Key points

Over the past decade, there has been an increase in the number of gender variant children and adolescents seeking care at gender clinics and centers around the world. Many of these gender variant youth are seeking care at younger ages for many reasons, including greater access to information about transgender or gender variant youth via the Internet, more exposure to gender variant or transgender characters in the media, and greater openness toward dialogue concerning one’s gender with his or her peers and family members.

Gender variance is an umbrella term used to describe the behaviors, interests, appearance, expression, or an identity of persons who do not conform to culturally defined norms expected of their natal gender. Related terms include gender nonconforming , gender creative , transgender , and, in Aboriginal culture, two-spirited . To meet the needs of such youth, there has been an increase in the number of pediatric clinics in Canada, the United States, and Europe that specialize in the care of gender variant children and adolescents.

For most youth, the natal gender (ie, the gender assumed based on the physical sex characteristics present at birth) is consistent with their gender identity (a person’s intrinsic sense of self as male, female, or an alternative gender). In a small minority, however, there is a discrepancy between assigned (or natal) gender and gender identity. The distress that is caused by this discrepancy is called gender dysphoria (GD). This article reviews the epidemiology of youth with gender variance and GD and the models of care used to manage youth with GD.

Terminology

When working with youth and their families, medical professionals should be inclusive, sensitive, and respectful regarding the use of preferred names and gender pronouns. There is an abundance of gender-related terms that may be used by youth, their families, and health care professionals.

Epidemiology

The prevalence of gender variant behavior and GD in childhood and adolescence are largely unknown. One study investigating gender variant behavior found that 2% to 4% of boys and 5% to 10% of girls behaved as the opposite sex from time to time. Another study found that 22.8% of boys and 38.6% of girls exhibited 10 or more different “gender atypical behaviors.”

As opposed to studies of gender variant behavior, other studies have attempted to investigate the prevalence of GD, a psychiatric diagnosis present in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ). Using such criteria in adults, the prevalence of GD ranges from 0.005% to 0.014% for assigned men and 0.002% to 0.003% for assigned women. Such numbers are based on referrals to medical and surgical reassignment clinics and are likely modest underestimates. Sex differences are also noted in referrals to pediatric specialty clinics focused on gender variant youth. In children, sex ratios from natal boys to girls range from 2:1 to 4.5:1, whereas in adolescents the sex ratio is close to parity.

In May 2013, the DSM-5 replaced the term gender identity disorder (GID) previously found in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) ( DSM-IV ) with the term GD after much complex debate. Many view the replacement as a paradigmatic shift toward depathologizing gender variant identity and behavior. The criteria for GD (with or without a disorder of sex development) are detailed in the DSM-5. No studies have thus far used these newer criteria to determine the prevalence of GD in children and adolescents.

Terminology

When working with youth and their families, medical professionals should be inclusive, sensitive, and respectful regarding the use of preferred names and gender pronouns. There is an abundance of gender-related terms that may be used by youth, their families, and health care professionals.

Epidemiology

The prevalence of gender variant behavior and GD in childhood and adolescence are largely unknown. One study investigating gender variant behavior found that 2% to 4% of boys and 5% to 10% of girls behaved as the opposite sex from time to time. Another study found that 22.8% of boys and 38.6% of girls exhibited 10 or more different “gender atypical behaviors.”

As opposed to studies of gender variant behavior, other studies have attempted to investigate the prevalence of GD, a psychiatric diagnosis present in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ). Using such criteria in adults, the prevalence of GD ranges from 0.005% to 0.014% for assigned men and 0.002% to 0.003% for assigned women. Such numbers are based on referrals to medical and surgical reassignment clinics and are likely modest underestimates. Sex differences are also noted in referrals to pediatric specialty clinics focused on gender variant youth. In children, sex ratios from natal boys to girls range from 2:1 to 4.5:1, whereas in adolescents the sex ratio is close to parity.

In May 2013, the DSM-5 replaced the term gender identity disorder (GID) previously found in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) ( DSM-IV ) with the term GD after much complex debate. Many view the replacement as a paradigmatic shift toward depathologizing gender variant identity and behavior. The criteria for GD (with or without a disorder of sex development) are detailed in the DSM-5. No studies have thus far used these newer criteria to determine the prevalence of GD in children and adolescents.

Gender identity development

Gender identity development begins around 2 to 3 years of age. At this age, children have a general sense of what is male or female and identify their own gender soon after. At 6 to 7 years of age, a child realizes that one’s gender is likely to remain constant.

The findings from studies investigating the trajectory of gender variant children who meet the criteria for GID or GD as an adult are inconsistent. The percentage of children initially diagnosed with GID who display persistence of GID range from 12% to 27%. Such studies suggest most children who meet the criteria for GD do not have persistence of GD by the time they have initiated puberty. There is research to suggest, however, that this may be caused, in part, by an internalizing pressure to conform rather than a natural progression to non–gender variance. Studies have also indicated that a significant percent of prepubertal gender-nonconforming youth eventually identify as gay at puberty and may not have been on a transgender trajectory in the first place, as discussed later. Studies have been carried out to identify predictors of persistence of GD. Factors that increase the likelihood of persistence of GD in adulthood include more gender-variant behavior in childhood, greater intensity of GD in childhood, and persistence of GD during adolescence. Qualitative research also found that cognitive statements were predictive of gender identity outcome (eg, I am of the other gender.) versus affective statements (eg, I wish to be of the other gender.). There are also many individuals whose GD emerged in adolescence and adulthood.

Sexual orientation is often confused with gender identity. Just as cisgender individuals can have any sexual orientation, the same holds true for transgender individuals.

Issues faced by gender variant and transgender youth and their families

Although gender variance is not a disorder, many gender variant youth face a variety of issues that affect emotional and psychological wellbeing. Very often, gender variant youth experience levels of stigma, social ostracizing, and verbal and physical violence so great that their psychological well-being is compromised, potentially leading to depression and/or anxiety. A recent study found that gender variance during childhood was a risk factor for experiencing childhood physical, psychological, and sexual abuse. Moreover, gender nonconformity predicted an increased risk of lifetime posttraumatic stress disorder. A recent study investigating transgender-identified youth and younger adults found very high rates of suicidal ideation and suicide attempts. These studies suggest that such rates increase as youth reach adulthood.

Gender variant children experience a higher level of social rejection from their peers, and this may increase through their years in school. A study examining transphobia in the education system found that 56% of gender variant students were called names, made fun of, or bullied compared with only 33% of their cisgender peers. A Canadian survey found that 90% of trans youth heard transphobic comments daily or weekly from other students. Moreover, the rates of verbal and physical harassment of transgender students because of their gender expression were 74% and 37%, respectively. More than three-quarters (78%) of transgender students indicated feeling unsafe in some way at school. For such reasons, the truancy rates were also much higher in lesbian, gay, bisexual, transgender, and questioning (LGBTQ) teens than non-LGTBQ teens.

Some parents continue to have intolerant views toward their child’s gender expression. Studies have found that gender variant children have poorer relationships with their parents. Another study found that gender variant youth were more likely than nongender variant children to experience abuse and violence from their own family members. A recent report from Ontario, Canada found greater satisfaction with life and self-esteem in transgender youth whose parents were “very supportive” versus those whose parents were “somewhat to not at all supportive.” At the same time, depression and suicide attempts were significantly decreased in transgender youth whose parents were supportive in comparison with those whose parents were not supportive. Unfortunately, many youth feel unsafe at home and leave their homes, being rejected or forced out by their families because of their sexual orientation or gender identity. LGBTQ youth are also overrepresented in youth accessing housing programs, such as shelters.

Just as gender variant youth may face rejection from their peers, some families may face rejection from friends and family members who do not accept their child’s gender expression and behavior or the parent’s decision to affirm their child’s gender expression and behavior. Although many are well intentioned, some parents may also have conflict with each other in deciding how to support their child. Lastly, various professionals and child welfare authorities may incorrectly seek reparative approaches and apprehend gender variant children from their parents out of concern that support of gender variant expression and behavior constitutes child abuse.

Evolving approach to prepubertal gender variant children

In the 1960s, children with gender variance began to be viewed through a disease medical model whereby such behaviors, expression, and identity were pathologic and needed correction. Such children and adolescents were subjected to psychological interventions to attempt to redirect behaviors, expression, and identity so they were consistent with social norms. The main goal of this reparative approach was to prevent children and adolescents from identifying as transgender. The inclusion of GID in children in the DSM-IV in 1980 was seen by many to further pathologize nonconforming gender identity and expression and reinforce gender stereotypes.

There has been a steady shift from the reparative approach in gender variance in childhood and adolescence toward an affirmative model that validates and encourages parents supporting their gender variant children and adolescents. The major premises of the gender affirmative model are as follows: (1) Gender variations are not disorders. (2) Gender presentations are diverse and varied across cultures and, therefore, require our cultural sensitivity. (3) To the best of the authors’ knowledge at present, gender involves an interweaving of biology, development and socialization, and culture and context, with all of these factors influencing an individual’s gender self. (4) Gender may be fluid and is often not binary, both at a particular time and, if and when it changes within an individual, across time. (5) If there are mental health or behavioral concerns, it more often stems from negative cultural reactions (eg, transphobia) rather than from within the child. In this approach, the goals are not to pathologize the child or adolescent’s behavior or identity but to destigmatize gender variance, promote the child’s self-worth, allow for opportunities to access peer support, and enable parents and other community members to create safer spaces for such children in day care, schools, and other social environments. Although a gender-affirmative model encourages parents of gender variant children to follow their child’s lead, parents should be careful to avoid imposing their own preferences on their children.

Many parents who favor the gender affirmative approach will support their child’s social transition. A social transition consists of a change in social role to their affirmed gender and may include a change of name, clothing, appearance, and gender pronoun. Parent and clinician reports suggest that children’s happiness may vastly improve after socially transitioning. Because the approach is completely reversible, proponents of social transition argue that children can be reminded that they may return to their natal gender at any time and another transition is possible. Those who oppose social transitioning in prepubertal children argue that it may contribute to GD persistence and increase one’s likelihood of identifying as transgender in adolescence. The decision for a child to socially transition is not a simple one and should be made jointly among the child, the parents, and supportive professionals if available.

Many prepubertal gender variant children do not seek help from medical centers. In these cases, parents and the adults surrounding such gender variant children are able to create safe environments where these youth are able to explore their gender and are supported in living in a gender role that corresponds to their internal gender identity. Other prepubertal gender variant children and their parents may present to medical centers seeking guidance and resources. These parents may be either supportive or not supportive of their child’s gender expression and/or identity. These children and their families may benefit from validation of their gender concerns and learning about puberty and the physical changes that may occur in the upcoming years. Meetings at earlier ages may also facilitate greater comfort with medical professionals, as many youth may not want their parents to address or monitor pubertal development. Lastly, medical clinics may coordinate or facilitate access to individual or group therapy to provide greater insight and understanding of their gender identity, screen and monitor for mental health concerns, and improve resiliency through peer support. Recent evidence indicates that youth in gender clinics incorporating an affirmative model have experienced significantly fewer behavioral problems.