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Behavior: Ask the experts



BEHAVIOR: Ask the Experts

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Q My practice encounters many parents, especially fathers, who are concerned about the "gentle" behavior of their 3- to 8-year-old sons. Typically, these children like to play with girls and seem unable to handle the aggressive behavior of their male peers. These parents' underlying anxiety, of course, is about homosexuality. Am I on solid ground when I tell these parents that their sons' behavior does not predict their sexual orientation?

John A. Lowe, MD
Wheaton, MD

A Parents' concerns about children's gender identity and later sexual orientation may challenge the pediatrician's knowledge, attitudes, and beliefs. Behaviors thought to be characteristic of the opposite gender are, at times, common and expected. At other times, such behaviors may simply be an indicator of gender nonconformity. Less often, such behaviors may reflect emotional difficulties. Only when such behaviors are intense, persistent, and pervasive should you consider the possibility of a childhood gender identity disorder.

Children's understanding of gender is influenced by their level of cognitive development. By age 2 1/2 to 3 years, children can accurately label themselves by gender and by 5 to 6 years of age understand that gender is fixed and stable. With this understanding comes a marked increase in same-sex interests typical for each gender, a preference for play primarily with same-gender peers, and a decrease in aggressive behavior in girls.

Parents worry about later sexual orientation and identity when their child predominantly engages in play and behavior more characteristic of the other gender. If the child is young, your discussions with parents should focus on the issue of gender identity, rather than later sexual orientation. Thus, you can reassure parents of preschool and early school-age children by reviewing the time frame for children's development of gender identity. Also tell them that interests that don't conform with gender, such as boys who avoid aggressive play and girls who are "tomboys," do not predict later gender identity problems—or sexual orientation. As long as the child does not display cross-gender preoccupations that interfere with age-appropriate functioning, the parent need not worry. Examples of such preoccupations are a preference for being the other sex or a strong interest in cross dressing.

Paul H. Dworkin, MDHartford, CT

DR. DWORKIN is Professor and Chairman of Pediatrics, University of Connecticut School of Medicine, and Physician-in-Chief, Connecticut Children's Medical Center.


Q A 13-year-old patient of mine often acts inappropriately in public, according to her foster parents. She may, for example, suddenly burst into a song in the middle of a high-school game. When her parents have guests, she often acts up. She says she does not care what others think and refuses to tell me why she acts this way. I don't think she gets enjoyment from these outbursts. The youngster has been in and out of foster care and has a lot of background issues. Help!

Doris Kim, MDMemphis, MO

A This young adolescent presents a difficult therapeutic challenge. The history of being "in and out of foster care," lots of background "issues," histrionic behaviors, a professed lack of concern about others' opinions, and refusal to talk about possible reasons for the behaviors suggest an unfolding character disorder.

It's no surprise, of course, that this 13-year-old girl finds it difficult to develop a trusting relationship with anyone, including a pediatrician. After all, she has been subject to multiple foster-care placements and rejections and frequent moves. One may hypothesize that she has a poor self-image and an uncertain future; she lacks relationships that convey unconditional positive regard and has uncultivated social skills. She also is probably lonely and lacks acceptance by her peers, along with other unidentified risk factors. That she will not—or cannot—identify reasons for her actions or respond to suggestions for behavioral changes is consistent with her sad history of dispiriting life experiences.

Establishment of a therapeutic relationship will take considerable time and skill, requiring your patience, empathy, and tolerance of slow progress. Explain this to the agency responsible for the placement and gain its support. While you initially can facilitate the belated help this girl urgently needs, her best interests would ultimately be served by a psychiatrist, psychologist, social worker, counselor, or other mentor who has the therapeutic skills or access to appropriate supervision to help an adolescent with such deeply seated difficulties. The foster parents also deserve counseling.

The pediatric phase of this plan, the goal of which is to have the adolescent accept a more definitive intervention, may require months of biweekly or monthly interviews, which should be limited to 15 minutes or so. Focus on the girl's current life experiences and explore her goals for the next few months or years, and how she can achieve them. Eventually, she should accept referral to another therapist with the requisite interest, experience, skill, and time to promote her progress toward a happier and healthier adolescent identity.

Morris Green, MD
Indianapolis, IN

DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics Editorial Board.


Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2000;12:39.

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