Earlier puberty development among children who wish to be the opposite gender

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A new study from Aarhus University shows that children who have expressed a desire at the age of 11 to be a different gender enter puberty earlier than their peers. However, more research is required, says the researchers behind the study.

The transition to puberty can be difficult for children who are afflicted by doubt about their own gender identity. New research from the Department of Public Health at Aarhus University suggests that these children also enter puberty earlier than children who are not in doubt about their gender identity. Master’s programme student Anne Hjorth Thomsen and Professor Cecilia Ramlau-Hansen are behind the study.

The study, which is one of the first in the world to examine the correlation between children’s desire to be the opposite gender and their development in puberty, was undertaken as part of the research project “Better Health for Generations” (BSIG), which has monitored 100,000 Danish women’s pregnancies and births, as well as the growth and development of their children, since 1996.

In the study, the children were asked at the age of 11 about a possible desire to be the opposite gender. This information was then combined with data in which, every six months, the children reported their current stage in various puberty milestones. At age 11, around 5% of the children in the study reported either a partial or a full desire to be the opposite gender.

“The results indicate that children who at age 11 reported a desire to be the opposite gender tended to go into puberty before children who had not expressed a desire to change their gender. In the study, both birth-assigned boys and girls with a previous expressed desire to change gender entered puberty around two months earlier than their peers,” says Anne Hjorth Thomsen.

Anne Hjorth Thomsen stresses that more research is needed before any final conclusions can be drawn, but that it is important that health staff are aware of children’s previous puberty development.

“Health professionals may encounter a desire to slow down puberty, because the child may not feel comfortable in their own body, or able to identify with it. It is therefore important that the healthcare professionals possess basic knowledge about the puberty development of the children, so that treatment can be applied at the right time.”

Anne Hjorth Thomsen and Professor Cecilia Ramlau-Hansen recommend that the research results be followed up by new studies.

“In this study, we see earlier puberty development among children who wish to be the opposite gender, compared to children who do not wish to be the opposite gender. But we do not know whether the children’s own gender perception affects their puberty development, or whether there may be other explanations. We do not know the underlying causes,” says Anne Hjorth Thomsen.


For the vast majority of humans, being labeled a boy vs girl at birth is straightforward, based on genital anatomy, and is experienced as “obvious” – without need for a “choice”. Similarly, for many diagnoses that fall within the Disorders/Differences of Sex Development (DSD) umbrella, clear recommendations for male versus female assignment can be made on the basis of outcome data, even when genital anatomy is atypical. However, for some DSD diagnoses, recommended sex assignment at birth1 is less clear, and a “choice” must be made in terms of which gender label (boy vs. girl) a child is to be assigned [1]. Parents of children with a DSD identify uncertainty about initial gender assignment as very stressful; as children grow older, parents also experience considerable distress if their child displays behaviors they deem typical of the “other” gender [2, 3]. Parents also note high stress related to reconciling what they perceive to be conflicting information about their child’s DSD [2]. To promote optimal decision making and child/family adjustment, both the health care team and families must have a shared, accurate understanding of both biological sex features and gender identity, as well as how they differ. [4]. To that end, this article provides 1) a concise overview of the construct of gender identity, 2) proposes terminology and definitions to promote consistent and accurate communication (see Table 1), and 3) reviews psychosocial contextual factors to enhance conversations about gender with families.

Table 1:

Gender terms

Broad termFeaturesExamplesNotes
Biological “sex”Chromosomes46,XX
46,XY
46,XX with deletions or redundant sections
46,XY with deletions
47,XYY, etc
47,XXY
Currently, karyotype sex is deemphasized since genetic direction of sexual differentiation is at the genetic level of the autosome as well as sex chromosomes, as illustrated by 46XX males and 46XY females who developed as such by gene expression, independent of sex chromosomes
Internal anatomyGonads, uterus, fallopian tubes, vagina, urethra,vasa defferentia, prostate, ejaculatory ductsInternal duct development is largely a result of the presence of functioning testes that secrete AMH to inhibit female internal structures and testosterone to stimulate male development. Hence, testicular failure can result in female structures in a 46,XY DSD individual.
Internal anatomy can be altered through hormonal or surgical intervention. In some cases, anatomy needs to be altered in order to improve functioning.
External anatomy (e.g., genitalia)Labia majora/ scrotum
Clitoris/Penis
Empty scrotum
The development of the embryonic structures into labia majora or scrotum and a clitoris or penis is dependent upon the amount of testosterone during the first trimester of fetal life. Lack of testes in the scrotum may mean that they are undescended, missing or that gonads are ovaries.
External anatomy can be altered through hormonal or surgical intervention. In some cases, anatomy needs to be altered in order to improve functioning. In some cases, surgery is not necessary for function but is chosen by individuals or families soley to change appearance.
Hormonal activityAndrogens
Estrogens
Other gonadal hormones
All have specific functions, although androgens hold a major role in both internal and external reproductive system development.
GenderGender identityA sense a person has about themselves as to whether they are a boy/man, girl/woman or some other gender categoryTypically consistent with gender assigned at birth and typically expressed consistently by 4 years of age.
Gender can be experienced in a binary fashion (e.g. experienced as being a boy fully and completely), or can be more fluid (e.g., experienced as having a sense of being both a boy and a girl).
Many people with gender dysphoria or who are transgender will report that their gender identity has actually been consistent since childhood but they did not feel comfortable sharing this information; more recently, there have been cases of “late-onset” gender dysphoria in which there is a dramatic shift in gender identity.
In some DSD conditions, gender identity may shift specifically during pubertal development (e.g., 5α-reductase 2 deficiency)
Gender roleBehaviors, personality traits and features of appearance that are typically linked with a particular genderGender roles are greatly influenced by factors within family and peer systems (e.g., parental preferences, favored peers’ activities) as well as the larger sociocultural context (e.g., gender stereotypes). As sociocultural influences change over time, so, too, can gender roles (e.g., the increase in women athletes since Title IX).
Gender/sex assigned at birthThe “guess” that parents and medical providers make about which gender a child will identify with later in life, typically based on fetal/infant anatomy/physiologyBoth phrases are used within DSD; “Sex assigned at birth” is a phrase that is most commonly used within LGBTQ communities, and has been more recently gained favor within DSD.
Gender dysphoriaSignificant distress related to one’s gender identity not corresponding with the gender assigned at birth.In some cases, gender dysphoria resolves by a person making socio-cultural, hormonal or surgical changes that allow them to more fully express themselves and/or be accepted in a way consistent with their gender identity (e.g., as seen in the transgender population); in some instances, gender dysphoria remits over time.
OtherIntersexSome affected individuals prefer the term “Intersex” rather than “DSD” or a diagnosis specific term (e.g., “CAIS”). “Intersex” can refer to the co-occurrence of biological/somatic features typically associated with males and females (e.g., a person with 46,XY karyotype who also has a uterus). For other individuals, “intersex” also connotes a psychosocial identity, as does other gender identity categories (e.g., “gender fluid”).

Note: There are numerous terms to describe a myriad of gender categories. These terms are constantly changing. When individuals or families reference a specific gender term, asking for clarification of what the term means to them is advisable. Many websites offer lists of terms and definitions (e.g., https://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf).

Gender identity review
DSD refers to conditions in which the biological sex features that typically distinguish males from females are discordant or have developed atypically. Biological sex features are usually consistent with a person’s gender identity [i.e. their sense of themselves as a boy/man or girl/woman (if binary)]. In other words, most children with a penis (biological sex feature) think of themselves as a boy (gender identity).

Gender identity is a “lived experience” – only a person themselves can know what their gender identity is. Thus, the “boy” or “girl” label given prenatally or at birth (and celebrated at gender reveal parties), does not actually reflect a gender identity – it is the “best guess” (and usually a really good guess, based typically on genital appearance) that parents and health care providers have as to a person’s future gender identity. The formation of gender identity is the result of complex interactions between biological and social factors, and relies on cognitive development [5, 6]; by age 2 years children understand gender labels, by age 3 years children typically will label themselves a particular gender (“I am a girl!”), and by age 4 years the gender label is typically being expressed consistently. Gender atypical behavior is often first recognized in early childhood, and can range from interests/activities culturally atypical for a particular gender (e.g., a boy wearing a dress) to expressed desire to be a different gender or insistence that one is actually a different gender [7]. The best predictor of gender identity is sex assignment at birth.

In many societies, there has been a paradigm shift in gender identity expression in recent years. In the US, 15 states offer non-binary ID options, and legislation has recently been proposed that adds a 3rd gender option to US passports [8]. 35% of youth categorized as “Gen Z” report personally knowing someone who uses gender-neutral pronouns, and nearly 60% support the availability of non-binary gender options on form or online profiles. Of note, these percentages are higher compared with older generations; e.g., for Millennials, 25% reported knowing someone who uses gender-neutral pronouns, and 50% supported non-binary options on forms/online profiles [9]. Thus, increased exposure to and acceptance of a range of gender identity expression may continue into future generations.

Gender identity has been conceptualized as a multidimensional construct including aspects such as gender typicality (whether behaviors/interests conform to gender stereotypes), gender contentedness (the degree to which a person feels glad to be their gender), and felt pressure for gender differentiation (i.e., pressure to conform to stereotypes)[6]. These concepts are distinct, albeit related constructs [10], and are important to distinguish for patients and, in particular, families. In DSD, children may express a high level of gender atypicality, while at the same time having high gender contentedness (e.g, a child with CAH who strongly aligns with a female gender identity but likes to do more boy-typical activities). The multi-dimensional model of gender identity has recently been extended to include the potential for determining the degree to which an individual feels similar or dissimilar to both genders [6]. Both gender contentedness and gender typicality have been shown to be related to positive adjustment for children; felt pressure for gender differentiation is noted to have a particularly negative impact on adjustment, particularly in the context of gender discontentment or atypicality. Several measures assessing children’s gender identity have been developed, including the Parent-report Gender Identity Questionnaire for Children (for children 2.5 to 12 years of age) [11], the Gender Identity Interview for Children (for children 2.5 to 12 years)[12], and the Multidimensional Gender Identity Scale (for children 8 years of age and older) [13].

Careful consideration of sex assignment based on prediction of future gender identity is important, but it must be realized that it is impossible to predict with certainty so parents must be prepared to respond when gender identity does not develop as assigned. Ideally this can be recognized before gender dysphoria occurs. The rate of gender dysphoria is higher in several DSD diagnoses compared with the general population [14]. Gender dysphoria is diagnosed when there is 1) “marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration”, and 2) this incongruence is associated with clinically significant distress [15]. In prospective studies of children with gender dysphoria in the general population (i.e., non-DSD samples), gender dysphoria remits in the majority of children [16]. Youth with gender dysphoria present with high rates of anxiety, depression and suicidal ideation [17]. Youth with non-binary gender identities (presumably initially raised with a binary gender assignment) also demonstrate poor mental health outcomes [18]. “Not choosing” a gender until the child declares their own gender identity is a path recently taken by some families [19]– it is unclear what the psychosocial ramifications of this approach will be given the rarity of the experience. Protective factors that mitigate the risk conferred by gender variance include healthy self-esteem and positive relationships with parents and peers [20].

Consideration of gender must consider the family influences on gender identity [21]. In addition to genetic transmission of biological factors from parent to child, the family provides formative gender-related experiences to a child. For example, parents provide a model for gender typical behavior (through their own interests and activities), create opportunities for gendered behavior through their control of the environment, shape the gendered behavior of their children through attention and consequences, and verbally share their own beliefs about gender with their children. Siblings may also play an important influential role in gender identity development and gender-related parenting (e.g., less gender-stereotypical parenting in families with same-sex siblings vs both sons and daughters). And, as noted previously, family acceptance and support of gender variance (when it is present) appears to be important for positive adjustment [20]. More broadly, parental self-efficacy (a parent’s belief that they can influence their child toward successful outcomes) and parental coping both positively predict better child adjustment [22].

Other cultural factors that contextualize sex assignment (both initial assignment and openness to change) include societal views on gender, which can change over time [23]. In most societies, expressed gender plays a role in resource allocation, including income and inheritance. Gender also often impacts division of labor, rules of conduct, educational attainment, health, political empowerment, and initiation of and freedom in relationship building (particularly, marriage) [24, 25]. The influence of gender on these arenas likely depends on a number of factors, e.g. the rigidity of the gender binary in a society; societal variations in these gendered facets impact the gender ideologies that parents and health care providers bring to the discussion of gender assignment. For example, Joseph and colleagues [26] observed family preference for male sex assignment in their case series of DSD in India, interpreting this preference in light of the social advantages male gender confers in that society, and difficulty in arranging marriage for infertile girls. It is also important to understand whether there is an understood “third” (or more) gender category in the family’s culture – while binary sex is the dominant sex categorization across societies, many cultures have specific terms recognizing people who identify outside the binary (e.g., Indian “hijras”, Hawaiian and Tahitian “māhū“, Samoan “fa’afafine”, Indigenous North American “two-spirits”). Families from these cultures may be interpreting information related to their child’s DSD through the lens of their cultural experience of “intersex.” These culturally recognized categories differ widely in the roles and social status that they hold in their respective societies, and are often quite stigmatizing; the assumptions that families from these cultures bring into the DSD context must be voiced and understood [26–28]. Even within one nation, geographical differences in gender ideology may exist. For example, in a recent large US study, gender diverse youth in rural settings had higher rates of gender-related harassment relative to youth in urban settings (50.6% vs 41.4%, respectively). Of note, the positive influence of protective factors such as supportive families and teachers was similar across geographical locations [29].

Religious background also may posit a strong influence on a family’s perspective related to sex assignment and change. In some faith traditions, gender influences access to spiritual activities, and some religions have very strong negative views on sex assignment change [24, 25, 30]. Furthermore, some religions include systems of law that will influence sex reassignment. For example, families from Islamic countries may be influenced by their awareness of fatwas (formal legal opinions from experts in Islamic law) relating to sex assignment and reassignment [31].


Original Research: Open access.
Gender incongruence and timing of puberty: a population-based cohort study” by Cecilia Ramlau-Hansen et al. Fertility and Sterility

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