Atypical gender development

• This publication is intended for professionals training or practicing in mental health and not for the general public
• The opinions expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP
• This publication seeks to describe the best treatments and practices based on the scientific evidence available at the time of writing
• Some medications may not be available in some countries
• Readers should consult the specific drug information since not all dosages and unwanted effects are mentioned
• This is an open-access publication under the Creative Commons Attribution Non-commercial License
• Gender dysphoria


  The sense of discomfort with one’s biological sex and assigned gender role
• Gender dysphoria may present in children from the age of 2 years
• Some children may express unhappiness at their gender and often may express the desire to change sex
• This can have a significant impact on child development in a broad way and also on family functioning
• Family responses to a child’s cross-gendered preferences

  • Acceptance and tolerance
  • Anxiety and desire to resolve the issue
• There are scarce data available as to the prevalence of gender dysphoria in children
• The evidence base about treatment in children is limited and the ethical issues are complex
• Supporting children with gender variance involves family counselling, individual work with the child and attention to the school environment
• The use of hormonal interventions around the time of puberty remains controversial
• Biological sex


  Refers to anatomical and biological (genetic and hormonal) categories of male and female
• Gender


  Refers to a prevailing socio-cultural model and defines social expectations of masculinity and femininity
• Gender identity


  Refers to the individual’s sense of himself or herself as a biological, psychological and social male or female
• Gender role


  Refers to the behaviors, attitudes and personality traits designated socio-culturally as masculine or feminine
• Sexual orientation


  Defined by response to sexual stimuli
• Sexual identity


  Refers to the definition of oneself in terms of sexual preference
• Money and Ehrhardt (1968) studied the rearing of children with disorders of sex development in the 1950s
• They concluded the sex of rearing was the most important factor in producing a “successful” outcome as male or female
• They stated that attempting to change gender after the age of 2.5 years was not likely to be successful
• It is clear that, whether or not gender variability is seen as a mental disorder, it is strongly influenced by cultural expectations of gender behavior
• What is seen in one culture as problematic may not be seen in the same way by another culture
• Children with gender dysphoria present with a range of cross-gendered fantasies and behaviors
• Young boys around 2-3 years of age may be interested in persistent cross-dressing
• Some of these little boys may show clear preference for playing with girls and prefer dolls and home themes in play
• Mary, aged 2 years, was born with multiple pelvic abnormalities
• Mary needed emergency surgery to the urinary system and bowel and was raised as female having later genital surgery
• While there is some evidence that male and female brains develop differently in utero, socialization is a very important influence on gender identity
• Mary had abnormalities, including an imperforate anus, ambiguous external genitalia with penile agenesis, and urinary system abnormalities.
• Examination of chromosomes showed the infant to be 46,XY.
• An ultrasound examination showed internal undescended testes.
• Mary needed emergency surgery to the urinary system and bowel.
• Mary was raised as female having later genital surgery.
• At the age of two, Mary is a secure child with female appearance who enjoys “female-type play” but also “rough and tumble” activities.
• There is some evidence that male and female brains develop differently in utero.
• Socialization is a very important influence on gender identity.