Pink Boys with Puppy Dog Tails
Human Bodies
Alice Dreger, 12/06/2010

Pink Boys with Puppy Dog Tails

(Human Bodies) Permanent link

In my e-mail in-box a few weeks ago, I received a polite message from a woman named Sarah Hoffman who was writing to ask why I was being such a gender conservative. Sarah didn’t quite put it that way, but that was the gist of her message, and given that I’m usually accused of being a gender radical, I sat up and listened. And as I read the whole of Sarah’s message, I realized she was absolutely right.

Sarah identifies herself as a mother of a “pink boy” – a boy whose manner of play and dress has often tended toward what’s common in girls. Sarah was writing to me specifically in response to a piece I’d written for the Hastings Center Report called “Gender Identity Disorder in Childhood: Inconclusive Advice to Parents.” There I had outlined the two basic clinical approaches taken to children labeled as having “gender identity disorder,” and had mentioned my sympathies for and reservations about each.

The approach I called “therapeutic” seeks to see a child’s gender dysphoria evaporate, if at all possible. This typically involves strictly limiting the child’s access to gender-atypical activities and trying to help the child adjust to fit a social environment that (supposedly) requires gender divisions. It also often involves family therapy.

Though it would seem to promise to make a child more comfortable with his body, there’s very little data that the therapeutic approach “works.” Moreover, the proponents of it have tended to be obsessed with measuring outcomes in terms of ultimate gender identity and sexual orientation rather than ultimate well-being, which surely is what should really matter.

By contrast, the approach I called “accommodating” seeks to prepare the gender dysphoric child for a transgendered life – a life that will ultimately involve hormonal and surgical sex change. Though it seems superficially more gender progressive, the problem I have with this approach is that it may end up sending more children down a high-medical-intervention path than is really necessary to maximize well-being in the population of children who go through gender dysphoria.

“You’ve done a good job of outlining the warring factions,” Sarah told me. But, she added, “I think that there is a third, quieter point of view – the perspective that, sure, transgender kids exist, but really, most of these gender-nonconforming kids are just kids who don't fall to the most-masculine or most-feminine ends of the spectrum, and that's okay. They don't need treatment, they don't need sexual reassignment, they just need a supportive home life, schools with anti-bullying protocols, and therapy for any harassment they face for being different.”

I felt kind of stupid reading Sarah’s message, because I realized that I had, in fact, left out this approach. I had targeted my article to parents who report that their male children are insisting they are girls or that their female children are insisting they are boys. But the truth is, as Sarah was suggesting, that a lot of “gender nonconforming” kids don’t have a simple story of being “trapped in the wrong body.” They are expressing more subtle, more complex, and more varied messages of self. What they need isn’t therapy; what they need is to know that it’s okay to be gender nonconforming. It’s perfectly okay to be a male who has feminine-typical interests, behaviors, and desires, or a female who has masculine-typical interests, behaviors, and desires.

Take Sarah’s son Sam as an example. Starting in toddlerhood and continuing through early elementary school, Sam expressed an interest in wearing a dress. Sarah, being progressive, didn’t see Sam’s wish as his unruly desire to collapse the social order. She didn’t see it as a sign of a profound mental illness. She saw a boy who wanted to wear a dress. And, as she pointed out to me, we don’t think so much (anymore) of girls who want to wear cargo pants. So why get so upset about Sam’s wish? Why not just recognize that he’s gender nonconforming and understand that if he gets bullied for that, the problem is the bullying and the suffering he is made to experience by the bully?

I asked Sarah if we could converse by phone more about this, and we ended up talking for about an hour, and then more in follow-up e-mails. It was quickly obvious to me that Sarah was right: In my essay, I had set my expectations for parents’ and schools’ abilities to adjust way too low. This was rather disappointing, I have to say, in that I’m constantly criticizing health care professionals for setting their expectations of parents of “different” children too low.

“You basically said in the essay that, in our culture, we don’t have a space for boys who are gender nonconforming, that they’ve got to conform or cross over into girlhood,” Sarah told me. “But our culture has, over the years, made space for women: to dress how they want, to vote how they want, to act however they want in the home and as parents, and we continue to make progress for girls and women.”

So why not allow our culture the same potential for growth where males are concerned? “We don’t have to accept that our culture is unwilling to make a space. I’m not a Pollyanna,” Sarah clarified. “I don’t think there will be grand acceptance soon. But I think we can begin to make more space for boys to fully express who they are.”

I asked Sarah if she thought there was ever a good reason for parents of a child with gender nonconformity to seek out clinical help. She answered sensibly again: “I think that, given the social context, a lot of families could benefit from mental health assistance. Children who are gender nonconforming are often persecuted and their families don’t know how to approach that, especially in communities that disallow nonconformity. Some therapists help parents to do the hard work of accepting a child who is different than the one they expected. Fathers – and, interestingly, the more masculine partner in a lesbian couple – tend to have stronger feelings about this. Parents need time to deal with their own issues, and help learning how to support their kids. And if the kids are being bullied, they need tools for dealing with it.”

But, she went on, “there’s nothing inherently wrong with these boys,” boys who might want to wear dresses or take on a traditionally feminine role. I’ve actually written about this, about how in some places, like Samoa, there are systems that welcome such children. So why was I expecting so little progress in North America?

It’s worth keeping in mind that in North America, some of the advocates of the “therapeutic” approach to childhood gender dysphoria have had a very negative view of sexual minorities, and so they’ve sought to “cure” children who might otherwise turn out gay, lesbian, bi, or transgender. That’s changed to some extent, and thank goodness. But now I really think we are seeing a problem coming in on the other end, namely that strong advocates of the accommodation approach are, I worry, too quick to conclude that a gender nonconforming child is destined to be transgender. The move toward transitioning children early may look progressive, but if you step back, you have to wonder why the Samoan approach isn’t the most progressive.

I actually had a (truly) progressive pediatric endocrinologist at one of my talks express just this concern to me a few months ago – the concern that kids are being sent the route of sex-change too quickly. What we know about gender dysphoria in childhood suggests that we don’t actually know that much. Outcomes vary wildly, and it isn’t clear what effects clinical interventions have, if any.

In case it isn’t obvious, sending a child the transgender route is not trivial. Lupron is typically used to delay puberty (to avoid unwanted pubertal changes), but this use of Lupron is off-label and poorly studied. Endocrinologists all over the country have worried to me about the long-term effects of this use. Surgical sex change will render a person infertile, in need of lifelong hormone replacement therapy, and carries significant risk to sexual function and physical health.

Some transgender advocates don’t like to hear this. Because sex change saved their lives – and it really does save lives for people who are transgender – they understandably want children like them to have the best possible experience of transition. The problem is, it just isn’t clear which children are children like them – the children in whom significant gender dysphoria will persist.

What we know is that, in a large percentage of children, gender dysphoria appears to go away (or maybe to become accepted as part of their personalities, so that the pressure to change stops?). We also know that a significant number of gay men report having had interests in wearing typically-feminine clothes and doing traditionally-feminine activities as children. So how on earth can we know when a boy who wants to wear a dress will need an endocrinologist? Or even a psychologist? It’s not that simple.

I’m going to say something incredibly politically incorrect: some pink boys may benefit simply from meeting a swishy gay man – or better yet, two or three such men who can show them you can grow from being a pink boy to a pink man and have (dare I say it?) a fabulous life. I’ve actually met one therapist who whispered to me at a meeting that when he met a “gender dysphoric” pink boy who seemed to need this kind of “intervention,” it’s just what he provided (with a consultation by a colleague). The point was to let the boy know that there were even grown-ups like him, men who love “girly” things like beautiful clothes and Martha Stewart (and, um, men), and who are perfectly at home in their bodies and their selves.

Why can’t you have (and keep) a penis and love sparkles? Lots of men have.

I asked Sarah – who has engaged with many parents in situations similar to hers – about whether she thought some parents seek out the transgender route for their children because it will mean they might end up going from having a gay son to having a straight daughter. Was homophobia motivating these parents?

Sarah observed that what seemed to be motivating many of these parents is what motivates all us parents – the desire for certainty, and maybe some sense that things will feel “normal” somewhere down the line if all goes as planned. Duh again – this is what I wrote about in an essay called “What to Expect When You Have the Child You Weren’t Expecting” in a book, Surgically Shaping Children. There I was writing about children born with norm-challenging bodies, but a boy in a dress – same experience of having the child you weren’t expecting.

Being a parent of a boy who wants to wear sparkles and grow his hair long – especially when you don’t know where it’s all going to go – it’s hard stuff. I’m not being politically incorrect in acknowledging that, am I? I get that parents want to feel like they’re doing what they can to help resolve whatever suffering their child may be feeling, and prevent more suffering in the future. Sometimes they’re sold on the idea that a particular clinical approach will do that. The truth – that we’re not sure what “works” clinically, that it isn’t clear this should even be considered a clinical problem in any conventional sense, but that we are sure that many people still brutalize boys who wear dresses or even just have long hair – is pretty hard to take.

Sarah concluded our conversation this way: “I want to be clear that I believe that people who are truly transgender should have societal support and access to whatever therapeutic care they need. If my own son were transgender, I would love and accept him as I do my gender-normative daughter, just as I will love them whether they are straight, gay, or bisexual. My position does not come out of lack of trans acceptance, it comes from wanting to see broader social acceptance for the entire spectrum of gender expression so that kids can really figure out who they are and not be pushed into a box that doesn’t fit.”

And I’d add that we should especially avoid pushing children into a box that involves surgery and lifelong hormone treatments if it turns out that’s not what they need to be well. Being well needs to be the outcome we measure.

I thank Sarah for helping me through these ideas. I highly recommend Sarah’s blog on raising a “pink boy.”

Alice Dreger is s a professor of clinical medical humanities and bioethics at Northwestern University’s Feinberg School of Medicine.

Posted by Susan Gilbert at 12/06/2010 09:25:54 AM | 

We are not about gender theory.

I'm happy this was posted. I think that I speak for the other authors of and other people like us who were born different, in saying that gender atypical behavior or interests or aspect is a bad reason to reverse one's assignment of sex. It's a practical course of action in our opinion when the socio-sexual problems which are created by being different cannot be solved by any other means other than reassignment. Realistically, this can only be decided by ourselves and should be decided at an age when we are aware of our sexuality because we believe that our sexuality is important and a precious part of our humanity. But if things work out fine without reassignment, if we can somehow work out a practical and happy adult life, no matter how gender different we seem, then fine.

We do not believe that theory, whether about gender or any other part of our lives, is really of value when it comes to our socio-sexual functionality. What matters is what works, what makes us feel alive and part of the world, able to live a life in which we have a chance to attain love and happiness. Like other people.

Kiira Triea
Posted by: ( Email | Visit ) at 12/6/2010 11:39 AM

As a friend of Sarah's, and member of her community of parents, I see you had fallen into the myth of the excluded middle; that we must preserve the gender binary in one of two ways; fixing the gender non-confomings behavior, or their bodies, to match. The excluded middle here are the femme male, the butch female.

Sarah and I live in the most progressive cities in the country, and we have both found that it is possible to exist somewhere in the middle; where a child's gender presentation doesn't map onto any preset anatomical destiny.

My 12 year old son presents as female, has boy and girl friends and interests, goes by whatever pronoun you feel good about, has no interest in puberty blocking or surgery, and is finding his way through life in a supportive community. His self-esteem is strong. He's a good kid.

He gives something to his class, to his community; his freedom creates more freedom, for everyone, to be authentic. There's no downside.

Had he lived somewhere where he had to suppress this side of himself continually, create a fake persona, and hide it at home...would he have ended up where we are now? Accepting himself? Not needing a surgical intervention? There's no way to know.

We don't accommodate; we accept. An accommodation suggests that something is wrong in the first place. We deny that anything is wrong. Our children are like the left handed; they don't need behaviorism to beat this out of them; they need left-handed scissors.

I would never have thought that we could move the culture as fast as we are moving it, but it is possible. We're doing it. We live it.

One cure for some (but not all) Gender Dysphoria which could be listed in the DSM should be moving to San Francisco or Cambridge MA.

Funny, a mental illness which can be cured by a zip code.

You can read about my our family's journey at
Posted by: ( Email | Visit ) at 12/6/2010 2:53 PM

Am I the only one who thinks you are missing another critical point? There is a big difference between a boy wanting to wear a dress and a boy insisting he is a girl. You can simply ask the child "Do you want to be a girl?" and if they say yes ask why. If they just want to be a girl for the toys and dresses just love and support their desire and tell them boys can do those things to. If they say they know they are a girl or they don't want to be a man or it feels right it seems more likely they are trans.

Obviously you should not encourage a child to transition if they just want to play with girls toys or dresses. But if they insist they are a girl and that they want to grow up to be a girl that could be a sign you have a trans child and it may be worth exploring options for transition.

I honestly don't get why this distinction is so common in the adult population (crossdresser or transsexual) but no one mentions it for youths.
Posted by: ( Email ) at 12/15/2010 11:51 AM

nightengale27 is spot on. It should be about choices, not coercing the child into a role that doesn't fit.

From my readings of the research, children who show temporary (less than several years continuous) cross-gendered play patterns are "normal" to use a common phrase.

Those whose cross-sexed play patterns persist over several years are probably going to be gay, or at least bi.

Those where the patterns persist past age 10, and concurrently express the belief that they're really of the opposite sex despite biological difference, should certainly be offered the option of delaying puberty till they're legally competent to decide on permanent measures.

IMHO this should be the age of consent, whatever that may be in that jurisdiction.

Note thay I used the phrases "cross-sexed" and "cross-gendered". These are distinct. The first means biologically and neurologically instinctive behaviours that are sexually dimorphic. For example, the male patterns observed in CAH girls, boys, and juvenile male vervet monkeys and male chimpanzees. They are an indication that parts of the lymbic system have been masculinised.

They are a pretty good predictor (~0.9) of future gynephilia, but less useful(~0.3 in assigned females) for a male "gender identity". If one part of the brain is masculinised to a great degree, it increases the probability of other parts also being masculinised, but is never a 100% certain predictor.

There is no solid evidence that cross-gendered behaviour, that which is not biologically based but a social construct, can be used as an indicator of brain masculinisation.

Our best guide is still to *ask* the child what sex they are.

This means, inter alia, that "normalising" surgery on most Intersexed infants is unwise before they reach their teens.

It also appears that many people (~0.3) are bi-gendered, and can function adequately as either sex, depending on circumstances. Neurological sex is no more a binary than somatic sex in other areas. These bigendered people are unlikely to present clinically though, for obvious reasons, they show no signs of distress with their assigned gender, no matter what that is.

It does mean that early surgical assignation of an arbitrary sex to Intersexed children is only a disaster in 0.3 of cases rather than the 0.5 we would expect if bigender didn't exist. This varies though with the exact syndrome. ~0.9 of XY children with cloacal extrophy will be male. ~0.1 of XX children with CAH will be male. XY plus 5ARD or 17BHDD - ~1/3 of each, M, F, and Bigendered.
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