Gender in Children
Children are still developing in many ways. Their self-image, preferences and experience of their bodies change along with the growth of their brains, their social environment and the stages they go through. The Cass Review describes childhood, adolescence and young adulthood as dynamic developmental periods for gender expression, cognitive development and brain maturation (source). Caution with children is therefore not an old-fashioned reflex, but a serious consideration.
A child in development
According to the Cass Review, children usually realise at around the age of two or three that they are a boy or a girl. A child’s gender identity usually matches their sex registered at birth, although the pace at which children realise this and the way they express it differ (source). A child showing gender-atypical behaviour — a boy who enjoys wearing dresses, a girl who likes tree climbing and football — occurs from a young age. The report states that some children show behaviour that does not strongly fit their sex registered at birth but have a gender identity that does match it, and that they can grow up to be heterosexual, homosexual or bisexual adults (same source).
The Cass Review states that there is no definitive evidence for biological causes of gender incongruence, although a biological predisposition may exist; psychological, personal and social factors also influence how gender identity develops (source). What children learn at primary school during the Week of Spring Fever is described for each year group at lente-kriebels.nl.
What research shows about how things develop in children
Steensma and colleagues (2013) followed 127 adolescents who had been referred as children (under 12) for gender dysphoria. They found that the intensity of gender dysphoria in childhood was associated with its persistence, and that persistence was more common in girls than in boys (Steensma et al. (2013), PubMed). According to the Cass Review, earlier studies showed that in roughly 15 per cent of children referred before puberty the gender incongruence persisted into adulthood, and that most of these children became homosexual or bisexual adults without a transgender identity. Those first studies have been criticised because not all children had a formal diagnosis; later studies of children who did meet the diagnostic criteria found, according to the same report, persistence rates of 10 to 33 per cent (source).
This phenomenon — known as desistance — belonged to a cautious, observant approach: giving space and waiting (“watchful waiting”). In the United Kingdom, according to the Cass Review, that approach remained in use until 2011. The gender-affirmative model, which immediately affirms a child’s self-declaration, is according to the report now dominant in many countries; staff at the British GIDS clinic stated that in their practice they did not automatically affirm a child (source). That model is criticised internationally, including by the Cass Review (2024) in the United Kingdom. Sweden’s Socialstyrelsen has recommended since 2022 that hormonal treatment of minors be given within research settings and otherwise only in exceptional cases (source). The Norwegian investigative commission Ukom advised in 2023 that puberty blockers and hormonal and surgical treatment of minors be classed as experimental treatment (source). In Denmark, the medical journal Ugeskrift for Læger wrote in 2023 that the country has adopted a more cautious approach to hormone treatment (source). Regarding the Finnish guideline of 2020, the Cass Review writes that it advocates extreme caution with puberty blockers under 18 (source).
Social transition in young children is not a neutral step
Some parents and professionals propose immediately responding to a child who says they are ‘really’ the other sex by using a new name, different pronouns and different clothing. Within healthcare, the Cass Review calls social transition an ‘active intervention’ (translated), because it can have significant effects on the child’s psychological functioning and on longer-term outcomes (source). According to the report, views differ: some think social transition can improve mental health, others that a child who might have stopped experiencing gender dysphoria around puberty takes a different course that ends in medical treatment. The systematic review for the Cass Review found no clear evidence that social transition in childhood has positive or negative effects on mental health. Those who had previously socially transitioned did more often go on to a medical pathway, although according to the report these studies cannot show whether the social transition caused this (same source).
The Cass Review points out that for children the attitude and beliefs of parents influence the possibility of socially transitioning, whereas adolescents have more agency of their own. The report advises that families deciding on a social transition of a child before puberty be seen as early as possible by a clinical professional with relevant experience (recommendation 4; same source). See also Social transition in children.
What parents and the surrounding environment can do
It is tempting for parents either to affirm everything immediately (“otherwise the child will be unhappy”) or to reject everything outright. A child needs adults who listen and allow space. The Cass Review advises healthcare professionals to help families recognise normal variation in gender role behaviour, avoid premature decisions and consider choosing a partial rather than a full transition, so that options remain open (source). According to the systematic review for the Cass Review, young people in gender care more often have co-occurring problems, such as autism, ADHD, anxiety, depression and eating disorders; the report asks that care also assess and address those needs (same source). See also The role of parents.
Gender identity and sexual orientation are different things
A child who displays gender-atypical behaviour can grow up to be a homosexual or bisexual adult without gender dysphoria (source). It is therefore important not to conflate the two: a sensitive boy or an athletic girl is not a ‘trans child in the making’. The history of gay emancipation warns against too quickly medicalising what is in reality a variation in expression or a later sexual orientation. More information can be found in the article about gay and lesbian young people in the gender debate.