Once I asked a three-year-old girl what she wanted to be when she grew up. Without hesitation she said, “A pony!” All the adults laughed, but her answer reflected two things we know about child development. First, more than a few kids develop obsessions that can stay with them for weeks, months, or even years. These can be as quirky as a fascination with blenders or as commonplace as an intense interest in dinosaurs. Before my little friend outgrew her equine interests, her parents indulged her with pony books, movies, and stuffed animals. They did not, however, buy her a live pony. Second, the pony incident illustrates the fact that children do not begin life with a sense of body permanence. At first they don’t even see their future as species specific. Gradually during their first five years or so, they come to understand that, except for increasing in size, their bodies will not change into something utterly different.
Sometimes instead of obsessing about blenders, dinosaurs, or ponies, a child obsesses about gender. Consider JeongMee Yoon’s pink-obsessed daughter who inspired the Pink and Blue Project. The child’s obsession led her mother to create an art project, but neither Yoon nor the mother of the girl who wanted to be a pony took their children to see a psychologist. If, however, the pink-obsessed child had been born with testes, a scrotum, and a penis, he might indeed have been brought to a therapist. This is because gender obsessions are often medicalized in a way that other obsessions are not.
Indeed we are in a moment of national panic about children who transition from the sex into which they were born to the sex/gender with which they identify. Recently the debate has focused on bathrooms, with the Obama administration’s interpretation of Title IX pitted against state laws that insist school children must align the places they pee with their birth certificates rather than their internal sense of self. Anti-trans activists sometimes argue that trans teens and adults have an unformed or even whimsical sense of identity. Such a view wrongly uses the metaphor of choice, misunderstanding how implacably imprinted gender identity (trans or cis) becomes as children develop. But what interests me in this essay is the less clear-cut issue of how best to nurture very young (ages 3–7) gender-nonconforming children when the boundaries between evolving and settled self-knowledge are not yet fully formed.
Gender obsessions are often medicalized in a way that other obsessions are not.
Even after children come to grasp a sense of their body’s fixed nature, some continue to experience a mismatch between their physical sex and their gender identity. The pink, Barbie-obsessed child may identify as a boy who happens to love Barbies. Or they may come strongly to feel transgender—a girl in a boy’s body. We have no clue as to why transgender ideation develops in some cross-gender-expressing children and not others, nor how frequently this happens. For some, transgender identity emerges during the preschool years, while for others it develops during adolescence. Many children with cross-gender expression do not develop transgender identities as adults, although exactly how many do is a subject of bitter dispute between transgender activists and researchers. Finally, we do not know if encouraging or even simply not resisting a small child’s inclination to transition, to present themselves as transgender publicly—at school, to relatives and friends—keeps them on a road to adult transgender identification that they might otherwise have ceased to walk.
This absence of solid knowledge creates a blank field on which arguments rage about what kind of care parents should give to gender-nonconforming children. Treatment for adolescents is a quite different matter, with an urgency shaped by a high risk of suicide and self-harm among trans teens (caused by the heightened confluence of the same risk factors that cause many teen suicides: rejection by friends and family, discrimination, physical abuse, low self-esteem, intersecting minority identities, and more). But how should parents and other adults respond to a young child—a five-year-old, say—who is gender nonconforming in ways that may include play preferences, interests, and clothing preferences, or who vehemently claims that they are a girl-not-boy or boy-not-girl? (The medical term for this is gender dysphoria.) Parents cannot know for sure whether a child is just quirky in their interests or whether—and, if so, when—the child needs to transition, first socially and later medically, in order to develop a healthy psyche.
Parenting organizations offer common-sense advice for handling toddlers who seem obsessed with tiaras, dinosaurs, or tutus. Parents Magazine, for example, suggests that parents “roll with it”—never shaming a toddler or trying to force them to give up the obsession—and “seize the opportunity” to expand the child’s horizons. This might mean using an obsession with pink as an opportunity to talk about gender labels or sexism, or even to discuss the science of light and color. The magazine also suggests that parents “set limits.” This is a controversial strategy when the obsession is gender. However, parents set limits all the time, and one could make a case for doing so in the interest of expanding a child’s repertoire. The final piece of advice from the magazine is “don’t stress” so long as your child is interacting socially with you and others in their life.
Among professional organizations, the most widely accepted Standards of Care for children with gender dysphoria was published in 2012 by the World Professional Association for Transgender Heath (WPATH), an organization of transgender activists and advocates as well as professional researchers and therapists. WPATH’s advice does not differ dramatically from the common-sense approaches found in parenting magazines. The Standards document urges mental health professionals to help families reduce a child’s stress. It insists that seeking to make the dysphoria disappear by, for example, refusing to buy pink clothes or Barbies for a dysphoric boy is both unethical and ineffective. WPATH also believes that counselors should encourage clients to explore a range of possible gender expressions, not just the binary of male or female.
The most controversial question involving very young dysphoric children is whether they should transition socially. A child might partially socially transition by having a hairstyle, wearing clothing, or using a name, pronouns, and bathroom that reflect a gender different from their anatomical sex. WPATH’s Standards is ambivalent about the wisdom of early social transition, noting the absence of studies on the long-term outcomes. Social transition in early childhood may promote a sense of psychological comfort and well-being, but a child of five may change their mind at seven or eight and then suffer harmful stress from re-transitioning. Early transition may also unnecessarily fix a child on a path to complete medical transition. As WPATH notes, only 6–23 percent of gender dysphoria in young children persists into adulthood.
Many, including myself, worry about possible long-term physiological health effects of puberty suppression, cross-hormone treatment, and major body-modifying surgeries. A concern that early social transitioning may push children into a pipeline that makes these interventions feel inevitable must be weighed, however, against findings of alarmingly high suicide rates and self-harm among transfolk, especially trans teens. The problem is, which kids will be helped by early social transitioning and which ones harmed? We have no way to tell.
Mental health researchers are collecting much-needed data as I write. In the meantime, I urge careful individual case evaluation and common therapeutic sense in the face of ramped-up rhetoric meant to foreclose a robust debate, so desperately needed, about how best to help gender-nonconforming children. The road forward will become clearer as we develop reliable data. And maybe better data will lessen some people’s anxiety about bathrooms.