Download An Unexpected Chief Complaint Addressing

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An Unexpected Chief Complaint
Addressing gender variance in pediatric primary care
ALEXANDRA GARZA FLORES, M.D.
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Meet Tommy*
 Tommy
is a 4 year old boy noted by his
parents to “really like girl things”
 He
prefers playing with girls than with other
boys
 He
wants dolls and necklaces for Christmas
 He
likes dresses, skirts, and other girl
clothing
 His
favorite colors are pink and purple
*Name has been changed to protect patient confidentiality
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Parents’ main concerns:

Parent’s have tried
redirecting his interests,
explaining what things are
“for boys” vs. “for girls”

Tommy has recently started
“acting out” by throwing
temper tantrums

Kids at school have started
saying things to him like:
“Pink is for girls!”
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Overview
 Children’s
understanding of sex and gender
 Importance
 Gender
of gender in society
variance vs. gender identity disorder
 Protective
factors against psycho-emotional pathology
 Addressing
 Resources
gender variance in pediatric primary care
for families
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Children’s understanding of sex
and gender

“Sex” denotes a person’s anatomic definition (male vs.
female body parts)

“Gender” is a person’s social definition (male vs. female
roles in society)

At ~2 yrs  identification of own sex

~3 yrs  understanding that sex is stable over time

~4-6 yrs  understanding that sex is a constant condition,
regardless of outward changes in appearance

~5-6 yrs  sense of what behavior are “appropriate” for
social group
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Gender in society

Is a powerful socially-defining
characteristic

Traditionallythought of as a binary
entity: male vs. female

Today, understood to be more of a
spectrum, with all people manifesting
natural tendencies that fall
somewhere along it

Is society comfortable with this
reality???
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vs
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Gender variance

Interests and behaviors that are outside of typical
cultural norms for each of the genders

Strong and persistent behaviors that are typically
associated with the opposite sex

NOT the result of parenting style or abnormal
development!!!

In boys: interest in make-up, girl clothes, female
cartoon characters, pretending to have long hair, girl
playmates

In girls: interest in boy clothes, short haircuts, want to
be the father when playing house, rough-and-tumble
play, team sports, swim trunks

Incidence is equal in boys vs. girls, though boys are
seen more frequently in clinical settings
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Androgyny ≠ gender variance
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Androgyny = displaying interests or characteristics pertaining
to both sexes

Is a great thing, and represents a child with a wide variety of
interests

These kids are flexible in the types of activities they participate
in and genuinely enjoy

Ex: A boy that plays cowboys and indians when he goes over to a
friend’s house, but plays “house” with his older sister and her
dolls at home

Ex: A girl that likes to wear an apron and pretend to cook like
mom, and likes to watch sports on the couch with dad

MANY kids display androgynous behaviors; these DO NOT
represent gender variance
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Gender identity disorder
 Gender
variance PLUS the strong persistent desire to
belong (or of belonging) to the opposite sex
A
strong cross-gender identification and a
persistent discomfort with their biological sex, or
gender role associated with their sex
 Condition
is termed “disorder” IF and only IF it
causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning
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“Distressed? Who said
anything about being
distressed??!”
For some children and their
families, gender-variance / gender
identity disorder is simply not a
source of distress
For others, the distress is largely
produced by society itself, and is not
an intrinsic quality of the child
There is a large movement
advocating to depathologize the
condition in the same manner that
homosexuality was depathologized
in 1973
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Natural course of gender variance
 2-3
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Children manifest natural interest in activities and behaviors
typically thought of as pertaining to opposite sex
Development of temper tantrums and other behavioral
problems if parents attempt to “correct” their choices
Frustration and distress (gender dysphoria) starts to become
evident
 5-6
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
years of age:
years of age:
Gaining of understanding of gender-appropriate behavior
typical social group  realization that natural interests are
not condoned by society  negative self-esteem issues
begin
Stigmatization of those who “don’t fit the norm”  bullying
social ostracism  reinforcement of negative self-esteem
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Natural course of gender variance
(cont.)
 Elementary school years:
 Many children “go underground” to avoid social isolation
 Internalizing symptoms become more obvious (anxiety, sadness,
social withdrawal
 Externalizing symptoms (anger, oppositionality, attention problems)
 Adolescence:
 GV kids can grow up to be homosexual, heterosexual, bisexual, or
transgender (minority); most boys become gay while most girls
become conventionally heterosexual or bisexual
 Persistent gender dysphoria in 20% of gender-variant teens
 High risk of persistent psycho-emotional pathology (depression,
anxiety, etc.)
 High risk of suicide
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Protective factors
 Family
support!
Family
support!
Family
support!
Family
support!
Family
support!
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Protective factors
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Without parental support, child may believe stigma and
ostracism are deserved
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Positive family environment:
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Critical counterweight to negative societal responses
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Main catalyst to promote psychosocial resilience in the world
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Source of skills and strength to deal with bullying and other
stressors
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The home must be a guaranteed safe place for the child to
feel loved and accepted exactly the way he/she is,
regardless of how the rest of the world may feel

Every kid needs their parent to be their cheerleader!
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THE BOTTOM LINE:
“The happiest and most well-adjusted
children, [gender-variant and gendertypical alike], are the ones who know they
are loved and supported.”
- Brill & Pepper, “The Transgender Child”
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Back to Tommy… How do we
address his parents’ concerns?
① Empathize with their concerns and struggles 
acknowledge their natural need to grieve over a loved,
but misunderstood child
② Educate them! Gender variance is NOT a
pathology.
③ Normalize the situation by providing access/exposure
to the many other families/children in their position
④ Provide helpful resources (books, articles, support
groups, helpful websites)
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How do we address his parents’
concerns? (cont.)
⑤ Encourage open-mindedness about the future of
their child, rather than deciding on an idea about
what they will be like as adults (homosexual,
heterosexual, etc.)
⑥ Stress the importance of being the child’s #1
advocate, and making the home a safe place full of
unconditional love and support
⑦ Refer for family counseling if desired
⑧ Screen child for psycho-emotional pathology
during current and subsequent visits
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Tips for parents
 Enjoy
 Keep
who your child is!
home a safe place
 Talk
about stigma, teasing, bullying, and ostracism, and
prepare child to cope
 Encourage
child’s interests and talents, especially
gender-neutral ones
 Don’t
use “boy”or “girl”to label toys or activities
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Tips for parents (cont.)
 Read
books/watch TV programs including GLBT
adults and teens; discuss; celebrate!
 Advocate
 Join
in school
or initiate anti-bullying programs
 Educate
 Seek
extended family and friends
supportive counseling and/or peer support
group
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Fun reading for kids and young adults

“My Princess Boy” by Cheryl Kilodavis
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“The Sissy Duckling” by Harvey Fierstein
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It’s Perfectly Normal” by Robie Harris
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Reading for parents
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“Not like other boys” by Marlene Fanta-Shyer
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“Gender born, gender made” by Diane Ehrensaft
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“Sissies & tomboys: Gender non-conformity & homosexual
childhood” by Matthew Rottnek
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Websites and support groups for
the whole family
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Outreach Program for Children with
Gender-Variant Behaviors and their
Families:
www.dcchildrens.com/gendervariance
Download “A Guide for Parents”! 
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Websites and support groups for
the whole family (cont.)
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Parents, Friends and Families of Lesbians and Gays
(PFLAG): www.pflag.org
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Trans Youth Family Allies: www.imatyfa.org
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www.genderspectrum.org
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www.transyouthequality.org
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Gay Lesbian and Straight Education Network (GLSEN):
www.glsen.org
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Bibliography
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Children's National Medical Center, Outreach program for children with gendervariant behaviors and their families. “If you are concerned about your child's gender
behaviors: A guide for parents.” Washington, DC.

Menville, EJ. “An affirmative intervention for families with gender variant children: A
process evaluation.” J of Gay and Lesbian Mental Health. 2011:15,1. 94-123.
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EJ Menville, C Tuerk, EC Perrin. “To the beat of a different drummer: the gendervariant child.” Contemporary pediatrics. 2005.
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MSC Wallien, H Swaab, PT Cohen Kettenis. “Psychiatric comorbidity among
children with gender identity disorder.” J of Am Acad of Child and Adoles Psych.
2010: 46,10. 1307-1314.
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Mukkades, NM. “Gender identity problems in autistic children.” Child: Care, health,
and development. 2002:28,6. 529-532.
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Perrin, EC. “Sexual orientation in child and adolescent health care.” Kluwer
Academic/Plenum Publishers. New York. 2002: 48-49.