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Gender identity has both a cognitive component and an affective component. There is now considerable evidence that by the age of 2 to 4 years, children have a rudimentary cognitive understanding of their gender identity. They are, for example, able to self-label as a boy or as a girl. Although it is normative for children in this age range to self-label correctly, a more sophisticated cognitive understanding of gender is lacking. A girl, for example, who can correctly self-label as a girl might readily declare that she will be a daddy (or even a giraffe) when she grows up. With cognitive maturity, however, children eventually master the notion that gender is an invariant part of the self. Coinciding with a cognitive-developmental understanding of gender, there is a corresponding affective pride in gender identity self-labeling in that children appear to value themselves as being a boy or being a girl, and there is a tendency to overvalue other members of one’s sex and devalue members of the other sex—a type of “in-group vs out-group bias.”1,2

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Early in development, it is common for children to hold rather stereotyped views about behaviors that are “appropriate” for boys and for girls. Some theorists argue that this is related to the tight connection that children make between subjective gender identity and surface-related gender role behaviors. Thus, young children will adhere to the notion that “only girls” can wear dresses (dubbed the “pink frilly dresses” phase3) or that “only boys” can become doctors. Over time, greater cognitive flexibility in gender role attributions emerge, although affective behavior preferences might remain strong for culturally defined gender role behaviors.1

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The pediatrician is often the first professional that parents might consult regarding the child whose behavior departs from conventional patterns of sex-typed behavior. Developmentally related sexual behaviors emerge at various ages in young boys and girls (Table 90-1). Issues surrounding gender often cause intense anxiety for parents. Are the behaviors in question “only a phase” that the child will outgrow? Or, are the behaviors in question prognostic of longer-term developmental issues? Regarding gender development, parents often want to know if the behaviors of their young child are prognostic of a later homosexual sexual orientation or of transsexualism, the desire to receive contrasex hormonal treatment and physical sex change (eg, in males, penectomy/castration and the surgical creation of a neovagina; in females, mastectomy and the surgical creation of a neophallus). Parents also often worry about the stigma that their child’s pervasive cross-gender behavior might elicit within the peer group and in society at large.

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Table 90-1. Developmentally Related Sexual Behaviors 

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