In her groundbreaking first book, Gender Born, Gender Made, Dr. Diane Ehrensaft coined the term gender creative to describe children whose unique gender expression or sense of identity is not defined by a checkbox on their birth certificate. Now, with The Gender Creative Child, she returns to guide parents and professionals through the rapidly changing cultural, medical, and legal landscape of gender and identity.

In the follow-up to her first book, Dr. Ehrensaft explains the interconnected effects of biology, nurture, and culture to explore why gender can be fluid, rather than binary. As an advocate for the gender affirmative model and with the expertise she has gained over three decades of pioneering work with children and families, she encourages caregivers to listen to each child, learn their particular needs, and support their quest for a true gender self.

The Gender Creative Child unlocks the door to a gender-expansive world, revealing pathways for positive change in our schools, our communities, and the world.

Dr. Ehrensaft, a developmental and clinical psychologist, is the cofounder and director of mental health at the Child and Adolescent Gender Center at the University of California–San Francisco. She is an associate professor of pediatrics, and an attending psychologist at the Benioff Children’s Hospital Child and Adolescent Gender Clinic. Her work with—and advocacy for—gender creative children has been widely covered, including by The New York Times, the Huffington Post, and NPR. She has been featured on the Los Angeles Times online, Wired online, and has appeared on Anderson, The Oprah Winfrey Show, and The Today Show.

Robert Frashure: Welcome back, Dr. Ehrensaft!

Dr. Ehrensaft: Thanks again for having me!

Robert Frashure: Of course, I wanted to start by asking you about the courage it takes for youth to push back against gender stereotypes and rigid boundaries. The rules on gender expression seem to be some of the most rigid rules in our society.

Dr. Ehrensaft: Absolutely, and the most strictly enforced.

Robert Frashure: When do you think this policing of gender roles begins to happen for kinds?

Dr. Ehrensaft: That’s a great question, and a very important one.

First of all, I always think of that old song from South Pacific: “You’ve got to be taught to hate.” If you think about it, the only way a 12-year old would know to be bigoted is that they learned it. And so it’s a learning curve and, if nobody teaches them that, they won’t say that. But when it starts in our culture, it starts when the baby is born with the kind of clothes you buy based on the gender of the people think the baby is, at least.  It can be three, four, or five, where kids have a sense of what is expected of them with regard to their gender and they begin to internalize the notion of gender socialization. This is what boys do, this is what girls do. So that is a path that is exactly in that age period.

Many kids are much more accepting and fluid in preschool, even though you see the beginnings of the gender policing among the children. But when you get to school age, which is why some kids are really happy until they get to grade school when they’re gender outlawed, because then you get into the developmental period of rules and regulations. And then, kids can be pretty rigid about, you know, what goes and what doesn’t go.

Robert Frashure: School-age children tend to face more pressure about their gender identity then?

Dr. Ehrensaft: Yes exactly, because that’s when kids get more of the teasing and the bullying. But, you know, I can…Just remember, this is a story. This was a preschooler, and this is a very, kind of, self-conscious, anxious little preschooler who was telling his family, “I’m a girl, assigned male at birth,” and then what he did at preschool was huddle in a corner, clutching a little baby carriage and not going anywhere in the classroom. So the parents finally recognized, they got some professional out and they recognized that their child was transgender. So they made room for the child to socially transition, and the child did not wanna wait until kindergarten which is coming up the next fall, but – once it was identified that this was a transgender child – wanted an immediate transition, so they said okay. And so the child went back to school and, all of a sudden, was playing with all the other kids, not huddling in a corner.

And there was this boy in the class who’s a bit of a bullying kind of boy, and the child had changed names to a very different girl’s name. And so this kid came up to her and said, “I don’t care what anybody else says. I’m still gonna call you X,” which is what’s the boy’s name. And this little kid who never talked to people before looked right at this boy and said, “You can do that but I won’t answer,” and walked away.

This is what I call gender resilience, that you have a way of standing up to the case and to help them out. The kid didn’t bother him anymore.

Robert Frashure: Do you have any more stories like this?

Dr. Ehrensaft: I have many hundreds of stories from my clinical practice, since I have been doing this for years!

I will never forget this eight-year old boy who hadn’t yet transitioned from male to female. In terms of his gender presentation,  he loved wearing flowery kind of t-shirts with sparkles on them and butterflies. And so one day in class, some older boys came over and circled around him and said, “You can’t wear pink. Pink is for girls,” and he just at them and said, “Well, I’m a boy and I’m wearing pink, so I guess they can,” and walked away. So those are the kinds of things, you know, that you start to see in preschool that are happening, more likely, in grade school. And, you know, for some kids, they can stand up to it, but if you’re really a self-conscious kid, all you want to do is go in your turtle shell and hide, or never even show up in your pink shirt, only in your bedroom, because you’re too scared about getting that kind of a response. So it depends on who you are.

Robert Frashure: Do you think it’s possible to have early intervention strategies for kids who might be wanting to explore their gender? I know there’s a focus in all the departments that I’ve worked in with kids with early intervention for all kinds of things, for developmental delays and things like this, but not for gender. I haven’t heard so much about early intervention strategies for non-conforming gender development as much.

Dr. Ehrensaft:  Well, essentially I think they’re there – but I don’t think that that’s the terminology to choose – but I think you’re right, it is early intervention. So, you know, this goes to the different models for gender care. So in the gender affirmative model, the idea is to make sure a child, at whatever age, is given the freedom to live in the gender that’s most authentic to them. And in that model around early intervention is to pay attention to early signs because they’re there – not for all kids, but for some kids – and that some of these kids, you know, will be transgender; some will just want to form their gender, not by the rules of society. Whichever one it is, the important thing is not to police those children and to give them freedom from an early age to be who they are, and acknowledge that they can know who they are at an early age, that you don’t have to wait until later to know, and that has made a tremendous difference.

And what I have heard reported repeatedly from trans adults, particularly older trans adults is the following, “I sure wish somebody knew that when I was growing up. My life was hell. I could have had such a different childhood and it would have made a difference up to the present, because now I have the baggage of all those years living in fear, or living a false life, or being rebuked for trying to be who I was,” and so forth. So early…I would say, in that sense, early intervention – where appropriate – is absolutely ideal. One of the things is with some kids, they’re not gonna know until they’re older. So the point is, intervention whenever is the time for it to happen.

And some kids won’t start exploring their gender until they’re 12 or 13. Puberty is often a hot-spot that, for some kids, either because they repressed it or, just, it wasn’t coming up as an issue in their life, they hit puberty and, all of a sudden, they panic. Their body is changing in a way that is absolutely not okay with them. And that’s often where the SOS signal comes in and where kids start communicating their unhappiness to their parents. Unfortunately, it’s often the age where some kids get extremely depressed, dysphoric, and even attempt suicide. So we have that as a real risk factor, which is why, you know, intervention…You know, intervention takes so many different forms because acceptance is intervention, support is intervention and psychotherapy is intervention. And for the older kids…psychotherapy.

We now also have medical interventions to use, and a lot of people think that’s too early of an intervention and that is not what we’re seeing at all. My gender medical experts say that the time is right when a youth is clear about who they are and what will help to get their body and their psyche in better alignment.

Robert Frashure: What is your hope for the future of how families, schools, mental health professionals, and others directly involved in the care of LGBT youth might work together to nurture children who, as you say, “live outside gender boxes?” What changes need to be made? What is working now, and where can we improve? Which pathways toward a gender-expansive world seem most promising to you as we fertilize the seeds for a “gender orchard”?

Dr. Ehrensaft: Well, schools at the very minimum should have sex and gender education that is expansive enough to include alternative gender and sexual orientations. It is a problem if a school’s sex education program is predicated on the fact that boys have penises and girls have vaginas because that rules out all the trans kids. And if you just talk about penis and body, if you wanna talk about reproduction – not just puberty – and you can talk about penis and body people, and vagina and body people, and that people can understand that, because there’s all kinds of mixes and matches that come from that, that’s makes for better sex education. And I know it is important to snuff right out that your sexual identity is not your true identity. They are two separate things. But when you do sex education it often starts with genitalia and, you know, who produces sperm, who produces eggs. And there’s gonna be some girls walking around the school who produce sperm and boys walking around the school who produce an egg, and that should be inclusive in any education for kids because this is for all kids. You know, I think it’s just like having a more accurate representation of the world they live in.

Robert Frashure: In your practice, have you seen cases where sex education from schools has gone wrong?

Dr. Ehrensaft: Yes, increasingly I have observed that there are a number of trans men who end up getting pregnant because they don’t think they can. And they end up pregnant. Additionally, there are a lot of STDs that go around and a high incidence of HIV infections. That stems from a lot of different things, but really working with kids around safe sex would make a big difference.

Robert Frashure: What do you recommend in terms of working with the whole family system? How do you work with families that aren’t accepting to their LGBT child?

Dr. Ehrensaft: There are a number of families that say, “we’re supportive,” and that can mean many things. It can mean a positive thing or a negative thing. For example, if support means, “I’m gonna help my child to learn to conform so they’re never beat up, and they have to know that society expects this and this is the way you behave, and the Bible said so.” Basically, they’re supporting their child but it’s not in the child’s best interest. So we start there, that I believe that most parents believe they’re supporting their kids. So from that premise comes my optimism about that most families at their heart want to do what is best for their child. And, unfortunately, there are some who don’t have their childrens’ best interests at heart and those we have to be especially mindful at being aware of.

From what I have seen in my practice, love usually overcomes prejudice even in the most gender conventional families. It can often take some time for a family to reconcile opposing view of both loving their child and being turned off by the LGBT community: for example, “I had a baby, I fell in love with my baby, I love my child, and I think queer people, anybody in the LGBT community are sick and, all of a sudden, I’ve got one.” So either you reject on the basis of your values which, unfortunately, some families do, or you see transition and realize that you have to give up those thoughts and values because of the child you love, and so you change. It has been inspiring to see how many families have adapted to fit the needs of their child.

Robert Frashure: How would address a family that isn’t supportive even after some family intervention?

Dr. Ehrensaft: This can be very difficult work. For example, I have seen some families that say: “You know, that they can go when they’re 18. They can do what they want.”

But the problem is that in my clinical office I got a 16-year old and she’s suicidal, right? So I basically have to say to the parent, “Yeah, that’s right. Until your child is 18, you are really the guiding force of her life and, indeed, you know, you’re the final decision maker. So I honor that. So I just wanna tell you the risk factors involved in the pathway you’re taking. And I can’t say this will happen to your kids, but these are risk factors that we know about. And I really…You know, I…Listen, I can tell you as a professional, I’m still obligated to tell you, that the higher risk for anxiety, depression, suicidality, self harm, poor school performance, dropping out of school, alcohol and drug abuse, and dangerous sexual activity.”

Well, most parents don’t want that for their kids and then they change.

Robert Frashure: Do families typically respond to that kind of message?

Dr. Ehrensaft: Yes, they do. It’s a very sobering message and they often grasp that their decision to support their child could be the choice between life or death for them. I try to let them know that all of those bad outcomes will happen to your child, but doing nothing is doing something and this just might be the outcome of that. I have an ethical responsibility to tell them these things and I’ve seen parents change and I think it’s possible.

Now the question comes, what if this type of family intervention still doesn’t influence the family and they still are hostile to their child? At some point mental health professionals know that your chosen family is much more important sometimes than your family of origin in keeping you afloat and this is true for the trans youth community as well. Sometimes we as mental health professionals have to help trans youth find alternative places and relationships. I’m not saying necessarily moving them from their home but making sure that there’s an alternative supportive spaces for them, and somebody who can mentor them.

And sometimes you do wanna think about removing them from the home because it’s abusive. It’s as if they are being abused, and that’s a hard thing to call. But I think that the, kind of, severe gender solution that can happen in a home, I’d qualify it as abuse. It’s not the kind of abuse that I can report to CPS. It’s not considered physical abuse typically, but we can call it emotional abuse. So you can do that as well.

If you can get a child out of an abusive situation, or get the family to stop being abusive, that’s your goal.

Robert Frashure: Do you usually work with the whole family or do you prefer to work individually with the child?
Dr. Ehrensaft: Sometimes I work with the whole family. I’m trained as a family therapist. I’d rather send those cases to a dedicated family therapist because I like doing individual therapy and parent consultation much better. And often I find it’s much better to work with the parents without the child there, because some of the things they’re saying would be very difficult to their kids, and I’d rather have it be in a private space where they’re gonna say whatever they’re gonna say, but that we’re not, yeah, that we build a firewall around the kid. So that’s often why I will purposely say that I want the parents to come in without their kids, you give them space, and then sometimes after that I bring them all back together.

Robert Frashure: Could you tell me more about your work at the UCSF Gender Center?

Dr. Ehrensaft: Yes, of course. The Child and Adolescent Gender Center is a put together in 2009 by a group of professionals that recognized a need for LGBT youth that wasn’t being met. Our clinic is in the Department of Pediatrics at Benioff Children’s Hospital at UCSF. We basically we have an interdisciplinary chain: we have two psychologists, myself and one other person, and we have an endocrinologist. Additionally, we have medical doctors, nurse practitioners, an educational consultant, a legal consultant, a social worker, and mental health practitioners. The clients all come in for gender care. Some of them are youths wanting puberty blockers or hormones. Some just wanna have, you know, a place where they know that they have providers that they can have over time.

So most of the families that come to our clinic are accepting of their kid, but we do have situations where one parent is and one parent isn’t: that’s not uncommon. And then we basically work with the family, and what we do is then we refer them back out to some of our community providers who can do the ongoing work with them.

Robert Frashure: That sounds like an amazing program.

My final question to you is: what advice do you give to parents who have children that are gender creative or seem to be embarking on a path of gender or sexual orientation exploration?

Dr. Ehrensaft: The biggest thing I would say is to listen to your child. If you listen, they will tell you what you need to know.

Secondly, I would remind parents to not be hesitant to reach out for support from the mental health community. There are so many wonderful resources and supportive professionals available today that can make a world of difference for the developing gender creative child. Parents and families don’t need to walk this path alone, there are many others who are sharing a similar journey with their own children.

Robert Frashure: Thank you so much, Dr. Ehrensaft!

Dr. Ehrensaft: Thank you for your questions, Robert. I very much look forward to seeing the work that you do in the future, something tells me you will continue to do many great things. Well done!