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Dear Abby

Dr Osborne Answers:


Q: My son noticed that my hairdresser is now a woman. At what age is it appropriate to explain sex changes or cross-dressing with my child?

It is said among transgendered folks that kids are among the toughest critics when you are trying to “blend in” as the opposite gender. As early as preschool age, children are keenly attuned to the ways in which we divide the world into male and female, and they will notice gender change or incongruity. So it certainly makes sense for parents to be prepared with age-appropriate explanations for transgender behavior as soon as a child shows an awareness of these distinctions.

Unfortunately, most adults, including health professionals, lack an adequate understanding of the nature and causes of gender variation. Misinformation and prejudice often result in fear and public ridicule, which is why so many gender-discordant individuals delay seeking treatment until they are in serious crisis. The fact is, most people born with this condition have been more or less aware of it since early childhood, but have felt too ashamed or afraid to discuss it with anyone. By the time the gender issue is acknowledged and faced (often in middle adulthood), the unintended pain inflicted on loved ones by this disclosure creates additional guilt and alienation. As responsible parents and educators, we need to learn the facts about gender identity development and relate them to our children and students in a manner that they can understand.

Let’s start with some basic concepts that are often confused. Sex refers to those body parts we recognize as male or female, while gender identity refers to one’s internal experience of being male or female. In simplest terms, sex is “what’s between your legs” and gender is “what’s between your ears.” Society also teaches us a great deal about the expectations of gender, and many aspects of gender roles are culturally rather than biologically determined. Gender identity, as it has been defined here, does not result from social learning, but from biogenetic factors. There are, in fact, specific structures in the brain that are different for males and females and appear to control gender identity. An infant’s sex and gender identity are essentially determined in the first six weeks of fetal development, often before the mother even realizes she is pregnant.

In most cases, a person’s gender identity and sex agree with one another. A boy born with a penis feels like a boy, and grows up more or less content in his male role, and vice versa for girls. However, Nature can usually be relied upon to throw in some variation, and this area is no exception. For example, some infants are born with genital features of both sexes. Such intersex conditions are not that uncommon, occurring as often as 1 in 80 live births. In the recent past, well-intentioned doctors routinely performed surgery to “correct” this condition. Mistakes were sometimes made in predicting the child’s actual gender identity based on inspection of the genitals, with sad results. Today, physicians are better informed and can help parents make better decisions about what to do when their child is born with ambiguous or both kinds of genitals.

A transsexual person is one whose birth sex seems obvious, but does not match up with the brain’s gender identity. There are currently no objective tests to verify the diagnosis, so gender specialists must rely on clinical interviews. No form of psychotherapy has been shown to be effective in reversing the condition. The recommended treatment for severe forms is for the person to undergo sex correction procedures. Before being accepted for surgery, the individual must live full-time in the other gender for at least one year, and receive counseling and hormone therapy. Cross-dressers experience a milder form of gender discord. In these cases, periodic dressing as the opposite gender seems to relieve the distress, without the need for permanent change.

In some cultures, including Native American ones, gender variant people are honored as “two-spirited,” and considered to have special insights. Children’s questions about this issue should be handled in a matter of fact manner such as, “John was born with a condition that made him feel more like he was a girl than a boy, so he is getting help from doctors to change his body into the one that feels right for him.” There is no evidence whatsoever that children will experience personal gender confusion by exposure to cross-gender behavior. We should teach our children that gender questioning is an uncommon but normal part of human diversity.

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