Understanding Gender Identity

Jason Rafferty, MD, MPH, EdM

Our understanding of gender is rapidly evolving. The subject of gender identity is more common these days and, for many, it has become challenging to keep up with a lot of recommendations and the terms being used. What is clear is that children struggling with gender identity need our support and understanding.

Recently, the American Academy of Pediatrics (AAP) issued a policy statement on this topic. As a member of the committee, I can say that a lot of consideration was put into the terms used throughout the policy statement.

Our focus was on a strengths-based approach that avoids negative connotations. Using certain language and explicitly appealing to a child’s strengths and resiliency, regardless of their gender identity, can have profound effects in promoting positive development.

Before we can talk about the policy, let us shed some light on some commonly misunderstood terms.

  • Gender identity: One’s internal sense of who one is, based on an interaction of biological traits, developmental influences, and environmental conditions. This may be male, female, somewhere in between, a combination of both, or neither.
  • Gender expression: The various ways individuals display their gender through clothing, hair styles, mannerisms, or social roles.
  • Gender perception: The ways others interpret someone’s gender expression.
  • Gender diverse: Used to acknowledge and include the diversity of gender identities that exist. It replaces the former term “gender nonconforming,” which has a negative and exclusionary connotation.
  • Transgender: A subset of individuals whose gender identity does not match their assigned sex and generally remains consistent over time. This is not a diagnosis, but rather a personal way of describing one’s own gender experience.
  • Cisgender: Someone who identifies with a gender that is consistent with the sex assigned to them at birth.
  • Sexual orientation: This is not synonymous with “gender identity.” Sexual orientation refers to a person’s identity in relation to the gender to which they are sexually and romantically attracted. Being transgender does not imply a sexual orientation, and transgender people still identify as being straight, gay, bisexual, etc.

How pediatricians can help

Understanding that there are many influences on a child’s development, the AAP’s policy statement provides recommendations for pediatricians and for the larger health care system to promote acceptance of gender diversity. Pediatricians should offer gender-affirmative care, appreciating the child’s gender experience at their stage of development and maintaining a nonjudgmental partnership with the child and family.

Ideally, pediatricians can assist the parents and child in understanding each other’s concerns. Family-based therapy and support should be offered to help with emotional and mental health needs of parents, caregivers, and siblings of a transgender youth. Pediatricians can also advocate, educate, and develop relationships with school districts and other community organizations to promote acceptance and inclusion of all children. On a larger scale, pediatricians are encouraged to advocate for policies and laws that protect transgender youth from discrimination and violence.

The AAP recommends that electronic health records and clinical research should be designed to respect the asserted gender identity of each patient while maintaining confidentiality, and that insurance plans offer coverage for health care needs specific to the needs of transgender youth, such as medical, psychological, and surgical care, when indicated.

It is important to note that this policy statement went through extensive review among pediatricians in the field. But most importantly, there was an effort to make sure people who identity as part of the transgender and gender diverse community also had the opportunity to read it and provide feedback. 

Gender affirmative care

Current research suggests that, rather than predict or prevent who a child may become, it is better to value them for who they are now, even at a young age. This fosters secure attachment and resilience. Gender affirmative care is based on the belief that all children benefit from love and support. The goal is not treatment. It is to listen to the child and, with the help of parents and families, build understanding. 

Through strong, nonjudgmental partnerships with patients and their families, pediatricians create an environment of safety in which complicated emotions, questions, and concerns related to gender can be appreciated and explored. Gender affirmative care is most effective in a collaborative system with access to medical care, mental health, and social services, including specific resources for parents and families.

Research suggests that children who assert a gender diverse identity know their gender as clearly and consistently as their developmentally matched peers and benefit from the same level of support, love, and social acceptance. It used to be the case that for children, gender diverse assertions were held as “possibly true” and not acknowledged until an age when the child was believed to be old enough to know for sure. This does not serve the child, because it increases discomfort without offering critical support and understanding. Attempts at predicting or changing who a child may become have shown to be unsuccessful, and even harmful.

These recommendations are aimed at creating a system where gender diverse feelings and concerns in children and teens are appreciated and respected, rather than suppressed. Parents are provided resources to help them provide understanding, love, and appreciation for their child as they are in the moment.

Family and community support

Family and community supports are also essential for the healthy development of all children. Increasing evidence shows that support or rejection ultimately has little influence on the gender identity of youth. It may, however, profoundly affect a young person’s ability to openly discuss or disclose concerns about their identity and feelings. When a child feels they must suppress their gender concerns, it negatively affects their mental health.

On a larger scale, lack of support, discrimination, and stigma in society leads transgender and gender diverse individuals to avoid academic opportunities, routine medical care, and other prosocial experiences. Therefore, the AAP’s policy statement focuses on the importance of listening to, respecting, and supporting transgender and gender diverse children. We know that older transgender teens with supportive families are less likely to have severe depression or report suicidal thoughts than those in families that report no support at all. Even being able to identify just one supportive person significantly decreases distress for these individuals.

Common questions from parents

It is understandable that parents have questions regarding their children and gender identity. There are some common themes that emerge. Parents may wonder if children can become transgender due to friends or online information. They may also question if there were signs that they missed in their child. The fact is being transgender is not contagious. Some youth may not have confronted gender diversity, or feel they must suppress gender diverse traits, until they find nonjudgmental and affirming peer or online communities that provide exposure to a wider range of gender identities and expressions. 

If parents discovered their child is gender diverse, or the child works up to disclosing such suppressed feelings, it may seem sudden and unexpected. Some transgender youth expect immediate acceptance, but often family members proceed through a process of becoming more comfortable and understanding of the youth’s gender. The process often resembles the stages of grieving, as it may require parents to let go of strongly held expectations for their child. Pediatricians can help by promoting open dialogue and perspective-taking between the youth and their parents.

Most importantly, remember that these are children and they need our support. You can learn more about the services we provide for these families here.

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