Navigating The Murky Waters Of Best Interests With A Transgender Child

Dr. Diane Ehrensaft, child psychologist and author of the acclaimed book "One Pill Makes You Boy, One Pill Makes You Girl," describes "a growing cohort of children who, at ages as young as three or four, announce they do not accept...the gender assigned to them at birth." Similarly, a leading expert on medical treatments for childhood/adolescent gender dysphoria at Harvard Medical School, Dr. Norman Spack, describes that his patients, as young as eight years old, "have been digging in their heels for five years or longer about their gender identity and gender role."

According to the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), gender dysphoria, previously classified as gender identity disorder of childhood (GIDC), is characterized by a marked difference between the individual's expressed gender and the gender assigned to him or her at birth. Gender dysphoria is manifested in children in a number of ways, including strong desires to be treated as the other gender or to be rid of the characteristics of the child's birth sex. The child may also embrace a strong conviction that he or she has feelings and reactions typical of the other gender.

While there is no reliable data as to the frequency of gender dysphoria due to the subjective diagnostic criteria, as well as children suppressing their cross-gender identification into adulthood, experts estimate that at least one in 500 children exhibit gender dysphoric behaviors. And with gender issues increasingly gaining public attention, the visibility of these children will no doubt increase in the years to come.

Still, with little precedent and a generally binary understanding of gender, the legal profession has yet to catch up with the shifting tides. Judges and lawyers alike oftentimes lack experience with issues related to gender and children. That lack of understanding can have serious consequences for the transgender and gender-nonconforming youth.

Without the proper support, caregiving and structures, transgender youth can develop an increased risk of clinically significant distress, anxiety, increased risk of suicide or impairment in social, occupational or other important areas of functioning in children. A 2009 study conducted by Dr. Caitlyn Ryan found that these risk factors are directly linked to the level of family rejection of a child's gender nonconformity, rather than to anything inherent in nonconformity itself. In drawing that causal connection, the study controlled for the effects of other factors, including social pressure a child may experience to conform to gender stereotypes. She and others, including Dr. Ehrensaft and Dr. Spack, advocate for a "supportive approach" or "gender affirmative" model that focuses on providing the gender nonconforming child with support and acceptance as a means of reducing internal...