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As mentioned previously, Gender identity is one’s self-conception of their gender. Sex is the term to refer to the biological differences between males and females, such as the genitalia and genetic differences. While gender refers to the socially constructed characteristics of women and men, such as norms, roles, and relationships between groups of women and men. Cisgender is an umbrella term used to describe people whose sense of personal identity and gender corresponds with their birth sex, while transgender is a term used to describe people whose sense of personal identity does not correspond with their birth sex.

Gender expression, or how one demonstrates gender (based on traditional gender role norms related to clothing, behavior, and interactions), can be feminine, masculine, androgynous, or somewhere along a spectrum. Many adolescents use their analytic, hypothetical thinking to question traditional gender roles and expression. If their genetically assigned sex does not line up with their gender identity, they may refer to themselves as transgender, non-binary, or gender-nonconforming.

Fluidity and uncertainty regarding sex and gender are especially common during middle childhood and early adolescence when hormones increase and fluctuate, creating a difficulty of self-acceptance and identity achievement (Reisner et al., 2016). Gender identity is becoming an increasingly prolonged task as attitudes and norms regarding gender keep changing. The roles appropriate for males and females are evolving, and some adolescents may foreclose on a gender identity as a way of dealing with this uncertainty by adopting more stereotypic male or female roles (Sinclair & Carlsson, 2013). Those that identify as transgender or ‘other’ face even more significant challenges.

The biological approach explores how gender identity development is influenced by genetics, biological sex characteristics, brain development, and hormone exposure.

Humans usually have 23 pairs of chromosomes, each containing thousands of genes that govern various aspects of our development. The 23rd pair of chromosomes are called the sex chromosomes. This pair determines a person’s sex, among other functions. Most often, if a person has an XX pair, they will develop into a female, and if they have an XY pair, then they will be male.

Around the sixth week of prenatal development, the SRY gene on the Y chromosome signals the body to develop as a male. This chemical signal triggers a cascade of other hormones that will tell the gonads to develop into testes. If the embryo does not have a Y or the if, for some reason, the SRY gene is missing or not activate, then the embryo will develop female characteristics. The baby is born and lives as a female, but genetically her chromosomes are XY. Rat studies have found that the reverse is also possible. Researchers implanted the SRY gene in rats with XX chromosomes, and the result was male baby mice.

Individuals with atypical chromosomes may also develop differently than their typical XX or XY counterparts. These chromosomal abnormalities include syndromes where a person may have only one sex chromosome or three sex chromosomes. Turner’s Syndrome is a condition where a female has only one X chromosome (XO). This missing chromosome results in a female external appearance but lacking ovaries. These XO females do not mature through puberty like XX females and they may also have webbed skin around the neck. Cognitively, these females tend to have high verbal skills, poor spatial and math skills, and poor social adjustment.

Klinefelter’s Syndrome is a condition where a male has an extra X chromosome (XXY). This XXY combination results in male genitals, although their genitals may be underdeveloped even into adulthood. Even after puberty, they tend to have less body and facial hair and may develop breasts. From infancy, these children often have a passive, cooperative, and shy personality that remains into adulthood. Cognitively, they are often late to talk and have poor language and reading skills.

As we learned in the physical development chapter, sex hormones cause biological changes to the body and brain. While the same sex hormones are present in males and females, the amount of each hormone and the effect of that hormone on the body is different. Males have much higher levels of testosterone than females. In the womb, testosterone causes the development of male sex organs. It also impacts the hypothalamus, causing an enlarged sexually dimorphic nucleus, and results in the ‘masculinization’ of the brain. Around the same time, testosterone may contribute to greater lateralization of the brain, resulting in the two halves working more independently of each other. Testosterone also affects what we often consider male behaviors, such as aggression, competitiveness, visual-spatial skills, and higher sex drive.

Cognitive Learning Theory

Cognitive learning theory states that children develop gender at their own levels. At each stage, the child thinks about gender characteristically. As a child moves forward through stages, their understanding of gender becomes more complex.

The following cognitive model, formulated by Kohlberg, asserts that children recognize their gender identity around age three but do not see it as relatively fixed until the ages of five to seven. This identity marker provides children with a schema, a set of observed or spoken rules for how social or cultural interactions should happen. Information about gender is gathered from the environment; thus, children look for role models to emulate maleness or femaleness as they grow.

Stage 1: Gender Labeling (2-3.5 years). The child can label their gender correctly.

Stage 2: Gender Stability (3.5-4.5 years). The child’s gender remains the same across time.

Stage 3: Gender Constancy (6 years). The child’s gender is independent of external features (e.g., clothing, hairstyle).

Once children form a basic gender identity, they start to develop gender schemas. These gender schemas are organized set of gender-related beliefs that influence behaviors. The formation of these schemas explains the process by which gender stereotypes become so psychologically ingrained in our society.

Gender Schema Theory

Sandra Bem’s Gender Schema Theory, rooted in Piaget’s cognitive developmental theory, views children as active learners who build mental frameworks—or schemas—to understand gender as a social category. Children observe and categorize behaviors, roles, and attributes associated with gender, and over time, they assimilate new information into these schemas or adjust them through accommodation. This process helps refine their understanding of what is considered “appropriate” for each gender based on social input. According to this theory, gender schemas can be organized into four general categories. The sex-type schema is the belief that gender matches biological sex. Sex-reversed schema is when gender is the opposite of biological sex. Possessing both masculine and feminine traits is an androgynous schema. While possessing few masculine or feminine traits is an undifferentiated schema.

Social Learning Theory is based on outward motivational factors that argue that if children receive positive reinforcement, they are motivated to continue a particular behavior. If they receive punishment or other indicators of disapproval, they are more motivated to stop that behavior. In terms of gender development, children receive praise if they engage in culturally appropriate gender displays and punishment if they do not. When aggressiveness in boys is met with acceptance or a “boys will be boys” attitude, but a girl’s aggressiveness earns them little attention, the two children learn different meanings for aggressiveness as it relates to their gender development. Thus, boys may continue being aggressive while girls may drop it out of their repertoire.

Individuals who identify with the role that is different from their biological sex are called transgender. Approximately 1.4 million U.S. adults or .6% of the population are transgender, according to a 2016 report (Flores et al., 2016).

Transgender individuals may choose to alter their bodies through medical interventions such as surgery and hormonal therapy so that their physical being is better aligned with gender identity. They may also be known as male-to-female (MTF) or female-to-male (FTM). Not all transgender individuals choose to alter their bodies; many will maintain their original anatomy but may present themselves to society as another gender. This expression is typically done by adopting the dress, hairstyle, mannerisms, or other characteristics typically assigned to another gender. It is important to note that people who cross-dress or wear clothing that is traditionally assigned to a different gender is not the same as identifying as transgender. Cross-dressing is typically a form of self-expression, entertainment, or personal style, and it is not necessarily an expression against one’s assigned gender (APA 2008).

After years of controversy over the treatment of sex and gender in the American Psychiatric Association Diagnostic and Statistical Manual for Mental Disorders (Drescher 2010), the most recent edition, DSM-5, responded to allegations that the term “gender identity disorder” is stigmatizing by replacing it with “gender dysphoria.” Gender identity disorder as a diagnostic category stigmatized the patient by implying there was something “disordered” about them. Removing the word “disorder” also removed some of the stigmas while still maintaining a diagnosis category that will protect patient access to care, including hormone therapy and gender reassignment surgery.

In the DSM-5, gender dysphoria is a condition of people whose gender at birth is contrary to the one with which they identify. For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized (APA, 2013). Changing the clinical description may contribute to greater acceptance of transgender people in society. A 2017 poll showed that 54% of Americans believe gender is determined by sex at birth, and 32% say society has “gone too far” in accepting transgender people; views are sharply divided along political and religious lines (Salam, 2018).

Many psychologists and the transgender community are now advocating an affirmative approach to transgender identity development. This approach advocates that gender non-conformity is not a pathology but a normal human variation. Gender non-conforming children do not systemically need mental health treatment if they are not “pathological.” However, care-givers of gender non-conforming children can benefit from a mixture of psycho-educational and community-oriented interventions. Some children or teens may benefit from counseling or other interventions to help them cope with familial or societal reactions to their gender-nonconformity.

Studies show that people who identify as transgender are twice as likely to experience assault or discrimination as non-transgender individuals; they are also one and a half times more likely to experience intimidation (National Coalition of Anti-Violence Programs 2010; Giovanniello, 2013). Trans women of color are most likely to be victims of abuse. There are also systematic aggressions, such as “deadnaming,” (whereby trans people are referred to by their birth name and gender), laws restricting transpersons from accessing gender-specific facilities (e.g., bathrooms), or denying protected-class designations to prevent discrimination in housing, schools, and workplaces. Organizations such as the National Coalition of Anti-Violence Programs and Global Action for Trans Equality work to prevent, respond to and end all types of violence against transgender and homosexual individuals. These organizations hope that by educating the public about gender identity and empowering transgender individuals, this violence will end.

Like other domains of identity, stage models for transgender identity development have helped describe a typical progression in identity formation. Lev’s Transgender Emergence Model looks at how trans people come to understand their identity.  Lev is working from a counseling/therapeutic point of view, thus this model talks about what the individual is going through and the responsibility of the counselor.

Stage 1: Awareness. In this first stage of awareness, gender-variant people are often in great distress; the therapeutic task is the normalization of the experiences involved in emerging as transgender.

Stage 2: Seeking Information/Reaching Out. In the second stage, gender-variant people seek to gain education and support about transgenderism; the therapeutic task is to facilitate linkages and encourage outreach.

Stage 3: Disclosure to Significant Others. The third stage involves the disclosure of transgenderism to significant others (spouses, partners, family members, and friends); the therapeutic task involves supporting the transgender person’s integration in the family system.

Stage 4: Exploration (Identity & Self-Labeling). The fourth stage involves the exploration of various (transgender) identities; the therapeutic task is to support the articulation and comfort with one’s gendered identity.

Stage 5: Exploration (Transition Issues & Possible Body Modification). The fifth stage involves exploring options for transition regarding identity, presentation, and body modification; the therapeutic task is the resolution of the decision and advocacy toward their manifestation.

Stage 6: Integration (Acceptance & Post-Transition Issues). In the sixth stage, the gender-variant person can integrate and synthesize (transgender) identity; the therapeutic task is to support adaptation to transition-related issues.