Olivia loves Disney’s Frozen princesses, all things sparkly, bright tights and ballet. During her family’s Cuban vacation last summer, she danced in the children’s “mini-disco” before the evening shows, twirling and leaping across the stage. One night another guest turned to her parents, exclaiming, “Your daughter is the girliest girl I’ve ever seen!”

Olivia was born a boy.

She “socially transitioned” from male to female, in nursery school last year. She was four years old.

Today, she attends kindergarten at a Montreal primary school. Only her teachers and the school board know she is transgender, for now.

Olivia (not her real name to protect her identity) is part of a growing phenomenon that is being celebrated but which is also raising strong emotions: an increasing number of children as young as preschoolers appearing at gender identity-clinics across the country, convinced they are of the opposite sex.

As society becomes more accepting of LGBT people — witness a famed Olympian’s male-to-female transition playing out in the glossy pages of celebrity magazines, and trans rights bills and laws mandating gender-neutral bathrooms making their way through legislatures — families are increasingly supporting, not forbidding, their children to live in the gender they feel, and not the one “assigned” at birth.

“We don’t get a lot of demand for ‘Fix my child,’ or ‘Change my child,’ thankfully,” says Dr. Stephen Feder, co-director of the Children’s Hospital of Eastern Ontario’s gender diversity clinic in Ottawa.

But the proliferation of gender clinics and the growing trend to “socially transition” children barely out of toddlerhood are raising some thorny questions, among them: how can a four- or five-year-old possibly know their gender at such a young age? When is too young to begin the changeover?

Doctors say they are seeing a slow, but steady increase in referrals for children as young as three and four displaying “gender non-conforming behaviours” that run a spectrum, from boys dressing in stereotypical “girlish” clothes, or sometimes even pretending to not have a penis by pushing it between their legs, to “gender dysphoria” — psychiatry’s label for the distress that may accompany the “incongruence” or mismatch between “one’s experienced or expressed gender and one’s assigned gender.”

“I’ve had children say, ‘God made a mistake,’ or, ‘when will my penis fall off,’ or ‘when will I grow a penis,’” says Feder.

He and others in his field were outraged when two Alberta family court judges, in a bitter custody dispute involving a five-year-old in Medicine Hat, ruled that the child, born male, couldn’t wear girls’ clothes in public.

Experts called the restriction (later lifted by a third judge on the advice of a court-appointed child psychologist, according to the child’s mother) ludicrous and potentially dangerous. Many said it smacked of prejudice and want to outlaw, as Ontario has already done, “reparative,” or “conversion” therapies that posit there’s a certain plasticity, or malleability to a child’s brain so that the right intervention could somehow cure them of their gender nonconformity. In other words, don’t let a boy play with Barbie or wear sparkly eye shadow and there’s a good chance his brain will respond and revert back to identifying with his anatomical sex.

Groups such as the Canadian Paediatric Society have denounced that approach as unethical.

Still, the issue of persistence is a minefield. One widely quoted study co-authored by Dr. Kenneth Zucker — the controversial psychologist and sexologist who last year was ousted from his 30-year directorship of the Centre for Addiction and Mental Health’s gender-identity services after an external review concluded that not all his practices, according to CAMH, were “in step with the latest thinking” — reported 80 per cent of children treated for gender dysphoria are no longer expressing gender identity issues by high school. They grew to accept the sex they were “assigned” at birth.

However, critics say the study didn’t distinguish between children with “consistent, persistent and insistent” gender dysphoria (a diagnostic criterion) and boys who just liked to play with dolls or girls who acted more masculine but were never truly trans to begin with.

Feder argues treatment of the child shouldn’t be sidetracked by any “statistical predictions.”

“It is probably safe to say that those who are most entrenched in gender expression that is different from their assigned gender are most likely to identify as trans after puberty.”

The research, however, is sparse. Doctors aren’t aware of any cause. There’s some speculation around exposure to hormones in the womb, but Feder and others say what’s clear is that transgender isn’t an “acquired phenomenon,” or the result of exposure to a particular experience or abuse. “It’s part of their biology,” he says. “Why their biology turns out in that way, I don’t think that’s known.”

Sydney Webster’s hair used to be long, though it was never loose but always braided or in a ponytail. Whenever people would say, “You’re such a princess,” it seemed to bother Sydney.

As a toddler, Sydney had a drawer full of dresses and skirts — none ever worn. Sydney liked wrestling and playing with boys, cars and trucks. Mother Angie Webster couldn’t put her finger on it but says she always sensed her only child felt somehow lost.

This past spring, Sydney told Angie, “I feel like a boy, mom.”

No mom, I feel like a boy

“I said, ‘so you like to play with boys, and things boys would typically like to play with.’ And he said, ‘no mom, I feel like a boy.’ ”

Sydney asked to have his head shaved. When Angie and her husband, Cole, a geologist, agreed to have it cut short and scrubby first, not entirely bald, “the look of confidence on his face, he was just so happy.”

He asked to start using male washrooms (which he did). He asked his parents not to correct others when they called him a boy. Then, in September, “he told us he wanted us to use male pronouns,” Angie says. Sydney (his birth name) returned to school for second grade as a boy.

The family says it has received overwhelming support from the school and the Calgary Board of Education, which earlier this year strengthened and entrenched rules around gender diversity under Alberta’s Bill 10.

“Until he told me, ‘I feel like a boy,’ I could sense he was searching for something,” Angie said. “I’ve never really been someone who, you know, when you hold your baby and imagine their life and imagine them getting married. I’ve always just loved Sydney. Sydney is just Sydney to me.”

Sydney has told his parents he doesn’t want to go through puberty as female. “He wants to have a beard; he wants to experience being like a man, fully, physically,” his mother says.

“For now, Syd is able to just enjoying being a kid. It’s all very innocent. But I know in the future, as Sydney approaches puberty, he, and we, will have some important grown-up decisions to make.”

What at birth defines our gender? It’s not our “externals,” says Dr. Norman Spack, co-director of the Gender Management Service program at Boston Children’s Hospital.

Gender is different from anatomic sex, and from sexual orientation. It describes our self-concept, Spack said in a 2014 TED talk. “Do you see yourself as male or female or somewhere in the spectrum in between?”

Spack says it’s normal for children to act in a “cross-gender play and way.” However, by puberty — 10 to 12 for girls, 12 to 14 for boys — a child who is still convinced “they are in absolutely the wrong body is almost certain to be transgender and is extremely unlikely to change those feelings no matter how anybody tries reparative therapy or any other noxious things,” Spack says.

Doctors argue that using puberty blockers gives children time to explore their gender identity, without the trauma of watching their bodies evolve into the “wrong” sex. Feder describes trans boys (female to male) who wanted to cut their breasts off, or who bound them with tensor bandages.

But others argue gender isn’t fully formed until a child goes through puberty. Ethicists, as well, question when children are mature enough to provide informed consent, or fully appreciate what it is they are agreeing to, not just puberty blockers that can affect bone density, but later, cross-sex hormones — estrogen so the trans girl develops a more rounded figure, testosterone to give trans boys a more angular jaw and masculine physique. What happens if they begin medically transitioning and change their minds? How far do we intervene with a young child?

“We don’t have a lot of data that say, if we do this, stop puberty, are you happy later on,” says bioethicist Arthur Caplan.

When you’re dealing with a young kid, it’s really murky

“It’s one thing to be respectful of what an adult chooses to do. But when you’re dealing with a young kid, it’s really murky.”

Others such as the University of Washington’s Kristina Olson insist that the only intervention being made with the youngest children is a non-medical and entirely reversible one — a social transition.

A newly published study by Olson and colleagues tracking American and Canadian transgender children report those who socially transitioned have no higher rates of depression than their non-trans siblings, or a group of age- and gender-matched “controls,” and only slightly higher rates of anxiety, a finding that’s in stark contrast to other studies showing higher rates of depression, anxiety, suicidal thinking and self-harm among teens and young adults prevented from social transitioning when they were younger.

Those who work with transgender children argue parents aren’t being pushed into socially transitioning every child who isn’t conforming to cultural gender norms.

Even with the Medicine Hat case, “I think there’s an assumption that because this child wished to express their gender in a certain way, that automatically meant that the kid was going to be transgender later on. That may or may not be the case,” says Dr. Joey Bonifacio, a Toronto pediatrician and adolescent medicine specialist.

However, “if a child is presenting at age three, four or five, there probably is something that is biological that we haven’t yet found,” Bonifacio says.

Olivia’s mother is a university economics professor, her father a project leader in materials science. They view the world through a scientific lens and, so, when Olivia kept announcing, beginning at age two, ‘when I grow up, I will be a girl,’ they tried to rule out the variables. When she hung shirts on her head and down her back to pretend she had long hair, was it all just innocent make-believe? When she pulled skirts out of the daycare dress-up box and almost only ever played with the girls, was it because some of the boys were so rough?

“We thought, maybe he can’t find his place,” Olivia’s father says. So they switched daycares. “The same thing happened.”

Her parents turned to the gender variance clinic at Montreal Children’s Hospital, where they were encouraged to “open her horizons,” her father remembers. They bought dresses and skirts. Early this year, Olivia switched to a feminine name and using the feminine pronouns “she” and “her.” Recently, her parents, under Quebec’s Bill 103, changed her birth name and gender on her birth certificate. She feels, and “presents” herself to others as a girl, and her parents are raising her accordingly.

Olivia’s transition hasn’t been easy. At the daycare where she transitioned, the teachers refused for weeks to call her by her chosen female name. “They let the other children make comments — ‘you’re not a real girl,’ ‘you have a boy face,’ without understanding these comments are a form of intimidation, affecting Olivia’s self-esteem,” her mother says.

She thinks parents are judged more when a child transitions at such a young age. “We received many looks that implicitly said, ‘They’re messing up their boy by letting him wear girl clothes and believe he is a girl. What freaks, what are they thinking? Did they want a girl? Or aren’t they able to tell their boy that he is and should act as a boy?’ ”

“Gender is non-binary,” Olivia’s father argues. “Later on she may continue to be a girl, or she may be more fluid or androgynous. We don’t know yet.

“So things are more complicated than, ‘We understand. She’s a girl forever.’ ”

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