Gender incongruence, or gender nonconforming, a conflict between a person’s
physical or assigned gender and the gender with which that person
identifies, may be something you’ve heard more about lately. It’s likely
you have questions, especially if you have a child who is questioning his
or her assigned gender.
In my 20 years as an OB-GYN, I’ve seen patients as young as 4 and as old as
77 who experience this. I started working with the transgender population
in 2012 and have since helped establish Mid-Atlantic Permanente Medical
Group’s transgender health services. I work with patients and their
parents, and as a team with other health care providers to make sure
patients are correctly identified and get the gender-affirmative care they
need.
What exactly is gender incongruence?
Sometimes called gender dysphoria, gender incongruence is the now-preferred
term that covers the anxiety, concerns, or depression that can come with
people not feeling like they identify with the gender they were assigned at
birth. They often feel uncomfortable with their body or the traditional
roles associated with their assigned gender. I often explain that gender is
defined as the neck up – it’s based on social norms and can evolve over
time. Sex is the biological differences between males and females.
How is someone diagnosed with gender incongruence?
Gender incongruence isn’t a diagnosis so much as a label. Health care
providers can help patients whose depression or anxiety is related to
gender get the counseling they need. Ultimately, when a primary care
provider hears from a patient that he or she is experiencing these issues,
I counsel the provider to refer the patient to a behavioral therapist,
particularly one who has experience in transgender therapy, who can better
figure out if gender incongruence is the cause.
What kinds of therapy are available?
Patients experiencing gender incongruence can go to therapy individually,
in groups and with their families. In fact, I recommend at least three
simultaneous therapy sessions: a patient sees someone one on one, a patient
and his or her parents meet as a group and parents see someone together. A
therapist can help parents understand their child’s struggles and learn how
to best love and support their child. This is also an opportunity for
patients and their parents to learn about and discuss what the child’s
chosen pronouns may be – she/her, he/him, theirs/they, etc. – and what name
is preferred. Anything that can create anxiety or depression is important
to deal with as early on as possible.
Once patients and their parents go through therapy, siblings and even
extended family members can go to counseling. With siblings, I recommend
that they go with their parents to group sessions with other families who
have children experiencing the same thing.
What about surgery?
Some patients want to take steps to have irreversible medical transitions.
The most common surgeries I perform are top surgeries for trans males –
those who were assigned a female gender at birth, but have a male gender
identity – where a mastectomy is performed and a male chest is created for
the patient. This often involves many steps, including therapy, a readiness
letter (including questions about what a patient knows about a surgery, who
one’s support group will be and how to prepare) and the several surgeries
once they are approved.
I don’t recommend medical transitions for most under 18. Instead, I will
often suggest reversible options until patients reach adulthood. This could
include hormone blockers, which essentially delay puberty. The majority of
states require parental consent before prescribing medication to patients
under 18. Patients can also make social transitions, such as choosing
another name or pronoun, and dressing or expressing in a way that is more
aligned with their gender identity.
Gender incongruence is a complex and delicate topic, but parents can help
their children navigate this with the help of experts. Aside from talking
to your child’s primary care provider and/or contacting a behavioral
therapist who has experience working in the transgender community, you can
learn more by visiting the American Psychological Association’s Office on
Sexual Orientation and Gender Diversity’s website at
apa.org/pi/lgbt.
Books for Patients and Their Parents
When patients and their parents have questions about gender incongruence, I
often recommend the following books:
- “I Am Jazz” by Jessica Herthel, Jazz Jennings and Shelagh
McNicholas. This is a children’s book about a transgender child.
You may be familiar with the TLC reality television show of the
same name, which features Jennings. - “The Gender Creative Child: Pathways for Nurturing and Supporting
Children Who Live Outside Gender Boxes” by Diane Ehrensaft and
Norman Spack. This book is a resource for parents on
gender-nonconforming children and adolescents. - “Red: A Crayon’s Story” by Michael Hall. This is a children’s book
about being true to your inner self and following your own path.
