Gender identity is a term that describes both an internal sense of who and "what" one's gender is, and by extension, "who" one is. It also includes the ways in which a person presents physically (via one's dress, body carriage and other physical markers), behaviorally and socially - through peer relationships, filial bonds, along with school and work relationships.

With children and adolescents, there is typically little doubt about one's gender. Children typically view themselves as either male or female. For most individuals, assigned sex at birth is congruent with their physical body and gender identity. 

There are some children and adolescents who experience incongruence between their assigned sex at birth and the assumed gender norms that accompany being male or female. These children can be described as gender non-conforming, genderqueer or another signifier that feels right to that child. Often, the term "gender fluidity" is both an accurate and positive way to describe gender identities that do not match assigned sex. 

It is important to note that being gender non-conforming is not a mental health problem. There is nothing wrong or harmful about having traits and behaving in ways that do not conform to gender norms.  

There are critical and distinct differences between gender fluidity and gender dysphoria. Some children may be comfortable with their sex assigned at birth but challenge and expand the boundaries of what society expects them to be in their male/boy or female/girl gender roles. The term transgender refers to children who consistently and persistently feel that their gender is different from their natal or assigned sex. Transgender children and youth may be more likely to experience gender dysphoria (i.e., distress related to their physical body or sex assigned at birth not matching their preferred or internal sense of gender). Children and adolescents with gender dysphoria have a "marked incongruence between the gender they have been assigned at birth and their experienced/expressed gender" (APA, 2013). Gender dysphoria refers to the distress about this incongruence (APA, 2013).

A portion of gender non-conforming youth will want or need to transition, which may involve a social transition (changing physical appearance, name, pronoun), and/or a medical transition (hormonal and surgical intervention). Medical treatment may take the form of hormone blockers, synthetic hormones or surgery, with the aim of bringing one's physical body and outward appearance in line with their felt gender and internal experience of gender. The ability to transition (socially and/or medically) is often essential in the treatment of gender dysphoria.

As more children and adolescents emerge in some way as gender nonconforming, it is critical that clinicians develop competency in working with children, families and school communities in order to support and advocate for presenting needs. Clinicians can help children and their families cope with distress related to gender dysphoria and associated problems. Children with gender dysphoria and their families may benefit from psychological treatments aimed at helping them with mood- and anxiety-related problems, which are common, and may or may not be related to gender issues. The clinician can also help the child and family navigate decisions regarding further medical interventions and timing should they choose to pursue it.

The nationally respected Child & Adolescent Psychiatry Division at Cambridge Health Alliance has expertise on gender dysphoria. Please contact us at 617-665-5965 for more information.

WPATH (World Professional Association for Transgender Health) is an organization devoted to transgender health, providing resources and education. www.wpath.org