Gender incongruence, or gender nonconforming, a conflict between a person's physical or assigned gender and the gender with which that person identifies, may be something you've heard more about lately. It's likely you have questions, especially if you have a child who is questioning his or her assigned gender.

In my 20 years as an OB-GYN, I've seen patients as young as 4 and as old as 77 who experience this. I started working with the transgender population in 2012 and have since helped establish Mid-Atlantic Permanente Medical Group's transgender health services. I work with patients and their parents, and as a team with other health care providers to make sure patients are correctly identified and get the gender-affirmative care they need.

What exactly is gender incongruence?

Sometimes called gender dysphoria, gender incongruence is the now-preferred term that covers the anxiety, concerns, or depression that can come with people not feeling like they identify with the gender they were assigned at birth. They often feel uncomfortable with their body or the traditional roles associated with their assigned gender. I often explain that gender is defined as the neck up - it's based on social norms and can evolve over time. Sex is the biological differences between males and females.

How is someone diagnosed with gender incongruence?

Gender incongruence isn't a diagnosis so much as a label. Health care providers can help patients whose depression or anxiety is related to gender get the counseling they need. Ultimately, when a primary care provider hears from a patient that he or she is experiencing these issues, I counsel the provider to refer the patient to a behavioral therapist, particularly one who has experience in transgender therapy, who can better figure out if gender incongruence is the cause.

What kinds of therapy are available?

Patients experiencing gender incongruence can go to therapy individually, in groups and with their families. In fact, I recommend at least three simultaneous therapy sessions: a patient sees someone one on one, a patient and his or her parents meet as a group and parents see someone together. A therapist can help parents understand their child's struggles and learn how to best love and support their child. This is also an opportunity for patients and their parents to learn about and discuss what the child's chosen pronouns may be - she/her, he/him, theirs/they, etc. - and what name is preferred. Anything that can create anxiety or depression is important to deal with as early on as possible.

Once patients and their parents go through therapy, siblings and even extended family members can go to counseling. With siblings, I recommend that they go with their parents to group sessions with other families who have children experiencing the same thing.

What about surgery?

Some patients want to take steps to have irreversible medical transitions. The most common surgeries I perform are top surgeries for trans males - those who were assigned a female gender at birth, but have a male gender identity - where a mastectomy is performed and a male chest is created for the patient. This often involves many steps, including therapy, a readiness letter (including questions about what a patient knows about a surgery, who one's support group will be and how to prepare) and the several surgeries once they are approved.

I don't recommend medical transitions for most under 18. Instead, I will often suggest reversible options until patients reach adulthood. This could include hormone blockers, which essentially delay puberty. The majority of states require parental consent before prescribing medication to patients under 18. Patients can also make social transitions, such as choosing another name or pronoun, and dressing or expressing in a way that is more aligned with their gender identity.

Gender incongruence is a complex and delicate topic, but parents can help their children navigate this with the help of experts. Aside from talking to your child's primary care provider and/or contacting a behavioral therapist who has experience working in the transgender community, you can learn more by visiting the American Psychological Association's Office on Sexual Orientation and Gender Diversity's website at apa.org/pi/lgbt.


Books for Patients and Their Parents

When patients and their parents have questions about gender incongruence, I often recommend the following books:

  • "I Am Jazz" by Jessica Herthel, Jazz Jennings and Shelagh McNicholas. This is a children's book about a transgender child. You may be familiar with the TLC reality television show of the same name, which features Jennings.

  • "The Gender Creative Child: Pathways for Nurturing and Supporting Children Who Live Outside Gender Boxes" by Diane Ehrensaft and Norman Spack. This book is a resource for parents on gender-nonconforming children and adolescents.

  • "Red: A Crayon's Story" by Michael Hall. This is a children's book about being true to your inner self and following your own path.


E.W. Emanuel, MD, MBA, is a board-certified obstetrician/gynecologist for the Mid-Atlantic Permanente Medical Group. He sees patients at the Kaiser Permanente Capitol Hill Medical Center.