Gender-Diverse & Transgender Children

By: Jason RaffertyMD, MPH, EdM, FAAP

Some children have a gender identity that is different from their gender assigned at birth, and many have interests and hobbies that may align with the other gender.

Some children, as our policy statement explains, do not identify with either gender. They may feel like they are somewhere in between or have no gender. It is natural for parents to ask if it is "just a phase." But, there is no easy answer.

Accepting your child's gender-diverse identity

Research suggests that gender is something we are born with; it can't be changed by any interventions. It is critically important that children feel loved and accepted for who they are.

When disclosing their gender diverse identity, some kids might expect immediate acceptance and understanding. However, there is evidence that family members go through their own process of becoming more comfortable and understanding of a child's gender identity, thoughts and feelings. One model suggests the process resembles the stages of grief: shock, denial, anger, bargaining and acceptance.

Just as gender diverse children do best when their feelings are explored and validated, some parents may need their own emotional supports. They may also have many questions along their child's journey.

What parents can do

• When your child discloses their identity to you, respond in an affirming, supportive way. Understand that although gender identity is not able to be changed, it often is revealed over time as people discover more about themselves.

• Accept and love your child as they are. Try to understand what they are feeling and experiencing. Even if there are disagreements, they will need your support and validation to develop into healthy teens and adults.
  

• Stand up for your child when they are mistreated. Do not minimize the social pressure or bullying your child may be facing. See How You Can Help Your Child Avoid & Address Bullying.

• Make it clear that slurs or jokes based on gender, gender identity or sexual orientation are not tolerated. Express your disapproval of these types of jokes or slurs when you encounter them in the community or media.

• Be on the look out for danger signs that may indicate a need for mental health support, such as anxiety, insecurity, depression, low self-esteem and any emotional problems in your child and others who may not have a source of support otherwise.

• Connect your child with LGBTQ organizations, resources and events. It is important for them to know they are not alone.

• Celebrate diversity in all forms. Provide access to a variety of books, movies and materials—including those that positively represent gender diverse individuals. Point out LGBTQ celebrities and role models who stand up for the LGBTQ community, and people in general who demonstrate bravery in the face of social stigma.

• Support your child's self-expression. Engage in conversations with them around their choices of clothing, jewelry, hairstyle, friends and room decorations.
  

• Reach out for education, resources and support if you feel the need to deepen your own understanding of LGBTQ youth experiences. See Support Resources for Families of Gender Diverse Youth.

Gender affirmative care

Gender affirmative care is based on the belief that all children benefit from love and support. The goal of gender affirmative care is not treatment; it is to listen to a child and, with the help of parents and families, build understanding.

Pediatricians provide gender affirmative care by creating a safe environment 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, mental health and social services, including specific resources for parents and families.

Mental health support for gender-diverse kids

Support or rejection ultimately has little influence on the gender identity of youth; however, it may strongly affect young person's ability to openly share or discuss concerns about their identity and feelings. Gender-diverse identities and expressions are not mental disorders, but suppressing gender concerns can harm a child's emotional health and development and possibly contribute to high rates of depression, anxiety and other mental health issues.

A large proportion of teenage suicide attempts are linked to issues of gender and sexuality, particularly feelings of rejection. Many gay, lesbian, bisexual and transgender individuals unfortunately attempt suicide during their lifetime.

As a parent, even when you struggle to understand and may not see eye-to-eye, your most important role is to offer understanding, respect and unconditional love for your child. This builds trust and puts you in a better position to help them through difficult times. Research has shown that if a transgender teen has even just one supportive person their life, it greatly reduces their risk of suicide.

Transgender and gender-diverse children—like all children—need support, love and care from family, school and society. When supported and loved as they grow and develop, kids mature into happy and healthy adults. Pediatricians stand ready to assist in the healthy development of transgender and gender-diverse children.

How I Raised My Kids With Inclusiveness & Resilience in Mind

By Nancy Netherland

I have two teenagers. One identifies as 'non-binary'; and sometimes as 'I don't know'; uses the pronouns she/they/them; has a girlfriend and identifies their sexual orientation as queer. The other identifies as she/her and pansexual.

When I had children, I didn't know if they would be CIS-gendered, non-binary or trans, nor did I know what their sexual orientation would be. But my training as a therapist and the time I spent working in the early days of the AIDS pandemic had me well aware of elevated risk factors for children and young people who identify as LGBTQ+.

I knew that homophobia and transphobia could result in disturbing and dangerous outcomes. For example, I knew that nearly half of LGBTQ+ kids and young people seriously considered suicide in the past year, and that LGBTQ+ youth of color report higher rates of suicide attempts than their white peers.

But I also knew that LGBTQ+ youth who felt high social support from their family reported attempting suicide at less than half the rate of those who felt low or moderate social support.

So, knowing all this, I consciously tried to work resiliency and protective factors into how I parented from the time my kids were infants. Here are some guideposts that have served me well as a parent of non-gender conforming and queer children:

• Ask, don't assume. Since family acceptance is such a huge factor in protecting the mental health and well-being of LGBTQ+ kids, I decided not to assume anything about my children's gender identity and sexual orientation. When my oldest child told me about their first crush in middle-school, I made sure to ask if the person was a girl, boy, trans or non-binary. I saw the relief on my child's face when I said "girl" and she said "that one." I ask my kids their preferred pronouns, as well as their permission before sharing their pronouns outside of our immediate family.
  
  
• Seek positive role models. Our community and inner circle include people who identify as gay/queer, trans and non-binary. I also commit to finding developmentally appropriate ways to integrate LGBTQ+ literature, role models, film, cultural events and celebrations into our lives. My children and I have joined Pride parades in support of my sibling who is non-binary and queer. Our family's social media feeds include LGBTQ+ influencers, and we stream and watch shows together featuring queer and trans youth and their families.
  
  
• Prioritize inclusion. I consciously use language and, when the kids were young, found stories that were inclusive: mommies who married mommies, kids born girls who realized they were really boys, and people who were both male and female. Our bookshelves include graphic novels and books detailing the contributions of LGBTQ+ people across the globe and history. If a form only has two genders on it – I change the form.
  
  
• Enlist the support of trusted adults. I have made it a point to ensure my children's medical providers and other trusted adults are inclusive and familiar with serving LGBTQ+ youth. My oldest child has a therapist who specializes in working with youth who are not CIS-gendered and identify as LGBTQ+. Our refrigerator has a list of youth help lines and mental health programs that my kids can call if needed. On that list are a bunch of LGBTQ+ organization and resources.
  
  
• Ask for help. I make mistakes (still working on not misgendering) and I have a lot to learn. So, I call upon friends and family who grew up queer and non-gender conforming to support my children and my parenting. I have also reached out to our pediatricians for mental health and wellness resources. I look for and use online resources specifically for parents of LGBTQ+ kids.

I know that I cannot protect my children from the discrimination that is directed towards them and all people who are LGBTQ+, but I can make sure they feel accepted and seen in our home, and that they are connected with as many resources as possible to help them navigate health futures.

Nancy Netherland is a mother and advocate for her two daughters, both former foster children born, and living, with chronic medical complexities. Nancy serves advisory panels for the State of California's Medicaid Children's Health Advisory Panel , the UCSF Children & Adolescent Psychiatry Portal , the California Advancing and Innovating Medi-Cal Workgroup for Foster Youth and Families, and the family advisory councils at UCSF Benioff Children's Hospital San Francisco and Oakland. Nancy founded Kids and Caregivers, a nonprofit supporting caregivers of children living with chronic and complex illnesses . She is also Director of Parent Engagement for the California Children's Trust.

When to get help

If your child is struggling with symptoms of depression, anxiety, isolation or other emotional concerns, they may need to see a mental health professional who can offer additional support. If your child mentions any suicidal thinking, bring it to the attention of your pediatrician or mental health professional right away.

Ask your pediatrician if a telehealth visit by phone or video call is an option. Your child may feel more comfortable talking to their doctor from home. For teens, the telehealth visit should take place in as private of a place as possible so they can have a one-on-one conversation with the doctor. You can make a plan with the doctor about talking before or after they talk to your teen privately. If it's a video call, and your child or teen would prefer to have the camera off, they can ask their doctor if that is okay. Telehealth visits can also be used for follow-up visits to check on your child's progress.

Talk with your pediatrician early & often

Children as young as preschool-age may start having difficult feelings and concerns about their bodies, feelings and relationships. It is important to recognize that cross-gender preferences and play is a normal part of exploring gender and relationships for children regardless of their future gender identity. Routine conversations about gender creates an environment of support and reassurance so that children feel safe bringing up questions and concerns. It is also good practice for continuing these discussions at home.

The best approach, for parents or pediatricians, is to nonjudgmentally ask questions that allow the child to talk about their experience and feelings before applying any labels or assumptions. For more information or help finding a support group for yourself or your child, please talk with your pediatrician.

More information

• Parenting a Gender-Diverse Child: Hard Questions Answered
• Support Resources for Families of Gender-Diverse Youth
• Gender Identity Development in Children
  
• Sex, Gender Identity & Puberty
  
• How You Can Help Your Child Avoid & Address Bullying
• Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents (AAP Policy Statement)

About Dr. Rafferty:

Jason Rafferty, MD, MPH, EdM, FAAP, is a "Triple Board" residency graduate who is pediatrician and child psychiatrist at Thundermist Health Centers, a Patient-Centered Medical Home in Rhode Island. Dr. Rafferty specializes in adolescent substance use disorders and gender and sexual development, and also practices in related specialty clinics at Hasbro Children's Hospital and Emma Pendleton Bradley Hospital. Dr. Rafferty is an advocate in his local community and on a national level through work with the American Academy of Pediatrics on issues including the emotional health of young men, access to care for LGBTQ youth, and prevention of childhood homelessness.