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Young Children With Gender Nonconforming Behaviors and Preferences

Reilly, Marie MD*; Desousa, Vanessa DO; Garza-Flores, Alexandra MD; Perrin, Ellen C. MD§

Journal of Developmental & Behavioral Pediatrics: January 2019 - Volume 40 - Issue 1 - p 60–71
doi: 10.1097/DBP.0000000000000612
Special Article

Background: There is growing awareness and exposure in both the medical community and the lay media about the characteristics and complex needs of individuals who believe that their gender identity does not match their birth sex. Despite research and lay publications about teens with gender dysphoria and those who identify as transgender, little guidance is available regarding young (prepubertal) children with questions about their gender identity. Although many terms are used to describe these children, we have chosen to describe them as “gender nonconforming” (GNC).

Objective: Primary care and developmental-behavioral pediatric providers are often the first professionals with whom young gender nonconforming children and their families discuss their concerns about their emerging gender identity. It is important, therefore, that pediatric providers be knowledgeable about the dilemmas, conflicts, and choices that are typical of these children and their families to guide them appropriately.

Overview: In this special article, we present observations, informed by clinical experience, an emerging body of research, and a developmental-behavioral pediatric framework, of the complex needs of prepubertal gender nonconforming children and their families and an approach to their care. The article begins by outlining the cognitive and biological bases for gender identity development, as well as the natural history of gender nonconforming preferences and behaviors. It then sets the context for understanding the care of GNC children as an area in which developmentally sophisticated providers can play a crucial role in support of the complex developmental patterns and need for advocacy in multiple settings among these children.

This article has supplementary material on the web site:

*Division of Developmental Medicine, Boston Children's Hospital, Boston, MA;

Department of Pediatrics, Santa Rosa Medical Center, The Permanente Medical Group, Santa Rosa, CA;

Department of Clinical Genetics, Cook Children's Physician Network, Texas Health Fort Worth, Cook Children's Healthcare System, Fort Worth, TX; and

§Division of Developmental-Behavioral Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, MA.

Address for reprints: Marie Reilly, MD, Division of Developmental Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail:

Disclosure: The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (

Received March 14, 2018

Accepted July 17, 2018

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