of gender could be a girl,” but he appears relatively The youth depicted in these vignettes development in gender-variant youth. happy and well-adjusted when wearing illustrate how gender identity and ex- “boy clothes” to kindergarten. pression might present across develop- SOCIAL GENDER TRANSITIONING ment. Although there are overlapping re- Currently, the topic of social gender A Peripubertal Natal Female with curring themes for all youth with gender transitioning in prepubertal children is Gender Dysphoria variance, there are also common presen- controversial. Social gender transition- Lily is an 8-year-old natal girl pre- tations within each developmental co- ing refers to individuals’ intention to senting with a headache. She appears hort. As mentioned earlier, the trajectory present—in name, in preferred gender different since the last visit, with a short of young children with gender variance, pronoun, in dress—as a gender different haircut that leads the pediatrician to such as Andy, may reflect a number of from their birth-assigned gender and in mistake Lily for her older brother. Her identity outcomes later in life. Support- a manner consistent with their affirmed mother describes Lily as a “tomboy,” ing children and families as they navi- gender. Proponents of social transition- preferring to play sports and spend time gate open-ended exploration of gender ing in prepubertal children argue that with mostly boys. However, Lily has be- that does not presume later identity children allowed to transition to their come withdrawn in the past few months, outcomes is a hallmark of working with affirmed gender will experience less scratching herself where breast buds this age group.9,21 An older child on the social distress and, because the transi- appear to be developing. She has been cusp of pubertal changes, like Lily, may

PEDIATRIC ANNALS • Vol. 43, No. 6, 2014 e129 CME Copyright 2014 Pediatric Annals present with anticipatory anxiety about pression, anxiety, and bipolar disorder mental health needs of youth with gen- the emergence of secondary sex charac- were most commonly observed. der variance while providing support for teristics. Further exploring gender iden- Transgender adolescents in the Unit- family and community around the child tity and the correlation between physical ed States face high rates of verbal ha- or adolescent. development and anxiety or other mood rassment, physical assault, and peer and changes is critical in this group. Adoles- family rejection, and many experience MENTAL HEALTH ROLE cents such as Tommy may experience homelessness, economic marginaliza- The World Professional Associa- an emergence or intensification of GD tion, and lack of access to medical and tion for Transgender Health (WPATH) during puberty. The development of un- mental health services.2,7,24,25 Findings Standards of Care outline the role of wanted secondary sexual characteristics from the National School Climate Sur- the mental health professional work- is often exceptionally distressing. Some vey suggest that transgender high school ing with children and adolescents with adolescents who feel “different” may at students often encounter hostile school GD as including: (1) assessment of GD, first declare a gay, lesbian, or bisexual environments and, overall, report higher (2) provision of family counseling and sexual orientation but later realize that levels of victimization at school than supportive psychotherapy to assist with what they are experiencing is related to their lesbian, gay, and bisexual peers.26 exploring gender identity, (3) assess- discordance between their gender iden- When asked if they had ever experiment and treatment of coexisting mental tity and physical anatomy. Others may enced harassment and assault based on health concerns, (4) referral to medical recognize this earlier and declare that gender expression, 75% of transgender providers for consideration of transition they were born in the wrong body. Ex- students reported verbal harassment, services, (5) education and advocacy on ploration of gender identity with older 32% reported physical harassment, and behalf of children with GD, and (6) refer- youth, who have an increased ability to 17% reported physical assault.26 ral for peer and parent support groups.1 think abstractly, helps differentiate those Several psychotherapeutic approaches who are experiencing GD, same-sex at- CARE FOR GENDER-VARIANT to treating children with GD have been tractions, or both. CHILDREN AND ADOLESCENTS: proposed and are described elsewhere.6 A MULTIDISCIPLINARY MODEL For youth with gender variance who are MENTAL HEALTH Currently, there is no consensus not gender dysphoric, providing educa- Children and adolescents with gen- regarding the best course of manage- tion and support for families is the pri- der variance may experience coexisting ment for children and adolescents with mary goal, and referral to medical pro- mental health problems, and it is un- GD, and although a body of research is viders for physical transitioning is not known to what extent these are reflective growing, outcomes in this area are lack- indicated. of societal responses to gender variance ing. Although management may vary rather than genetic predisposition. One between clinics, there is consensus that MEDICAL PROVIDER ROLE study of children with GID referred the most comprehensive care is deliv- Puberty is often a time of heightened to Dutch and Canadian gender clinics ered through a multidisciplinary team distress for youth with GD. Many, but found behavior problems and peer-rela- comprised of medical and mental health not all, desire hormonal intervention. tion difficulties in both groups.22 In ado- clinicians with gender-related exper- Current guidelines for medical treat- lescents with GD, anxiety and depres- tise and familiarity with developmental ment of GD have been published by sion are reported frequently. A Dutch stages of childhood/adolescence.27 The WPATH and the Endocrine Society.1,27 study of youth referred to a gender clinic model of care at the Gender and Sex All patients considering hormonal inter- in Amsterdam (mean age 14.5) reported Development Program at Ann & Robert vention must fulfill specific criteria and that 32% met DSM-IV criteria for one H. Lurie Children’s Hospital of Chicago meet with a mental health professional or more co-occurring psychiatric disor- embraces a gender-affirming model that to rule out psychiatric comorbidity that ders, with anxiety and depression most does not view gender variance as a men- could interfere with the identification frequently described.23 This is similar to tal illness. An affirming philosophy sup- of GD, ensure psychosocial support, findings at a pediatric multidisciplinary ports children and adolescents living as and confirm that the patient fully under- gender clinic in Boston, which reported they feel most comfortable and promotes stands the effects of treatment.1,27 Here, that 44% of adolescents (mean age 14.8 exploration of gender identity without we briefly outline two forms of hormon- years) had received psychiatric diagno- presuming a specific “one-size-fits-all” al intervention. A more thorough discus- ses prior to their initial presentation at trajectory of gender development.28 The sion of hormonal treatments (including the clinic.5 Among these diagnoses, de- goal of care is to meet the medical and management considerations, dosing,

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