• Understanding Gender Diversity: A guide for Professionals Working with Children

    Gender diversity is a broad category that encompasses any individuals who do not identify or conform to the traditional gender binary in a way consistent with their sex assigned at birth. This encompasses people who are transgender, non-binary, genderqueer, genderfluid, pan-gendered, and others. As the concepts of non-cis-genders have become more prevalent in the public awareness and acceptance of gender non-conformity has expanded, more people now have language to describe their experience and feel safe enough to make public their non-conformity (Ehrensaft, 2014). Understanding gender diversity is vital for professionals who work with children and families because of the increased public disclosure, and the dire consequences to mental health and suicidality that occur in these populations when they are not well supported. Queer and gender-nonconforming youth have a significantly higher prevalence of self-harm (65.3%), suicidal ideation (73.8%), and suicide attempts (25.7%) than their peers (Jadva et al., 2023). Youth whose gender identities are not supported by their parents experience a 14-fold increase in suicide rate (Newhook et al., 2018). This article seeks to provide a basic primer for professionals who work with children and families.

    Before exploring gender identity development, we must disambiguate gender, sex, sexuality, and attraction; each of these terms is a spectrum and is often conflated in our culture. Sex is assigned at birth based on the appearance of an infant’s genitals. Most folks are assigned as male or female, but roughly .01% of the population have ambiguity in genitals and are labeled intersex (How Common Is Intersex? | Intersex Society of North America, n.d.). The surgical assignment of gender for intersex infants is falling out of favor and is a topic that exceeds the scope of this article. Despite appearances, sex is also determined by genes, specifically the presence of XX or XY chromosomes. You may recall a recent controversy in sports where it has been discovered that elite female athletes have been tested and found to have a Y chromosome despite having the appearance, identity, and social status of being female. These athletes have been stripped of their medals because sex chromosomes govern hormone expression (testosterone/estrogen), and are seen to provide an unfair advantage.

    Sexual attraction and sexual preference also largely occur on a spectrum and refer to who a person is attracted to. Much as the conversation around gender has deepened and become more nuanced in recent years, there has been an increase in language and subtlety to the conversation around attraction, subdividing attraction into sexual attraction, romantic attraction, friendship attraction, physical attraction, and so on. Some folks don’t experience sexual attraction at all and may identify as asexual. This does not mean that they do not have partnerships or sexual relationships, just that sexual feelings don’t organically arise within themselves. The most common categories of sexual attraction are straight or heterosexual (attracted to the opposite sex), bi- or pan-sexual (attracted to two or more genders), and gay, lesbian, or homosexual (attracted to a single, same-sex). Who a person is attracted to isn’t necessarily related to their gender identity.

    Gender identity is developed throughout the lifetime, though the majority of key milestones occur early in childhood. When babies are born, they have no concept of sex or gender. Until a child is about four years old, concepts of gender can naturally be very fluid. Around the age of 4, children begin to assimilate social pressure around gender performance and tend to split into gendered play groups (Barbor-Might, 2020). At this point children who are consistent, persistent, and insistent that their gender does not match the sex they were assigned at birth start to be identifiable as transgender (Ehrensaft, 2014). Other children may feel strongly about their gender one day, and less strongly another, or perhaps don’t perform their gender as strongly as their same-sex peers; some of these children will grow into non-binary or genderqueer individuals given the language and safe environment to express this part of their identity. Some folks are slower to come to grips with their gender nonconformity; puberty marks another milestone when many folks become aware that their assigned sex doesn’t fit them as secondary sex characteristics develop and cause considerable distress. The majority of prepubescent children who are gender nonconforming desist, and end up identifying as gay / bi- / lesbian as they hit puberty. Adolescents who begin expressing gender nonconformity have a very high persistence rate, indicating that a reliable indicator is when clarity around gender forms in adolescence. (Coleman et al., 2012).

    Recognizing gender nonconformity can be a helpful skill to develop to support families early (while keeping in mind that prepubescent children are incredibly creative with their gender expression, which is not typically indicative of their gender expression later in life). Once a child is five or older, signs of gender non-conformity may be seen in the characters they play, their clothes, costumes, and aesthetic preferences, but is most obvious in what they say. If a kid tells you their gender, pronouns, and name preference, it is advisable to believe them, even if it changes regularly (Newhook et al., 2018; The Trevor Project, 2023).

    One of the primary concerns for families around gender diversity is how we respond to support youth. There is a great deal of fear around invasive, irreversible changes as if gender-affirming care means immediate, dramatic action, like performing surgery on children. This is a key area I want to address. Gender-affirming care is a spectrum, and different interventions become available as a child ages; every individual is different, and what is appropriate for one person will not be for another. Before puberty, the primary form of intervention is to socially transition or to use the name, pronouns, and gender that a child identifies with. For many folks, socially transitioning is all they ever want or need. Indeed, before the last 50 years or so, it was the only option for most people. Puberty is marked by the onset of secondary sex characteristics (i.e. breasts, body/facial hair/deepening voice), which is when many children begin to experience gender dysphoria and a decrease in mental health, which inspires some families to choose to pursue puberty blocking medicine which delays the onset of puberty. This can give an individual or family more time to make decisions regarding future care. Taking hormones allows folks to develop secondary sex characteristics consistent with their gender. This process is slow, with many body changes taking a year or two to fully develop (you may recall your puberty did not occur overnight). For many, hormones can support their androgyny or gender expression and are sufficient to live the quality of life they desire. Surgery is the final frontier of gender-affirming care and is predominately available for adults. Surgeries span from altering the primary sex characteristics (genitals), any unwanted secondary sex characteristics that may have developed if hormones/hormone blockers were started after puberty (breast removal), and facial reconstructive surgery (facial masculinization/feminization surgery).

    The primary concern for parents whose adolescents are asking for hormones is around side effects or a concern that their child will change their mind. De-transitioning does occur in about 5% of prepubescent children, measured at a five-year follow-up (Olson et al., 2022). Regret has also been measured in <1% of the adult population who had undergone gender-affirming surgical procedures, but the vast majority of these folks reported dissatisfaction due to an unsafe or unaccepting social environment. While the best person to discuss the side effects of medical gender-affirming care is the child’s gender healthcare team, it can be helpful to know the basics to discuss with parents. Unfortunately, medical care to support gender non-conformity is a relatively new field, (the first gender-affirming surgical procedures were reported in the 1930s) and one with the burden of reducing the prevalence of suicidality from this swath of the population (Serano, 2024). Due to the relative newness of this branch of medicine, research on long-term side effects is still underway. However, any concern about side effects should be balanced with the impact of “doing nothing,” or disaffirming a child’s identity. It is worth contemplating how we do not question or pressure cisgender children on their assertions of gender.
    Medical interventions to affirm gender fall broadly into three categories: fully reversible, partially reversible, and irreversible (Coleman et al., 2012). Puberty-blocking drugs are fully reversible (including side effects impacting bone growth). Partially reversible interventions are taking hormones, such as acne, body fat distribution, and hair growth patterns. Irreversible changes can also happen with hormone-only interventions, such as deepening voice with testosterone, and infertility. Most irreversible changes are due to surgery.

    In conclusion, it is vital to learn about gender diversity to help families assess their options, and support youth to find optimal mental and physical health. There are many local and internet-accessible resources to aid youth, families, and supporting professionals with this topic. Family Matters of Marin regularly works with these issues. The Trevor Project is an excellent internet resource, as is WPATH, which has guidance for professionals. Please reach out if we can support you or the families you work with!