Gender and gender identity may seem like complex concepts beyond the reach of a child’s mind. But actually, understanding comes quite early in life, says David Inwards-Breland, MD, MPH, chief of the Division of Adolescent and Young Adult Medicine and co-medical director of the Center for Gender-Affirming Care at Rady Children’s Hospital-San Diego and a Clinical Professor for the Department of Pediatrics at University of California San Diego School of Medicine. “Kids know if they are a boy or a girl by the age of 3,” he says. “Most times, that knowledge is based on what their parents and society have said, but there are some kids that will feel they’re not the gender assigned to them at birth.”

Dr. Inwards-Breland states that conversations about gender often begin through parents’ observations of their children’s play. “If you notice your child might be expressing a different gender and want to bring it up, just ask,” he suggests. “You can say something like, ‘Do you feel like a girl, or do you feel like a boy?’ They’ll tell you. But, I don’t think you need to talk about it or even bring it up. Let them explore who they are.” He emphasizes that cross-gender play before puberty is completely normal — for example, if a child assigned female at birth shows an interest in traditionally male-centric toys, such as cars or trucks, it’s normal, just like another child assigned female at birth child setting up dollhouses or caring for a stable of tiny horses. “Through puberty, if the trend continues, that may be more indicative of a transgender or nonbinary identity,” he says. An individual who is transgender does not identify with their biological sex, and an individual who is nonbinary/gender non-conforming may identify with the gender opposite of what they were assigned at birth, both male and female, neither or some other gender. Dr. Inwards-Breland explains that both “transgender” and “nonbinary” are umbrella terms and encompass a number of gender identities.

If a child in your life does come out as transgender or nonbinary, Dr. Inwards-Breland pinpoints a few essentials to keep in mind.

• Don’t assume their sexual preferences based on their gender identity. “They’re different constructs,” he says. “Someone can be assigned male at birth and identify as a female, and the assumption shouldn’t be made that they like boys. They might actually like girls, or both.”
• Don’t question their preferred names or pronouns. Saying things like “are you sure?” or “why would you choose that?” can be hurtful and damaging. Do make every effort to respect their requests. If you accidentally use a different pronoun or name than they’ve asked for, apologize and move on. “When you dwell on it, it makes it uncomfortable to the person,” Dr. Inwards-Breland notes.
• Don’t “out” anyone. “This is super important,” urges Dr. Inwards-Breland. “There could be a lot of repercussions in their social, personal, and educational or professional lives, especially for trans women (women assigned male at birth) and trans women of color. Traditionally, they face higher rates of violence than trans men or white individuals with gender dysphoria.” Per the American Psychiatric Association, gender dysphoria is “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”
• Do act as an ally — in an individualized way. “Whether it’s your child, your family member or a child’s friends, ask how you can be an ally for them,” recommends Dr. Inwards-Breland. “Everyone will have different wants and needs.” He also suggests getting involved in organizations like PFLAG, or, if taking direct action is your thing, connecting with advocacy groups or volunteering with LGBTQIA+ youth.
• Do support the child in social settings, both with your own peers and with theirs. Dr. Inwards-Breland notes that many struggles occur at school due to bullying or administrators not being fully equipped to meet the needs of a child with gender dysphoria. In this case, act as an advocate and work with the school to ensure it serves as a safe and welcoming space.
• Don’t categorize gender dysphoria as a mental health condition. It’s not. However, it can coexist with conditions such as anxiety and depression due to ostracization or lack of support from peers, loved ones and society at large. Should a child begin displaying signs of these disorders — including withdrawing from typically enjoyed activities, changing sleeping or eating habits significantly, or discussing suicidal thoughts — or expresses a desire for help, do take their struggle seriously. “A lot of adults think, ‘they’re teens; they always have angst.’ Sometimes that angst is really serious and needs further evaluation,” Dr. Inwards-Breland states. He advises connecting with their primary care physician right away. Doctors can help identify appropriate mental health resources, even those tailored specifically to the needs of the LGBTQIA+ community; as well as youth, parent and family support groups.

The primary care physician is also the first contact to make if a child wants to pursue specialty care related to gender dysphoria. At Rady Children’s Center for Gender-Affirming Care, the patient intake process begins with a physician referral followed by a family-based assessment with a social worker. Including caregivers and the child in sessions helps address all questions, and provides greater opportunity to support the child with every step of their unique care plan. After the initial evaluation, patients have between two and four sessions with the social worker, who determines if they meet criteria for gender dysphoria and refers to the CGAC accordingly.

Patients then see Dr. Inwards-Breland; Maja Marinkovic, MD, CGAC co-medical director; or a Rady Children’s endocrinology specialist for a medical intake and a conversation about options such as pubertal blocks, hormone treatments, menstrual suppression and referrals to additional gender-affirming services. If they decide to proceed with the options discussed, they undergo baseline lab assessments, the final step before starting treatment. Dr. Inwards-Breland notes that in a two-parent household or when two parents share custody, both must agree on moving forward. If they don’t, they’re given options for additional resources, such as parent support groups. In addition, CGAC patients can connect to services such as speech therapy, resources for legal assistance with matters such as name change and fertility preservation. The center also offers limited mental health therapy for children who do not otherwise have access.

Many important factors link to helping transgender, nonbinary and gender-expansive members of our community feel included and valued, and one of the most crucial is modeling acceptance. “Every moment is a learning moment,” Dr. Inwards-Breland notes. “Kids will learn from you, and if there’s judgment, they’ll notice.” He says that often, schools send a letter to families indicating a student has identified as transgender, nonbinary or gender-expansive, which is a great way to start a conversation. “You can say, ‘Oh, I hear so and so is asking to go by X name now. I think that’s great. What do you think?’” If such a moment doesn’t arise, though, or your child doesn’t ask any questions, “then it doesn’t need to be discussed,” he adds. “Kids are often more accepting than adults.”

For more information on the Center for Gender-Affirming Care, visit https://www.rchsd.org/programs-services/gender-affirming-care/. For a list of educational and support resources, visit https://www.rchsd.org/programs-services/gender-affirming-care/resources/.