Cedar Neary, MD
3rd Year Resident
Providence Physiatry Residency
Gender dysphoria is a burgeoning diagnosis, with an estimated prevalence of up to 1% on self-report surveys1. Many children and adolescents present to pediatricians with concerns and uncertainties about their gender identity, and those with significant dysphoria seek gender affirming medical treatment. These interventions can help alleviate the associated mental health burden, which often manifests as depression, anxiety and/or substance abuse.
For many years, our society has viewed gender as an unwavering binary: a person is born as a boy or a girl, who then grows up to be a man or woman, respectively—end of story. It was also previously assumed that phenotype (i.e. genitalia) was the determining factor of this gender designation. Intriguingly, gender is much more dynamic and fluid than many of us were socialized to believe.
Let’s dive deeper into the concept of gender. First, gender can be conceptualized in two distinct components: gender identity and gender expression. Importantly, gender must be distinguished from sex assigned at birth (which many people inaccurately equate with gender identity). However, sex assigned at birth is a designation based on phenotype, primarily external genitalia.
Gender identity describes how someone internally identifies. Some examples include trans non-binary, trans woman, trans man, cisgender woman, cisgender man, bigender, girl, boy, etc. Gender identity is independent of sex assigned at birth, sexual orientation, and gender expression. Even very young children can articulate their gender identity, many years before they become aware of their sexual orientation.
Gender expression is how an individual presents themselves to the world. Examples include hairstyle, clothing style, speech patterns, hobbies, makeup/jewelry, and even body posturing. Gender expression is independent of sex assigned at birth, sexual orientation, and gender identity.
A person assigned female at birth may identify as a transgender man (he/him), present as non-binary in his gender expression (with facial hair, a fitted button up floral shirt and a feminine hairstyle) and be attracted to both cisgender and transgender men. Notice that each of these components of his identity are independent of the other.
When interacting with transgender and gender-nonconforming people, keep these key principles in mind:
- We all have a unique gender experience
- Sex assigned at birth (based on phenotype) does not equate to gender identity
- Gender expression is an individual choice, which can shift and evolve over time (regardless of gender identity…which can also evolve!)
- Don’t assume someone’s gender identity based on outward appearance
- Gender identity does not equal (or determine) sexual orientation
- Always ask people what pronouns they use
For more information on gender affirming treatment, refer to AAP’s 2016 document: “Supporting and Caring for Transgender Children,” which can be accessed at https://www.aap.org/en-us/Documents/solgbt_resource_transgenderchildren.pdf
1Byne, William et al. “Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists.” Transgender health vol. 3,1 57-70. 1 May. 2018, doi:10.1089/trgh.2017.0053
*Editor’s Note: The Washington State Legislature just passed SB 5313, which requires the HCA, managed care plans and providers that administer gender-affirming care through Medicaid programs may not discrimate in the delivery of a service based on a person’s gender identity or expression. The bill, sponsored by Rep. Marko Liias, also prohibits Medicaid from applying cosmetic or blanket exclusions to gender-affirming treatment.