Who am I?

Exploration, not affirmation, is the correct response to a child who believes they are the opposite sex

Photo by Liv Bruce on Unsplash

How do I know who I am?

Babies come into the world knowing nothing, but with a great capacity to learn. Their first experiences are sensory, reacting to what they can see, hear, smell, touch, taste, and experience. They are not born with an innate sense of who they are. They are born with characteristics and abilities, but they have no language with which to describe themselves, other people, their experiences, or their environment.

Children acquire language in the first three years of life by exposure to speech and conversations with others. They are born with an innate ability to figure out the rules of the language around them, and interaction with others expands their vocabulary and forms of expression. The ability to understand and communicate with others is the foundation of all learning, both formal and informal.

Concept formation is the mental process of organising information into categories, or concepts, based on our experiences and perceptions. The four steps of concept formation are abstraction, generalisation, experience, and analysis. Abstraction involves isolating the similarities between two or more things, and generalisation applies the concept to objects or situations with shared characteristics that have not previously been observed.

Through the stages of experience and analysis that follow, the child learns to apply the concept to the world around them. For example, in the process of acquiring the concept of animals, a child might notice the features of creatures called cats, then see the similarities between cats and dogs, and by observing more animals, gradually gain the ability to recognise new organisms as animals and distinguish between those that aren’t.

Individuals can only learn from what they are exposed to and interact with, even for characteristics that are innate. For example, Australian Aboriginal people who had lived in isolation for thousands of years were confused by the first white men they saw, believing them to be ghosts of their people who had died, as they had no concept of race.

In the same way, if a child were raised in a society where the sexes were strictly segregated until after puberty, they would have no concept of what it meant to be male or female, girl or boy, woman or man.

How do we know what sex we are and what gender we are expected to be?

This question has become a defining issue of modern times.

The World Health Organisation (WHO) summarises the difference between sex and gender in the following way—

Sex refers to “the different biological and physiological characteristics of males and females, such as reproductive organs, chromosomes, hormones”

Gender refers to “the socially constructed characteristics of women and men, such as norms, roles and relationships of and between groups of women and men”

As for “society,” that term refers to a group of people living together in a community with common traditions, interests and institutions. By “culture,” we mean the norms and social behaviour found in a society such as customs, habits, beliefs, and laws.

Although some health professionals have adopted the current fashion of saying a baby’s sex is “assigned” at birth, leaving open the possibility that the health professional may have got it wrong, a person’s sex cannot change. It is impossible for a human who has the capacity to provide sperm to become a human able to provide eggs, and vice versa.

The conditions known as “disorders of sexual development” do not generalise to people without such a disorder. People who are infertile are either an infertile male, or an infertile female.

Gender roles, that is, the socially or culturally accepted and expected behaviours of females (girls, women) and males (boys, men), can change across time and place, even in the same society in the period of a person’s life—for example, consider the impact of the feminist movement, which not only liberated women from restrictive gender roles, but benefitted men as well.

Children typically learn to distinguish between males and females (biological sex) at different ages, and their gender identity (a sense of being a girl or a boy, woman or man) develops in stages—

Age 2: Children become aware of physical differences between boys and girls

Age 3: Most children can identify themselves as a boy or a girl, although they may not know the meaning of male and female

Age 4: Most children have a stable gender identity

Age 5–6: Children become more aware of social/cultural gender rules and expectations

Age 6–7: Children may rely less on making outward expressions of gender as they feel more confident that others recognise their gender

In this article, I am discussing children from birth to early adolescence.

Until recent times, the WHO’s definitions covered the accepted understanding of who were girls, boys, women and men; the terms “sex” and “gender” were used interchangeably.

From the 1990s on, because of the concerted campaign to “challenge heteronormativity” by the new queer theorists, children are now being taught it is possible to be “born in the wrong body”, that their sex was “assigned at birth”, and they may not be the girl or boy they were told they are, meaning that a child may be born in the sexed body of a female but have the gender identity of a male, and vice versa.

A disturbing development is the claim by some health professionals that, “From a medical perspective, the appropriate determinant of sex is gender,” because of the new belief that there are more than two sexes.

So, how and, just as importantly, why, does a child come to the belief that they are born in the wrong body, that a boy is really a girl, and a girl is really a boy?

The place to begin is to understand that the theory put forward by gender-affirming health professionals is too simplistic. “Gender-affirming care” rests on the theory that gender is an innate/inner sense of gender and the child “knows who they are,” so assessment and management must be “child led.”

The current standards of care (SOC-8) from the World Professional Association for Transgender Health (WPATH) do not begin to address the complexity of the development of gender identity in children.

A comprehensive psychological review of more than 100 articles on gender development took the following approach—

“We review theory and research on the assessment, development, and consequences of individual differences in gender identity, as studied among ordinary school children. Gender identity encompasses children’s appraisals of compatibility with, and motivation to fit in with, gender collectives; it is a multidimensional construct.

“Five dimensions of gender identity are considered in depth: felt same-gender typicality; felt other-gender typicality; gender contentedness; felt pressure for gender conformity; and intergroup bias [whereby one favours members of one’s in-group over members of other groups.]

“A host of cognitive, affective, social, and defensive processes contribute to these forms of gender identity, all of which in turn affect children’s psychosocial adjustment.”

A twin study published in 2022 explored possible biological/genetic influences on gender identity, using data derived from a large register-based population in Sweden to examine the prevalence of gender dysphoria among twins and non-twin siblings of individuals with a formal diagnosis of gender dysphoria. They surveyed 2,592 full siblings to a dysphoric sibling, of which 67 were twins (identical and fraternal); age at the time of the dysphoria diagnosis ranged from 11 to 64 years.

Opposite-sex twins were found to be more likely to both be trans (37 per cent of sibling group) compared to same-sex twins (no trans twin with a trans-twin sibling); the no-twin pairs also had a very low rate of both being trans (less than 1 per cent).

The results are the opposite of what would be expected if genetics were a significant factor. It raises the question of what were the factors influencing the opposite-sex fraternal twins that were either not present or not significant for the same-sex twins.

A report from 2016 published in The New Atlantis magazine concluded there is not scientific evidence to support the hypothesis that gender identity is an innate, fixed property of human beings independent of biological sex.

The best that can be said at the moment is that while biological factors may predispose some children to have a gender identity that doesn’t reflect their sex, the biopsychosocial model, as well as social contagion, is more likely to account for the sudden increase in gender-questioning children.

Even if there are some biological factors that may influence a child to believe they are the other sex, it is unclear how these particular influences could override all the other known biological differences between females and males. In my view, the most likely outcome would be a gender non-conforming child rather than a child who is the other sex.

Given that Western society has come a long way in accepting gender non-conforming people, why has trans ideology become so popular, particularly with children and adolescents? There are a number of likely factors, among them the powerful influence of social media, and the self-esteem movement. That movement from the 1980s held every child to be special and capable of achieving whatever they aim for. Hence, the search for an identity that allows a child both to stand out and to join in a social group.

Of concern is the belief that children as young as three can know they are transgender and should be socially transitioned to an identity unrelated to their sex both at school and gender clinic. Social transition is not a neutral act and can lead to the locking in of what would have been a temporary phase, interfering with the normal development of the child, and increasing the chance of unnecessary medicalisation.

The dismissal of social influence as a significant factor in the dramatic increase in gender-diverse children is a major flaw in the current model used by gender-affirming clinicians. It is plausible that this influence affects not only young people but their parents.

It is important to note that adolescents also discover their sexual orientation, not only their gender identity, by the same process of concept formation. The difference is that in becoming aware of their sexual preference, they don’t want to be the person they are attracted to, they want to have a relationship with them. This can bring its own challenges and disappointments, but the sexuality-questioning adolescent can explore their sexuality without being committed to permanent alteration of the body by medical and surgical procedures.

What sex and gender am I?

Depending on their interactions with mixed-sex groups and whether they ever see bare bodies, one of the first differences children notice occurs when they observe urination, becoming aware of the penis and the vulva. Adults label children with a penis “boys,” those with a vulva are labelled “girls,” helping the child form the separate sex concepts.

Other observable differences in prepubescent children that also become attached to the concepts of girl and boy can include height and weight, body shape, and some general behavioural differences such as boys’ tendency to develop gross motor skills (running, jumping, balancing) slightly faster, while girls’ fine motor skills (holding a pencil, writing) improve first.

The concepts are solidified when the sexes are dressed in different types of clothing, given different toys to play with, and generally treated differently.

In Western society there are less rigid boundaries between the gender roles of the sexes, so some traditionally gendered toys, clothing and behaviours have become unisex. Boys play with dolls, girls play with trucks, some girls run fast and climb trees, some boys prefer to play with a toy stove or push a doll in a pram, but observable sex differences remain.

The concepts of the gender roles of females and males are further reinforced by any differences in the roles that children observe in adults, in the home, at school, in general society—does one gender seem more respected, successful, confident, independent, content, free than the other?

By observing the people around them, taking into account all these differences, a child may realise they prefer the clothes, toys, activities, treatment by adults, and the company of children of the gender culturally associated with the other sex.

Given that gender expectations vary dramatically around the world, would a gender-questioning person in one society not be so in another?

Would a male who says he is a woman in Western society feel the same way in a society where women are rendered almost invisible, with no rights at all, as in Afghanistan? Would a woman who feels restricted by gender expectations in one society be content in one which gave her personal freedom to live as she wants? As far as I know, this remains a hypothesis that has not been researched.

What does gender-affirming care do for the gender-questioning child?

The major flaw in gender-affirming care is that it takes a dangerously simplistic view of the best way to assess and manage a gender-questioning young person before or after puberty. There are a multiplicity of reasons why a child or young adolescent might come to the belief that their life would be better if they were the other sex. These possibilities are either ignored or not addressed in detail in the much-cited treatment guideline, SOC-8, from WPATH. There is no dedicated section on differential diagnosis or alternative treatment pathways.

Consider the diagnosis of gender dysphoria in the psychiatric manual known as DSM-5. A child is considered gender dysphoric if that child states they would prefer to dress, play, and act according to the gender role of the other sex, and strongly rejects the gender role of their own sex. When this leads to the child developing a strong dislike of their sexual anatomy, the child is likely to be recommended for gender-affirming care, initially social transition, but the next step is puberty blockers.

In some cases, children as young as nine or ten are prescribed puberty blockers. Despite the common statement that puberty blockers are completely reversible, there is reason to doubt this.

Do gender-affirming clinicians explore all the various issues that the child might be grappling with before social or medical treatment is recommended? Here are just a few of the issues that need to be gently, safely, respectfully explored—

What is this child rejecting: their expected gender role or their sex?

Are there family dynamics that might lead to a child believing they would be more loved/accepted if they were the other gender?

Do they have healthy and supportive friendship groups, and if not, why not?

Has the young person come to the belief that the other gender is generally treated better in their social setting?

Does the child or parent believe that any co-morbid, pre-existing mental health problems such as autism, ADHD or anxiety will be solved by transitioning (rather than a gender clinician dismissing these problems as the result of “minority stress” in a “transphobic” society)?

Are there early indications that the child may be same-sex attracted?

What has been the influence of the social media that they or their parents are exposed to?

Is there a history of childhood traumatic events?

Is the child using cross-dressing or other activities as a form of self-soothing, that is, as a way of calming themselves when they are worried or anxious?

The difference between “preference for” and “being”

A child comes to the conclusion they are the other gender because they prefer the clothes, treatment, toys, etc of the gender role attached to the other sex, and modern transgender theory says that not only can they adopt the gender role of the preferred sex, they can actually become that sex. In my opinion, this is the greatest betrayal by the health professionals involved in gender-affirming care.

This belief that a person can change their sex is supported by laws in many countries where people are able to change their legal sex without requiring any supporting medical report.

Puberty blockers are part of the dishonesty: they may block the puberty a child doesn’t want, but this intervention cannot deliver the puberty the child states they want. If they later proceed to cross-sex hormones, these cannot deliver the puberty of the preferred sex: a transgirl does not have a womb, will not menstruate, and will only develop breasts with the help of the hormones; a transboy will not experience anything vaguely similar to an erection and ejaculation.

They are forever reminded that they are trans because they must remain on hormonal treatment for the rest of their lives, and even with gender-affirming surgery to give them the appearance of their preferred gender, their natal sex cannot change. This has implications beyond reproduction to other areas of health.

Transsexuals of earlier times, and many transpeople now, do not reject biological reality and therefore have a better chance of having a more contented life.

Of course, natal females and males have reproductive disorders, but they are having the lived experience of being a person of that sex with that disorder. A transwoman and transman can only experience their reproductive problems as a natal male or female, respectively, who doesn’t have the function of their preferred gender because they are not the corresponding sex.

This notion that trans people change sex is reflected in the “trans women are women” mantra used by trans activists such as UK broadcaster India Willoughby, who has said—

“Changing sex is FASCINATING. It’s a shame we’re not educating people about a really interesting, joyful, liberating process that some human beings go through the world over.”

US paediatrician Dr Julia Mason responded to a social media post about a male who had trans surgery only to realise he has not become a biological woman: “He was told the doctors would change his sex. He believed them. He was a child.”

Practitioners are failing gender-questioning children and adolescents by not being thorough in their assessment and not being completely honest with the child and their parents.

Gender is cultural, sex is universal

Gender ideologues are correct when they say gender is a cultural concept, but wrong when they make bizarre claims that sex is also a social construct, that a person can change sex, and there are more than two sexes.

Despite the prevalence of gender clinicians who like to gloss over the biological reality that sex relates to the reproductive strategy of humans, there is no society which does not depend on the existence of fertile women and men to maintain or increase their population. Every person on the planet exists because an egg from a female was fertilised by sperm from a male.

Until there is a case of a sperm-producing man who undergoes transformation to become an egg-producing woman, I remain unmoved by the belief that it is possible to change sex.

If health professionals who work with gender-questioning children hold such beliefs, what hope do their patients have for receiving safe, appropriate, evidenced-based care?

Dr Sandra Pertot retired not long ago after 50 years of practice as a clinical psychologist specialising in human sexuality, including sexual dysfunction, sexual orientation and gender diversity