Children whose behavior doesn't conform to gender expectations -- girls who swing swords and play with trucks, boys who tend to dolls and are drawn to high heels and frilly dresses -- are only rarely tipping their hand about their future sexual orientation. But such behavior does predict that a kid is more likely to experience psychological, physical or sexual abuse during childhood, and will go on to suffer post-traumatic stress.
Behavior that defies gender stereotypes is remarkably common, reports an editorial published alongside two studies on gender-defying kids in the journal Pediatrics this week. As many as 13% of teenage boys and 26% of teenage girls report that they engaged in cross-gender behavior as younger kids. And between 2% to 5% of boys and 15% to 16% of girls reported they sometimes wished they could be the opposite gender.
Such behavior can hint at future sexual orientation or gender identity, but not with great accuracy. A new study published in Pediatrics finds that, of children who most intensively engaged in behavior that crossed gender stereotypes (the top 10%), about 60% would identify themselves as heterosexual between the ages of 19 and 27. (That still counts as a "strong association" between child gender non-conforming behavior and homosexuality, but it's far short of predictive.)
And even fewer of those who defy gender expectations as kids will end up wishing to switch genders.
Children who wish to change genders, a second study found, have high rates of psychological distress (about 44% of one study sample had a history of mental health issues) and are at high risk of self-harm (with just over one-in-five self-mutilating and about 9% having attempted suicide).
"Our study," the authors wrote, "cannot determine the causal relationship between abuse and gender nonconformity; in other words, the extent to which nonconformity is a risk factor for abuse versus an indicator of abuse." They concluded: "Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed."
For children who consistently express discomfort with their gender, earlier medical intervention -- specifically, the administration of hormones to slow or forestall puberty -- improves mental health, the second Pediatrics study found. Researchers tracked 97 patients who sought treatment at a newly founded Boston clinic for kids with gender identity disorder, and found that their average age upon arriving at the clinic was 14.8 years old.
More important, they found that by the time many of these patients came forward for treatment, they were well into puberty, when gender characteristics that are difficult to reverse -- breast enlargement, voice changes, hair patterns and the development of an "Adam's apple" -- have already begun to take place. That means that the hormones now widely recommended to suppress pubertal changes -- and thereby provide a child and his or her family time to figure things out -- are of more limited use.
The authors said they advocate early evaluation -- well before pubertal changes begin -- for kids who may feel they have been born into the wrong gender. Kids whose "gender dysphoria" persists or intensifies as they enter the phase of puberty when boys see an enlargement of the scrotum and testes and girls see the appearance of breast buds should be considered for treatment with puberty-slowing hormones, the authors wrote.
"Clues indicating [gender-identity disorder] in genotypic male children," the second study states, "include preference for female clothing and underwear, always sitting to void, exclusive play with female toys when given a choice, and desire for long hair. Clues indicating GID in genotypic female children include preference for male underwear, breast binding, refusal to wear female swimsuits, and psychiatric decompensation at the onset of menstruation."