What does gender development in children look like?

Infants as young as three to four months old can tell the difference between male and female faces, and by six months they can match these faces to male and female voices. Before a child reaches their first birthday, they are often able to associate faces of men and women with gendered objects like jewelry and tools, suggesting that early on, children are able to categorize by way of stereotypes.

Between one and three years of age, children rapidly develop language and understanding of gender. Using gender labels in speech usually manifests between 18 and 24 months. Toddlers who know and use gender labels are generally more likely to show a preference toward gender-stereotypical play with toys. In general, toddlers spend a longer time investigating gender incongruent than gender congruent behavior, indicating that they understand the difference. Despite their burgeoning ability to separate what are considered male and female attributes and behaviors, children at this age maintain significant flexibility around gender. A three-year-old may inquire if an adult was a boy or girl growing up. They may also be assigned male at birth and state that they would like to grow up to be a mother or female at birth and want to become a father, not knowing that most adults would not consider this possible.

p. 69↵Most four-year-olds will be able to tell you their gender and the genders of their peers. They will also be able to tell you that the girls in their classes are going to grow up to be women and the boys, men. But probe a little further and you may be surprised by the concepts they don’t yet seem to understand. Try posing this question: “Uncle Jim has short hair. If Uncle Jim were to grow his hair long, would he be a man or a woman?” Many four-year-olds would tell you that if Uncle Jim grew his hair long, he would be a woman.

In the 1960s, researchers studying young children began to theorize about how children learned about gender. They fell into two main “camps,” the first being those who believed that children’s understanding of gender came from their environments (social learning theory) and the second being those who thought that children’s brain development determined their ability to understand gender (cognitive developmental theory). Both groups of researchers had reasons to believe that their ways of thinking were correct.

According to social learning theory, children learn about how gender functions in the world through modeling of gendered behaviors, experiencing rewards and punishments for their own gendered behaviors, and being directly taught ideas such as boys being smarter and girls kinder. There is significant evidence for social learning theory if we compare men’s and women’s behaviors around the world. Those who grow up in areas where gender roles are more rigid tend to see themselves and others as more strictly defined by their gender roles, while those who learn about gender in more open environments allow themselves and their peers more freedom of expression.

Cognitive developmental theorists also saw their theories play out in observations of children. They were able to predict that children of certain ages would grasp concepts that they had been unable to understand at earlier ages. One well-known test is to show a child two beakers, each containing the same amount of water. The researcher then pours the water from each of these beakers into a separate glass—one tall and p. 70↵thin, and one short and wide. When asked to compare the amount of water in the two glasses, most children under seven will say that the tall thin glass has more water, despite having just watched identical amounts of water being poured into each glass. Older children understand the concept of “conservation” and correctly assert that the two glasses have the same amount of water. Cognitive developmental theorists believe this is because children’s brains develop in a predictable pattern over time.

There is evidence that cognitive development affects children’s understanding of gender. Psychologist Lawrence Kohlberg posited that there are three main cognitive stages of gender development in children. In the gender labeling stage (ages two to three), children begin to understand what gender is and start to be able to identify their own gender and the genders of the people around them. In the gender stability stage (ages three to five), children learn that gender is a stable trait in most people and that boys generally grow up to be men and girls to be women. Finally, in the gender constancy stage (ages five to seven), children realize that gender does not change with shifts in clothing or behavior and that a man remains a man if he puts on a dress or grows his hair long.

Sandra Bem’s gender schema theory is another way of thinking about how children’s cognitive processes affect their ability to understand gender. A schema is a framework we use to understand a concept. For example, we may have a schema for a book, in which we have learned that a book is something that we can hold in our hand, has pages we can turn, and has words on the pages. If we come across a new type of book, such as one that is too big to hold in a hand, has pictures but no words, or does not have pages we can turn (e.g., an e-book), we have to revisit our schema for a book and decide if the new book changes our schema of books in general or should be let into the category as an exception.

Schema theory, as it is applied to gender, suggests that children develop schemas for “male” and “female” and that p. 71↵they test new information against these schemas to determine whether they should change their schemas or make exceptions. There is evidence that children pay more attention to the schemas that apply to their own gender, likely because they are trying to learn as much as possible about how they are supposed to interact in the world.

There are numerous criticisms of both social learning and cognitive developmental theories of gender. Critics of social learning theory argue that our brains are hardwired to understand concepts at certain developmental stages and that children do not learn about gender purely through social forces such as modeling and reinforcement. If they did, we could teach very young children to understand gender as adults understand it.

Those who question cognitive developmental theories of gender point out that gender is a largely social phenomenon and that without social influences, humans would have no concept of gender. Some have questioned whether the stages of cognitive development around gender actually represent what they claim to represent. For example, in the gender constancy stage, when children are thought to be learning that gender is a constant trait regardless of clothing or behavior, some social theorists argue that what children are really learning is that genitals (representative of our sex) are constant and that our society equates genitals with gender. If this is the case, then children may innately be understanding of transgender identity in a way that adults have unlearned through societal teaching.

An unspoken assumption in much of the gender development work to date is the alignment of bodily sex with gender identity. While there is an expected degree of gender creativity in childhood play, children who do not develop in accordance with societal expectations have historically been pathologized as not having achieved a critical developmental milestone. Moreover, models to explain gender development in young p. 72↵people have relied heavily on a binary approach to gender, without room for identifying in other ways.

Only recently has transgender identity begun to be considered a valid developmental trajectory. Historically, transgender children have presented with heightened levels of depression and anxiety, among other signifiers of distress, including poor school performance and poor social integration. However, recent studies have shown that transgender children match their cisgender peer groups when raised in affirmed settings. Poor functioning has been reconsidered not to be a result of “not doing gender right,” but rather a psychological response to the experience of minority stress, hostility, and isolation.

Notably, research demonstrates that transgender children and their siblings view gender as more flexible than other children do. Transgender youth and their siblings are less quick to assume that a person’s gender will remain the same over the course of their lives. Are these young people operating with a social deficit, or do they simply understand more about the fluid nature of gender? With less time on earth burdened by suffocating gender stereotypes, these youngsters may present a more holistic understanding of gender, particularly as they live in an age where gender may not serve the same purpose it once did.

Today, a small percentage of parents are raising their children in gender-neutral settings, carefully limiting positive and negative reinforcement of gender-based preferences and activities. Some of these children are being brought up without an assumed gender identity. Keeping the size and shape of genitals private, parents are using gender-neutral pronouns like they/them until a child is able to self-determine their gender as being boy, girl, or something else. Looking to this next generation may shed light on current gender identity construction and development, particularly when children are raised without the assumption that sex and gender will or should match. When these two structures are unlinked, “gender p. 73↵congruent” and “gender incongruent” qualifiers cease to exist. We may very soon need to look deeper into gender development models, as the systems used to measure progress and alignment may be rendered outdated.

What is gender dysphoria?

The term gender dysphoria is used by both mental health professionals and by transgender community members, although often in different ways. Gender dysphoria is listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. Separate from the DSM-5 diagnosis, the phrase gender dysphoria is sometimes used by trans community members colloquially to refer to emotional difficulty related to living in bodies or societal roles that do not fit.

The DSM-5 diagnosis of gender dysphoria is characterized by significant distress or difficulty functioning related to an incongruence between assigned sex and experienced gender identity. There is significant controversy over this DSM-5 diagnosis. Some trans people and providers advocate for continued inclusion of a gender-related diagnosis to ensure insurance payment for medical and surgical transition. However, others feel that insurance coverage can be negotiated in a different manner and that removing gender-related diagnoses from the DSM-5 is an important step in normalizing transgender identity.

How have trans people historically been approached by the medical field?

Transgender and gender-diverse populations have long been pathologized in psychiatric settings, despite the fact that a diverse array of gender identities have existed throughout cultures and over millennia. Early interventions for those who presented with trans identities typically focused on realigning p. 74↵gender identity with sex assigned at birth, assuming that the client was delusional or did not understand themselves as well as their provider did. Even those physicians who supported trans people typically saw them as psychiatrically ill and in need of treatment. Up until the mid-20th century, treatment included psychotherapy, shock therapy, religious training, hypnosis, lobotomy, and commitment to an asylum. Gender-affirming surgeries in the United States were illegal, and public opinion of transgender people was low. Despite these limitations, psychiatric care for trans people began to slowly change in the early 1900s with pioneering work by a few physicians.

The word transvestite originated in the 1910s and was coined by German sexologist Magnus Hirschfeld. Hirschfeld would later develop the Berlin Institute (also known as the Institute for Sexual Science), where the first gender-affirming surgery took place. Hirschfeld defined transvestism as the desire to express one’s gender in opposition to their assigned sex at birth. Despite the now-antiquated language, Hirschfeld progressed the accessibility of gender-affirming care for his patients. He was working during an exciting time in medicine, when hormones were first being identified by western physicians. Hirschfeld offered hormone therapy and surgical interventions to help his patients achieve more authentic and satisfactory gender presentations. Most of his contemporaries at the time continued to try to “cure” individuals with cross-gender identifications.

Supporting a person’s agency and decision-making process about altering their body, Hirschfeld worked to align body and mind. At his clinic, Felix Abraham began conducting what is now considered the first gender-affirming surgeries: a mastectomy on a trans man in 1926, a penectomy on a domestic servant named Dora in 1930, and a vaginoplasty on Lili Elbe, a Danish painter, in 1931. Unfortunately, much of the history of the institute’s early work was destroyed in the Nazi book burnings in 1933.

p. 75↵Alfred Kinsey, who had studied in Hirschfeld’s clinic, founded the Institute for Sex Research (now known as the Kinsey Institute) at Indiana University in 1947. In his 1948 study, Sexual Behavior in the Human Male, Kinsey criticized the use of the term transsexual as a synonym for homosexual because it implied that homosexuals were “neither male nor female, but persons of a mixed sex.” After all, at that time, Americans believed that being transgender and gay were one and the same—gender identity and sexuality were not yet clearly defined as separate. The same year, Kinsey referred one of his patients, “Van,” to endocrinologist Harry Benjamin, who would later standardize treatment for transgender individuals. Van, then 23 years old, was assigned male at birth and had been living as a girl since the age of three.

In 1952, the Associated Press published an article titled, “Bronx ‘Boy’ Is Now a Girl,” announcing the medical transition of American World War II veteran Christine Jorgensen. Jorgensen’s surgeon, Danish doctor Christian Hamburger, received hundreds of personal letters in the months following Jorgensen’s publicity. It became clear that gender transition was not exceptional, but rather there was a significant portion of the population who felt their gender was misaligned with their bodies. Like Kinsey, Hamburger referred these clients to Benjamin.

Harry Benjamin, a German endocrinologist who emigrated to the United States, believed that those who felt their sex to be discordant from their gender deserved humane treatment in the form of hormonal therapy and affirming surgeries. By 1964, the concept of “gender identity” emerged, conceptually providing clarification that one’s own understanding of their gender could be different from the sex they were assigned at birth, largely decided by visual inspection of the genitals. In 1966, Benjamin published The Transsexual Phenomenon, proposing a radical change in treatment: Genital reconstructive surgery, rather than religious indoctrination or lobotomization, p. 76↵was an appropriate treatment for those who felt their gender identity and sex assigned at birth to be at odds.

Benjamin’s approach, along with his colleagues, was not universally accepted. Transgender people continued to be seen as deviant. The Journal of the American Medical Association published a 1978 article stating that “most gender clinics report that many applicants for surgery are actually sociopaths seeking notoriety, masochistic homosexuals, or borderline psychotics.” Still, proponents of affirming care were making headway. Gender clinics, providing hormonal and surgical care (albeit only to those who met strict, heteronormative criteria) were popping up at university medical centers all over the country. In 1974, Norman Fisk popularized the concept of gender dysphoria, and in 1979, the Harry Benjamin International Gender Dysphoria Association (later renamed the World Professional Association for Transgender Health) published its first Standards of Care.

However, the same year, a study out of Johns Hopkins permanently altered the course of medical care for transgender people. At the time, Johns Hopkins had one of the leading gender clinics in the United States. Paul McHugh, then chair of the Department of Psychiatry, made it a mission to put an end to this. With his support, the clinic published a study calling sex reassignment surgeries into question by suggesting that psychosocial outcomes in transgender patients who underwent reassignment surgery were no better than those who went without surgery. Despite criticism of its methodology, McHugh and others were able to use the study to justify the closure of the clinic. Over the years that followed, the United States would see the eventual closing of nearly all university medical center gender clinics.

What sprang up in their place, perhaps slowly, but more organically, were community-based health clinics created to serve LGBTQ people. Without the backing of major universities, these early clinics were less able to offer certain aspects of transition-related care, such as surgical procedures, but, p. 77↵over time, private surgeons began to fill in the gaps, and, eventually, some university hospitals re-entered the arena of transgender medical care.

Although the Diagnostic and Statistical Manual of Mental Disorders (DSM) had not included gender-related diagnoses in its first iteration in 1952, by its second version, in 1968, a diagnosis of transvestitism appeared in a section called Sexual Deviations. Just as gay activists finally succeeded in removing homosexuality from the DSM, the third edition (DSM-III), in 1980, added the diagnoses transsexualism (for adults) and gender identity disorder (for children). The fourth edition (DSM-IV) followed suit, naming most gender-related diagnoses some version of gender identity disorder. For 30 years, from the 1980s to the 2010s, transgender people, whether they were psychologically distressed or not, could be given this diagnosis. It was not until 2013, with the publication of the DSM-5, that gender identity disorder was replaced by gender dysphoria, a less pathologizing name, but also a diagnosis that intentionally did not apply to all transgender people—only to those suffering from significant distress or impairment in function related to their gender identity. While, for some, this was an improvement, many transgender people continue to look forward to the day that gender-related diagnoses are completely removed from the DSM.

Even with this shift toward a more affirmative model of psychiatric care for trans people, there are still many within the field who continue to believe that transgender identity is a mental illness. Conversion therapy, also known reparative therapy, an ineffective and damaging practice that attempts to change a person’s sexual orientation or gender identity, remains widespread in the United States. Although some states have moved to ban conversion therapy in minors, the majority still allow it. The Williams Institute estimates that 20,000 U.S. youth currently aged 13 to 17 will undergo conversion therapy before age 18.

p. 78↵Unfortunately, young psychiatrists may continue to be poorly equipped to understand transgender identity. Research shows that, on average, medical students are exposed to only five hours of LGBTQ-related content over their entire four years. During psychiatry residency, there is also no standard curriculum on these issues, leading to a workforce that is tasked with treating a population it knows little about.

What are the current controversies about transgender identity within psychiatry?

One major controversy related to transgender identity within the field of psychiatry is the role of a gender-related mental health diagnosis. The most current version of the DSM, the DSM-5, includes the diagnosis of gender dysphoria.

While less criticized than its predecessor, gender dysphoria remains a contested diagnosis. Its presence alone in a manual designed to identify and treat problematic behaviors and symptoms signals to some people an underlying cultural disapproval of transgender individuals. It is difficult for many to separate the updated gender dysphoria diagnosis from decades of pejorative and devaluing language employed by top psychiatrists and other physicians.

On a world scale, historically, the International Classification of Diseases (ICD) has followed a somewhat similar trajectory to the DSM, but has been quicker to depathologize transgender identities in more recent years. The eleventh edition of the ICD, published in 2018, removed gender-related diagnoses from the section on Mental and Behavioral Disorders and created a new label called gender incongruence, which avoids the more stigmatizing diagnosis of gender identity disorder.

The iterations of these gender diagnoses evidence many conflicting opinions from professionals in the field and community members alike. The ICD is approved by the World Health Organization (WHO). WHO is an agency of the United Nations, grounded in human rights protections and global p. 79↵health. As there is significant evidence that the continued pathologization of transgender identities is harmful, WHO not only has to consider objective symptom presentation but also the system by which we pathologize and the harm done in doing so.

For transgender people, a diagnosis of gender identity disorder or gender dysphoria can be a double-edged sword. Continued use of these identifiers has, for some, perpetuated harm and isolation, either self-imposed or experienced explicitly from their environment. Emotional harm aside, the diagnosis has in some cases been used as a pre-existing condition, disqualifying trans people from health care or raising their premium costs. Once identified as transgender to their insurer, many transgender people find themselves under increased scrutiny. Some trans people have reported a sudden discontinuation of insurance coverage for routine services after the diagnosis has been listed on their account. Particularly as health care systems change, there is significant anxiety with regards to what the future implications of carrying these diagnoses may be.

While times are changing, for years these diagnoses have been used without regard for clinical relevancy. Entering a doctor’s office for a broken bone or sore throat, a transgender person might be diagnosed with a psychiatric disorder while undergoing no psychiatric assessment. In practice, these diagnoses have been used carelessly to identify transgender patients and not their symptom presentations. The results have been stigmatizing at best. At worst, these diagnoses can cause major problems down the line and can “out” a person as transgender without their consent.

At the same time, gender-related diagnoses are often used to justify care. For a transgender individual seeking puberty blockers or gender-affirming hormone therapy or surgeries, treating physicians typically require a diagnosis of gender dysphoria. Not only do current clinical treatment recommendations use gender dysphoria as a basis for ongoing care, most p. 80↵insurance plans will not cover gender-affirming treatment without documentation of gender dysphoria. Within our current healthcare systems, it is nearly impossible to provide treatment without specific documentation of a problem. When the issue is related to gender, we are presented with a conundrum: pathologize the identity or refuse care.

Not all transgender people see the diagnosis of gender dysphoria as problematic. Some people feel their incongruent bodily sex and gender identity is an issue and needs to be fixed—akin to a so-called birth defect. For others, having diagnostic criteria to draw from feels validating and affirming. For some transgender people, being able to see in written form an explanation for their emotional pain provides relief. It becomes tangible and recognizable, and there exists a course of interventions to help treat distress.

In addition to diagnostic controversies, mental health providers, especially those who routinely work in transgender care, also wrestle with their role as “gatekeepers” to medical and surgical care. While hormonal treatment is now more widely available on an informed consent basis, surgeons (and the insurance companies that fund surgeries) typically require either one or two letters of support, often from therapists or psychiatrists, to proceed. This puts mental health practitioners in the position of judging who is appropriate or not appropriate for transition-related surgeries. While a cisgender woman can arrange for her own breast augmentation without a psychiatric evaluation, the same is not true of a transgender woman.

Why do transgender people have higher rates of mental health concerns?

Without taking into account the cultural context around transgender identities, it might be easy to assume that high rates of mental health and substance abuse issues are reflective of a psychological issue inherent to this population. According to the American Psychiatric Association, children diagnosed with p. 81↵gender dysphoria are at higher risk of emotional and behavioral problems, including anxiety and depression. Transgender adults have increased rates of depression, substance abuse, and suicidality. Taking a step back, it becomes clear that these issues stem from years of societal stigma and discrimination, rather than from an inherent difference between transgender and cisgender people in terms of predisposition for mental illness.

Rejection that transgender people encounter is significantly harsher than the negative attitudes experienced by lesbian, gay, and bisexual youth and adults. Numerous reports point out that marginalization of transgender people from society has devastating effects on their physical and mental health. Transgender people, particularly transgender women of color, are targets of violence and abuse at higher rates than others. The subtle build of microaggressions across a lifetime, combined with outright discrimination, hostility, threats, and actual perpetrated violence, can leave a transgender person experiencing devastating symptoms associated with trauma. As such, transgender people systemically report higher levels of anxiety, depression, substance abuse, domestic violence, and homelessness. Transgender people are vulnerable to both homicide and suicide, as well as family rejection and joblessness. These negative health outcomes however, are not associated with their identity per se, but rather the profound experience of marginalization and discrimination.

Perhaps the most relevant model to contextualize transgender health disparities is minority stress theory. Minority stress theory posits that social stressors stemming from stigmatized identities account for poorer psychological functioning and compromised well-being. Health disparities among transgender individuals, in this model, can be explained in large part by stressors induced by a hostile, transphobic culture, experienced over a lifetime of harassment, maltreatment, discrimination, and victimization.

p. 82↵Building on earlier versions of the minority stress model, Ilan Meyer proposed a model of minority stress with lesbian, gay, and bisexual people wherein both distal stressors and proximal stressors helped to predict disproportionately high rates of psychological distress. Distal stressors were considered external to the person, such as experiences of heterosexist discrimination, and proximal stressors were internal to the person, such as awareness of stigma and internalized heterosexism. Aaron Breslow expanded Meyer’s model specifically to capture the experience of transgender people. Breslow identified anti-transgender discrimination as a distal stressor, related to symptoms of psychological distress, including suicidal ideation, anxiety, and depression, in addition to poor physical health outcomes. Internalized transphobia, or the ways in which a transgender person might incorporate society’s negative evaluations of transgender people into their self-concept, was a proximal stressor, which could lead to negative self-appraisals. An additional proximal stressor identified in their work was the expectation or fear of encountering future discrimination, which they called stigma awareness.

Breslow found that higher levels of minority stress (antitransgender discrimination, internalized transphobia, and stigma awareness) were associated with greater psychological distress. Resilience was found to be strongly associated with lower levels of psychological distress, suggesting that resilience may protect marginalized groups from the impact of minority stress.

There are likely many contributing factors to each trans person’s individual experiences of trauma and stress. If there were questions about a child’s gender identity when they were young, a parent’s ability to manage their own reactions could have impacted the young person’s development, their sense of safety, self-acceptance, and ability to think constructively about their future. Rejection of identity by a caregiver or forced identification as cisgender can set up a child for feelings of guilt and worthlessness. They may grow up incorporating p. 83↵feelings about themselves as being wrong, unnatural, or sinful. If confronted with bullying at school, their ability to connect with peers and socialize can be hindered. They could be preoccupied in classes, distracted by anticipation of being misgendered by their classmates or teachers, or may feel unwelcome or unsafe in their school, all factors that contribute to their overall academic achievement.

Because societal rejection, rather than something innate to transgender people, is what leads to poor mental health outcomes, there is hope that future generations will have improved mental health. In fact, recent research published in the journal Pediatrics shows that trans children who grow up in supportive environments have similar levels of depression and anxiety as their cisgender peers. Numerous studies of trans adults demonstrate that quality of life improves and depression and anxiety decrease with access to affirming medical and surgical care.

What do medical and surgical options look like for transgender people?

Medical and surgical interventions play an important role in the transition process for many transgender people. However, there are social changes that can also help trans people to feel more comfortable in their bodies and social roles. For some, “social transition” is an extremely therapeutic step. For some trans people, social changes are the focus of transition, as they may not desire medical or surgical treatment. Social transition can include changing pronouns, name, haircut, and style of dress. It may involve updating documentation to reflect the person’s gender identity. These social changes can help integrate the person into their world in a more desirable and authentic way and decrease the amount of time they spend internally reacting or adjusting to being called a name or by a pronoun that feels in their core inappropriate, or even in opposition, to their gender.

p. 84↵In addition to social changes, many trans people also desire some form of medical and/or surgical treatment. If assigned female at birth and currently identifying as male, masculinizing interventions such as taking testosterone can help someone feel more at ease in their body, as well as operate and function in the world as male. The same is true of feminizing hormones (typically estrogen and spironolactone in the United States) for those assigned male and identifying as female. Nonbinary individuals may choose to take hormones as well, sometimes, but not always, in lower doses or for a defined period of time. Masculinizing hormone therapies can change hair growth patterns, vocal range, muscle and fat distribution, along with suppressing menstruation and changing the appearance of the genitals. Feminizing hormone therapies are used to elicit breast growth and alter fat distribution. They can also block the effects of testosterone, including halting the progression of male pattern baldness, and decreasing spontaneous erections and testicular volume.

Numerous surgical interventions are available to masculinize and feminize bodies. Breast tissue can be reduced or enlarged. Genital structures can be modified to resemble a typical penis or vagina. Surgical contours can be made to the body and face that help to signal masculinity or femininity. Both behavioral and surgical interventions can assist with developing a more masculine or feminine voice.

When gender identity and body appearance are aligned, there is usually less distress. However, not all bodies can be medically and surgically altered to reflect an internal gender identity, and not all people desire to seamlessly “blend in” with cisnormative ideals. For nonbinary individuals, matching their outside physical body to their internal identity can mean incorporating both masculine and feminine markers of gender. Their goal may not be simply to “pass” as a cisgender man or woman, but rather to express authentic qualities of both. For any individual transgender person, there may be a variety of reasons they choose not to engage in an “all or nothing” p. 85↵approach to medical transition. They may simply not identify with or want certain changes, find costs prohibitive, or not be able to undergo such invasive procedures due to other unrelated medical concerns.

Can transgender people have biological children?

In 2008, the sensational story of Thomas Beatie, “the pregnant man,” burst onto news networks across the country. Beatie, a transgender man, made appearances on Oprah, Larry King, The View, and Good Morning America. People magazine captured his life in a six-page photo spread. Beatie explained that his wife was unable to become pregnant, and so he chose to do so instead.

For many Americans, Beatie was the first man they had ever heard of who was pregnant or had given birth. However, many transgender men have children every year. The numbers are difficult to estimate, but their stories have spawned multiple news articles and documentaries.

Surprising to most people is the fact that testosterone does not generally cause permanent infertility in trans men. While continued fertility is not a guarantee, many trans men have started testosterone and then stopped it later, resumed menstruation, and become pregnant. Some trans men have even had accidental pregnancies while on testosterone if the dose was not high enough to prevent ovulation. Because testosterone can cause birth defects, it is recommended that all trans men on testosterone who are at risk of becoming pregnant use a form of birth control, and that trans men trying to conceive stop taking testosterone.

Many surgeries that trans men undergo do not remove the possibility of later giving birth. The most common type of surgery amongst trans men is “top surgery” (the creation of a male-contoured chest). This type of surgery does not interfere with reproductive capacity. It does decrease breast tissue and often removes milk ducts; however, there are many different p. 86↵variations of “top surgery,” and some trans men are able to “chestfeed,” even after top surgery.

Besides becoming pregnant themselves, there are other ways for trans men to have children that are biologically connected to them. Many trans men have harvested eggs and used in vitro fertilization to implant embryos in a partner who later gave birth. Some trans men decide to preserve eggs or embryos for later use. Either of these methods tends to be more expensive than becoming pregnant via natural conception or sperm donation. However, they may allow for the possibility of the trans man not carrying the pregnancy to term himself.

For some trans men, the idea of becoming pregnant and giving birth is uncomfortable. Pregnancy is considered by most people to be a feminine activity. In a 2014 survey of trans men who had become pregnant, many of the men purposefully chose words like “dad,” “carrier,” and “gestational parent” to describe themselves in masculine or gender-neutral ways. Some of the men discussed their reasons for becoming pregnant in exclusively pragmatic terms, saying things like, “I looked at it as something to endure to have a child” and “My body was a workshop, building up this little kid.”

Becoming pregnant as a trans man can bring up feelings of intense gender dysphoria, and many trans men avoid it for this reason. However, others don’t have as many contradictory feelings. It can be difficult for pregnant trans men to interact in social situations, as many of the people they encounter will have little experience with male pregnancy and can even become hostile or aggressive. In the end, the choice about whether to become pregnant is a personal one but influenced by the society in which we live.

So far, no transgender women have yet been able to become pregnant. Scientifically, many predict that this will one day be possible. In fact, a handful of cisgender women born without a uterus have now given birth after uterine transplants, the first in 2014.

p. 87↵Transgender women who would like to have biological children generally do so either through natural conception prior to beginning hormone treatment or by preserving sperm, which is later used by a partner or a surrogate. Unlike trans men, trans women do not generally have the option of starting hormone therapy and then choosing fertility options, as feminizing hormones can lead to rapid irreversible infertility. For this reason, trans women who are at all considering having biological children are often encouraged to think about sperm-banking prior to initiating hormones.

Like trans men, trans women may have the possibility of breastfeeding, although this practice is fairly new, at least within the medical field. The first case study of a health center inducing lactation in a transgender woman was published in 2018.

It is likely that as the field of transgender health progresses, more options will become available for transgender people to pursue various ways of creating families.

What role do mental health professionals play in the field of transgender health?

Many transgender people cope well with the stress of living with societally marginalized identities. However, there is much to be gained from working with mental health practitioners who have experience helping to navigate gender-related stress.

Even when fully cleared for medical transition, many people who seek intervention to alter their physical body with the hopes of alleviating gender dysphoria may benefit from mental health support to help explore the process. Like any major medical change, processing risk, managing anxiety, and preparing aftercare are all vital when undergoing such a major step, in addition to thinking critically about what aspects of life are likely to change with medical transition and what will remain the same despite such alterations. Mental health p. 88↵providers who treat trans clients therefore often explore with them the psychological implications of gender related interventions, as well as help them concretely plan to ensure ideal outcomes.

A therapist may also help someone manage living with gender dysphoria, particularly when medical and surgical interventions do not fully resolve the difficulties of living in a body or societal role that feels inappropriate to a person’s identity. These clinicians may help people increase their tolerance of distress, provide space to explore the evolution of one’s gender identity, and work toward creating opportunities for acceptance, support, and validation.

Transgender people can benefit immensely from community support, particularly when early in the process of transition. Especially helpful are support groups, community conferences, and educational events wherein information and resource sharing is the primary focus. Other social interventions may include participating in transgender cultural events, socializing on a sports team or in a theater group, linking up with a mentor who has been through a similar process, or even participating in an online community or forum. The goal of these interventions is primarily to decrease isolation.

There is no one-size-fits-all approach to treating gender dysphoria, due to the variety of ways in which people experience distress around their gender, as well as the diversity of gender, gender identity, and gender expression. Youth may benefit from support around social and legal transition to change their name and legal gender to reflect a lived gender identity rather than what was assigned at birth. They may also respond well to affirming individual psychotherapy, family therapy, support around gender transitions at school, puberty-suppressing hormones (to block the masculinizing and feminizing byproducts of puberty and reduce the need for surgical interventions later on) and cross hormone therapies, and possible surgical interventions when mature. Adults who have passed their own puberty are generally not appropriate candidates for puberty p. 89↵suppression medication, but benefit from many of the same interventions, along with couples counseling and support around workplace transitions.

Current best practice for mental health practitioners in the treatment of gender dyphoria is to take an affirmative approach that views trans identity not as a pathology but a normal human variation. As such, treatment focuses on reducing the anxiety and depression associated with pervasive transphobia and an experience of feeling “othered” in social settings. Affirming approaches generally suggest mental health treatment be offered but not enforced or mandated; highlight education for caregivers, friends, and family; and encourage community engagement.

Affirming interventions come in stark contrast to conversion therapies, which work to undo any cross-gender identifications. These techniques have been shown to be both harmful and unsuccessful. Gender identity does not appear to be malleable, and therapy aimed to change it typically leads to increased trauma and overall distress. Current research supports inclusive therapies, finding that affirmative approaches can decrease depression and suicidality. These findings are supported by most ethics boards, which generally condemn conversion therapies and ask clinicians to find ways to support their transgender clients, be it via traditional talk therapy modalities or by linking them to medical providers who can help them access gender-affirming interventions.

Why is access to care an issue for transgender people?

Transgender people often benefit from medical and mental health interventions to alter their bodies to reflect more authentically their lived gender identities and to process what can be an overwhelming experience of transphobia. Yet many find it nearly impossible to get the care they need to feel better.

The United States Transgender Survey, most recently conducted in 2015, found that 86% of respondents reported they p. 90↵were covered by a health insurance or health coverage plan. The remaining 14% were uninsured, which was slightly more than the 11% of the general U.S. population who were uninsured the same year. Of note, however, is the discrepancy existing between transgender and cisgender individuals’ utilization of healthcare. While less likely than the average American to be insured, transgender people require access to medical systems for aspects of their daily lives in ways that others do not. If taking hormones, they may need daily medication and routine blood work to ensure optimal functioning. Preventive care is particularly important as this current generation of transgender people age, particularly given the lack of research and longitudinal data available for long term use of hormone therapies.

In the United States Transgender Survey, insurance coverage differed by region, race, and immigration status. Those in the South were uninsured at a rate of 20%, compared with 13% in the Midwest, 11% in the West, and 9% in the Northeast. Among people of color, Black transgender people in the United States were uninsured at a rate of 20%, compared with 18% of American Indian respondents, and 17% of Latinx individuals. Asian and Middle Eastern respondents were uninsured at a rate of 11%, and white respondents, at a rate of 12%. Those who were not U.S. citizens were more likely to be uninsured, including nearly one fourth (24%) of documented noncitizens and 58% of undocumented residents.

For those individuals who were insured, over the past year, one in four respondents experienced a problem with their insurance related to being transgender, such as being denied coverage for care related to gender transition or being denied coverage for routine care because they were transgender. More than half of respondents who sought coverage for transition-related surgery in the past year were denied, and one fourth of those who sought coverage for hormones in the past year were denied.

p. 91↵One third of transgender respondents who saw a healthcare provider in the past year reported having at least one negative experience related to being transgender, with higher rates among people of color and people with disabilities. Issues included being refused treatment, verbally harassed, or physically or sexually assaulted. Many had to teach their providers about transgender people to get appropriate care. Unsurprisingly, many respondents did not see a doctor when they needed to—23% because of fear of being mistreated and 33% because they could not afford it.

These concerning statistics reveal systemic inequities. The best insurance policies are offered to those who have steady employment, usually necessitating one be educated at a certain level, an impossibility for some young transgender people facing unbearable discrimination in their homes and schools. Among transgender people, family rejection is associated with increased odds of suicide attempt and substance abuse. To think systematically about increasing one’s chances for optimal health insurance coverage, we must consider early childhood environment and every subsequent experience as cumulatively affecting chances for inclusion, success, and ability to access appropriate care.

Even for those trans people who are able to see medical and mental health providers, experiences may vary significantly. Education about trans care is routinely left out of graduate training programs, and clinicians typically lack training and core competencies needed to appropriately care for a transgender person. This lack of education renders even the most well-intentioned clinicians at risk of saying something harmful to their transgender client. Negative experiences in healthcare settings may reduce a transgender person’s actual or perceived ability to get their current needs met. Access to care is confounded by numerous factors not limited to financial inequalities; lack of access to insurance coverage and specialists in the field; and lifelong experiences of transphobia, rejection, and pathologization in the home, school, and social spheres. p. 92↵Intersectional experiences that force someone to navigate systemic racism, ableism, and xenophobia can further complicate their lifelong success in accessing affirming and inclusive healthcare.

What role has gender played in the diagnosis and treatment of mental health concerns?

Colloquially, the word hysteria is used to describe excess emotion, out of proportion to life events. Historically, when used by doctors, it has referred to women who report physical symptoms without a known medical cause, although it was often broadly applied to women who presented with anxiety, depression, and other mental health concerns. Hippocrates, a Greek physician in the fifth century bce, was the first to use the term hysteria, believing that these types of ailments were linked to the movement and placement of the uterus, or hystera, in Greek. Well into the 19th century, hysteria continued to be thought of as a result of problems with women’s sexual or reproductive functioning; treatments included marriage and orgasms.

In the late 19th century, symptoms of hysteria, or what we today call conversion or somatization, began to be linked to trauma. One of the leading proponents of this theory was French neurologist Jean-Martin Charcot, who argued that men could also have somatic symptoms, particularly if they had experienced traumatic events. Suddenly, a disorder that had been thought of, for millennia, as being the fault of women’s inferior bodies, was now potentially linked to a force outside of them.

Today, women are 75% more likely than men to be diagnosed with borderline personality disorder (BPD), a chronic condition characterized by mood instability, feelings of emptiness, fear of abandonment, suicidality, and self-harming behaviors. BPD is thought to be directly linked to trauma, particularly what is called “complex” trauma, which involves p. 93↵multiple traumatic events, often early in life and usually interpersonal, such as sexual abuse, which is more common in girls and women. Despite its roots in trauma, BPD is a stigmatized diagnosis. Those with this condition are thought of as difficult, irritational, and manipulative. Even many clinicians take the stance that clients with BPD are responsible for their symptoms as part of a moral failing, rather than understanding that this condition is a result of trauma. In her book Women and Borderline Personality Disorder: Symptoms and Stories, author Janet Wirth-Cauchon writes that “the label ‘borderline’ may function in the same way that ‘hysteria’ did in the late 19th and early 20th century as a label for women” (p. 8).

The history of hysteria (and BPD today) is emblematic of the way western societies, including their physicians, have approached women’s emotional lives. Even today, women’s medical and mental health concerns are often brushed aside, and women are painted as overreacting and overly emotional in comparison to men, who are thought of as more motivated by reason and more in control of themselves. Women’s mental health issues also continue to be blamed on something inside of them, rather than looking for societal causes.