Helping children with gender identity confusion

Transgenderism is an increasing focus of pop culture, social media, politics, and the academic world. As a result, Focus on the Family Canada has seen an upsurge in questions about this issue. Some of the most heart wrenching are from parents whose son announces, “I’m really a girl,” or whose daughter says, “I identify as a boy.”

We want to acknowledge from the start that this is a sensitive, complicated subject. The research on this issue is very limited, and even the “experts” don’t understand everything that creates confusion and distress over gender identity. In addition to being complex, the conversation about transgenderism has become loud and angry, so you as a parent might feel caught in the middle of a raucous public debate – stuck between your faith and the many voices demanding that you affirm and help your children live as the gender of their choice.

So what’s a loving, caring parent to do? If you are the parent of a child struggling with gender identity issues, know that we offer the best information we can from a biblical, clinical, and scientific perspective. And, though this question-and-answer article is primarily geared toward parents faced with a child’s transgenderism, we trust that family members and friends will also be able to obtain helpful guidance about this difficult issue.

Is there hope?

For those of us who have placed our faith in Christ, our hope is in the Lord, and we know that He is always with us. He is our strong and sure shelter. He does not abandon us when we go through dark times. As the Psalmist writes: 

"God is our refuge and strength, a very present help in trouble." (Psalm 46:1, ESV)

We encourage you to place your hope – for yourself, your family, and your child – in the Lord.

We also want to remind you of this truth from God's Word:

"So God created man in His own image, in the image of God He created him; male and female He created them." (Genesis 1:27, ESV)

Though your child may be confused or influenced by messages to the contrary, we believe there’s comfort in the assurance that God created your child in His image – distinctly male or female.¹ We also want to emphasize that we know from testimonies and research that it is reasonable to hope that children who struggle with gender confusion will work through it to accept their God-given bodies.

There is no quick fix or easy answer, but many individuals come to embrace their biological sex and live in line with their faith as the sex they were born – male or female. They do this through a variety of means, including: faith in Christ; obedience to God’s Word; the power of the Holy Spirit; godly counsel and pastoral care; prayer – their own and others; confession; forgiveness; embracing truth; and giving and receiving love and support from Christian friends and family. As a parent you have the opportunity to encourage and nurture your child toward embracing this truth and pursuing God’s design for his or her life.

What does the terminology surrounding "transgenderism" mean?

People and cultures throughout history have recognized that men and women are different. They also recognize that some men struggle to achieve a masculine identity and some women struggle with their femininity. But the modern transgender movement, ideology, and activism seek to redefine God’s creation of humanity, which He separated into male and female.² This movement suggests that instead of two sexes, there are a multitude of “genders.”

In light of the fact that this is a recent movement, the basic terminology used is often newly invented and can change frequently. With easy access to the internet, many children, teens, and young adults see and become familiar with these terms quickly – often before you as a parent. And because transgender ideology is taught in some schools – and even preschools – young children may have an awareness of this terminology. Therefore, it’s helpful to understand the basic terms and concepts behind this ideology while maintaining awareness that these definitions are fluid and changeable among those who create and commonly use these words.

• Sex – The state of being male or female.³ Transgender activists differentiate between “sex” and “gender.” They view “sex” as having to do with anatomy and “gender” as what a person believes, thinks, or feels about who they are.
  
  
• Gender – A term borrowed from linguistics by the psychology profession starting in the 1950s and 60s. Until then, the noun “sex” was used to specify being male or female. Many academics adopt the idea that “gender is a social construct” – not grounded in physical reality. Some also argue that there are no real differences between men and women, so gender can be redefined or reconstructed as societies and individuals see fit. Gender activists believe that people may switch between genders and that there are a multitude of genders. Using the analogy of a computer, they acknowledge that the “hardware” (biology) is male or female, but they promote the idea that the “software” (the individual’s mental and emotional perception) takes precedence over the biological sex of a person and is the determiner of gender.
  
  
• Gender expression – How people outwardly express themselves: as male, female, some combination of the two, or neither. A person’s gender expression may change from day to day. Gender expression includes language, clothing, actions, makeup, and more.
  
  
• Transgender – A broad umbrella term covering many individuals, including those who believe their “gender” differs from their bodily sex. It includes cross-dressers (those who dress as the opposite sex), drag performers (those who perform as the opposite sex), those who believe they are neither male nor female, and those who believe they are some combination of the two. Identifying as transgender does not necessarily mean that individuals have taken hormones or undergone surgery in attempts to align their outward gender expression with their internal gender identity.
  
  
• Cisgender – A recently coined term used to serve as an opposite to “transgender.” It describes those who have never experienced a disconnect between their physical body and their perceived identity. These individuals have always readily identified in alignment with their biological sex – men as male and women as female.

More terms are being created, but though someone may identify as “transgender” or as a different “gender,” there is no legal, medical, or psychological criteria or diagnosis to quantify or establish exactly what that means. The person making the claim is the sole determiner of what it means in relationship to his or her personal situation.

What are “gender identity disorder” and “gender dysphoria”?

The Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition, is published by the American Psychiatric Association (APA). The DSM describes and lists the characteristics of various mental health issues. In 1980, the DSM’s third edition included “transsexualism” and “Gender Identity Disorder” (GID) for the first time.

The fourth edition of the DSM described GID as “a strong and persistent cross-gender identification.”⁴ The manual provided a list of characteristics, such as when a young boy repeatedly states or insists upon the desire to be a girl, strongly prefers girls as playmates, and persistently rejects stereotypically masculine clothing and activities.

The fifth edition of the DSM, published in 2013, now uses the term “Gender Dysphoria” instead of GID. A fact sheet by the APA says, “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.”⁵

In simple terms, the APA (and the Canadian Psychological Association too) no longer view it as a mental disorder when children or adults believe they are the opposite sex. Their approach is to recommend that these individuals be given access to clinical and medical care, which could include “counselling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender.”^6,7

Rather than encouraging psychological treatment to help overcome the dissonance between one’s feelings and biological sex, the APA and CPA, along with some other secular clinical groups, have shifted to advocating for normalizing and even celebrating a person’s gender confusion. Some clinicians even use terms like “gender variant” or “gender identity creativity” and view children with gender confusion as “transgender,” further promoting children’s misperceptions.

On the other hand, those who affirm the Bible’s teaching believe God designed us male and female in His image. Even though the human, post-Fall condition can create various challenges in life, we believe He wants young children to grow into an understanding of healthy masculinity or femininity and accept their biological sex. As a Christian parent of a gender-confused child, you may face opposition if you want to guide your child toward embracing their biological sex. This might not only come from clinicians or groups like the APA or CPA, but you also could face legal conflict.

What causes gender confusion?

While science has learned a great deal about diseases and disorders of the human body, issues of the soul and spirit are less tangible and can be very complex. Among mental health professionals there is widespread disagreement about diagnosis, causation, and treatment of many mental health issues, including gender confusion. Unlike chemistry and physics, psychology and psychiatry are not hard sciences. In other words, there is greater subjectivity in these fields, so when speaking to issues of the human condition, the interpretations are often based on ideology and theoretical positions.

Over time, transgender activists, researchers, and clinicians have offered a variety of narratives about what causes different types of transgenderism, including:

• Transgender-identified individuals have a body that is one gender and a brain that is another. You’ll hear a person describe himself this way: “I’m a girl trapped in a boy’s body,” or, “I have a girl’s body but a boy’s brain.”
  
  
• Transgenderism is caused by hormonal imbalances during pregnancy or early childhood.
  
  
• Gender confusion is caused in boys when the brain is not masculinized by testosterone – even though the rest of the body is completely masculine (and vice versa for girls).
  
  
• Chemicals in our ecosystem may cause the masculinization of women and the feminization of men.
  
  
• Gender confusion is a type of fetish where some adolescent boys and men are aroused by putting on women’s clothes. (This is sometimes called “autogynephilia” – love of oneself as a woman – or “transvestic fetishism.”)
  
  
• This is just “how some kids are.” It doesn’t matter what causes this; we should accept them and get over it.

Some transgender activists argue that transgenderism is “scientifically proven” to be biological and innate. But the truth is quite different. Kenneth Zucker is one of the leading researchers and clinicians on gender identity disorders in children. He responds to the theories about the biological origins of transgenderism by saying, “In terms of empirical data, this is not true. It’s just dogma…”⁸

In a review of much of the research to date, Dr. Lawrence Mayer and Dr. Paul McHugh summarize two key points about causation:

• The hypothesis that gender identity is an innate, fixed property of human beings that is independent of biological sex – that a person might be “a man trapped in a woman’s body” or “a woman trapped in a man’s body” – is not supported by scientific evidence.
  
  
• Studies comparing the brain structures of transgender and non-transgender individuals have demonstrated weak correlations between brain structure and cross-gender identification. These correlations do not provide any evidence for a neurobiological basis for cross-gender identification.⁹

So, to be as scientifically honest as possible, there are probably many contributing factors – spiritual, psychological, social, and possibly biological – that interact together and can vary for each individual. In addition, there also might even be varying types of transgenderism.

For Christians, it’s clear that the post-Fall condition of humankind can be seen in many areas of life where things have gone awry. In those situations, we need to convey God’s message of redemption, healing and grace while also gently and strategically guiding a person back to the Creator’s gracious intention and design.

What are some possible "contributing factors"?

Dr. Miriam Grossman, a physician who specializes in pediatrics and child psychiatry, described in a testimony before the California State Legislature the usual progression for a child’s development: “…at around age three, a boy knows that he is a boy. He identifies himself as a boy. That’s called Gender Identity.” She explains that the child then goes on to develop a sense of Gender Stability; that is, he knows “that he’s going to grow up to be a man.” And by age “six, seven at the latest,” Grossman continues, a boy “is supposed to know that he cannot become a girl even if he wears a dress. And that’s called Gender Permanence.”

Since we live in a broken world where all of us experience the complex results of sin within our social and familial systems, some children have difficulty navigating these normal developmental phases. They are derailed from the usual process of aligning their identity with their body. Here are just a few factors that, singly or in combination, might contribute to gender confusion:

• Two clinicians with decades of experience, Kenneth Zucker and Susan Bradley, note that one factor for children is “a high level of anxiety or insecurity.”¹⁰
  
  
• Zucker and Bradley also note that there may be stressors in a family during a child’s first three years of life, including “loss of important family members, illness in parents or children, and intense parental conflict.”¹¹
  
  
• Some recent studies and reviews suggest a link between autism and gender confusion. This may suggest neurological issues play a role for some children.¹²
  
  
• For girls, the American College of Pediatricians (ACPeds) notes that though there are not systematic studies, clinical observations suggest relational difficulties may lead a daughter to disidentify with her own femininity.¹³
  
  
• ACPeds also suggests that sexual abuse may be a factor for some children, as some victims of sexual abuse struggle with their gender identity. In addition, some reports correlate higher levels of childhood sexual abuse among the transgender population. ACPeds cautions that more research is needed to determine if there may be a causal link with transgenderism.¹⁴
  
  
• The rise of social media, coupled with increased attention on and celebration of transgenderism, may be leading to a greater number of children and adolescents identifying as transgender – a sort of “social contagion.” There is anecdotal support for this, as the past few years have seen a significant rise in referrals to clinics. In the U.S., the number of transgender youth clinics grew from a single clinic in 2007 to 40 by 2015.¹⁵
  
  
• Those struggling with gender confusion – children, adolescents and adults – also exhibit higher rates of a number of additional psychological, relational, and developmental issues, including depression, suicidality, isolation, difficulties with peer relationships, anxiety disorders, and substance abuse issues.¹⁶

It appears there’s not simply a single influence that creates circumstances where a child struggles with gender confusion or comes to eventually identify as transgender. With this in mind, we strongly encourage you as a parent to consider seeking Christian counselling from a qualified provider who has experience dealing with areas of sexuality, as well as training in family systems dynamics. As a first step in exploring that possibility, we invite you to call the Focus on the Family Canada counselling line at 1.800.661.9800.

Will most children “get over” their gender confusion?

Yes. Most children who are reported to have early symptoms of gender confusion eventually resolve the issue and become congruent with their biological sex. While a small percentage of children might continue to struggle with gender confusion beyond childhood, research done by leading scholars consistently finds that the vast majority of children identify with their biological sex by the time they reach puberty.¹⁷ Generally, this change takes place from ages 10 to 13.

During this crucial time, children often drop their gender-variant behaviour and identity. This, however, may require gentle, affirming, non-reactive strategies that do not shame the child, but which also avoid accentuating and encouraging the gender breach. A Christian counsellor with expertise in providing guidance to those with gender identity confusion can be a tremendous help to the child and family as they work through this process.

Scholars in the Netherlands recognize three factors of maturing that influence a child to identify with his or her biological sex: 

Changing social environment – As the social differences between girls and boys increase during these ages, it was noted that "The greater social distance between the sexes …seemed to create a desire to add gender typical interests to their repertoire." Happily, these children "indeed started to experience a stronger affiliation with children of their own gender and more often initiated and enjoyed same-gender friendships."¹⁸

Changing bodies – Both the anticipation of and the actual changes in children’s bodies at puberty seemed to have a significant effect. It was as if their bodies were telling these children, “Now this is who you actually are. See how you’re developing?”

Falling in “love” – Both changing bodies and social environments lead to another very significant development: the onset of infatuations and the development of sexual feelings. While we trust this information provides reason for hope, we also need to add a word of caution. Some children, though no longer dealing with gender confusion, do develop sexual attractions toward their same sex. Even those who don’t struggle with homosexuality may still need help to gain deeper healing and personal peace as they work toward healthy relationships and self-acceptance of their biological sex.

Do experts recommend that parents allow gender-confused children to present and live as the opposite sex?

Although there are now numerous clinics in the U.S. that embrace gender dysphoria as a diversity to celebrate, encouraging children to live as the opposite sex, many leading experts do not recommend this. Even in the Netherlands, where transgenderism is widely accepted, “The Dutch Model,” developed and practiced by the Amsterdam Gender Identity Clinic (AGIC), recommends:

… that young children not yet make a complete social transition (different clothing, a different given name, referring to a boy as "her" instead of "him").¹⁹

Children who are allowed or encouraged to live as the opposite sex were followed over time, and some reported how difficult it was for them to decide, take action, and explain to those around them that they wanted to switch back and live according to their birth sex. While we do not support or endorse this model in its entirety, we do agree with the AGIC on this point. Even this liberal organization explains that for parents who feel they need to accept and facilitate their child’s transgender desires, research shows that this “contributes to their child’s lack of awareness of these [negative] consequences.”²⁰

Other professional groups agree that children should not be influenced to pursue their desire to identify with a gender opposite of their biological sex. The Christian Medical and Dental Associations (CMDA) writes:

… Parents should guide their children in appropriate gender identity development. For children who are experiencing gender identity confusion, the Christian community should provide appropriate role models and informed guidance.²¹

The American College of Pediatricians also argues against the current trend toward encouraging gender-confused children to live as the opposite sex. They note that this is a moral and ethical issue. So from a Christian perspective, as we seek to live in grace and truth, treatment should focus on helping children embrace their God-given biological reality. They write:

The norm for human development is for an individual's thoughts to align with physical reality; for an individual's gender identity to align with biologic sex. People who identify as "feeling like the opposite sex" or "somewhere in between" or some other category do not comprise a third sex. They remain biological men or biological women. GD [Gender Dysphoria] is a problem that resides in the mind not in the body. Children with GD do not have a disordered body – even though they feel as if they do.²²

The group shares the recommendation of expert Kenneth Zucker “that gender-dysphoric pre-pubertal children are best served by helping them align their gender identity with their anatomic sex.”²³

What can parents do?

• As a parent, you will want to artfully and strategically intervene with your child in the event he or she exhibits signs of gender confusion. It is advisable to work with a skilled, objective family therapist – one who shares your world view – to develop a specialized, individualistic and adjustable plan.
  
  
• It is important for you to continue to develop and improve your relationship with your son or daughter. Avoid provoking shame and guilt in your child that will complicate your relationship. Do whatever you can to express your love for your child as a one-of-a-kind masterpiece made fearfully and wonderfully in the image of their Creator.
  
  
• Gently encourage your child to develop same-sex friendships with other children and to connect with adult role models of your child’s birth sex. Talk with your child about how same-sex friendships can develop and grow.
  
  
• Help your child develop a wide range of interests and play activities that match their biological sex. While gender-neutral (and even some typically gender-opposite) activities should not be completely off-limits, you should seek a sensible middle ground.
  
  
• Gender-variant children are often highly sensitive and vulnerable to developing a negative sense of self. This situation may sometimes tempt you to agree with, facilitate, or even encourage your dysphoric child’s wishes. But this type of reactive accommodation and encouragement is not the remedy to a healthier sense of self in such children. Affirm your child without emphasizing gender issues.
  
  
• Establish healthy and safe environments for your child. Help him or her develop skills to handle circumstances where there may be natural negative reactions to their expressions of dysphoria. As part of this process, set guidelines regarding what is and is not acceptable, helpful or wise behaviour in various social settings.
  
  
• Children also need help dealing with disappointment and frustration. Clothing, hormones, and surgery cannot turn a boy into a girl or a girl into a boy, despite a child’s deepest wishes and desires. Your child will need assistance navigating the frustration, anger, and grief as he or she works through thoughts and feelings related to gender dysphoria.
  
  
• It’s vital that parents be united in their approach. If there is conflict between you and your spouse concerning how to respond to your gender-confused child, your child will certainly recognize this, and it will make helping him or her more difficult. You may want to seek out a trained Christian marriage therapist who can assist you in coming to agreement about how best to help your child and also to strengthen your marriage.
  
  
• Be open to a family system assessment by a knowledgeable, well-trained and compassionate family systems therapist who shares your world view and might help objectively detect the various roles, if any, that the child’s symptoms play in the family. Sometimes a child’s symptoms serve as “messengers” to the entire family unit. It’s important to become aware of how symptoms may unknowingly be impacted by family dynamics and to consider what changes could be helpful. This assessment requires objective outside help from someone trained in family therapy.
  
  
• Parents can provide valuable guidance by explaining to their children that it is okay for a boy or girl to have interests that are different from “most” boys and girls, while still helping them to identify with their biological sex. For a comprehensive treatment of this topic, you may wish to read Glenn Stanton’s book Secure Daughters, Confident Sons: How Parents Guide Their Children into Authentic Masculinity and Femininity.
  
  

Remember you are not alone!

We began with a reminder that God is with us and for us. The author of Lamentations experienced great challenges and saw many negative events come against the people he loved. Yet, in the midst of these grievous circumstances that prompted a heart-wrenching lament, he writes:

"The steadfast love of the Lord never ceases; his mercies never come to an end; they are new every morning; great is your faithfulness."(Lamentations 3:22-23, ESV)

Know that God is gracious and good even when we as parents walk through painful circumstances and don’t know what to do.

Here at Focus on the Family Canada, we are committed to helping you and your family through life’s challenging situations in whatever way we can. Please give us a call at 1.800.661.9800. One of our professional family counsellors would be glad to speak with you, both to offer a consultation and a time of supportive prayer. We can also refer you to qualified professional counsellors in your area who will help you explore your concerns in depth.

1 We recognize that there are rare instances when parents have an intersex child. However, these genetic anomalies do not negate the binary nature of humanity’s division into male and female. Such circumstances require parents to exercise great wisdom and discernment. See the article series What about intersexuality?

2 See, for example, Jeff Johnston, “Transgenderism: Blurring the Lines,” 2012.

3 http://www.merriam-webster.com/dictionary/sex. 

4 Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.), (Washington, DC: American Psychiatric Association, 2000), p. 537.

5 American Psychiatric Association, “Gender Dysphoria Fact Sheet,” 2013.

6 Ibid.

7 Canadian Psychological Association, “Psychology Works Facts Sheet: Gender Dysphoria in Adolescents and Adults,” 2016.

8 Quoted in Hanna Rosin, “A Boy’s Life,” Atlantic Monthly, November 2008, p. 67; for more on biological determinism for transgenderism, see N.E. Whitehead, Ph.D., “Is transsexuality biologically determined?” (“Transsexual” is often used as a synonym for “transgender” in the British Commonwealth).

9 Lawrence S. Mayer and Paul R McHugh, “Sexuality and Gender: Findings from the Biological, psychological and Social Sciences,” The New Atlantis, Fall 2016, p 8.

10 Kenneth J. Zucker and Susan J. Bradley, Gender Identity Disorder and Psychosexual Problems in Children and Adolescents (New York: The Guilford Press, 1995), p. 259. 

11 Ibid., p. 260. 

12 See, for example: Annelou L. de Vries, et al., “Autism Spectrum Disorders in Gender Dysphoric Children andAdolescents,” Journal of Autism and Developmental Disorders, Aug. 2010, pp. 930-936; and Aron Janssen, et al., "Gender Variance Among Youth with Autism Spectrum Disorders: A Retrospective Chart Review," Transgender Health, Volume 1.1, 2016. 

 13 American College of Pediatricians, “Gender Dysphoria in Children,” August 2016. 

 14 Ibid. 

15 Ibid.; also, Calum McKenzie, “Child gender identity referrals show huge rise in six years,” BBC News, 11 February 2016; and Scott Farwell, “Free to be themselves,” Dallas Morning News, 4 June 2015. 

16 Mayer and McHugh, op. cit., pp. 73-ff; Richard P. Fitzgibbons, Philip M. Sutton, and Dale O’Leary, “The Psychopathologyof ‘Sex Reassignment’ Surgery,” The National Catholic Bioethics Quarterly, Spring 2009, pp. 111,ff.; and Kaltiala-Heino et al., “Two Years of Gender Identity Service for Minors,” Child and Adolescent Psychiatry and Mental Health, April 2015. 

 17 Thomas D. Steensma, Roeline Biemond, Fijgjie de Boer and Peggy T. Cohen-Kettenis, “Desisting and Persisting Gender Dysphoria After Childhood: A Qualitative Follow-Up Study,” Clinical Child Psychology and Psychiatry 16 (2010) 499-516. 

18 Steensma, Biemond, de Boer and Cohen-Kettenis, 2010, p. 512. 

19 Annelou L. C. de Vries and Peggy T. Cohen-Kettenis, “Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach,” The Journal of Homosexuality, 18 March 2012, p. 307-308.

 20 Ibid., p. 308. 

21 https://cmda.org/article/transgender-identification/. 

22 ACPeds, op cit. 

23 Ibid.