Part VIII in entirety

Part 8

New Kids on the Block

When we speak we are afraid our words will not be heard or welcomed. But when we are silent, we are still afraid. So it is better to speak. —Audre Lorde

This final section comprises three pieces that focus primarily on the gender-nonconforming boy. They include a guide for parents, which has been distributed widely in the past decade, and two articles published recently in a journal for professionals who work with children and adolescents.

In some sense, these three pieces represent the culmination of the journey that this book is about. I mean not that my work is done, but that these are, for me, major pieces of writing that embody the overarching understandings, opinions, and concerns to which the last twenty-plus years have led me.

As the journal articles make clear, I am very concerned that, in the United States today, the boy who manifests strong and persistent gender-nonconforming behaviors is too readily believed to be transgender when there is a much greater likelihood that he is gay. This is a large and complex issue with major ramifications for children and parents. And it’s an issue on which intelligent, well-meaning people hold widely divergent views. Here, in closing, I offer my view.

A Guide for Parents

There is no shortage of parenting literature, with an abundance of resources addressing nearly all aspects of child development and care. But Dr. Edgardo Menvielle and I could find nothing that offered parents practical guidance in understanding and supporting the gender-nonconforming child. In 2003 we published If You Are Concerned about Your Child’s Gender Behaviors: A Guide for Parents under the auspices of the Gender and Sexuality Advocacy and Education Program at the Children’s National Medical Center. This groundbreaking booklet has reached thousands of parents, teachers, and others who work with children, with English and Spanish versions of the guide also available for download at http://www.childrensnational.org/gendervariance. The textual content of the booklet is reprinted here, with permission, without photos and drawings.

If You Are Concerned about Your Child’s Gender Behaviors:

A Guide for Parents

Some children are different in their gender behaviors

By the age of three years, most children express an interest in or preference toward activities and behaviors typically associated to their specific gender. We call these behaviors “gender typical” because the members of one of the sexes favor them. For example, boys enjoy rough-and-tumble play and identify with male heroes, while girls enjoy such activities as playing with dolls and pretending to be a mommy. By age five to six years, children have a strong sense of the gender-appropriate behavior that is typical for their social group.

However, some children develop in a different way. Some children have interests more typical of the other sex and sometimes want to look and act like the other sex. For example, a seven-year-old boy plays with Barbie™ dolls and pretends to have long hair and be a princess. A six-year-old girl is only interested in playing outside with the boys, refuses to wear anything except jeans and T-shirts, and talks about being a boy. We call these gender-variant behaviors and interests.

Gender variance and gender nonconformity refer to interests and behaviors that are outside of typical cultural norms for each of the genders. Children with gender-variant traits have strong and persistent behaviors that are typically associated with the other sex. Sometimes they reject the physical appearance (clothing and hairstyle) typical of the child’s own sex. Gender variance does not apply to children who have a passing interest in trying out behaviors and typical interests of the other sex for a few days or weeks.

What Are Gender-Variant Behaviors?

Patterns of gender-variant behavior are usually first noticed between the ages of two and four years. Children with a gender-variant pattern display many of the following characteristics:

Boys may show an interest in women’s clothes, shoes, hair, and make-up. They play-act and identify with female characters such as Barbie™, The Little Mermaid™, Snow White, or Cinderella. They wish to have or may pretend to have long hair, prefer girls as playmates, and avoid rough-and-tumble play and team sports. Others may describe them as gentle, sensitive, artistic, sweet, cute, and very affectionate. When young, they may express the desire to be a girl or claim that they really are girls.

Girls may insist on wearing boys’ clothing and short haircuts and refuse to wear skirts, dresses, and female bathing suits. They tend to reject play activities that are associated with being a girl. Instead, they prefer games and toys that are typically considered more appropriate for boys such as GI Joe™, Superman™, and cars and trucks. These girls may identify with male characters and refuse to assume female characters in play-acting. For example, they may want to be the father when playing house. They prefer boys as playmates and are interested in rough-and-tumble play and contact or team sports. These girls may also express the desire to be a boy, announce they are really are boys, and enjoy being mistaken for a boy.

Behaviors that are observed frequently before the child starts school may become less frequent once the child has more contact with peers. A decrease in observed behaviors may indicate that as the child matures and experiences peer criticism, he voluntarily hides or avoids some behaviors in order to blend in.

Why Does Gender Variance Occur?

Gender variance is not new. It has been described throughout history and in many different cultures. Child development specialists used to believe that gender-typical and gender-variant behaviors were the result of the ways in which children were raised. Today, experts believe that the presence or absence of these behaviors is mainly the result of the biological or genetic diversity among individuals. In other words, the genetic propensity for these behaviors is hard-wired in the brain before or soon after birth. Of course, the specific content of male and female roles has to be learned by all children, even though some children seem to be biologically predisposed toward manifesting some of the gender role characteristics of the other sex. Some experts used to believe that gender variance represented abnormal development, but today many have come to believe that children with gender-variant behaviors are normal children with unique qualities—just as children who develop left-handedness are normal.

Although science has yet to pinpoint the causes, we know that gender-variant traits are not typically caused by parenting style or by childhood events, such as divorce, sexual abuse, or other traumatic experiences. Children do not choose to have gender-variant interests any more than other children choose gender-typical interests. Both types of interests represent what comes naturally to each child. Gender variance is not caused by an emotional disorder. However, because of societal prejudice, children with gender-variant traits may experience ongoing rejection, criticism and bullying, causing adjustment difficulties.

What Can I Expect In The Future?

As an adolescent and adult, your child may be emotionally and physically attracted to persons of the opposite sex, the same sex, or both sexes. Although these three outcomes are possible, research on boys with gender-variant histories suggests that most of them have a same-sex orientation (i.e., they are gay). These boys may grow up to be masculine and conventional in their appearance. Gender-variant girls are most likely to be conventionally heterosexual or perhaps bisexual in their sexual orientation.

On rare occasions, children continue to develop a strong cross-gender identification as they enter adolescence and adulthood. These persons may be transgender and experience persistent discomfort with his or her social sex role. Some may eventually seek sex reassignment so they can more fully and effectively live as the other sex. Some transgender persons do not completely identify with either gender.

How Will My Child View Himself?

Good self-esteem is vital to a child’s ability to deal with life’s trials effectively. However, generalized social stigma and the hostile behaviors that stem from it can cause emotional distress in children with gender-variant behaviors, making their self-esteem development more challenging than necessary. Without support from parents, the child may believe that this stigma is deserved. Affirming parenting is key to protecting a child from these harmful effects.

Generally speaking, girls with interests or behaviors that traditionally are viewed as masculine-oriented usually have stronger self-esteem than boys who have traditionally feminine-oriented interests or behaviors. This may be due to greater social acceptance of girls who show masculine interests than of boys who show feminine interests.

Can It Be Changed?

At the age of five or six years, children begin to be influenced by social pressure to conform and may adjust their behavior in public to blend in. This does not necessarily mean that the child’s core traits have changed. What drives gender-typical or gender-variant traits cannot be changed through the influence of parents, teachers, coaches, or therapists. Although a child may alter his or her behavior in response to parental pressure or social pressure, such changes may be skin-deep and may not reflect how the child truly feels. Furthermore, pressuring/shaming is likely to undermine the child’s self-confidence and esteem. As we explain further below, we strongly oppose parenting approaches or therapies that focus on pressuring children to change and accommodate to a stereotype of how a girl or a boy is “supposed to be.”

How Can I Help My Child?

Love your child for who she is.

Like all children, your child needs love, acceptance, understanding and support. Children that have gender-variant traits sometimes need these in a special way. The more that society and their peers may be critical of them, the more important it is for them to have the support and acceptance of their families.

Question traditional assumptions.

Do not automatically accept traditional assumptions about social gender and sexual orientation. Learn to separate society’s judgments from the love you have for your child. Do not let other people’s critical opinions of what is right and wrong come between you and your child.

Create a safe space for your child.

Children are far more resilient and able to cope when they feel that their parent is on their side. Let your child know that you love him, no matter what. Let others know that you love your child unconditionally, and let your child know that you are there to support him. Many children with gender-variant traits experience social isolation or bullying. Your and your home may be the child’s only place of safety. If this is the case, assure your child that you always will allow and encourage him to be “who he is” in his own home. Create an atmosphere of acceptance, providing a safe place for your child to express his interests.

Seek out socially acceptable activities.

Encourage your child to find activities that respect her interests, yet help her to fit in socially. These might include gymnastics, swimming, computers, or theater for boys and athletic teams, leadership programs, or outdoor adventures for girls. Remember to encourage activities that appeal to the child.

Validate your child.

Talk with your child about the fact that there is more than one way of being a girl or boy. Encourage individuality, and avoid using statements such as, “only girls play with dolls,” and “boys love ball play but girls do not.” Instead, explain that although a majority of boys are not interested in dolls, there are some boys that love them and that’s OK too! The same goes for girls. Not all girls like to play mommy; some girls, for example, like to pretend to be a daddy or a soldier.

Speak openly and calmly about gender variance. Acknowledge to your child that she is different in positive terms. Talk with your child about what it feels like to be different.

Adults who look back on their own childhood of gender nonconformity often recall feeling different, which made them feel ashamed. Help your child realize that although not everyone understands or affirms her, liking different things is nothing to be ashamed of and can lead to special talents and success in adulthood. Most importantly, listen to your child without criticizing. Your child needs to feel that she is understood by you in order to be open with you.

Seek out supportive resources.

Share books and videos with your child that present the full range of human variation in gender roles and sexual orientation. Have these at your home, and ask that they be made available in the school library (see “Useful Resources”).

If your child is isolated from peers, acknowledge that this is hurtful but not his or her fault. Assure your child that he/she will make friends with others who have similar interests in the future. Seek connections with families who accept and celebrate differences among individuals.

Talk to other significant people.

Include siblings in as many discussions about gender variance as possible. They may find it difficult to accept a bother or sister with gender-variant behaviors or interests; they may feel embarrassed or become abusive. This is a challenge for them as well, so they may need your help in understanding their feelings. This can also be a challenge for other family members. Talk to members of your extended family, babysitters, and family friends. Let them know about your child’s needs and what you expect. You may want to have other significant adults read this booklet.

Prepare your child to deal with bullying.

Explain to your child that he will probably encounter criticism and even bullying, and ask him how this feels. Ask what will make him feel safe, and tell your child to come to you or other adults in authority for help. Let your child know that he does not deserve to be hurt.

From time to time, encourage your child to tell you if he is criticized or bullied. Children who are verbally or physically abused by peers are often afraid or embarrassed to talk about it. It is better if your child talks to you about being bullied; however, do not expect your child to always tell you. Be alert to possible warning signs that indicate your child may be in trouble. These signs can include refusing to go to school or outside, complaining of aches or pains, or crying excessively.

Be your child’s advocate.

You may want to anticipate problems and talk to the school, before you hear about them. Talk to your child’s teacher or the school administration or guidance counselor, and solicit their help in creating an atmosphere where your child will be safe from negative judgments. Insist on a zero-tolerance policy at school with regard to teasing and criticism. Do not assume that the school has an understanding of this issue; you may need to educate school staff. Sometimes the school environment may be such that an alternative school may need to be considered.

What Pitfalls Should I Avoid?

Avoid finding fault.

Do not blame your child, yourself, or your spouse. Your child’s gender variance came from within and cannot be turned off at will. It was not caused by anyone else and cannot be changed by anyone else. In fact, if you focus on blame or change, you may miss wonderful things about your child and spoil the rewards of being a parent. Your child needs to express herself as much as other children. If your child is interested in an activity more typical of the opposite sex, it is not an act of defiance. She is simply following her own instincts.

Do not pressure your child to change.

Avoid all actions designed to pressure your child to change. Some children may hide their interests and feelings from disapproving parents because they want to be loved and accepted by them, but this does not mean that the child’s deep-seated interests have changed. In fact, it teaches the child that he has to live a lie in order to be accepted. Do not negatively compare your child to a sibling or another child; this will only hurt both children.

Do not blame the victim.

Do not try to sweep being bullied under the rug or tell your child it is something she must learn to accept because she is different. Do not make your child responsible for other people’s intolerance. Being outside the norm does not give someone else the right to criticize or torment. Bullying is an unacceptable and cowardly act for which only the bully is responsible. Talk about what happened, and help the child understand why it is wrong.

As a Parent, How Do I Deal With My Own Feelings?

Examine your feelings and learn to accept your child.

You and other family members may feel uncomfortable and ashamed of your child’s interests and behaviors. This is common early on. Take time to figure out where your feelings are coming from.

You may have to adjust your dreams of how you expected parenting and your family to be. If these changes must occur, you may experience some of the emotions associated with loss, such as shock, denial, anger, and despair. These feelings are all part of the process toward acceptance. You must reach acceptance in order to affirm your child’s uniqueness.

Look for support.

Learning how to parent in a new way can be challenging. Asking for support is a wise decision for you, your child, and the rest of your family. If you are experiencing too much stress from signs of excessive worrying, loss of sleep, anxiety or irritability, do not hesitate to seek professional support. Sometimes, both parents may disagree on how to raise a child, especially a child with gender-variant traits. If you and the other parent have extremely different views, seek counseling to help mediate your discussions. Counseling will make your communication more productive by providing a safe and neutral space in which to share your feelings and differences.

Unfortunately, many times it is not easy to find support. Keep in mind that you are not alone and neither is your child. However, do not feel discouraged if it is difficult to find other families in similar circumstances in your community. You may consider joining or forming a parent support group in your community or joining the electronic discussion group described below under “Useful Resources: Parent Listserve.” In spite of initial apprehension, many parents like you have found support groups to be very helpful.

How Do I Know If My Child Needs Professional Help?

Seek professional help if your child becomes anxious, depressed, angry, or hyperactive in spite of your efforts to be supportive. If your child shows signs of self-destructive or suicidal behavior, seek professional help immediately. It may be useful to seek out structured approaches that teach children strategies to reduce the impact of bullying and skills to respond more effectively to bullying. Children who are very shy or have difficulty making friends may benefit from training to improve social skills.

How do you identify the right professional help?

Therapists who are competent with other childhood issues do not necessarily have the competence to deal with gender variance, so become an informed consumer and select a professional wisely. A red flag should be raised when the therapist seems to focus on the child’s behaviors as the problem rather than on helping the child cope with intolerance and social prejudice. In the past, professionals assigned the diagnosis of Gender Identify Disorder to children. This approach is flawed because it implies that these children suffer from a mental disorder. Along the same lines, therapists used to recommend techniques to change gender-variant behaviors. Such approaches may be harmful and should not be used.

Ask prospective therapists how they approach gender variance. Ask about their previous experience treating children with these issues. Discuss with prospective therapists what you have learned from this booklet. If you seek therapy for your child, make sure that guidance and support for the parents is a major component of the sessions. Be concerned if the sessions only involve the child, do not address your parenting questions, or do not provide you with ideas to help your child and your family.

Considerations for Families with Boys with Gender-Variant Behaviors:

Concerns about Cross-Dressing and Social Transition

2007

This paper was published in the October 2011 issue of Child and Adolescent Psychiatric Clinics of North America under a different title: “Considerations for Affirming Gender Nonconforming Boys and Their Families: New Approaches, New Challenges.” It is reprinted here with permission. I wrote it in 2007, when I was co-director of the Children’s National Medical Center program for families of children with gender-variant behaviors. I resigned from that position in 2009 but continue to conduct intake consultations for the program’s listserve.

The media and the public’s reaction have created the impression that the gender-variant behaviors of many children are indicative of transsexual identities. This has suggested to some parents that the best way to manage their sons’ gender variance, and perhaps gender dysphoria, is to allow them to dress as girls in increasingly more situations—to the extent that, for some, this becomes a transition to living full-time as a girl. This paper poses some considerations in exploring these issues. Because I have had contact with relatively few parents of gender-variant girls, I will not address these issues in this statement. The issues of raising gender-variant girls may be different from gender-variant boys and require a separate discussion.

Background of the Gender Variance Support Group: “Feeling Good, Fitting In”

The support group for parents of young children with gender-variant behaviors started in 1998. The goal was to help parents help their children to “feel good” about themselves and “fit in” with social realities. We thought that almost all of these boys would grow up to identify as gay. Perhaps because of my own experience with my gay son, the many gay men that I have known, and the research that I was familiar with, I had come to believe that the origins of sexual orientation were essentially biological. I was reacting to decades of mistaken beliefs that homosexuality resulted from the psychosocial environment—i.e., too much mom, not enough dad. I did not believe that allowing a boy to express his feminine interests would cause him to later become gay, but instead believed he was born gay. I felt that expression of feminine interests was part of the normal childhood development of many gay men. But I was also sensitive to the social environment of homophobia and heterosexism, and the prevalent belief that allowing a boy to openly express his femininity would stigmatize him. I hoped that our program would support or facilitate normal development with minimal shame.

The parent guide (included in this book at the beginning of this section) reflected a positive, supportive approach to fully affirm and celebrate the child. This new approach was to avoid the necessity to correct and suppress the expression of femininity. The creation of many safe places for the full expression of gender-variant behavior, primarily in the home, was encouraged. The initial group of parents was resistant to allowing their boys to fully express their feminine interests even at home. Parents were encouraged to develop a strategic approach for social interaction to minimize stigma. Dispelling the myth that there is or should be only one kind of boy became a central goal. Parents were encouraged to help the child understand the harsh realities of societal intolerance—i.e., the macho standard of only one kind of boy. In 2003 we published the parent guide, based upon the first five years of our experiences with the local parents’ group.

Also in 2003, Edgardo Menvielle, MD, co-director of the program, created a website and a listserve at the Children’s National Medical Center. At this time, public awareness of transgender issues was increasing. We were aware of the work of the PFLAG Transgender Special Outreach Network (later the Transgender Network, or T-Net) and the Trans Family listserve, which were excellent resources for parents of transgender children—mainly adolescents and adults. Within our listserve, a few parents reported that their boys seemed to be excessively distressed and insisted that they were girls rather than boys. Many questions arose about how the childhoods of transsexual boys may differ from those of gay boys. Professionals began to question whether the diagnosis of Gender Identity Disorder in childhood was appropriate to describe the common development of many gay boys, unnecessarily pathologizing children within the gender spectrum. It seemed there was a difference between the theatrical fun of gay boys playing dress-up, and the stressful attempts of transsexual boys, who believed they were girls, presenting as their correct gender. One of my transsexual friends captured this difference when she said, “The gay boys want to be fabulous like Barbie. I just wanted to be like my mom.”

In 2006 a trend began as more parents within the listserve felt their sons were transsexual girls, rather than gay boys. This trend was initiated and supported by the intense interest in stories in the media of children beginning gender transition at early ages.

In general, there are four ways that parents deal with the challenges posed by their boys with gender-nonconforming behaviors:

  1. Forced conformity to masculine gender normative behaviors. This is the traditional oppressive approach.
  2. A strategic compromise approach to dealing with social realities, as described in the parent guide. In this approach, safe places where feminine interests can be expressed are established and distinguished from places where the child could be stigmatized.
  3. The “free-to-be” approach allows children to dress and behave as they please, when and wherever they please. Parents choosing this approach are usually in more progressive situations where education about this issue is welcome.
  4. The transgender or transsexual approach allows the child to pass as a girl or to begin a social gender transition from male to female.

We have helped many parents move beyond the first approach. Up to this time, the parents in the local support group have embraced the strategic compromise approach. We are confident that the first approach causes harm. We believe that the second approach can enable most children to feel good about themselves and also face the social realities. We have little experience with the “free-to-be” approach and even less with gender transitions of young children.

Gender Dysphoria and Variance in Males

There is considerable controversy around the issues of social categories of gender identity (as male or female), variance in associated gender behaviors (including sexual expression or orientation), and dysphoria (profound unhappiness) with the assigned gender. What do we think we know or believe that can help parents in raising their gender-nonconforming children?

Historically and across cultures, societies have had a two-gender system based on genitalia. A few societies make provisions for a relatively small number of individuals with another social gender role (i.e., men acting feminine), and a few more allow individuals to live in a gender different from that assigned at birth (i.e., men living as women). The specific content of the social gender roles varies greatly.

It is generally believed that more than 99 percent of the population is raised as either male or female, and remains in that gender throughout their lifetime. The incidence of transsexuals, who began life assigned to one gender and at some time changed to live their life in another gender is currently estimated at about one in 15,000 to 25,000 and may be increasing. These biological males who are transsexual are predominantly conventional in their gender roles before and after their gender transition. However, there are also some transsexuals who are gender variant before and/or after their gender transition. The incidence of predominant homosexuality in males is probably about five percent—one in twenty. About two-thirds of adult gay males report mild to intense gender variance in childhood, and an unknown but probably much smaller number report some history of gender dysphoria. Very few predominantly heterosexual males report a history of gender variance, although one-fourth do describe themselves as being gentle boys.

When research began on boys exhibiting extremes of feminine behavior, most professionals anticipated that these males would identify as transsexual. However, the research studies have shown that almost all of these males actually identified as gay in adolescence or early adulthood. Various therapies had no effect on their sexual orientation. However, the total sample size of these studies was relatively small and the men were still relatively young at the last follow-up. Based upon the low incidence of transsexuality in the population, it is possible that transsexuals may not have been picked up in the sampling. In contrast, work with adult transsexuals has only found some, but not many, who would have been classified as “sissy boys” during childhood. Almost all transsexuals do report gender dysphoria during childhood, but few expressed themselves in a gender-variant way that was evident to others.

The typical boy exhibiting extremes of feminine behavior shows a strong and persistent interest in the toys, play, and clothes of girls, and a preference for girl playmates. He has an infatuation with hyper-femininity, including shoes, make-up, hairstyles, and anything feminine. He plays with Barbie dolls, not baby dolls, because this is not about nurturing a baby. He also has an avoidance of rough-and-tumble play. At a young age he may verbalize wishing to be a girl, or being a girl. The gay child’s gender-variant behaviors seem to be playful expressions of creativity, fantasy, and beauty, and are theatrical in nature. It is common for the expression of gender-variant behavior to decrease later in childhood (around age nine to ten), although it may again emerge during “coming out” in adolescence.

The typical gender-dysphoric male who identifies as transsexual in adulthood reports that during childhood she had an internalized feeling of discontent with being male—i.e., dysphoria—and a desire to be female. She did not engage in overt gender-variant behavior. The initial coping strategy of these males is to try to be as conventionally masculine as possible. When this no longer works for them, they begin cross-dressing and seek to make a social transition by passing as females. Some of them may transition through the gay community, going through a period of time when they attempt to adapt by trying out being gay or presenting in drag, although their style may be more like a female impersonator than a drag queen. Some of them also go through a period of time in adolescence or adulthood when they define themselves as heterosexual cross-dressers. The parents of most transsexual males also report that they noticed little that was feminine about their boys, at least before adolescence, and were shocked when their adult child disclosed a desire to change sex.

This information about typical patterns of gender-nonconforming and gender-dysphoric boys is based on experiences from the recent past, during a time when boys grew up in a highly stigmatized social environment of homophobia and transphobia. However, today we are in a cultural period of increasing acceptance of gay, bisexual, and transgender people, as well as a time of change in the conceptualization of gender. So it is possible that these historical and cross-cultural incidences may change. Furthermore, positive, affirming parenting from an early age may have a huge impact. Whether the developmental patterns will change in this era of greater social acceptance cannot be determined until the present generation grows up. We do know, for example, that gay boys are coming out to others much earlier than in the past.

Social/Sexual Behavioral Rehearsal

Two years is a common age when parents say they began to notice gender-variant behaviors or feminine interests in their boys. At this age, children have idiosyncratic ideas of what it means to be a boy or a girl. Children learn about boys or girls from authority figures (parents and teachers) and from social cues, and apply this knowledge to themselves. When they enter preschool and kindergarten, their notions of how boys and girls behave are concrete, highly conventional, and rigid. These gender classifications may generate questioning in a boy who is so different, and even confusion about his gender identity. Although he knows he is a boy, he doesn’t like the activities of other boys and he does not see any other boys like himself—only girls. He does not realize that there are different kinds of boys, including boys who like girls’ things.

Also during childhood, children commonly rehearse social-sexual behavior that will fully develop later in adolescence and adulthood. A young gay boy may want to have a feminine presentation as a rehearsal for attracting the objects of his affection: other boys. The fact remains that because of stigma we can only speculate about the normal development of a gay male. However, one could reasonably assume that if a person’s love object is of the same gender and not the other gender, then that person’s social-sexual developmental behavior would be different.

Concerns about Cross-Dressing and Social Transition

In affirmation and support of their sons with gender-nonconforming behaviors, parents are often heavily influenced by the expressed desires of their children. Parents want their child to be happy and do not like setting painful limits. Parents want to affirm their child and to show they are not ashamed of him in public. For some parents and sons seeking to avoid the effects of the social stigma of gender variance, it seems to make sense to allow the boy to pass as a girl. Because young gender-variant boys can usually pass easily as girls when dressed in a skirt, this may be seen as a better option than dressing as a boy but wearing pink shoes and carrying a Barbie doll. Other parents truly believe that their sons are transsexual, and they wish to avoid the harm and pain that would ensue by limiting the child from living in the female role.

However, there may be possible pitfalls of allowing a boy to pass as a girl. We may contribute to gender confusion if it turns out that the child is not transsexual. We may limit the boy’s opportunity to learn conventional male-gender behavior. Boys who pass as girls may be forfeiting the opportunity to act on the realization that they can love someone of the same sex without changing their own sex. Some gender-variant gay men have gone through a time when they thought they would be more successful in romantic and sexual relationships with men if they were female. This has been a motivation for some men who later regretted sex reassignment.

Unacknowledged homophobia-erotophobia may also relate to decisions to allow a boy to transition to live as a girl. In certain subcultures in the United States and Mexico, feminine gay men and transsexuals live together as females for mutual support because of rejection from the larger culture that does not tolerate feminine male homosexuality. In Muslim cultures, as well as more sexually liberal cultures like Thailand and India, it is much more acceptable for feminine gay men to live as women than to be seen as homosexuals. Religious pressure in countries like Iran results in gay men having sex reassignment surgery as an alternative to the severe penalties, including death, for homosexual behavior.

The World Professional Association for Transgender Health guidelines for sex reassignment do not include cross-dressing in childhood. Their standards of care include only living full-time as a female in adolescence and adulthood as a requirement for sex reassignment. Sex reassignment during adolescence is controversial, but gaining increasing support. Thus far, there is no standard of care for gender reassignment in childhood.

Tentative Recommendations

Liberal cross-dressing in general social situations and full-time living as a female is totally new territory for boys with gender-variant behavior. Because of this, a compromise approach may be the best first approach. Start by creating as many safe spaces for feminine expression as possible. Celebrate the child’s interests. Give him lots of attention: It’s no fun getting all dressed up without being seen and interacted with. Explain about different kinds of boys to normalize boys who like girl things, which will help him understand where he fits in the boy-girl scheme. Try to expose him to other boys like himself so that he knows that he is not the only one. Also expose him to adult male role models of different ways of being men. Be empathetic and supportive but set limits. In general, resist cross-dressing in public or passing as a girl.

If this approach does not work over a period of time, it may indicate significant gender dysphoria. If the child’s distress increases and the “different kind of boy” concept provides no comfort or is consistently resisted and/or increases stress, then it is important to seek an evaluation by a professional with expertise in this area.
Do You Feel Like a Boy Today, or Do You Feel Like a Girl?

2011

A parent new to our listserve reported this question as something she was advised to ask her son each day. She began to wonder about asking such questions. In this essay, written in 2011, I use the term gender-noncomforming rather than gender-variant, which for many has become synonymous with transsexual. This essay was published in Child and Adolescent Psychiatric Clinics of North America in October 2011 as part of the preceding “Considerations” paper. It is reprinted here with permission.

I was giving a lecture to mental health professionals about gender-nonconforming children and their families in Florida in late 2006. A mother came up and introduced herself after the lecture. She was the mother of “Jazz,” a five-year-old biological boy who had such profound gender dysphoria that his parents decided, with professional help, that he would transition socially as a girl. It had been six months since a story about Jazz had been published in the Village Voice (May 30, 2006)—“See Tom Be Jane,” by Julia Reischel. A media blitz was in full force. We talked about Jazz. I had never heard a story like this before. I had never heard about such profound gender dysphoria happening at such a young age. We were both Jewish moms. She, like me, had tried everything. Her son’s transition was probably life-saving. But she also shared my fear that perhaps too many people with gender-nonconforming children would assume “transsexual” and would ignore the most likely outcome, “gay.”

We had a lot in common, but her story was about success and mine was about failure. Her situation was immediately embraced by the transgender community. My situation was vastly different. I had told our family’s story in the Washington Post in 1993. There was also a media blitz at that time—I appeared on Nightline and 60 Minutes, my son on Larry King—but it fizzled quickly. People were reluctant to face the fact that all human sexuality begins in childhood, and they certainly did not want to think about gay children. They much preferred the idea that some awful parenting style, or sexual abuse, was turning teenagers gay. Our story also stirred up anger and shame in gay men and their parents—no one wanted to talk about wanting to wear a princess dress and play with the ubiquitous Barbie doll, and they didn’t want to hear our story of parents turning into gender cops and other forms of “physician-assisted child abuse.” They didn’t want to relive the pain. No one else, neither other parents nor gay people, was willing to talk about it. In contrast, the transgender community rallied around the positive story of Jazz.

Shortly after my son came out to us as gay, I tried to write a book about our story. I had an agent and several top publishers were interested. When my book proposal was sent around to some of the gay readers employed by the publishers to review gay-related ideas, the response was quick and extremely negative. One reviewer simply wrote “RETRO” in big red letters. Another said, “There is nothing that I find about this mother and her story that is admirable.” It appeared that no one was ready for my story. It was too early.

PFLAG became my way to tell the story. Being president gave me an even bigger voice. Always in the back of my mind was the goal of starting a support program for parents of children like my son so that the abuse would stop. Like most people at that time, I knew almost nothing about transgender people. Not until the question surfaced in PFLAG chapters all over the country, “Was PFLAG for GLB people or GLB and T people?” When the issue was introduced at a national PFLAG convention in the mid-1990s, I listened to the pros and cons. For me it was a no-brainer: Of course our chapter was going to be transgender inclusive. I was totally shocked when I discovered that there were people on our PFLAG board who were very opposed. So we postponed the vote and engaged in a year-long educational program, which included professional speakers and people in the transgender community who shared their life stories. The stories were powerful. We all learned a great deal. I made transsexual friends, and our chapter had a transwoman (male to female) who was our liaison to the transgender community and continues to be a close friend and adviser. I saw almost no connection between the childhoods of my transwomen friends and my son’s childhood. Not one person had reported playing with Barbie dolls and princess dresses. All were pretty conventional boys who harbored an awful feeling about their bodies and discomfort about their assigned gender. All had horrible childhoods and most didn’t really become comfortable enough to transition until they were adults.

When I was talking with Jazz’s mother, we both shared the dream that the horror could stop, and it could stop in childhood—early childhood. After five years as president of the totally inclusive DC PFLAG chapter, in 1998 I turned my attention to starting a support group for gender-nonconforming children and their families. Thanks to child psychiatrist Edgardo Menvielle and the support of the Children’s National Medical Center, our program became a great success. As the first program of its kind, it influenced the way people came to understand the childhoods of gender-nonconforming children.

Over the last twenty years, I have talked with probably more than 400 parents about their gender-nonconforming children. The majority of these were professional consultations with parents entering the Children’s National Medical Center’s support group or listserve. During these consultations, I was always on the lookout for early gender dysphoria as described by transsexual friends and colleagues. I knew that some transsexual boys had a lot of feminine interests—not so much of the show-tune/Barbie/mermaid variety, but more the cooking/sewing/baby variety. Almost all the parents at that time focused on their fear of a gay outcome. I mostly looked for signs of dysphoria, boys not liking and feeling ashamed of their bodies, or other-sex bathroom and underwear practices. Occasionally I would see a red flag. When I did, I would suggest that the parent try the compromise/different-kind-of-boy approach. If the child reacted to this with a lot of resistance or increased anxiety, the parents should call me back and I would help them find a gender specialist to evaluate their child and provide professional guidance.

I also informed them of the only listserve that existed at the time, which was the Transfamily listserve created by Karen Gross, a PFLAG mother of a transsexual child. Later we created a special listserve for parents of girls. We also began a listserve for parents who may have had more gender-based concerns. We were able to find a core group of parents of gender-nonconforming girls, but no core group emerged from the parents with significant gender concerns.

Although some of the parents in our local support group (which is small compared to the listserve group) had gender concerns, nothing surfaced that didn’t seem to get resolved with age. As the children aged out of the group, the small number of parents with whom we stayed in contact reported that their children had identified as gay. Last year, parents of girls started coming to the support group. I understand that the group now has one child, age ten, who is identifying as FTM transsexual.

By the time Julia Reischel’s 2006 article appeared, the transgender community had come into its own. With the media blitz that followed her first article, everything changed. There seemed to be more parents who were willing to talk with the media about their gender-nonconforming children. People in the transgender community were overjoyed (rightfully so) by the possibility that transsexual children would be identified early and spared a childhood of horror. It was shocking for the public to realize that children were born in the wrong bodies, but in some way it may have been easier to deal with this “birth defect” phenomenon than with the idea that gay children exist—perhaps because of the extent to which people associate gay with sexual behavior rather than identity. After each major media presentation, requests to be on our listserve increased. Most parents were making the assumption that their children were transsexual. It became apparent that gay children and transsexual children were being conflated.

It reminded me of what my longtime friend and mentor Dr. Greg Lehne told me about the early days of the gender clinic at The Johns Hopkins Hospital. When adult gender- dysphoric people read about Christine Jorgensen’s sex-change operation in 1952, they finally understood what they had been feeling and the possibility that they could get help. But it wasn’t just adults who were demanding care, it was also parents of gender-nonconforming boys. Dr. Richard Green decided that this was the perfect opportunity to study the childhoods of transgender people. He began his classic fifteen-year longitudinal study—which ended, to his surprise, with the vast majority of individuals identifying as gay, either at the end of the study or informally after the study ended. There was only one undocumented transsexual outcome.

This period, post-Jazz, feels like a repeat of that history. Everywhere, lay people and professionals who tend not to know the history or have much experience in this area are making the same assumption: that gender nonconforming is equivalent to transsexual. The term gender variance has become synonymous with transsexual in many people’s minds. I recently talked with Julia Reischel, who had been aware of the conflation that was happening. She wrote a second article, called “Queer in the Crib” in the Pride Week issue of the Village Voice (June 19, 2007), one year after her first article. She was trying to remind the public not to overlook the little gay boys. It is interesting to note that the cover of that issue had a picture of a little boy dressed in leather with a whip, not a tutu.

After those articles, I decided to test the waters by writing about my concerns and circulating my Considerations paper (which precedes this essay) among people I knew who were involved in this issue. Some were parents. Others were activist friends and professionals—gay, straight, and transgender. The feedback was less than robust, which I interpreted as either they didn’t agree with my concerns, or they didn’t like the informal format (not listing my sources), or they were afraid to upset the transgender community. Indeed, my transsexual friends informed me that in the transgender blogosphere, my concerns were being interpreted as transphobia.

I realized that the paper was a rather amateurish way of testing the waters, but it did get people thinking. I am not an academic. I did not intend to write an academic paper, which is why I did not list my main sources. Most of what I have learned is from professionals in the field of gender and sexuality, from my own experience as a therapist, and from reading books, papers, and commentaries about people’s lives. I have lived part of that life myself, being the mother of a gay son who was gender nonconforming in childhood. I am also reliving that experience through a child who is very close to me.

Three years have passed since I wrote the Considerations paper. I continue to have the same concerns. More and more parents are convinced that their children are transsexual. More transgender listserves and programs are available. It might also be that parents are more aware of the red flags of gender distress. Maybe they are also more comfortable reporting and talking about the signs of dysphoria. Perhaps their children are more comfortable talking about these feelings with supportive and affirming parents. Also perhaps something is happening in the physical environment. In the past few years, new research suggests that possible effects of environmental chemicals may account for, among other things, an increase in male infertility and genital malformations in boys. Whatever the reasons may be, more and more children are being considered transsexual and sometimes they are told about the possibility of being “born in the wrong body” during the “magic years” when fact and fantasy are very much commingled.

I fear that the normal stage of the development of gender constancy could be undermined or prolonged. By gender constancy I mean the developmental milestone where the child realizes that his or her gender is fixed and does not change over time. It occurs somewhere between the ages of two and seven. Until it occurs, the child does not understand that people cannot change gender like they can change clothes, names, and their behaviors. Once a full understanding is attained, the child becomes increasingly motivated to observe, incorporate, and respect gender roles. This concept was developed by Lawrence Kohlberg, PhD. It has been and continues to be somewhat controversial. I am concerned that opportunities to help clarify the bewildering experience of gender-nonconforming children may be missed or not reinforced enough. We know, for instance, that adopted children frequently fantasize that it was some imperfection in them that resulted in rejection by their birth mothers. We also know that children often fantasize that they were somehow responsible for their parents’ divorce. We do not hesitate to clarify, consistently and repeatedly, their misconceptions in these situations. Although I appreciate the gender spectrum and the idea of gender fluidity, I believe it is easier for most children to be able to have some clear sense of gender that is consistent with being either a boy or a girl. Like it or not, we depend on gender to make sense of our sexuality, society, and ourselves. I fear that prolonged gender distress will lead to increased high-risk behaviors during adolescence, such as seeking illicit hormones or silicone injections, drug and alcohol abuse, or suicide. I also know that no matter how much we try to help them clarify their gender issues, for some children it will be simply impossible.

I do not want to sacrifice the life of one transsexual child, but I do get concerned about the vast majority of gender-nonconforming children who are gay and not transsexual. I think we should always proceed with caution, knowing that for these kids it is much easier to pass as a girl or be a girl rather than to be a boy who likes girl things. It would only be natural for kids who see no other kids like themselves, nor any adult role models, to be perplexed about where they fit in the world of boys and girls, and eventually men and women. They learn very early on that their way of being a boy is a problem for people, so they develop strategies to avoid the stigma and search for an understanding of themselves. This search is borne out by comments that children make:

“Maybe I’m half boy and half girl.”

“Maybe I’m a girl on top and a boy on the bottom.” Or, my favorite,

“Maybe I just swallowed a girl” (which fits with the pregnancy fantasy of some young children).

Perhaps when we fail to help these children understand their perplexity in not seeing others like themselves, the issue remains muddled and disturbing. In my experience, many (but not all) children express relief when they can have a way of defining and understanding themselves as just a different kind of boy. Many gay people report remembering times of gender confusion when they were young. One lesbian patient reported, “I remember the exact moment, at around eight years old, when I realized that I didn’t have to be a boy to grow up and marry a girl.” Many gay men remember, as young boys, disliking their fathers’ body hair and other masculine body features.

New research and clinical observations indicate how mental disorders may impact, or be impacted by, intense gender-nonconforming interests and behaviors. For example, concurrent conditions such as attention deficit-hyperactivity disorder, bipolar disorder, anxiety disorders, or the autism spectrum disorders may make a child more vulnerable to social ostracism or gender confusion. This may help us understand some of the disturbing reactions that are so often reported by parents, like emotional hypersensitivity, severe mood swings, oppositional behavior, temper tantrums, attention problems, anxiety, and depression.

After talking with parents, I have also become more convinced that some of the intensity of the interests that we see in gender-nonconforming boys is related to being talented in the arts, especially in graphic and theater arts. This seems reasonable when we think about the huge contribution to the arts made by gay people. Most intense and persistent interests and talents seem to start early. An article in the July 2009 Smithsonian magazine profiled an accomplished biologist who specialized in ant behavior. According to his mother, his interest in ants began when he was “in diapers.” Imagine if his interest in science at an early age had been stigmatized!

In the past, many transsexual people, especially female-to-male, transitioned through the gay and lesbian community, identifying first as gay or lesbian, only to realize a transsexual identity. Today, with a greater visibility and appreciation of the transgender community, perhaps we are seeing an opposite trend. It seems as though feminine gay men may be finding refuge in the transgender community, particularly in the minority communities where homosexuality is more stigmatized. Recently the director of an inner- city transgender community program told me that in his group for transsexual teens, many were actually identifying as gay. This made him change the title of his group to be gay inclusive.

I remember a presentation at an American Psychiatric Association meeting about a social worker who worked with mostly black and Hispanic severely disadvantaged inner- city children. He had followed a couple of them informally as they resurfaced from time to time within the city’s social service system. These gender-nonconforming teens, who had found homes and affirmation in the transgender community, had been highly homophobic and identified as transsexual. Many years later, the social worker had a chance encounter with one of the kids, now 26 years old. He had managed to overcome his tumultuous background, was gainfully employed, now identified as gay, and was living happily with a gay partner.

I recently met a woman during a Pride parade. I was very excited to talk with her because she was the mother of a transsexual male-to-female teenager. She reported that when her new daughter came out to her, she was absolutely unaware of any childhood gender-nonconforming behavior or any gender distress. This is consistent with the experiences of my transsexual friends who were also not interested in playing princess. However, looking back, she thinks that perhaps there may have been some clues that she missed.

I am overjoyed that the lives of transsexual children have the possibility of being much better. An aware and affirming parent may pick up early clues and completely change the childhoods of transsexual people, so they do not need to develop the masculine or even hyper-masculine defenses of denial and repression.

The World Professional Association for Transgender Health (WPATH) Standards of Care guidelines provide a slow and thoughtful progression toward gender transition for adolescents and adults. With young children it is hard to differentiate between impulsive survival instincts, inability to know how they fit into the world, and magical thinking without much ability to perceive what could lie ahead. Much research is happening, including some being started as part of our program at the Children’s National Medical Center. Never before have we had the opportunity to study the outcomes of a large number of children (boys and girls) with gender-nonconforming behaviors who have experienced positive parenting during early childhood. Things will become clearer. At some point, we will probably be able to differentiate between transsexual kids, gay kids, straight kids, and some who will undoubtedly be somewhere in between.

In the Considerations paper, after consulting several sources, I wrote that the incidence of transsexualism is one in 15,000 to 25,000. Now, it is not uncommon for people to say one in 500. That is a big difference. If that incidence is referring to individuals across the gender spectrum with gender dysphoria, then perhaps it is reasonable. If it is meant to indicate the incidence of transsexuals, then it seems doubtful. Once again we are left awaiting more well-defined and agreed-upon terms, and more research.

It is remarkable and wonderful that the transgender community is finally receiving the recognition and acceptance that the gay and lesbian community enjoys today, even though it is still far from true equality. For years I have said that the painful stigma of being gay doesn’t begin in middle school, it begins in nursery school. We can say the same for transgender people. But I am not sure that the gay “girly boys” are not once again being misunderstood—perhaps because of lingering homophobia, femphobia, erotophobia, and misogyny­—just when the concept of “queer in the crib” is making considerable headway.

An article titled “Is Your Child a Prehomosexual? Forecasting Adult Sexual Orientation” was published recently in Scientific American (September 15, 2010). Could this be a sign of the “comeback kid?”

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