I will start by asking two questions: at what age did you know your gender, and do you think someone else had to tell you what it was? I’m director of mental health at a leading gender clinic in the US. Our clinic is a half-decade old – and in that short period the number of families coming to us with questions about their child’s gender has grown astronomically every month.

We’re not alone. The BBC recently reported that the number of children aged ten and under who were referred to the NHS in the UK to help deal with transgender feelings had more than quadrupled in six years.

The main issue that brings children to our clinic is a child in the family who says: “Hey, you’ve got it wrong, I’m not the gender you think I am” or “I do not want to conform to the rules I see around me about how boys are supposed to be boys and girls are supposed to be girls.”

Some of these children are very upset about their gender conundrums; others skip happily outside the gender boxes that were outlined and filled in for them by the culture around them. Yet they all share something in common – feelings about their gender – and depending on how these feelings are negotiated by the adults who care for them, they will either rejoice is their “gender creativity” or suffer from the ill-fit between the gender everyone expects them to be and the gender they know themselves to be.

These feelings can surface as early as the second year of life, when a girl toddler frantically pulls the fancy barrettes out of her hair or a boy toddler wraps his blanket around his head to create long, flowing hair. Or, they can show up much later. Children, like any human, are all different.

All of these children will have had a sex assigned to them at birth. Most children feel quite in sync with that assignment, but a very small number do not. They are the children who often say, in both word and actions: “I’m a boy, not a girl” or: “I’m a girl, not a boy” or come up with some gender category that is neither boy nor girl but something quite in-between.

Other children, fine with the sex assigned to them on their birth certificate but not with the expectations about how they are supposed to perform that gender, might happily engage in the activities that feel best to them, wear the clothes that look nicest to them and play with the children who feel most compatible to them – until they are limited or policed by the socialisation agents in their environment, for example, when a father tells his son that he can’t wear his nail polish in public or a therapist advises parents to take away all their little girl’s “boy” toys. From this point, their feelings may change from jouissance (a sense of unbridled joy or pleasure) to stress or distress if the message mirrored back from the people around them, with strong feeling, is that the way they are “doing” their gender is inappropriate and unacceptable.

An obvious contradiction

In the field of mental health today, and in the general public, a debate is running as to whether young children could possibly know their gender at a young age and whether they might change their mind over time, just as they do about so many other aspects of life. Ironically, if one delves into the Western literature on gender development in young children, such as the work of Robert Stoller or Eleanor Maccoby, or Sigmund Freud before them, we uncover a contradiction.

In traditional theories, it is assumed that children clearly know their own gender by the age of six, based on the sex assigned to them at birth, the early knowledge of that assignment, the gender socialisation that helps a child know how their gender should be performed and the evolving cognitive understanding of the stability of their gender identity. Yet if a child deviates from the sex assigned to them at birth or rejects the rules of gender embedded in the socialisation process, they are assumed to be too young to know their gender, suffering from either gender confusion or a gender disorder.

Following this logic, if you are “cisgender” (your sense of your gender matches the sex assigned on your birth certificate), you can know your gender, but if you are transgender or gender-nonconforming, you cannot possibly know.

Yet a macro survey of transgender adults conducted in the US indicated that a large proportion of respondents knew at an early age what their true gender was – they just kept it under wraps because of social stigma in their childhood years. So we could say that gender-creative children can possibly know their gender – and do, at a very young age.

Messages from brains and minds

Recent clinical observations and research studies, such as a 2013 report from the VU University in Amsterdam, reveal a certain group of young children who are what we refer to in the vernacular as insistent, persistent and consistent in their affirmation of their cross-gender identities. This is not based on the genitalia they perceive between their legs or the gender label given to them by others, but by messages from their own brains and minds.

Research is underway to discover the biopsychosocial pathways to such identities, but it is becoming increasingly clear that chromosomes and external genitalia are not the driving forces for this subgroup of children – our youngest cohort of transgender people.

Those of us who operate within the gender-affirmative model – abiding by the definition of gender health as the child’s opportunity to live in the gender that feels most authentic to them – have developed assessment processes based on the dictum that: “if you listen to the children, you will discover their gender. It is not for us to tell, but for them to say.”

This makes adults nervous, as we were always taught that gender was a bedrock, determined not by the child but by the assessment of the medical professionals delivering the baby: penis for a boy, vagina for a girl. It’s both earthshaking and extremely anxiety provoking to have that trope challenged by young voices who might say to us that we got it wrong. And if the child is wrong and we go along with them, we could make a mess of things by having them bounce back and forth between genders or take the wrong path.

Over the course of time, if we do not impose our own reactions and feelings on the children, like the ones above, and allow a space for their gender narrative to unfold, the gender they know themselves to be will come into clearer focus. From there we can give them the opportunity to transition to the gender that feels most authentic, followed later by the choice to use puberty blockers to put natal puberty on hold and later cross-sex hormones to bring their bodies into better sync with their psyche.

If we do not give them this opportunity, they may feel thwarted, frustrated, despondent, angry, deflated – feelings reflected in the symptoms correlated with being a gender-nonconforming or gender-dysphoric child. The root of these symptoms is not the child’s gender, but rather the environment’s negative reactions to the child’s gender.

When acceptance and allowance of the child to live in their authentic gender replace negation or suppression of a child’s nonconforming gender, the symptoms have been known to subside or disappear completely, much to the surprise of those caring for the child. We might even consider gender as the cure, rather than the problem, privileging the child’s ability to not only feel, but know their gender.