Children who are uncomfortable with their gender are often in distress and represent a source of tremendous anxiety to their parents. Consider your role in such cases to be one of helping the family adjust to and support their child's development with the goal of optimizing the outcome for parents and child.
A child who is truly "gender-variant" is one who exhibits an ongoing pattern of behavior, not merely a passing interest in the clothes or the preoccupations of the opposite sex. Families with a gender-variant child often experience considerable stigma, isolation, and emotional distress. Although much research remains to be done and no clinical guidelines are available, our current understanding of childhood gender and sexual development is sufficient to guide the pediatric management of children with gender-variant behaviors and their families. A growing body of useful resources is available.
What is gender? Gender is a multilevel category. Physiology defines the most fundamental level, but every society surrounds the basic physiology with a system of rules and customs concerning what males and females are supposed to be and do. Gender is infused with affect to an extent that few other domains can rival, making it a remarkably salient parameter of social categorization.
Despite important social changes in the last half century, expectations for the childhood behavior and adult aspirations of boys and of girls have changed less than one might have anticipated. Current beliefs do allow for somewhat more flexibility, acknowledging that the qualities labeled as typically masculine and feminine exist to some extent in people of both sexes.
By 4 or 5 years of age, children have learned a host of social stereotypes about how boys and girls are meant to behave, and they react approvingly or disapprovingly toward each other according to their choice of sex-appropriate toys and play patterns. Young children also develop stereotypes regarding adult roles and careers, including fixed ideas about what each sex should do, wear, and feel. These behaviors are often observed in spite of adults' attempts to instill ideas that stress nontraditional roles and occupations, an indication of how rigidly young children categorize along gender lines.1
What is "gender variance"? We define gender variance as a behavioral pattern of intense, pervasive, and persistent interests and behaviors characterized as typical of the opposite gender. A striking similarity in interests and behaviors favored by these children is seen across history, in different families with various cultural backgrounds.
These gender-variant behaviors include play activities, toys and hobbies, clothing and external appearance, identification with role models, preference for other-gender playmates, and statements indicating a wish to be of the other sex. Avoidance of rough play is typically observed in boys, and aversion to female-typed clothing and appearance is often seen in girls.
These behavioral patterns overlap with the definition of gender identity disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) but also encompass children who may not meet full criteria for GID. We disagree with the DSM-IV labeling of gender variance as a mental disorder, since neither homosexuality nor transexuality is classified as a mental disorder, and significant distress or functional impairment are not necessarily intrinsic to this condition.
The hallmark of marked gender-variant behavior is its inflexible and persistent quality. Gender-variant children insist that only a small range of behaviors and interests is acceptable to them. A boy with gender variance may be consumed by an interest in Snow White or may want nothing else for his birthday except a new Barbie doll. His interests tend to be restricted to typically feminine ones, and generally he has observable discomfort with typically masculine pursuits. Similarly, a girl with marked gender variance shows a distinct discomfort with things that are typically associated with girls and often insists she wants to be a boy.