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Childhood gender nonconformity

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Childhood gender nonconformity (CGN) is a phenomenon in which prepubescent children do not conform to expected gender-related sociological or psychological patterns, or identify with the opposite sex/gender.[1] Typical behavior among those who exhibit the phenomenon includes but is not limited to a propensity to cross-dress, refusal to take part in activities conventionally thought suitable for the gender and the exclusive choice of play-mates of the opposite sex.

Multiple studies have correlated childhood gender nonconformity with eventual homosexuality; in these studies, a majority of those who identify as gay or lesbian self-report being gender nonconforming as children.[2][3][4] The therapeutic community is currently divided on the proper response to childhood gender nonconformity. One study suggested that childhood gender nonconformity is heritable.[4]

Manifestations

Gender nonconformity in children can have many forms, reflecting various ways in which a child relates to their gender.

  • Cross gender clothing and grooming preferences;
  • Playing with toys generally associated with the opposite sex;
  • Preference for playmates of the opposite sex;
  • Identification with characters of the opposite sex in stories, cartoons or films;
  • Affirmation of the desire to be a member of the opposite sex;
  • Strong verbal affirmation of a cross-gender identity ("No, I'm not a boy, I'm a girl", or "no, I'm not a girl, I'm a boy.")

Social and developmental theories of gender

The concept of childhood gender nonconformity assumes that there is a correct way to be a girl or a boy. There are a number of social and developmental perspectives that explore how children come to identify with a particular gender and engage in activities that are associated with this gender role.

Psychoanalytic theories of gender emphasize that children begin to identify with the parent, and that girls tend to identify with their mothers and boys with their fathers. The identification is often associated with the child's realization that they do not share the same genitals with both parents. According to Freud’s theories, this discovery leads to penis envy in girls and castration anxiety in boys. Although there is not much empirical evidence to back up Freud, his theories sparked new conversations surrounding sexuality and gender. [citation needed]

Social learning theory emphasizes the rewards and punishments that children receive for sex appropriate or inappropriate behaviors. One of the criticisms of social learning theory is that it assumes that children are passive, rather than active participants in their social environment.

Cognitive development theory argues that children are active in defining gender and behaving in ways that reflect their perceptions of gender roles. Children are in search of regularities and consistencies in their environment, and the pursuit of cognitive consistency motivates children to behave in ways that are congruent with the societal constructions of gender.

Gender schema theory is a hybrid model that combines social learning and cognitive development theories. Daryl J. Bem argues that children have a cognitive readiness to learn about themselves and their surroundings. They build schemas to help them navigate their social world, and these schemas form a larger network of associations and beliefs about gender and gender roles.[5]

Influences of androgens

Fetuses are exposed to prenatal androgens as early as 8 weeks into development. Male fetuses are exposed to much higher levels of androgens than female fetuses. It has been found that toy preferences, play-mates, and play-styles vary with the child’s exposure to androgens. Regardless of the biological sex of the child, increased androgen exposure is associated with more masculine-type behaviors, while decreased androgen exposure is associated with more feminine-type behaviors.

Toy preference studies

Studies with young rhesus macaques suggests that some gender preferences are not due to human socialization processes

Toys for girls tend to be round and pink, while toys for boy tend to be angular and blue. The subtle characteristics of toys may differentially appeal to the developing brains of female and male children.[6] In a study of toy preferences of twelve- to 24-month-old infants, males spent more time looking at cars than females and females spent more time looking at dolls than males. No preference for color was found.[7][8] Animal studies have lent further support for biologically determined gendered toy preferences. In a study of juvenile rhesus monkeys, when given the option between plush or wheeled toys, female monkeys gravitated toward plush toys, while male monkeys preferred toys with wheels. These findings suggest that gendered preferences for toys can occur without the socialization processes that we find in humans.[9] Female rhesus monkeys also tend to engage in more nurturing play activities, while males tend to engage in more rough-and-tumble play.

Girls with congenital adrenal hyperplasia (CAH) have atypically high blood concentrations of testosterone. In studies of toy preference, these girls show increased interest in male-typical toys, like trucks and balls. Overall, their play habits and preferences more closely resembled male-typical play than female-typical play. Even with children exposed a normal range of prenatal androgens, increased testosterone was associated with increased preference for male-typical toys, and decreased prenatal testosterone was associated with greater interest in female-typical toys.

Overall, the degree of androgen exposure during prenatal and postnatal development may bias males and females toward specific cognitive processes, which are further reinforced through processes of socialization. The male interest in balls and wheeled toys may relate to the androgenised brains preference for objects that move through space. The higher levels of androgens in the developing male brain could elicit greater attraction to cars and balls, while lower levels of androgens elicit a preference for dolls and nurturing activities in the female brain.[8]

Cordelia Fine criticizes toy-preference studies in non-human primates. She explains the disparity across research and the labeling of toys, with the rhesus monkey study deeming stuffed animals as inherently feminine, all the while a study with vervet monkeys shows males displaying a preference for stuffed dogs. Moreover, the effects of hormonal treatment are deemed inconclusive and significant long-term effects on rhesus monkeys being nonexistent, with treated prenatal females showing no increase in aggression and still adopting "feminine" social roles into adulthood.[10]

On the subject of Congenital Adrenal Hyperplasia, Fine presents the argument of correlation being confused for causality; are females with CAH interested in typically masculine activities due to their having an innate quality or is this a result of their association with boys and men as a gender? If a visual and spatial value is deemed as a preeminent element in typically masculine toys (such as trucks), females with CAH and males in studies should consequently show a much higher interest for neutral toys such as puzzles and sketchpads (as opposed to non-CAH females), something which they do not.[10]

Playmate and play-style preferences

Children's preference for same-sex play mates is a robust finding that has been observed in many human cultures and across a number of animal species. Preference for same-sex playmates is at least partially linked to socialization processes, but children may also gravitate toward peers with similar play styles. Girls generally engage in more nurturing-and-mothering-type behaviors, while boys show greater instances of rough-and-tumble play.[11] For much of human history, people lived in small hunter-gatherer societies. Over time evolutionary forces may have selected for children’s play activities related to adult survival skills.

However, it is not uncommon for girls and boys to prefer opposite-sex playmates and to engage in gender atypical play styles. Similarly to toy preferences, androgens may also be involved in playmate and play style preferences. Girls who have congenital adrenal hyperplasia (CAH) typically engage in more rough-and-tumble play. Hines and Kaufman (1994) found that 50% of girls with CAH reported a preference for boys as playmates, while less than 10% of their non-CAH sisters preferred boys as playmates.[11] Another study found that girls with CAH still preferred same-sex playmates, but their atypical play styles resulted in them spending more time alone engaging in their preferred activities. Girls with CAH are more likely to have masculinized genitalia, and it has been suggested that this could lead parents to treat them more like boys; however, this claim is unsubstantiated by parental reports.[12]

Adult traits

There have been a number of studies correlating childhood gender nonconformity (CGN) and sexual orientation; however, the relationship between CGN and personality traits in adulthood has been largely overlooked. Lippa measured CGN, gender-related occupational preferences, self-ascribed masculinity-femininity and anxiety in heterosexual and homosexual women and men through self-report measures. Gay men showed a tendency toward more feminine self-concepts than heterosexual men. Similarly, lesbian women reported "higher self-ascribed masculinity, more masculine occupational preferences, and more CGN than heterosexual women." Lippa's study found stronger correlations in CGN and adult personality trait in men than in women. Overall, Lippa's study suggests that gender nonconforming behaviors are relatively stable across a person a life-time.[13]

One of the advantages of Lippa's study is the relatively high sample size of 950 participants, that was diverse both in terms of representations of sexual orientation and ethnicity. Although there may be a tendency to want to generalize these findings to all heterosexual and homosexual men and women, awareness that a tendency toward certain behaviors does not mean that they are a monolithic group is necessary; for some individuals, sexual orientation may be the only thing they have in common.[13]

Measures of anxiety

CGN is associated with higher levels of psychological distress in gay men than in lesbian women. The findings were extended to heterosexual men and women, where "CGN [was] associated with psychological distress in heterosexual men but not in heterosexual women."[13] In effect, "CGN impacts men more negatively than women, regardless of sexual orientation."[13] The pattern of results may be derived by from society's greater acceptance of typically masculine behaviors in girls, and discouragement of typically feminine behaviors in boys.[13][14]

Sexual orientation

A great deal of research has been conducted on the relationship between CGN and sexual orientation. Gay men often report being feminine boys, and lesbian women often report being masculine girls. In men, CGN is a strong predictor of sexual orientation in adulthood, but this relationship is not as well understood in women.[2][4][15][16] Women with CAH reported more male typical play behaviours and showed less heterosexual interest.[12]

The fraternal birth order effect is a well documented phenomenon that predicts that a man's odds of being homosexual increase 33-48% with each older brother that the man has. Research has shown that the mother develops an immune response due to blood factor incompatibility with male fetuses. With each male fetus the mother's immune system responds more strongly to what it perceives as a threat. The mother’s immune response can disrupt typical prenatal hormones, like testosterone, which have been implicated in both childhood gender nonconformity and adult sexual orientation.

Bem proposes a theory on the relationship between childhood gender non-conformity, which he refers to as the "exotic become erotic."[5] Bem argues that biological factors, such as prenatal hormones, genes and neuroanatomy, predispose children to behave in ways that do not conform to their sex assigned at birth. Gender nonconforming children will often prefer opposite-sex playmates and activities. These become alienated from their same-sex peer group. As children enter adolescence "the exotic becomes erotic" where dissimilar and unfamiliar same-sex peers produces arousal, and the general arousal become eroticized over time. Bem's theory does not seem to fit female homosexuality. Perhaps, males who demonstrate gender nonconformity experience more alienation and separation from same-sex peers, because cultural constructions of masculinity are generally more rigid than femininity.[5]

Report biases in retrospective studies

Although childhood gender nonconformity has been correlated to sexual orientation in adulthood, there may be a reporting bias that has influenced the results. Many of the studies on the link between CGN and sexual orientation are conducted retrospectively, meaning that adults are asked to reflect on their behaviors as children. Adults will often reinterpret their childhood behaviors in terms of their present conceptualizations of their gender identity and sexual orientation. Gay men and lesbian women who endorsed a biological perspective on gender and sexual orientation tended to report more instances of childhood gender nonconformity and explain these behaviors as early genetic or biological manifestations of their sexual orientation. Lesbian women who endorse a social constructionist perspective on gender identity often interpret their childhood GNC as an awareness of patriarchal norms and rejection of gender roles. Heterosexual men are more likely to downplay GNC, attributing their behaviours to being sensitive or artistic. Retrospective reinterpretation does not invalidate studies linking GNC and sexual orientation, but we need to be aware of how present conceptualization of gender identity and sexual orientation can affect perceptions of childhood.[17]

Gender dysphoria

Children with gender dysphoria, also known as gender identity disorder (GID), exhibit the typical gender nonconforming patterns of behaviors, such as a preference for toys, playmates, clothing, and play-styles that are typically associated with the opposite-sex. Children with GID will sometimes display disgust toward their own genitals or changes that occur in puberty (e.g. facial hair or menstruation).[18] A diagnosis of GID in children requires evidence of discomfort, confusion, or aversion to the gender roles associated with the child’s genetic sex. Children do not necessarily have to express a desire to be the opposite-sex, but it is still taken in consideration when making a diagnoses.[18]

Some advocates have argued that a DSM-IV diagnosis legitimizes the experiences of these children, making it easier to rally around a medically defined disorder, in order to raise public awareness, and garner funding for future research and therapies. Diagnoses of gender identity disorder in children (GIDC) remains controversial, as many argue that the label pathologizes behaviors and cognitions that fall within the normal gender of variation. The stigma associated with mental health disorders may do more harm than good.[18]

Parental reactions

Parents with gender non-conforming children may not know where to turn to express their feelings. Many parents accept their child’s choice but are more concerned for the overall well being of the child. In some cases families are not accepting of their child’s non-conformity, typically lashing out with punishment grounded on homophobia and sexism. Regardless of the stance a parent decides to take on gender non-conformity, it will affect the child and the child’s relationship with the family.

Transphobia can occur when gender nonconforming children are met with others who do not understand or accept what they are going through. Dr. Diane Ehrensaft states that, "Transphobia is the anxieties, prejudices, aspersion, aggression, and hatred cast on individuals who do not accept the gender assigned to them at birth but instead play outside that definition of self or perhaps any binary categorizations of gender, possibly to the extent of altering their body."[19] Transphobia can become a serious conflict within the family and can damage the relationship the child has with his or her family.

Parents who recognize that they have gender non-conforming children sometimes experience a feeling of loss, shock, denial, anger, and despair.[20] These feelings typically subside as a parent learns more about gender nonconformity. However, there are families that remain unaccepting of gender nonconformity and correlate it to psychological or social problems. Licensed Marriage and Family Therapist Jean Malpas says, "Some react very negatively and the gender nonconformity can become a significant source of conflict between parents and a damaging source of disconnection between parent and child."[21]

Dr. Diane Ehrensaft cites that there are three family types that can affect the outcome of a child's gender nonconformity: transformers, transphobics, and transporters.[19] Transformers: Transformers are parents that are comfortable in supporting their child in their gender variant journey and can easily identify their child as a separate person. Ehrensaft states, “These parents will stand a good chance of overcoming whatever transphobic reactions may reside within them to evolve into parents who both meet their child where he or she is and become an advocate for their gender nonconforming child in the outside world." [19] Transphobics: Transphobic parents are not comfortable in their own gender, and may not understand that gender is fluid. Transphobic parents may feel their child is an extension of themselves and respond negatively when their child is faced with his or her own adversity. Ehrensaft believes these parents deny their child with an excess of negativity and transphobic “reactivity” this allows the child no room for nonconformity and undermines the love the parent claims to have for the child. 'Transporters: Transporters are parents that appear to be completely accepting of their child's gender nonconformity but on the inside have doubts about whether or not it is an authentic conformity. Transporter parents may say thinks like, "It's just a phase," or "he or she will grow out of it."

Peer reactions

Once children reach school age, girls who are considered "tomboys" and boys who are considered to be more "sensitive" then their gender typical peers, are more likely to face challenges during childhood than their gender-typical counterparts. It is possible that their nonconformity goes unnoticed, however it is more likely that they fall victim to bullying and harassment when they reach school age.[22] In a study on gender atypical fifteen year olds, atypical males self-report being lonelier, bullied more, less likely to have male friends, and be in "greater distress" than gender-typical males in the same demographic.[23]

Needs of gender nonconforming children and families

There is still controversy regarding the best approach for gender nonconforming children, but as gender nonconformity becomes more widely accepted many parents and professionals have identified things that gender variant or gender nonconforming children need to easily adjust to their transformation.[24] Parents have suggested that their children need the ability to discuss their gender non-conformity freely with their parent, to be loved throughout their transformation, and to be permitted to make choices regarding their gender on their own. They have also suggested a peer support team and supportive counseling in addition to support from their school and schools administrators and authorities.[24]

Parents must be mindful of a child's need for parent expressions of acceptance and validation. If not validated a child may begin sharing less with their parent and more with friends, this could lead to the parent thinking the gender nonconformity was just a brief phase.[25]

Disclosure is also a very important to a family when raising a gender non-conforming child. Parents need to consider whom to talk to about their child and what type of information they decide to share. Other members of the family must also be prepared to make decisions regarding what to say and who to say it to.[26]

In regards to their own needs, parents have suggested that they need information regarding gender nonconforming children that can better assist them and their child in making their transition. Additionally, parents have stated they need increased education on gender nonconforming children, and support from surrounding friends and family to help build parental confidence. Parents have also suggested they need counseling to help provide direction, support from medical professionals and peers, and access to transgender people to help provide them with a positive portrayal of transgender communities.[24]

Clinical treatments for gender dysphoria

It is important for clinicians to identify children whose gender dysphoria will persist into adolescence and those who outgrow their gender identity disorder (GID) or gender dysphoria diagnosis. In instances where the child’s distress and discomfort continues clinicians will sometimes prescribe gonadotropin-releasing hormone (GnRH) to delay puberty.[27] Identifying stable and persistent cases of GID may reduce the number of surgeries and hormonal interventions individuals undergo in adolescence and adulthood. Gender identity disorders persist into adolescence in about 27% of children with GID diagnoses.[27]

Diagnosis and treatment of GID in children can be distressing for the parents, which can further exacerbate distress in their child. Parents had difficulties accepting their child's desire to be the opposite sex, and are resistant to children wanting to alter their bodies.[28]

Supportive professionals

Some professionals, including Dr. Edgardo J. Menvielle of the Children's National Medical Center, who has specialized in this area in his clinical practice,[29] believe that the proper response to gender variant behavior is supportive therapy aimed at helping the child deal with any social issues which may arise due to homophobia / transphobia. These professionals believe that attempts to alter these behaviors, and/or whatever mechanism is responsible for their expression, are generally ineffective and do more harm than good. While not universally advocating for what childhood transgender advocates refer to as full social transition, the CNMC model generally supports allowing a child to express cross gendered interests at home in an age appropriate fashion. Other professionals associated with a supportive model include Dr. Norman Spack of Children's Hospital Boston,[30] Catherine Tuerk, MA, RN, Herbert Schreier, MD (Children's Hospital Oakland), and Ellen C. Perrin, MD of the Center for Children with Special Needs (CCSN) at TUFTS. Rosenburg (2002) recommends a parent-centered approach that helps parents learn to accept and support their child's identity and help the child to work through the issues surrounding identity, without trying to eliminate gender-variant behaviors.[31]

Reparative therapy

Other professionals, typified by Dr. Kenneth Zucker, the Head of the Gender Identity Service, Child, Youth, and Family Program and Psychologist-in-Chief at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada, believe that behavior modification to extinguish gender variance is the appropriate response to cross gender interests. Dr. Zucker asks the rhetorical question of whether it would be ethical to treat an African American child who wishes to identify as Caucasian with cosmetic surgeries to facilitate this identity, though his critics point out that gender identity is completely non-analogous to ethnic identity. Dr. Zucker's choice as one of the professionals creating the new DSM entry on GID has elicited a firestorm of controversy in the LGBTQ community. Dr. Zucker has expressed the opinion that if his therapies also occasionally prevent a homosexual outcome, they are a valid parental choice.[citation needed]

There is no one universal set of behavioural interventions designed to reduce stress in children with GID. Zucker (2000) asserts that childhood gender dysphoria is caused by "tolerating or encouraging cross-gender behaviour or by intentionally raising androgynous children."[32] He advises that behavioural treatments should aim to discourage gender-variant behaviours that have inadvertently been reinforced in the past. In contrast, reparative therapy for adults is generally discouraged by the ethics guidelines of major U.S. mental health organizations, including the American Psychological Association, American Psychiatric Association, the American Counseling Association. There is no such consensus around such therapies for children.[citation needed]

See also

References

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  2. ^ a b Baumeister, Roy F. (2001). Social Psychology and Human Sexuality: Essential Readings. Psychology Press. pp. 201–2. ISBN 978-1-84169-018-6.
  3. ^ Assessment and Treatment of Childhood Problems, Second Edition: A Clinician's Guide. Guilford Press. 2002. p. 229. ISBN 1606234226. Retrieved January 29, 2015. {{cite book}}: Unknown parameter |authors= ignored (help)
  4. ^ a b c Friedman, RC (2008). Sexual Orientation and Psychodynamic Psychotherapy Sexual Science and Clinical Practice. Columbia University Press. pp. 53–7. ISBN 978-0-231-12057-9.
  5. ^ a b c Bem, D.J. (1996). "Exotic Becomes Erotic: A Developmental Theory of Sexual Orientation". Psychological Review. 103 (2): 320–335. doi:10.1037/0033-295X.103.2.320.
  6. ^ Jadva, V.; et al. (2010). "Infants' preferences for toys, colors and shapes". Arch. Sex. Behav. 39 (6): 1261–73. doi:10.1007/s10508-010-9618-z. PMID 20232129.
  7. ^ Alexander, G.M. (2003). "An evolutionary perspective of sex-typed toy preferences: pink, blue, and the brain". Arch. Sex. Behav. 32 (1): 7–14. doi:10.1023/A:1021833110722. PMID 12597267.
  8. ^ a b Hines, M. (2010). "Sex-related variation in human behavior and the brain". Trends in Neurosciences. 14 (10): 448–56. doi:10.1016/j.tics.2010.07.005. PMC 2951011. PMID 20724210.
  9. ^ Hassett, Janice M.; Siebert, Erin R.; Wallen, Kim. (2008). "Differences in Rhesus Monkey Toy Preferences Parallel those of Children". Hormones and Behavior. 54 (3): 359–64. doi:10.1016/j.yhbeh.2008.03.008. PMC 2583786. PMID 18452921.
  10. ^ a b Fine, Cordelia (2010). Delusions of Gender: How Our Minds, Society, and Neurosexism Create Difference. W. W. Norton & Company. p. 338. ISBN 0-393-06838-2.
  11. ^ a b Hines, M.; Kaufman, Melissa; Francine, R. (1994). "Androgen and the Development of Human Sex-Typical Behavior: Rough and Tumble Play and Sex of Preferred Playmates in Children with Congenital Adrenal Hyperplasia (CAH)". Child Development. 65 (4): 1042–53. doi:10.2307/1131303. PMID 7956464.
  12. ^ a b Hines, M.; Brook, C.; Conway, G.S. (2004). "Androgen and Psychosexual Development: Core Gender Identity, Sexual Orientation, and Recalled Childhood Gender Role Behavior in Women and Men with Congenital Adrenal Hyperplasia (CAH)". Journal of Sex Research. 41 (1): 75–81. doi:10.1080/00224490409552215. PMID 15216426.
  13. ^ a b c d e Lippa, Richard (2008). "The Relation between Childhood Gender Nonconformity and Adult Masculinity–Femininity and Anxiety in Heterosexual and Homosexual Men and Women". Sex Roles. 59 (9–10): 684–93. doi:10.1007/s11199-008-9476-5.
  14. ^ Skidmore, W.C.; Linsenmeier, J.A.W.; Bailey, J.M. (2006). "Gender Nonconformity and Psychological Distress in Lesbians and Gay Men". Archives of Sexual Behavior. 35 (6): 685–97. doi:10.1007/s10508-006-9108-5.
  15. ^ Dunne, Michael P.; Bailey, J.M.; Kirk, K.M.; Martin, N.G. (2000). "The Subtlety of Sex-Atypicality". Archives of Sexual Behavior. 29 (6): 549–65. doi:10.1023/A:1002002420159. PMID 11100262.
  16. ^ Bailey, J.M.; Zucker, K.J. (1995). "Childhood Sex-typed Behavior and Sexual Orientation: A Conceptual Analysis and Quantitative Review". Developmental Psychology. 21 (1): 43–55. doi:10.1037/0012-1649.31.1.43.
  17. ^ Gottschalk, Lorene (2003). "Same-Sex Sexuality and Childhood Gender Non-Conformity: A Spurious Connection". Journal of Gender Studies. 12 (1): 35–50. doi:10.1080/0958923032000067808.
  18. ^ a b c Langer, Susan J.; Martin, James I. (February 2004). "How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children". Child and Adolescent Social Work Journal. 21 (1).
  19. ^ a b c Ehrensaft, Diane, PhD. "Boys Will Be Girls, Girls will Be Boys: Children Affect Parents as Parents Affect Children in Gender Nonconformity." Psychoanalytic Psychology 28.4 (2011): 528-48. Print.
  20. ^ Children's National Medical Center. If You Are Concerned About Your Childs Gender Behavior. N.p.: Children's National Medical Center, n.d. Children's National Medical Center. Web. 31 Oct. 2013.
  21. ^ Malpas, Jean. "Between Pink and Blue: A Multi-Dimensional Family Approach to Gender Nonconforming Children and Their Families." Family Process 50.4 (2011): 453-470. Print.
  22. ^ Haldeman, Douglas C. "Gender atypical youth: Clinical and social issues." School Psychology Review 29, no. 2 (2000): 192.
  23. ^ Young, Robert, and Helen Sweeting. "Adolescent bullying, relationships, psychological well-being, and gender-atypical behavior: A gender diagnosticity approach." Sex Roles 50, no. 7-8 (2004): 525-537.
  24. ^ a b c Reilly, Elizabeth A., Gomathi Sitharthan, Lindy Clemson, and Milton Diamond. "Recognizing the Needs of Gender-variant Children and Their Parents." Sex Education 13.6 (2013): 644-59. Print.
  25. ^ Menvielle, Edgardo J., M.D., and Catherine Tuerk, M.A.,R.N.,C.S. "A Support Group for Parents of Gender-Nonconforming Boys." Journal of the American Academy of Child & Adolescent Psychiatry 41.8 (2002): 1010-013. Print.
  26. ^ "Parent Considerations." Gender Spectrum. Gender Spectrum, n.d. Web. http://www.genderspectrum.org.
  27. ^ a b Wallien, M.S.C; Cohen-Kettenis, P.T. (2008). "Psychosexual Outcome of Gender-Dysphoric Children". Journal of the American Academy of Child and Adolescent Psychiatry. 47 (12): 1413–1423. doi:10.1097/CHI.0b013e31818956b9.
  28. ^ Hill, Darryl B.; Rozanski, C.; Carfagnini, J.; Willoughby, B. (2006). "Gender Identity Disorders in Childhood and Adolescence". Journal of Psychology & Human Sexuality. 17 (3): 7–34. doi:10.1300/J056v17n03_02.
  29. ^ *Edgardo J. Menvielle, MD, MSHS of the Children's National Medical Center
  30. ^ Gender Management Service (GeMS) Clinic at Children's Hospital in Boston
  31. ^ Rosenberg, M.; Jellinek, Michael S. (2002). "Children with gender identity issues and their parents in individual and group treatment". Journal of the American Academy of Child and Adolescent Psychiatry. 41 (5): 619–21. doi:10.1097/00004583-200205000-00020. PMID 12014795.
  32. ^ Zucker, K.J (200). "Gender identity disorder". Handbook of developmental psycholpathology. 2nd ed.: 671–86. doi:10.1007/978-1-4615-4163-9_36.
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