I take care of non-conforming teens, but I have many colleagues who are “uncomfortable” with what they call the “new” issues of sexuality. I am convinced it’s because they don’t know the science, the vocabulary and how to speak to non-conforming teens.

This presentation was put together for my pediatric surgery colleagues as a project for a course I’m taking, but several of them asked me to make it more available so they could share it, which is why I’m posting it here.

Research has demonstrated that most aspects of sexuality are far from binary (either-or). We now understand that sex, gender, identity, expression and attraction are separate aspects of sexuality – and that they can be quite varied and fluid (i.e. can differ over time or in different situations).

Pediatric surgeons are among the professionals who care for babies who are born with ambiguous genitalia or, more correctly, what is known as “disorders of sexual development“. For pediatric surgeons, it’s been clear for a very long time that there are three categories for “sex” – male, female and intersex. Almost 2% of children are intersex (which, by the way is the same percentage as the number of people who have red hair).

Gender refers to the identity we hold as an individual. I love this particular diagram with “Barbie” on the left and “GI Joe” on the right. What a delight that we have people all along this spectrum!  It’s also true that there may be days you are a 5 and other days your are an 8… whether your sex is male, female or intersex.

Because it’s such a spectrum, there are different ways to describe someone’s identity. This chart represents the most common words used.  Cis-gender may or may not be familiar to you, because it is the correct way to describe what is usually (but sometimes not correctly) assumed – i.e. that a person’s gender is the same as their sex.

When we have patients, friends or colleagues who are non-conforming, it is our responsibility to address them in a way that affirms them as human beings.  For those who have a clear gender identity (whether its cis-gender or transgender) it is fairly straight forward. When addressing non-binary folks, the correct pronouns to use are they/them/theirs. This is hard for most people because it’s new. It’s perfectly ok to tell them it’s hard but that you are going to try your best. The other important take home message is that if you aren’t sure, it’s ok to ask.

To add even more to the amazing diversity of human beings, how you express your gender is also completely separate from your sex and your gender identity!  So, you can be born with female genitalia (sex = female), identify as a girl (cis-gender) but still choose a gender expression that is more typically “male” in terms of behavior and dress. Gender expression is also amazingly fluid, since there are other times this same individual may prefer to express as “Barbie”, somewhere in the middle, or “GI Joe”.

Although most people are familiar with bisexual, homosexual and heterosexual as concepts, the fact that there are people who are asexual may be a new concept to many.

The Genderbread person is a wonderful visual representation that sex, gender, expression and attraction can all be independent of each other.

So what prompted this presentation and now this blog post? Gender dysphoria is real, although not common, and it is a state of suffering. There is so much stigma in our society around sexuality that these children and young adults feel ostracized and isolated.  As professionals who care for children and young adults, it is important that we understand these issues, learn to speak openly with patients and families experiencing the effects of gender dysphoria and refer them for appropriate medical and psychological care.

It’s hard to know what to say, but it’s so important to say it. Being open – even admitting that you don’t know much about sexual fluidity – is key. More importantly, caring enough to ask and learn may save a life.

BTW – if you are teen reading this and I’ve messed up, please contact me!