Connections: Children and gender identity: Questions, concerns, and treatments at every age | Winter 2018

Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.

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From the OHSU Doernbecher Children’s Hospital

Kara Connelly, MD

Kara J. Connelly, M.D.

Dr. Connelly is a board-certified pediatric endocrinologist at OHSU Doernbecher Children's Hospital. In addition to caring for children with diabetes mellitus and other endocrine disorders, she cares for gender-diverse and transgender children and teens and treats disorders of sexual development.

New definitions of "sex" and "gender"

From clinical codes to popular media, today's providers may feel they are on shifting semantic sands. What we likely called biological or natal sex in training, most often based on the appearance of the genitals, is now more precisely referred to as "sex assigned at birth."

Gender identity is another entity, the internal sense of whether one is male, female, or somewhere on a continuum between or outside the binary. Gender expression refers to how a person chooses to express their gender identity. For example, someone who identifies as female may express this in a traditionally "feminine" way or otherwise.

Sexual orientation – to whom a person is sexually attracted – differs from both sex assigned at birth and gender identity. You may have a patient with male assigned sex, female gender identity and sexual orientation and attraction to females, or vice versa.

Gender identity in child development

In general, gender identity follows this developmental pattern:

  • Age 2 – Children become aware of differences in genitals and between individuals.
  • Age 3 – Children begin to label themselves with a specific gender.
  • Age 4 – Gender identity becomes an internal constant. The identity established at this age usually "sticks," although some children lack words to express their identity, and some lack the freedom to express differences from the sex assigned at birth.

Is transgender identity permanent?

Children who express a gender identity different from their sex assigned at birth may be describing a permanent characteristic if they are 4 or older. However, it can be difficult to distinguish between a young child's gender identity and the expression of gender exploration. Variation from societal gender norms is extremely common for children through the grade school years. Recognizing a child who is transgender versus expressing gender exploration can be difficult in this age group.

The primary care provider's role

We recommend a gender-affirming care model of allowing the child to express their gender identity freely, without limiting what they wear, do or say.

Clinicians can ask, "Are you a boy or a girl or something else?" when patients are around 4. This sets the tone for talking about gender identity in a non-judgmental way and including gender in the provider-patient conversation. You can also ask, "What name would you like to go by?" and "Do you like to go by 'she,' 'he,' or something else?"

Mental health benefits of affirming gender

A study by Olson, et al., published in the February 2016 issue of Pediatrics, suggests that affirming a child's gender expression and identity has mental health benefits for the child. Prepubertal children with gender dysphoria allowed to express their chosen identities socially — with no physical treatment or changes — had normal levels of depression and only slightly higher than normal levels of anxiety. Children with gender dysphoria who are not affirmed in their gender typically have much higher rates of depression and anxiety than peers.

Puberty and physical transitions

Listening carefully to children is vital. A child who says, "I am a girl, not a boy," or "I was born in the wrong body," is making a strong statement. However, no medical decisions are necessary until puberty approaches.

The Doernbecher Gender Clinic offers consultation with you, patients and parents. Puberty-blocking medications to prevent the development of secondary sex characteristics not aligned with a child's identity, or hormones to induce pubertal changes more aligned with the youth's identity, are safe options. Some children ask about surgery. Again, Doernbecher clinicians can talk with the child and family about options and timing. Some transgender people choose to transition socially, without medication or surgery. Others take hormones but forego surgery, or vice versa.

About the Doernbecher Gender Clinic

The Doernbecher Gender Clinic provides comprehensive care for transgender and gender diverse children and families. Use the diagnosis code for "gender dysphoria" when making a referral.

A representative from the OHSU Transgender Health Program will contact the family to gather information, answer questions and connect them with community resources.

Next, the patient is scheduled to be seen in our clinic. We work closely with behavioral health specialists, when indicated, to individualize each patient's care. We count on strong partnerships with community mental health providers to help support patients and families through care with us.

Which child should I refer?

  • Children nearing or beginning to experience puberty (Tanner 2)
  • Children and adolescents who want to talk about puberty-blocking medication or hormones
  • Families with younger children who want to see a provider, whose questions may not be answered in an advocacy organization or by behavioral health.

Contact us

OHSU Doernbecher Children’s Hospital specialists are always happy to speak with you.

Please call the OHSU Physician Pediatric Advice and Referral Service at 888‑346‑0644 with questions. To refer a patient, please fax to 503‑346‑6854.