Asking specific questions leads to helpful discoveries about gender issues.
Psychologist David Schwartz, Ph.D., says gender identity is a feeling/belief of belonging or not belonging to one gender category or another. It is society’s construct and does not lodge anywhere in our bodies.
The DSM-5-TR indicates the prevalence of gender dysphoria is .005 to -.014% for biological males and .002 to .003% for biological females. The Pew Research Center research finds that about 5% of youth believe their gender is different than their natal sex.
Gender-nonconforming youth choose to be a different gender. They do not suffer distress. The gender-dysphoric develop anxiety and depression symptoms related to their distress.
In 2008, Madeline S. Wallien and Peggy T. Cohen-Kettenis conducted a study of the outcomes of gender-dysphoric children. They studied 59 boys and 18 girls. They discovered that 43% of the children who were gender-dysphoric at 5 to 12 years old were not gender-dysphoric ten years later. Most children were no longer dysphoric after puberty. Of the 27% who remained dysphoric after puberty, most developed a homosexual or bisexual orientation. Thirty percent of the study population was lost to follow-up, so their outcome was unknown.
In a later study, published in 2021, Singh, Bradley and Zucker studied 139 boys with gender dysphoria at a mean age of 7.5 years old. The boys were later reassessed at a mean age of 20.6 years old. Gender dysphoria persisted in early adulthood in 12.2% of the boys while 87.8% of the boys were not gender-dysphoric as young adults. The persisting dysphoria rate is less than half the rate reported by Wallien and Cohen-Kettenis in their earlier study in 2008.
The studies suggest that gender dysphoria in childhood does not persist in the majority into adulthood. The findings may open the way to thinking of childhood gender dysphoria for the majority as a time of sorting out who one is rather than being a fixed, immutable gender identity that persists into adulthood.
Both David Schwartz and Az Hakeem recommend psychotherapy for such children. One goal is to help the children discover how they evaluate gender as it relates to them personally. A second goal is to aid children in being comfortable and accepting of the gender role they tailor for themselves, regardless of their biological sex.
How Parents Can Help Their Children
Commonly, parents are distressed and anxious upon hearing their children’s desire to be a different gender. They do not know how to think about the issue, what to do, or what to say to their children.
Parents can help themselves and their children by gently probing with their children what the gender discomfort is all about. This will get your child thinking. It will also provide an opportunity for your child to share thoughts and feelings about their gender identity and uncertainties with you. It will create a familiarity and ease with talking about gender roles and concerns for both parents and children.
Ask open-ended questions. Get specific details/examples for each of what they feel and think:
1) Why do you feel/think you are not a boy (or girl)?
2) Why do you feel/think you are a girl/boy instead?
3) How are boys supposed to be? the good and the not-so-good?
4) How are girls supposed to be? the good and the not-so-good?
5) What do you worry about if you remain a boy? a girl?
6) What do you worry will happen if you grow up as the boy (or girl) you are?
7) What do you think will happen if you grow up as a girl (or boy) instead of the girl/boy
you have been?
The questions open the opportunity for dialogue, which helps mitigate the anxieties both parents and children have. It is an opportunity for parents to listen to their children’s discomfort and questions.
Gender discomfort and uncertainty can arise at any age among children and youth. I will describe cases of gender incongruity or dysphoria at three ages––preschool, school-age and adolescence. This may provide an idea of how gender dissatisfaction might contain deeper concerns that children attribute to being a boy or a girl. Parents can help tap into these deeper concerns.
Parents can also take a longer, more watchful, waiting approach with their gender-dysphoric children. They can allow their children to explore their desire for a different identity without steering them toward one gender identification or another. Maintaining a state of ambiguity is difficult for parents. Parents may be anxious, angry, or sullen over their child’s preference. Parents can help themselves by praising themselves for their support of their children as they search and eventually solidify their gender identity.
A four-old-girl suddenly announces she wants to be a boy. She quits playing with her dolls and wants toy trucks. She wants to wear jeans, a cowboy hat, and boots. When her parents talk with her, they learn she thinks boys get more attention and more and better toys. Girls get ignored more and just get “dumb dolls and dresses.”
What has happened to this girl? In talking further with her, her parents discover the change is due to a baby brother recently being born. He is getting the increased attention all newborns need. But to her four-year-old way of thinking, he gets more attention because he is a boy. She is jealous and wants the same attention for herself. She should be a boy, she thinks. Her parents explain how babies need more care, time, and attention. Sometime later she quits wanting to be a boy and reverts back to being herself.
A seven-year-old girl believes herself a boy since age three. She has never wavered in her belief. She wears a short haircut and insists on wearing only pants or shorts, no dresses. She enjoys playing games and sports with boys. She insists on being called her middle name as it is more boy-like. She wants to be called he/him. And, she declares openly to her parents that she wants a penis and a hairy chest.
She experiences depressive feelings when girls mock her for not wanting to play with them. She shuns playing with them. She often cries when her boyhood identity is made fun of or not acknowledged by other children. Since first grade her grades have dropped and she isolates herself.
Her mother exhibits a great deal of patience over her daughter’s insistence that she is a boy. The mother does not jump to conclusions and does not cast doubt on her daughter’s views. Over the course of the daughter’s development, they have had many discussions that allow for free exchange by the daughter about her views of herself. Her mother’s tolerance relieves some of the girl’s angst and dysphoria. Her mother’s slow going, unchallenging approach is wise. Her mother finds her a psychotherapist and the mother joins a support group for parents.
A fourteen-year-old girl has a history of many moves, missing school and few friends. She decides she wants to be a boy several months after joining an online gender-dysphoria group. She enjoys the support and comaraderie she gets from the other teenage girls, who also want to be boys.
She tells her mother of her desire, and they talk. The girl is asking to take testosterone supplements and have her breasts removed. Gradually, her mother realizes the girl enjoys the friendships and emotional support she gets from the online group. The girl discloses she feels she must fit in with wanting to be a boy to keep these friendships. Her mother tells her she thinks this is why she wants to quit being a girl.
Wisely, her mother gets the girl a therapist. The mother and girl also meet with school personnel to talk about other groups the girl can join to make new friends, groups that do not create gender dysphoria.
These case examples reveal the underlying issues, confusion, and distress children can experience when gender-nonconforming or gender-dysphoric. We also see how parents can dig deeper and help themselves and their children figure out what may be going on under the surface.
Parents may also help their children tread these delicate waters by supporting their children’s gender identity exploration and views. Children’s views of their gender may be fluid or static. Time will tell. Referral to a therapist for psychotherapy also helps.
Brown, A. Pew Research Center, 7 June, 2022. https://pewrsr.ch/3Qi2Ejd
Hakeem, A. (2012), Psychotherapy for gender identity disorders, Advances in Psychiatric Treatment, 18:1, pp. 17-24.
Schwartz, D. (2021), Clinical and ethical considerations in the treatment of gender dysphoric children and adolescents: When doing less is helping more, Journal of Infant, Child, and Adolescent Psychotherapy, 20 (4), pp. 1-11.
Wallien, MSC, Cohen-Kettenis, PT (2008): Psychosexual outcome of gender dysphoric children, J Am Acad Child Adolesc Psychiatry, 47 (12): 1413-23.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. (5th ed., text rev.)
Singh, D.,Bradley, S.J., & Zucker, K.J.(2021) A follow-up study of boys with gender identity disorder, Frontiers in Psychiatry, 12:632784, pp.1-18.