American Academy of Pediatrics Webinar Series
Part 1: What is Gender?
Ilana Sherer, MD, FAAP
Palo Alto Medical Foundation Palo Alto, CA
UCSF Benioff Children’s Hospital San Francisco, CA
September 11, 2015
Copyright Ilana Sherer
MD 2015
Faculty Disclosure Information
In the past 12 months, I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider(s) of commercial
services discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a commercial
product/device in my presentation.
Copyright Ilana Sherer
MD 2015
Objectives
Webinar 1: What is Gender? Terminology and
Definitions
• At the completion of this webinar, participants will be
able to:
▫ Define gender identity, gender expression, gender role,
gender variant, and transgender
▫ Describe ways pediatricians can support healthy gender
development in all children
▫ Identify “first steps” and resources to support parents in
developing healthy gender identity in their children
Copyright Ilana Sherer
MD 2015
What is Gender?
•
•
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Gender Biology
Assigned
Gender Identity
Within
Gender Expression Imposed
Copyright Ilana Sherer
MD 2015
Gender Biology (assigned sex) is
Assigned at Birth
(or before)
Copyright Ilana Sherer
MD 2015
Gender Identity is internal sense of self
Copyright Ilana Sherer
MD 2015
Gender Expression
• Culturally determined manifestation of gender
identity through outward appearance
• Includes hair, clothes, mannerism, name, gender
role, etc
Copyright Ilana Sherer
MD 2015
What is Gender Variant?
• Children whose gender identity and/or gender
expression differs from what others expect of
their gender biology/assigned sex.
• Also called: gender non-conforming, gender
creative, gender expansive, gender independent,
or transgender.
Copyright Ilana Sherer
MD 2015
What is transgender?
Gender Variant
Transgender
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MD 2015
“Being [gender variant] or transgender is a matter
of diversity, not pathology.”
▫ World Professional Association of Transgender
Health
Gender Identity Appears Early
Copyright Ilana Sherer
MD 2015
Kennedy and Hellen, 2010 ; Transgender Children - More than a
Theoretical Challenge
© 2007-14 Gender Spectrum®
®
Copyright Ilana Sherer
MD 2015
How Environment Shapes Gender
Expression and Roles
•
•
For most kids: imitate expected roles—> reward
Imitate the ‘other’ sex —> punishment (more for
boys than girls)
Punishment (and reward) for gender behavior cannot change
internal gender identity, it can only influence external gender
expression
Copyright Ilana Sherer
MD 2015
Gender Expression: Socially Influenced
Franklin Delano Roosevelt 1886
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MD 2015
Pink and Blue
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MD 2015
What is Gender?
•
•
•
Gender Biology
Assigned
Gender Identity
Within
Gender Expression Imposed
Copyright Ilana Sherer
MD 2015
Gender versus Sexual Orientation
• Sexual orientation is not a part of gender
(although it can influence gender expression)
• Attraction to other versus self
• Transgender people can have any sexual
orientation
“Who you go to bed WITH versus who you go to bed AS”
Typical Gender Development
Copyright Ilana Sherer
MD 2015
1-2 year olds
◦ Notice Physical differences and biological sex
◦ Know if they are boys or girls (or other)
3-4 year olds
Strong and consistent gender identity
Gender expression emerges
Playmates and activities aligned with gender
expression
May believe gender can change with expression
Typical Gender Development
Copyright Ilana Sherer
MD 2015
4-6 years
Established gender identity
Many gendered stereotypes and rigid
categories and beliefs
Sense of adult gender roles
6-7 years
◦ Believe that gender is a constant attribute
Teens
Become aware of Sexual Orientation
Gender is a Spectrum
Sex
Female
Copyright Ilana Sherer
MD 2015
Intersex
/DSD
Male
Gender Identity
Girl
Boy
Gender Expression
Feminine
Masculine
Gender is a Spectrum
Sex
Copyright Ilana Sherer
MD 2015
Intersex
/DSD
Female
Male
Gender Identity
Girl
Transgender/
Gender Variant
Boy
Gender Expression
Feminine
Masculine
Gender is a Spectrum
Sex
Copyright Ilana Sherer
MD 2015
Intersex
/DSD
Female
Male
Gender Identity
Transgender/
Gender Variant
Girl
Boy
Gender Expression
Feminine
Tomboy,
etc
Masculine
Gender is not binary
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MD 2015
Copyright Ilana Sherer
MD 2015
The genderbread person
• Itspronouncedmetrosexual.com
How Many?
Copyright Ilana Sherer
MD 2015
• The research is mixed
▫ One study (1991): 2-4% of boy and 5-10% of girls
behaved as the “opposite sex” from time to time
▫ Another study (1993): 22% of boys and 38% of
girls exhibited “gender atypical behaviors”
Achenbach, T.M. (1991). Manuel for Behavioral Behavior Check List/4-18 and 1991 Profile. Burlington, VT: University of Vermont Department for
Psychiatry.
Sandberg, D.E., Meyer-Bahlburg, H.F., Ehrhart, A.A. & Yager, T.J. (1993). The prevalance of gender atypical behaviour in elementary school children.
Journal of the American Academy of Child and Adolescent Psychiatry, 32, 306-14
Copyright Ilana Sherer
MD 2015
Healthy Gender Development for All
Children
• All children need opportunity to explore different
gender roles and styles of play.
▫ Toys: provide a wide range
▫ Books
▫ Support your child’s emotional expression (i.e. allow
boys to cry, girls to get angry, etc)
▫ Allow children to make their own decisions about what
activities and sports they want to participate in.
Copyright Ilana Sherer
MD 2015
Books for Kids
• http://www.welcomingschools.org/pages/lookingat-gender-identity-with-childrens-books
Copyright Ilana Sherer
MD 2015
Mental Health Therapeutic approaches
• Old method: pathologizing treatments aimed toward
changing behavior
• Contemporary approach: affirming treatment
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▫
▫
▫
▫
Destigmatize gender variance
Promote child’s self worth
Strengthen parent-child bond
Create opportunities for family peer support
Offer parents advocacy skills to create safe spaces in
schools, daycares, etc
Copyright Ilana Sherer
MD 2015
Guiding Families who have Gender
Variant Children
•
•
•
•
Family acceptance is crucial
familyproject.sfsu.edu
Follow the lead of the child
Network with other families (local PFLAG or LGBT
resource center to start)
• Mental health referral (for the parents) may be
helpful. Ask your local PFLAG/LGBT center
• Join a provider listserv
Copyright Ilana Sherer
MD 2015
“Gender independent children who are strongly
pressured to conform are prone to anxiety,
sadness, social withdrawal, self deprecation and
other signs of internalized distress.”
Carver, pr, Yunger,JL, and Perry, DG (2003). Gender identity and adjustment in middle childhood. Sex roles 49, 95-109
Copyright Ilana Sherer
MD 2015
Pediatricians: Creating Affirmative Offices
Use the correct name and pronoun. Train your
staff to use the correct name and pronoun
Offer multiple choices for gender on your intake
forms.
Have gender neutral or single stall bathrooms
available.
Have gender nonconforming toys or books in
waiting room.
Have posters/handouts in your waiting room.
Copyright Ilana Sherer
MD 2015
Resources for Families
• List of children's books that address gender identity
http://www.welcomingschools.org/pages/looking-at-gender-identity-withchildrens-books
National organizations that serve families with gender variant children
•
PFLAG
•
Gender Spectrum
•
Trans Youth Family Allies
Online sites by parents of gender variant children
o Trans Parenthood http://transparenthood.net
Raising my rainbow http://raisingmyrainbow.com
Sarah and Ian Hoffman http://www.sarahandianhoffman.com/blog/
Copyright Ilana Sherer
MD 2015
• Questions?
References
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Copyright Ilana Sherer
MD 2015
Achenbach, T.M. (1991). Manuel for Behavioral Behavior Check List/4-18 and 1991 Profile. Burlington, VT: University of
Vermont Department for Psychiatry.
Sandberg, D.E., Meyer-Bahlburg, H.F., Ehrhart, A.A. & Yager, T.J. (1993). The prevalence of gender atypical behaviour in
elementary school children. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 306-14
Grossman, A.H. and D’Augelli, A.R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life
Threatening Behavior, 37 (5), 527-537.
Spack, N.P., Edwards-Leeper, L., Feldman, H.A., Leibowitz, S., Mandel, F., Diamond, D.A., and Vance, S.R. (2012).
Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 129 (3) 418-425.
Steensma, T.D., McGuire, J.K., Kreukels, B.P., Beekman, A.J., Cohen-Kettenis, P.T. ( 2013). Factors associated with
desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. Journal of the American
Academy of Child and Adolescent Psychiatry, 52(6): 582-590.
Supporting Gender Independent Children and their families. Rainbow Health Ontario Fact Sheet. 2012.
www.rainbowhealthontario.ca
Ehrensaft, Diane. Gender Born Gender Made. (2012). New York. The Experiment.
Wingerson, L. (2009, May 19). Gender identity disorder: Has accepted practice caused harm? Psychiatric Times.
Retrieved September 3, 2010 from: http://www.psychiatrictimes.com /display/article/10168/1415037
Hill, D. B., Menvielle, E. J., Sica, K. M., & Johnson, A. (2010). An affirmative intervention for families with gender variant
children: Parental ratings of child mental health and gender. Journal of Sex & Marital Therapy, 36(1), 6-23.
Carver, pr, Yunger,JL, and Perry, DG (2003). Gender identity and adjustment in middle childhood. Sex roles 49, 95-109