A person’s sense of being male or female is their:

Clinical Presentation

Children and adolescents with a gender-nonconforming identity may experience 2 sources of stress: internal distress inherent to the incongruence between sex assigned at birth and gender identity [gender dysphoria] or distress associated with social stigma. The 1st source of distress is reflected in discomfort with the developing primary and secondary sex characteristics and the gender role assigned at birth. The 2nd source of distress relates to feeling different, not fitting in, peer ostracism, and social isolation, and may result in shame, low self-esteem, anxiety, or depression.

Boys with a gender-nonconforming identity may at an early age identify as a girl, expect to grow up female, or express the wish to do so. They may experience distress about being a boy and/or having a male body, prefer to urinate in a sitting position, and express a specific dislike of their male genitals and even want to cut off their genitals. They may dress up in girls' clothes as part of playing dress up or in private. Girls may identify as a boy and expect or wish to grow up male. They may experience distress about being a girl and/or having a female body, pretend to have a penis, or expect to grow one. Girls may express a dislike of feminine clothing and hairstyles. In early childhood, children may spontaneously express these concerns, but depending on the response of the social environment, these feelings may go underground and may be kept more private. The distress may intensify by the onset of puberty; the physical changes of puberty are described by many transgender adolescents and adults as “traumatic.” Boys and girls may also identify outside of the gender binary [e.g., as boygirl, girlboy, genderqueer, gender fluid] and describe their identity as neither male nor female, both male and female, in-between, or some other alternative gender different from their sex assigned at birth. Adopting anonbinary identity may be part of identity exploration or constitute a gender identification that persists over time.

Gender-nonconforming children and transgender adolescents may struggle with a number of general behavior problems. Both boys and girls predominantly internalize [anxious and depressed] rather than externalize behavioral difficulties. Boys are more prone to anxiety, have more negative emotions and a higher stress response, and are rated lower in self-worth, social competence, and psychological well-being. Gender-nonconforming children have more peer relationship difficulties than controls. Both femininity in boys and masculinity in girls are socially stigmatized, although the former seems to carry a higher level of stigma. Boys have been shown to be teased more than girls; teasing for boys increases with age.Poor peer relations is the strongest predictor of behavior problems in both boys and girls.

Transgender adolescents may struggle with a number of adjustment problems as a result of social stigma and lack of access to gender-affirming healthcare. Transgender youth, especially those of ethnic/racial minority groups, are vulnerable to verbal and physical abuse, academic difficulties, school dropout, illicit hormone and silicone use, substance use, difficulty finding employment, homelessness, sex work, forced sex, incarceration, HIV/sexually transmitted infections [STIs], and suicide. Parental support can buffer against psychological distress, but many parents react negatively to their child's gender nonconformity, although mothers tend to be more supportive than fathers.

Sexual identity

Gender identity describes the individual’s own psychological perception of being male, female, neither, both, or somewhere in between. Although a person’s gender identity is usually consistent with their biological sex, it does not have to be. Transgenderism describes the situation involving a person having biological sex of male who identifies as female, and vice versa [Lehmiller, 2018]. Let’s examine variations from several perspectives.

Biological sex variations—While most of us in the Western world think of biological sex as the two categories of “male” and “female,” sex is actually much more complex. For example, some people are born with bodies and genitals that do not appear completely male or female, but rather have features of both. In the past the term hermaphrodites was used, but these individuals are now referred to as intersexed. Apparently, being intersexed is more common than is generally believed; overall, intersexed individuals represent approximately 2% of live births [Blackless et al., 2000].

Gender expression—One way of expressing one’s gender is referred to as transgender, an umbrella term used to describe when one’s gender identity or expression differs from social expectations for a given sex. By contrast, those whose gender identity and expression is consistent with their biological sex are often referred to as cisgender. For transsexuals, gender identity does not match their biological sex. So, for example, a male-to-female [MTF] transsexual is someone who is born male but perceives herself as female, whereas a female-to-male [FTM] transsexual is born female but perceives himself as male. Gender dysphoria is the term reserved for the persistent distress and discomfort that may result from incongruence between one’s psychological gender identity and physical sex. The characteristics of transsexualism are described as follows: a strong desire to exchange one’s primary sex characteristics with the sex characteristics of the other gender; a desire to be the other sex, and to be treated accordingly; a belief that one’s feelings and behaviors are actually related to the other sex [American Psychiatric Association, 2000a, 2000b; Meyer-Bahlburg, 2010]. Transsexualism is relatively rare, estimated at less than 1 in 10,000 in born males and less than 1 in 30,000 among those whose birth sex is female [Zucker, Lawrence, & Kreukels, 2016]. Interestingly, research has indicated that a majority of FTM transsexuals report attraction to women [Chivers & Bailey, 2000], while a majority of MTF transsexuals report attraction to men [Rehman, Lazer, Benet, Schaefer, & Melman, 1999]. It seems that once the change of gender has taken place, the transgender is attracted [as others of his or her gender in the larger society] to the opposite sex.

In most parts of the world, sex is viewed as a binary construct: that is, people tend to think that one can be either male or female, with nothing in between. This means that a person with a penis is male and a vagina indicates that the person is female. Persons who violate these social norms are typically marginalized. Prejudice against transsexuals and transgender persons more broadly [known as transphobia] is very common [Norton & Herek, 2013].

Cross dressing—A subtype of transgenderism is cross-dressing and refers to the act of wearing clothing typically associated with the other sex. One variant of cross-dressing is transvestism, which refers to the act of obtaining sexual gratification from wearing clothing of the other sex.

Workup or Assessing Gender Exploration

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Ideally, medical and mental health providers, along with other child health professionals, will increasing incorporate a more sophisticated understanding of gender in multiple primary care and other settings, from as early as the prenatal visit [e.g., “Your newborn is assigned male at birth but over time will grow into their own gender identity.”] to elder care [e.g., “Many persons explore gender identity in their later years. Is this something you would like to discuss?”]. Parents, mentors, teachers, school counselors and nurses, coaches, friends, and faith leaders should also not make assumptions that gender assigned and gender identity are always congruent. Having discussions about the broad ways and means that people can assert their gender can be an invitation to open the door to disclosure, earlier identification, and affirmative support. Even having these conversations with cisgender children and adults has value in promoting understanding and a more tolerant social milieu.

Professionals interested in providing gender affirmative care may begin a process of framing their understanding of gender identity diversity as a developmental not pathologic process, and conveying this to patients can create a supportive and safe space for a person to explore their gender identity. For new patients, building rapport and establishing the interview as a safe space is critical. Additionally, inviting the person to share their gender narrative as their unique story of human development can make these discussions less daunting.

Medical providers, social workers, and therapists with experience in medical and behavioral health can perform these interviews. Mental health and social support may help patients cope with body dysphoria, treat comorbid mental health concerns, assist with social and emotional skill building, and create a safe and successful affirmation plan. Parents of a TGD child may benefit from counseling services for themselves if they are distressed, where they may address their own parental reactions privately and successfully focus on the child’s issues and needs. Consistently, research demonstrates that early family support, such as using the youth’s asserted name and pronoun, allowing them to express socially in the manner most comfortable to them, and providing access to puberty blockers if desired, are linked to positive mental health outcomes that extend into adulthood.

Clinical interviews may assess gender experience from childhood until present; desired name, pronouns, and past and current places on the gender spectrum; past and current steps to feminize or masculinize with clothing, hair, makeup, hormones [both prescribed and nonprescribed], and surgeries; and future goals for affirming their authentic, gender identity, and expression. Affirmation goals, gender identity, and expression will vary among each individual and may not fit into traditional binaries. For many children, parents may provide insight as to early childhood gender identity and expression. For some children, parental distress and denial of a TGD identity is the most problematic aspect of providing care. Given the importance of parental and family support, engaging parents is an important aspect of affirmative care. For TGD adults, their families, spouses, and work colleagues continue to be an important aspect of generating a safe, healthy affirmative plan of care.

Review for historic poorer health outcomes linked to minority stress by asking mental health specific questions about depression, anxiety, eating disorders, self-harm [cutting, suicidal ideation, suicide attempts], psychiatric hospitalization, and substance use. Patient history should also include sexual attraction and behaviors and risk for sexually transmitted infections and pregnancy; social history, experience of bullying, hate crimes, physical or emotional/verbal abuse, homelessness, joblessness, and survival sex. Resiliency theory also promotes focusing on patient strengths and identifying social support systems. Many LGBTQ+ persons find that building a family of choice or finding a faith community that is accepting can be important in creating safe spaces to fully live as their authentic self.

An initial visit may or may not include a physical examination, depending on the provider and patient goals. If the evaluation is a consultation for information and counseling only, an exam may be deferred until the patient is more comfortable and familiar with the provider. Many gender dysphoric persons are extremely uncomfortable with their genitalia and genital examination. Providers do not necessarily have to do genital exams for most patients unless requested by the patient [parent and prepubertal child are unsure of Tanner stage, gynecological concerns, testicular mass, etc.]. For peripubertal youth, providers may offer Tanner staging of genitalia and/or hormonal measures to estimate pubertal stage and appropriateness for puberty blockers or gender-affirming hormones. Ensuring that all patients feel safe, give consent for examination, and are respected are important for providers to consider.

Luteinizing hormone is a preferred lab for evaluating peripubertal children and gonadotropin-releasing hormone [GnRH] analogue use, but additional laboratory studies may include follicle-stimulating hormone, testosterone, or estradiol. For children, in particular, liquid chromatography microassays allow for more accurate measurements of these hormones. For older youth or adults starting gender affirming hormones [GAH], baseline laboratory values may include CBC, BMP, lipid panel, and liver function tests. GAH may affect hematopoiesis [testosterone-inducing polycythemia], but rarely, if at all, has clinical impact on cholesterol levels and liver function. More recent data suggest that extensive laboratory testing is likely unnecessary for most patients. Evaluating levels of estradiol or testosterone may be useful if clinical goals are not being achieved, patients experience unwanted side effects, or patients desire to increase or decrease dosing and levels. Potassium and blood pressure monitoring may be useful in transfeminine persons starting spironolactone to block male pattern hair growth.

Screening for sexually transmitted infections [urine, rectal, and oralChlamydia and gonorrhea; syphilis; HIV; hepatitis C] andpregnancy is indicated according to sexual practices. Transwomen, including transwomen of color, have some of the highest rates of HIV; consider offering pre-exposure or post-exposure prophylaxis [PrEP/PEP] for HIV if consistent with sexual practices.

Attention to regular routine health needs [vaccines, lab work, and screenings] should be addressed in all TGD individuals. Over time, patients should receive typical preventive and screening tests for both assigned and asserted gender in accordance with what hormones and anatomy are present.

Special considerations for subpopulations: LGBTQIA + communities

Gender identity/expression and sexual orientation are rarely appropriately addressed in systems [whether shelters, the correctional system, or mental health settings]. Many members of the LGBTQIA + community experience marginalization and hostile environments, adding a layer of trauma that may begin in childhood and continue into adulthood. Both the correctional system and the shelter system determine housing placement based on gender, which is treated as binary and often as biologically determined, ignoring the identities of nonbinary or transgender individuals. In both systems, those who do not conform to gender norms may face difficulties as a result of being out as their full authentic selves; in particular, their identity may lead them to be targeted for different types of violence and sexual assault [Couloute, 2018].

The tragic story of Layleen Xtravaganza Cubilette-Polanco's death on Riker's Island highlights the potentially devastating consequences of failing to appropriately address these issues [Sosin, 2020]. Layleen was a 27-year-old Afro-Latinx transgender woman who was being detained on allegations related to assault and sex work. She had a history of epilepsy, a diagnosis of schizophrenia, and previous psychiatric hospitalization. Layleen was held on $500 bail, but she remained at Rikers because she could not pay it, an example of the cash bail system as a form of economic discrimination. Layleen was placed in solitary confinement [identified by many human rights organizations, as well as the United Nations, as a form of torture], “for her own protection,” even though her medical and mental health issues should have prohibited it [Sosin, 2020]. Layleen's status as a member of two marginalized communities, Afro-Latinx and transgender, made her a target for incarceration and subsequent solitary confinement [National Center for Transgender Equality, 2018]; the trauma of marginalization is compounded by inappropriate treatment within the system. While in solitary confinement, Layleen was not monitored appropriately and she ultimately succumbed to a fatal seizure. Though this placement was purportedly intended to protect her, it resulted in her death. Of note, formerly incarcerated transgender or nonbinary individuals have an especially elevated risk for homelessness. This risk is even greater if they have experienced repeated cycles of incarceration and homelessness, becoming stuck in the “revolving door” [National Center for Transgender Equality, 2018].

Definition

This chapter reviews the concepts underlying the initial evaluation and management of patients with disorders of sexual development. By definition, such an individual has lack of concordance of various aspects of gender. These include chromosomal sex [46,XX, 46,XY, or other], gonadal or reproductive sex [ovaries, fallopian tubes, and uterus vs. testes, seminal vesicles, prostate gland, and ejaculatory ducts], genital sex [vagina and clitoris vs. scrotum and penis], and gender-specific behavior.1 Depending on chromosomal sex, most patients can be classified as incompletely masculinized 46,XY males, virilized 46,XX females, and patients with abnormalities of sex chromosomes, such as those with mixed gonadal dysgenesis. [In the past, 46,XY and 46,XX patients with disorders of sexual development were referred to as male and female pseudohermaphrodites, respectively, but these terms are no longer preferred.] Many conditions can cause disorders of sexual development [Table 220-1].

Conclusion

Our gender identity is influenced by our personal experiences throughout the socialization process, the people with whom we relate, and our own choices. Thus we must understand that gender roles and traits for men and women are dynamic. However, traditional models of masculinity and femininity show reluctance to change and, even today, many youth employ these models for self-definition and to also define and evaluate the behavior of others [Santoro et al., 2018].

Both traditional models have been related with TDV in face-to-face and digital contexts. In males, abuse can be employed to maintain their power relation with a partner or to access sexual relations. In females, abuse may come as a way to verify a partner’s loyalty and to maintain a relationship. In any case, understanding gender as a multidimensional variable that can mediatize romantic relationships will allow future research to more certainly understand the causes of TVD, as well as other forms of gender violence, which is extremely necessary knowledge if we really wish to develop effective prevention and intervention policies.

Avoidance of Harmful Interventions

Discouraging a child's gender identity or expression harms the child's social-emotional health and well-being and can have lifelong consequences [American Psychological Association, 2009].

The WPATH [2012, p. 32] identifies interventions “aimed at trying to change a person's gender identity and lived gender expression to become more congruent with sex assigned at birth” as unsuccessful and unethical, and the Substance Abuse and Mental Health Services Administration [SAMHSA] [2015, p. 1] concluded that any interventions aimed at changing a child's gender identity or expression are not appropriate. Broadly, physical/medical and mental health professional organizations have discredited so-called reparative or conversion therapies, condemning them as harmful.

Integrating one’s gender identity

Adolescents formulate their gender identities as they encounter diverse and sometimes competing social messages, role relationships, sexual motives and activities, and dyadic interactions. These gender identities are situated in interpersonal, institutional, and cultural contexts. One of the salient factors contributing to the emergence of gender identity is gender-role preference. This preference is based on an assessment of two factors: how well one can meet the cultural and social expectations associated with one’s gender, and how positively one views the status associated with it. As the norms for gender-related expectations shift, later adolescents may revise their view of whether their own physical appearance, traits, preferences, and talents are typical for their gender.

As they engage in new and varied environments and roles, adolescents’ views about their gender typicality and their gender preference may become more differentiated. They may view themselves as personally and socially typical of their gender and still not be satisfied with their gender if the culture or context assigns a low status to their gender. If later adolescents become aware that their gender prevents them from having access to resources, influence, and decision-making authority, they are likely to experience a decline in their gender-role preference. This could happen to men as well as women, depending on the paths they choose to pursue and the gender biases they encounter. For example, in general, we tend to think of career aspirations as being stifled for women as a result of attitudes on the part of men who think that women are not suited to certain types of work. However, the reverse situation may also apply for men who are interested in fields traditionally dominated by women.

The college population tends to set social trends by according more variety and less rigidity to sex-linked role expectations. Most studies find that during the college years, students become more flexible in their gender-role attitudes and more egalitarian in their views about how men and women ought to function in school, work, family, and community life. On the other hand, the noncollege population tends to set employment trends by breaking down barriers in many male-dominated areas of work, such as construction, trucking, and public safety. Individuals can shape and strengthen the nature of their gender identity by spending time with other people who support their views and values about how men and women ought to behave toward one another and what life paths are most desirable for them.

Later adolescents are not simply passive recipients of social influences. They transform this information into conceptions of a future self; and as a generation they often bring about social change, endorsing new visions of how gender is expressed through song, fashion, media, creative arts, and in day to day interactions [Bussey, 2011]. As societies change, new terms arise to characterize the flexibility and diversity of gender-related positions. The term “genderism,” which refers to the idea that gender, is binary is being questioned or resisted in many critical literatures, which associate this assumption with oppressive power structures and discrimination against people whose gender identities are more fluid or nonconforming [Dvorsky & Hughes, 2008].

Intersectional nature of transgender individuals’ identities

Because of the evolving view of gender identity and the diverse experiences of gender among transgender individuals, it is important to gain a more nuanced understanding of the intersection of transgender individuals’ identities, and the combined effects of their specific social identities. The process of developing one’s identity is based on a series of psychological events which occur both consciously and subconsciously over time [Chatman, Eccles, & Malanchuk, 2005], and help each individual reinforce a coherent sense of self. Buss [2001] further distinguished between personal identity and social identity, where personal identity refers to “the sense of being different from everyone else in appearance, behavior, character, or personal history,” and social identity is “knowing oneself to be a member of a nation, religion, race, vocation, or any other group that offers a sense of belonging to something larger than oneself” [p. 358]. In Chatman et al.’s [2005] view, an individual’s personal self is a compilation of the meaning one makes from the individual’s multiple identities and group memberships. Individuals are active and selective in accepting or rejecting beliefs, but also are influenced by the perceptions and assumptions of the groups they identify with [Swann, Johnson, & Bosson, 2009].

As humans encounter new physical and social contexts, they are challenged with the task of maintaining a balance between self-continuity and redefinition. When individuals are capable of negotiating their sense of self through new experiences, they are more likely to cultivate positive well-being [Chatman et al., 2005]. Holding a marginalized identity increases the likelihood that individuals will encounter or anticipate stigmatization, contributing to more experiences that force them to negotiate their self-narrative with that being projected onto them from others. Transgender individuals who hold intersectional minority identities experience increased challenges to negotiating these identities, which, in turn, strains their ability to protect a healthy sense of self.

The intersection of group membership and exclusion not only influence the ways in which others will interact with an individual, it also affects the level of access to resources and social mobility they are able to achieve within a broader social context. According to a 2015 survey conducted by the National Center for Transgender Equality, 38% of black transgender individuals reported living in poverty, compared to just 12% of the US population. There were also disparities in housing instability, with 51% of black transgender women reporting that they have experienced homelessness at one point during their lives. The survey also found that 26% of black transgender participants were unemployed, twice the rate of the overall transgender sample and four times the rate of the general population. Thus the intersection of stigmatized identities resulting in experiences of racism and transphobia appears to contribute to lower levels of economic stability and social mobility. The prevalence of structural inequalities coupled with the numerous assaults that have occurred on transgender women of color in the United States and globally, highlights the lack of acceptance and safety for individuals holding these intersecting, marginalized identities. In 2018 alone, the Human Rights Campaign [2018] tracked at least 26 deaths of transgender people in the United States due to fatal violence, a majority of who held multiple intersectional minority identities. The continual aggression shown toward these women is likely to have a profound impact on their meaning-making process, perpetuating the message that society devalues their existence and is not willing to ensure their safety.

Personal and social identities shape individuals’ experiences within and across groups, but also are experienced, at times independently, depending on the social contexts and interactions they encounter. As such, transgender individuals may identify more strongly with one social identity over another, and the meaning linked to one’s identity may be activated by contexts or situations in which that identity is salient. Alvarado [2012] proposes that no one social identity can be understood in its entirety without examining the interactions it has with each of the other social identities an individual holds. Moreover, the intersectional nature of multiple social identities may compound systemic barriers for transgender individuals as a group at the fringes of society, such as transgender women of color being excluded from social groups due to sexism and racism. In a sample of transgender women of color in San Francisco, for instance, Latina and black transgender women were found to experience higher levels of exclusion and transphobia in comparison to other transgender women of differing racial backgrounds [Sugano, Nemoto, & Operario, 2006]. In short, as a result of the intersectional nature of multiple identities, the experiences and consequences of transgender individuals’ transitions and identity disclosures vary greatly both within and across groups.

Legal procedures

Individuals can seek legal affirmation of their gender identity through options such as changing gender markers on legal documents [driver’s license, passport, etc.] and making legal name changes which would then make it possible to change their names on institutional documents involving healthcare and health insurance, school, and work-related records of employment and for retirement. As with medical interventions, such legal changes are not a necessary part of transitioning, particularly since it is no longer required by the WPATH SOC to allow for medical interventions [though may be necessary for certain health insurance companies to pay for some procedures]. Nevertheless, changing gender markers on legal documents can be a significant step for gender diverse people in seeking affirmation. These documents should include healthcare proxy forms as part of an individual’s advance directive to ensure that the individual’s that gender identity is respected in end-of-life care [Ansara, 2015]