An Unexpected Chief Complaint Addressing gender variance in pediatric primary care

1. An Unexpected Chief ComplaintAddressing gender variance in pediatric primary care ALEXANDRA GARZA FLORES, M.D.

2. 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

3. 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!”

4. Overview • Children’s understanding of sex and gender • Importance of gender in society • Gender variance vs. gender identity disorder • Protective factors against psycho-emotional pathology • Addressing gender variance in pediatric primary care • Resources for families

5. 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

6. 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???

7. vs

8. 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

9. Androgyny ≠ gender variance • 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

10. 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

11. “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

12. Natural course of gender variance • 2-3 years of age: • 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 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

13. 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

14. Protective factors • Family support! • Family support! • Family support! • Family support! • Family support!

15. Protective factors • Without parental support, child may believe stigma and ostracism are deserved • Positive family environment: • Critical counterweight to negative societal responses • Main catalyst to promote psychosocial resilience in the world • Source of skills and strength to deal with bullying and other stressors • 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!

16. THE BOTTOM LINE: “The happiest and most well-adjusted children, [gender-variant and gender-typical alike], are the ones who know they are loved and supported.” - Brill & Pepper, “The Transgender Child”

17. Back to Tommy… How do we address his parents’ concerns? • Empathize with their concerns and struggles  acknowledge their natural need to grieve over a loved, but misunderstood child • Educate them! Gender variance is NOT a pathology. • Normalize the situation by providing access/exposure to the many other families/children in their position • Provide helpful resources (books, articles, support groups, helpful websites)

18. How do we address his parents’ concerns? (cont.) • 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.) • Stress the importance of being the child’s #1 advocate, and making the home a safe place full of unconditional love and support • Refer for family counseling if desired • Screen child for psycho-emotional pathology during current and subsequent visits

19. Tips for parents • Enjoy who your child is! • Keep 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

20. Tips for parents (cont.) • Read books/watch TV programs including GLBT adults and teens; discuss; celebrate! • Advocate in school • Join or initiate anti-bullying programs • Educate extended family and friends • Seek supportive counseling and/or peer support group

21. Fun reading for kids and young adults • “My Princess Boy” by Cheryl Kilodavis • “The Sissy Duckling” by Harvey Fierstein • It’s Perfectly Normal” by Robie Harris

22. Reading for parents • “Not like other boys” by Marlene Fanta-Shyer • “Gender born, gender made” by Diane Ehrensaft • “Sissies & tomboys: Gender non-conformity & homosexual childhood” by Matthew Rottnek

23. Websites and support groups for the whole family • Outreach Program for Children with Gender-Variant Behaviors and their Families: www.dcchildrens.com/gendervariance Download “A Guide for Parents”! 

24. Websites and support groups for the whole family (cont.) • Parents, Friends and Families of Lesbians and Gays (PFLAG): www.pflag.org • Trans Youth Family Allies: www.imatyfa.org • www.genderspectrum.org • www.transyouthequality.org • Gay Lesbian and Straight Education Network (GLSEN): www.glsen.org

25. Bibliography • Children's National Medical Center, Outreach program for children with gender-variant 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. • EJ Menville, C Tuerk, EC Perrin. “To the beat of a different drummer: the gender-variant child.” Contemporary pediatrics. 2005. • 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. • Mukkades, NM. “Gender identity problems in autistic children.” Child: Care, health, and development. 2002:28,6. 529-532. • Perrin, EC. “Sexual orientation in child and adolescent health care.” Kluwer Academic/Plenum Publishers. New York. 2002: 48-49.