“Two little boys, how lovely! And so close in age, they’ll be tearing around getting muddy and kicking balls together.”
How many times did I hear comments like that? And how much further from the truth could they have been? I do have two boys. That much is true, although they’re not little anymore. My oldest, Lachie, is fifteen, and my youngest, Sam, is nearly fourteen. They are awesome kids, and it was great having just nineteen months between them, especially when they were little. They were always both super sleepers. We lived on an 8-acre lifestyle block, and with one of us on the tractor and another on the ride-on, we could get all the lawns mowed in afternoon nap time—the very definition of blissful, bucolic family life.
But the kids never took much to their rural surroundings. The rugby ball sat on the shelf in the garage unloved, and the gumboots were grown out of well before they’d been worn out. Lachie was more interested in books and cars, while Sam just wanted to don a fairy costume and try on all my shoes. It was cute when he was three, a little annoying when he was six, and quite frankly, somewhat alarming when he was nine. And then, finally, I caught up.
He’d quietly waited for the penny to drop in the maternal head. Bless him; he was a patient child. And through his wise guidance and unshakable sense of self, he’s taught me more about gender diversity than any book, podcast, TV show, conference presentation, or interaction with a gender-diverse patient ever could. I guess it’s that old adage that we learn as much about paediatrics from parenting our kids as we do from looking after everyone else’s sick ones—probably more.
Paediatrics can be tough. Sometimes, there are lessons we don’t want to learn. The key clinical sign we missed. The resus that went badly. The parental concern we didn’t heed. The diagnosis we failed to consider. But these situations are important opportunities to learn, improve, and do better next time.
Parenting can be tough, too. The toddler with tantrums. The teenager who won’t get off his device. The kid who won’t conform. This last one was my nemesis. Why couldn’t he just be normal?! I’m ashamed to admit how often that thought crossed my mind in the early days. But Sam stuck with me. He gave me time and space to learn to love him for who he is, always was, and always will be. As said, he is a patient child.
Not many of you will be lucky enough to have a gender-diverse young person in your life, so I will do my best to share some of the most valuable lessons mine has taught me.
1. Never assume
You’re on a busy shift in ED. The nurse tells you he thinks the child in room 12 is ready for discharge, and they need the bed. You’ve not met them before, but you’d like to help, so you go to review them. It’s a 3-year-old girl with preschool asthma. She looks lively, and the middle-aged woman in the room with her struggles to manage her presumably prednisolone-driven exuberance.
“Hello, you must be Grandma?”
You know what’s coming, right? We’ve all been there.
“Um, no, I’m Mum.”
Oops.
Want a worse one? Just this year, I’m at Sam’s parent-teacher interviews. We went to see the maths teacher. Now, Sam goes to a private co-educational school just by way of an explanation. They have a very strict uniform policy – boys wear pants, girls wear a skirt OR pants (different to the boys’ pants, and they don’t look anywhere near the same). They both wear the same shirt and tie. There are also strict rules regarding hair – boys must have short hair off the collar, while girls can have short or long hair, but the latter needs to be tied up neatly. No long hair for boys. Unless you’re Sam. His mother fought hard for that one. So, Sam wears the boys’ uniform but has long blonde hair tied back neatly, as per the requirements. Although everyone calls him Sam, his full name is Samuel – it’s on his student record, along with “Gender – male”, given that there are only two options.
So, back to the maths teacher. Her face lights up when she sees Sam enter the room.
“Hi Sam, so good to see you!” She clearly likes him. I’m not surprised – he’s a bit of a suck-up.
“Hi Miss, this is my Mum,” he says, unfailingly polite, as always. I glow a little with maternal pride.
“Nice to meet you, Mrs. Wallace. I so enjoy having Sam in my class. You have such a lovely daughter.”
I steal a quick sidelong glance at Sam. He nods almost imperceptibly, and my gaze returns to the teacher.
“Oh thank you, that’s so kind of you, but Sam’s actually a boy.”
The teacher pales, and there’s a deathly hush for a few seconds. I know what it feels like, and neither Sam nor I want her to despair. Sam beats me to it.
“It’s OK Miss,” he says. “It happens all the time.”
Unfortunately, this is true. Sam gets misgendered constantly, even in settings where people should know.
We all make assumptions, even in the face of quite convincing evidence to the contrary. Call it confirmation bias if you like. Really, though, it’s just an illustration of the natural human tendency to think that our world is the same one everyone else lives in. Long hair = girl. Middle-aged woman = Grandma. We all do it, but making assumptions is bound to lead to error sooner or later.
So, lesson #1: Never assume. Gender identity. Sexual Identity. Parental status. Social status. Ethnicity. Affluence. Health beliefs. Anything at all. Instead, be curious and ask questions, exercising caution, diplomacy, and kindness, especially at first meetings. Sam assures me that it’s perfectly okay to ask. And use all the available evidence as objectively as you can.
2. It’s not a phase, it’s not a choice
“Oh, don’t worry, it’s just a phase…” How many times do we hear that as parents? And how many times have we said it as Paediatricians? I can’t tell you how many people said that to me about Sam, even when he was much older when it was very clear that this was not a phase.
Sam is indeed living proof that gender diversity is not a phase. As soon as he could express his thoughts, personality and the characteristics that make him the individual he is, it was clear he was different. He gravitated to pretty, shiny, sparkly things. He loved dresses and high heels. His most important toys were his teddies and dollies. Angelina Ballerina was his favourite DVD. His friends were all girls. I say this like it was all obvious to me at the time. Of course, it wasn’t.
Sam was nine before I finally cottoned on, and he began expressing his gender identity more publicly. But it wasn’t Sam who changed at that time – he was always the same person, constantly giving me clear and direct messages about who he is. With the benefit of hindsight, I realise now how long I ignored this information. It is, and will always be, my greatest parental shame that it took me so long to work out that this was not a phase nor a deliberate choice on Sam’s part. Sam is the person he is, he has always been this person, and he always will be. End of story.
So, lesson #2: It’s not a phase, and it’s not a choice. Gender-diverse people are born this way. Young people are not coerced or influenced into gender diversity through peer or media pressure. It’s really, really hard to be different. No young person would choose gender diversity if cis-gender conformity were an option.
3. The world is very binary
Before I had a gender-diverse child, I never stopped to think about just how binary the world is when it comes to gender. The children’s clothes section in department stores is divided into boys’ and girls’ sections. Toys are purposefully marketed by gender—pink fluffy things for the girls, blue macho things for the boys. Teachers ask kids to line up in groups of boys and girls.
“Really?” you might ask. “Are we still doing these things?”
Yep, we sure are. Last term, Sam’s weekly class sports session was divided so the boys played badminton and the girls played table tennis. Which group was Sam supposed to go in? For the record, he went with the boys – although several kids asked him why he was in “their” group. He felt uncomfortable and out of place. After a discussion at home, Sam politely pointed out by email to the sports teacher that this division of groups was unhelpful, unnecessary, and outdated, which she appropriately acknowledged. The grouping wasn’t changed, though, and it was Sam’s responsibility to identify the error and advocate with the adults, who should know better.
So, lesson #3: Recognise how often we still group by binary gender and use your influence—as a health professional, a parent, or a concerned citizen—to stop that happening. Don’t leave it to gender diverse people to do all this work. They fight a hard battle every day just being true to who they are; they have enough to deal with. And aside from anything else, grouping by binary gender is completely uninspiring. There are so many more imaginative and inclusive options.
4. Gender diversity is complex
This one probably goes without saying to many of you, but when I started learning about gender diversity a few years ago, I had no understanding of just how clueless I was. I knew what LGBTQI+ stood for. Tick. I knew about the Rainbow community and wore a rainbow pin on my lanyard at work. Tick. The kids had even had their hair cut for a while by a very kind and lovely person who wore a dress and heels while sporting a heavy beard. Big tick. I was all over it like a rash.
Not. Especially when it came to understanding my child.
Sam is, I think, gender-fluid. That means he sometimes identifies as a boy, for example, when he goes to school or is out and about in town when he wears “boy” or at least “gender-neutral” clothing. He uses he/him as his pronouns at school and is happy to stick with that for people who know him. At other times, he prefers to present as a girl, for example, at home, when away on holiday, or with trusted friends. He wears dresses (he has many), pretty shoes, and at times, when he thinks I’m not looking, puts on make-up. He’ll always be called a girl if he meets someone he doesn’t know when being this version of Sam. I’m used to people telling me I have a lovely daughter now. It’s a little weird, but I’m rolling with it.
If I’m honest, I think it’s pretty clear Sam is happiest and most “himself” when presenting as a girl. But he understands the practicalities and decided early on that he wouldn’t change. He wants to be a parent. And I think a part of him still sees himself as male. Ultimately, though, he realises that once puberty hits, he’ll no longer be afforded the opportunity of choosing to present as either male or female. He can get away with it now, but that time will soon pass.
So, then, what? Does he walk the middle line and go with the gender-neutral option, choosing clothing that could go either way and keeping everyone guessing? Sounds sensible, but it’s a far cry from his love for frocks and frills. Does he “own it” and embrace the dress plus beard look? Maybe. Or does he take a leaf from Harry Styles’ playbook, wearing whatever he wants and being super-cool in the process? Not many “ordinary” people can truly get away with that. Society is accepting – for some, in high places. There are limits.
The truth is, I don’t know what will happen, but I do know that Sam will sort it out. As a much younger person, he’s done that so far, initially with completely ignorant parents, so I reckon he’ll sort it out again, this time with unconditional support.
So, lesson #4: Gender diversity is complex. Not all gender-diverse people think the same way, have the same struggles or wish to express their gender diversity publicly. We group gender-diverse people for convenience, but it behoves us to realise, especially as healthcare professionals, that everyone is an individual—the only opinion on how a gender-diverse person expresses themselves that matters is their opinion.
5. Gender identity is NOT sexual identity
Well, I’m owning up to the depths of my ignorance with this one. Apologies to all of you for whom this is, and always has been, abundantly clear. But it took a 12-year-old Sam to point this out to me.
It’s pretty simple. Being gender diverse does NOT mean that person is gay. That’s all, folks.
This is something Sam is particularly prickly about. He is completely good with being seen as part of the Rainbow community. He’s proud of it. He goes to Rainbow Club at school and has a rainbow flag in his bedroom. But ask him if he’s gay, and the hackles go up. He’s been very clear about this since we first discussed it, when he started wearing dresses to primary school. He likes girls. He always has. Along with the fact that he wants to be a parent one day, it’s part of the reason he decided not to pursue transitioning to female.
At least to some extent, this issue arises because LGBTQI+ people are grouped together. For good reason – there’s strength in numbers, and people who are different naturally understand what it feels like to be different. There’s no need to explain. They just get it. That’s why Sam likes Rainbow Club. It’s a safe space to be himself without people asking questions. The problem comes when everyone lumped into the group gets attributed all the same characteristics.
So, lesson #5: Gender identity and sexual identity are not the same thing. Shades of lessons #1 and #4 here – don’t make assumptions, and remember that everyone is an individual.
6. There’s a lot they don’t tell you
It’s taken me a long time to realise that Sam has to deal with the difficulties his gender diversity brings all the time. Every. Single. Day. He doesn’t tell me about it all. I suspect he only tells me a tiny proportion of the things he manages. For him, it’s normal.
Having some younger kid come up to you in the lunch queue and ask if you’re a boy or a girl? Normal. Having the reliever teacher (or maths teacher) call you a girl? Normal. Working out where you can safely get changed into your PE kit? Normal. Worrying about whether what you want to wear for non-uniform days will provoke harassment? Normal.
Except, these things aren’t normal – or at least, they shouldn’t be. It hurts my heart every time I hear Sam mention something like this that someone said or did. Every time he is “othered”, or excluded, or made to feel like a freak. And that’s probably why he doesn’t tell me.
I’m sure we are all well aware of just how difficult it is to be an adolescent these days – social media, living life online, school pressures and often dysfunctional family dynamics, not to mention the raging hormones, bad skin, and bamboozling body changes. Try adding dealing with gender diversity on top of that, and you have a tinderbox of potential mental health issues, even with a super-supportive, well-resourced family behind you.
So, lesson #6: There’s a lot they don’t tell you, especially if they think you won’t understand, won’t be supportive, or if they’re worried you might find it upsetting. The first two are most relevant for us as clinicians, and the last one is for parents. Be aware, and be curious. Talk to your gender-diverse patients with kindness and acceptance – if they start telling you the bad stuff, you’re winning.
7. Bathrooms are stressful
I’ve already hinted at this one with the PE kit comment. This is a biggie for Sam. His school has two “unisex” bathrooms on a campus covering about 10 acres. One is in the Senior block, reserved for Year 13 students, and the other is somewhere in the depths of the classroom blocks. The lock hasn’t worked on the second one all year, and it still hasn’t been fixed despite Sam and a buddy from Rainbow Club making an appointment to discuss it with the Headmaster. Hmmm.
In the school gym, where push comes to shove with getting your kit off in front of your peers, there are only male and female bathrooms.
Sam uses the male bathroom, as he presents at school as male. Sounds straightforward enough, except, of course, it’s not. He’s constantly on high alert, attempting to strategise ways to find a safer place to change. This might sound like an overzealous concern on his part. Still, perhaps you will understand better when I tell you that two years ago, a group of six older boys saw him go into the male bathroom at the gym and chased in after him, shouting and laughing and demanding to know why there was a girl in the boys’ changing room. Sam barricaded himself in a toilet cubicle while they beat on the door and continued the tirade. Eventually, a teacher heard the ruckus and found Sam cowering in the cubicle. The boys scarpered and were not held to account. Sam bears the scars, and once again, my heart hurts for him.
This should be an easy problem to solve, especially in Sam’s well-resourced school environment. It seems not, though, and I am sure this is a daily stress for many of our gender-diverse young people, both in school and in the community. Even when we are out in town together, and Sam needs to use the loo, we have a conversation about which one would be best to use. Usually, I take him into the women’s with me. But I can’t be there all the time.
So, lesson #7: Think about bathrooms for gender-diverse young people. What’s available in your clinical setting or the school your kids attend? What do the signs say? Changing a sign on a bathroom door is such a low-level, cheap intervention, but it can be monumentally important for gender-diverse people.
8. Good things take time
Hormones are bloody tricky things. I feel like I’m qualified to say that, given that I’m menopausal at the moment. We’re all aware of the conflicting arguments circulating currently around puberty blockers – the risks and benefits, the ethics, and the consent issues.
Sam made an independent decision early on that he didn’t want puberty blockers. He would ride the wave and see where it took him, knowing that the door was always open for discussion and support should he change his mind. At nearly 14 now, he’s been most fortunate to be a “late bloomer”, only recently starting to show any meaningful pubertal changes and still being able to “get away” with presenting as a girl. I’m not sure how he would have handled that if puberty had dawned earlier for him. Maybe we would have found ourselves knocking on the puberty blocker door – I was OK with that if it was needed.
The thing is, puberty blockers buy time. I didn’t realise how important this could be when I boldly navigated the first puberty blocker conversation I had with Sam several years ago. Fortunately for us, Mother Nature did the job for him herself. But for other kids questioning their gender identity, early or even normal timing of puberty takes away the opportunity to consider the options and work out who they want to be. Can we expect a 12-year-old to know if she wants to become a he for the rest of their life? Yikes, that sounds pretty stressful. What if they get it wrong? What if they change their mind?
For other young adolescents who are more certain about their gender identity, the onset of pubertal changes can invoke anxiety, depression or dysphoria. For these kids, puberty blockers buy time to support their mental health while they learn about the options and make a plan for transition. In either case, these are major life decisions we ask young people to make, sometimes without support or understanding from their families.
So, lesson #8: Good things take time. Young people questioning their gender identity deserve the opportunity to make these big life decisions with enough time to consider the options, appropriate guidance from health professionals and trusted adults, and support for any associated mental health issues. Puberty blockers can provide that, and offering them should be considered the standard of care for gender-diverse adolescents.
9. It’s the grown-ups who struggle the most
Sorry to tell you this, but WE are the problem. Many of you probably know that already. This has never been more apparent to me than through observing and conversing with friends, colleagues, and family about Sam’s gender diversity.
The older you are, the harder it is to get your head around. Of course, that’s a gross generalisation – but you get the gist. The immediate, unquestioning and kind acceptance of Sam demonstrated by his older brother’s friends has blown me away. They didn’t even bat an eye. The same was true of Sam’s friends at primary school, where he wore either the boys’ or the girls’ uniform as the mood took him for the last two years. The innately binary uniform rules at the current school forced him to decide that he was a boy at high school, so none of his school friends knew the true story. Except, I bet they do. They’re clever, they know. And the vast majority of them would just think, “Well, that’s Sam” because it is.
We are crusty adults, though, and we’re a different story. Teachers, parents of school friends, and even some of my paediatric colleagues, people I thought would be understanding and aware, have simply not been. The grandparents were the hardest. I get it; the world is so different from the one they grew up in. They got there eventually, with time and talking, and now they’re Sam’s biggest fans. Of course they are; they love him. I’m not sure they would be quite so accepting of other gender-diverse young people, though.
In some regards, this gives me hope. Young people are our future. Sam will grow up and live, work, and function largely in a community of his same-aged peers, and they seem to have this sorted—mostly. Posie Parker and her cronies will be long gone. But for the moment, we are still a society divided on this issue. Thanks, Posie.
So, lesson #9: Embrace your inner young person and lean into acceptance of gender diversity, even if you struggle to understand it. It’s not hard to do if you consider that every gender-diverse person is someone’s child, grandchild, sibling, or friend, and everyone deserves acceptance and unconditional love. If my ancient parents can do it, then you can, too.
10. This is me – love me for who I am
Recently, I find myself catching a glance at Sam every now and then, and just thinking how amazing he is. He might be in his school uniform; he might be wearing a dress. Either way, he still looks like a girl – at the moment, anyway, and people persist in telling me I have a lovely daughter. It truly doesn’t bother me anymore.
Sam is Sam. He’s doing him, and really, he’s pretty wonderful. I know that sounds corny, and of course, I’m biased, but indulge me a little here – he is an amazing young person. I’m in awe every day of his strength and courage to face the world authentically as Sam and to make his own decisions about how he does that. I know there will be challenges ahead, and Sam knows that, too. But it’ll be OK, as long as Sam is truly loved as the person he is by the important people in his life. And believe me, he is.
I trust that at least a few of you have got to the end of this and found some hope, enlightenment, shared experiences, and understanding. Life can be a rocky path at times, and we all have struggles. Perhaps we can lighten the load for our gender-diverse young people by learning some lessons from Sam.
