Gender variant and gender dysphoria in two young children.

CASE: Alexandra is 5 ½ years old, the youngest of four girls, and lives with her parents. She is described by her teachers as a thoughtful, imaginative girl with a good sense of humor, and strong literacy and math skills. Parents describe her typical mood as happy and easy going. She has many friends and engages in a variety of play activities. At 18 months, Alexandra insisted on wearing boys' underwear before she would complete toilet training. At 3 years, she told her parents that she "should have been a boy," and insisted on wearing boys' clothes. Alexandra now refuses to wear dresses and wears a coat and tie to formal occasions, which has led to conflicts with her grandparents. During make-believe play, Alexandra always chooses to play the male roles. She keeps her hair short and her dress and mannerisms are so masculine that people who do not know her assume that she is a boy. Alexandra makes frequent statements about being or wishing she were a boy. When asked directly she says "I'm a girl, but I'm a boy inside. " Her parents have recently become alarmed because Alexandra has begun saying "I hate myself," and once said that when her breasts grow she will "slice them off. " She has recently asked her parents to call her "Alex. " There is no apparent bullying or teasing from other children. Alex's parents are understanding and supportive of her quandary, though they have questions and concems about the long-term implications of these behaviors and choices. Chris is a 9-year-old boy, referred because of his preference for traditionally feminine clothing, toys, and activities. Chris's parents are divorced; he lives with his father and paternal grandparents, visiting his mother once a week. Chris met developmental milestones on time and always seemed "smart" and eager to learn. By 2 years of age, his family noticed that he was attracted to pretty and shiny things like dresses, sequins, and glitter, although he has always worn boys' clothing without complaint. During the next few years, he asked for Barbie dolls for his birthday and seemed fascinated by long blond hair. When coloring, he preferred pink and purple crayons and usually drew female characters, very decorated and with long hair. In comparison, his drawings of himself were small and plain. He occasionally said "I know I'm a boy, but I'm a girl in my head. " His pediatrician advised the family to throw out the dolls and "girlish" toys, emphasize "male" activities, and insist that he draw boys as well as girls. Chris was so distraught by this that he was allowed to keep one Barbie doll, as long as he only played with it indoors and did not talk about the doll with friends. In kindergarten and first grade, Chris played mostly with girls and was not interested in sports or rough-and-tumble play. He was teased by other children and had few friends, mostly girls. He started to have sudden outbursts at home and at school that seemed beyond his control, sometimes kicking walls and punching himself in the head. At the beginning of third grade, Chris agreed to join the soccer team as his father wanted. His family no longer sees him playing with Barbies and he has agreed to a few play dates with new boys in his class. Chris is quieter than he used to be, with fewer outbursts. For his birthday, he privately asked his father's fiance for a blond long-haired wig, but when his father confronted him, he denied it. His father reports that "the phase" has finally passed.