Childhood gender nonconformity

Childhood gender nonconformity is a phenomenon in which pre-pubescent children do not conform to expected gender-related sociological or psychological patterns, and/or identify with the opposite gender. Typical behaviour 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 non-conformity with eventual gay/bisexual and transgender outcomes. In some studies, a majority of those who identify as gay or lesbian self-report being gender non-conforming as children. However, the accuracy of these studies has been questioned from within the academic community. The therapeutic community is currently divided on the proper response to childhood gender non-conformity. One study suggested that childhood gender non-conformity is heritable.

Manifestations of gender non-conformity in children
Gender non-conformity in children can have many forms, reflecting various ways in which a child relates to his or her 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. This discovery leads to penis envy in girls and castration anxiety in boys. Freud’s theories are valuable in that they sparked new conversations surrounding sexuality and gender. However, there is not much empirical evidence to back up Freud’s theories.

Social learning theory emphasizes the rewards and punishments that children receive for sex appropriate or inappropriate behaviours. 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. 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.

Influences of androgens on childhood gender non-conformity
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’s 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 behaviours, while decreased androgen exposure is associated with more feminine-type behaviours.

Toy preference studies
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. 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. 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. 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.

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 behaviours, while boys show greater instances of rough-and-tumble play. For much of human history, people lived in small hunter-gatherer societies. Overtime 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. 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's been suggested that this could lead parents to treat them more like boys; however, this claim is unsubstantieated by parental reports.

Childhood gender non-conformity and 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 behaviours are relatively stable across a person a life-time.

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, we have to realize that a tendency toward certain behaviours does not mean that they are a monolithic group. In fact, for some individuals sexual orientation may be the only thing they have in common.

Childhood gender non-conformity and 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.” In effect, “CGN impacts men more negatively than women, regardless of sexual orientation.”  The pattern of results may be derived by from society’s greater acceptance of typically masculine behaviours in girls, and discouragement of typically feminine behaviours in boys.

Childhood gender non-conformity and 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. Women with CAH reported more male typical play behaviours and showed less heterosexual interest.

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.” 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.

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 behaviours as children. Adults will often reinterpret their childhood behaviours 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 behaviours 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 effect perceptions of childhood.

Gender identity disorder
Children with Gender Identity Disorder (GID) exhibit the typical gender nonconforming patterns of behaviours, 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). 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.

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, many argue that the label pathologizes behaviours and cognitions that fall within the normal gender of variation. The stigma associated with mental health disorders may do more harm than good.

Clinical treatments for gender identity disorder
It is important for clinicians to identify children whose gender dysphoria will persist into adolescence and those who outgrow their Gender Identity Disorder (GID) diagnosis. In instances where the child’s distress and discomfort continues clinicians will sometimes prescribe gonadotropin-releasing hormone (GnRH) to delay puberty. 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.

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.

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, 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, 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 behaviours.

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.

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.”  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.