Parents typically report that cross-gender behaviors are apparent before 3 years of age. However, it is usually not until their early grade school years that most children with gender dysphoria are referred for clinical evaluation.

What percentage of children have gender identity issues?

Among a sample of boys under the age of 12 seen by doctors for a range of clinical problems, 10 percent reported that they wanted to be the other sex. Among a sample of girls under the age of 12 referred for clinical treatment, 5 percent wanted to be the other sex. Four to five times as many boys than girls are seen for gender dysphoria. However, this is hypothesized to be due in part to the societal stigma toward feminine boys. The sex ratio is equal in adolescents referred for gender dysphoria. Despite these numbers, researchers have observed that many children who have shown gender nonconforming behavior do not grow up to be transgender adults, and many people who later come out as transgender adults were not identified as gender nonconforming during childhood.

What are the causes of gender identity issues?

The exact cause of gender dysphoria is unknown, and there is much debate over the possible causes of gender dysphoria. Recent studies have suggested that there may be biological causes associated with the development of gender identity before birth. These may involve malfunctioning hormones or other rare conditions, such as congenital adrenal hyperplasia and intersex conditions.

From a psychological perspective, some psychoanalysts believe that a child’s gender identity is influenced in part by the mother-child relationship during the child’s first years of life. During this period, mothers normally facilitate their children’s awareness of, and pride in, their gender. Children are valued as little boys or girls. However, some children are given the message that they would be more valued if they adopted the gender identity of the opposite sex. Rejected or abused children may act on such a belief. Gender identity problems can also be triggered by a mother’s death, extended absence, or depression, to which a young boy may react by totally identifying with her.

The father’s role is also important in the early years, and his presence normally helps a child’s separation-individuation process. Without a father, mother and child may remain overly close.

Do people with gender identity problems have other medical issues?

Children diagnosed with gender dysphoria show higher rates of depressive disorders, anxiety disorders, and impulse-control disorders. Those diagnosed with gender dysphoria may also be more likely than others to fall within the autism spectrum.

Adults diagnosed with gender dysphoria show higher rates of depressive disorders, anxiety disorders, substance abuse, suicidality, and self-harming behaviors. The lifetime ratio of suicidal thoughts in transgender people is thought to be about 40 percent.

What are the treatments for gender identity issues? 

In children, treatment of gender identity issues typically consists of individual, family, and group therapy that guides children in exploring their gendered interests and identities. Conversion therapy, which attempts to change a person’s gender identity or sexual orientation, is strongly opposed by the American Psychiatric Association and practice guidelines of the American Academy of Child and Adolescent Psychiatry. Conversion therapy is banned in 14 states as well as the District of Columbia.

As gender-nonconforming children approach puberty, some show intense fear and preoccupation related to the physical changes they anticipate or begin to experience. Some clinicians may prescribe puberty-blocking medications to temporarily block the release of hormones that lead to further sex characteristics, giving adolescents and their families time to reflect on the best options moving forward. Gonadotropin-releasing hormone (GnRH) agonists have been used for many years and are felt to be safe.

Treatment of adults who identify as transgender may include psychotherapy, hormonal treatment, and surgical treatment. Hormonal and surgical interventions may decrease depression and improve the quality of life for such individuals.

What are intersex conditions?

Intersex conditions include a variety of syndromes in which individuals are born with anatomies that do not correspond with typical male or female bodies. These disorders include congenital adrenal hyperplasia, involving an enzymatic defect in the production of adrenal cortisol; androgen insensitivity syndrome, in which the body is unable to use testosterone or other androgens; Turner’s syndrome, in which one sex chromosome is missing; Klinefelter’s syndrome, where an extra X chromosome is present; and 5-a-reductase deficiency, an enzymatic defect that prevents the body’s proper use of testosterone.

Intersex conditions should be addressed as early as possible so that the entire family can regard the child in a consistent, relaxed manner. However, families are encouraged to choose the sex of rearing that is flexible and to wait for the intersex person to decide on their own later whether to have surgery. Early surgeries are typically avoided now because they may interfere with later reproductive capacity and sexual functioning.

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