For many people, the news of expecting a child elicits an unparalleled joy, followed by a nervous anticipation about the pregnancy and infant. Despite the numerous questions a parent may have, the most common question anyone else asks is, “Do you know what you are having?” In an era in which gender issues have emerged at the forefront of both pediatric medicine and the popular press, this question has become far more complex.
In some regions of the world, sex determination of the fetus has often led to sex-selective abortion; laws have thus been passed in these countries prohibiting ultrasonography for the purpose of sex determination.1 Although this has not been a problem in the United States, there are scenarios in which a sex assignment may later be questioned or reversed, leading to a significant amount of distress. Historically, expectant parents were able to learn about the infant’s genital anatomy at 18 to 20 weeks’ gestation. They subsequently had ∼5 months to share the news with friends and family, decorate the nursery, and buy a color-themed wardrobe. Over the past decade, however, “the gender reveal” has become increasingly elaborate. Although some still choose to open an envelope privately, many expectant parents throw large parties where blue or pink cakes are cut or boxes are delivered with colored balloons flying out. Widespread use of social media has expanded the size of the audience exponentially, growing from 50 people invited to a party, to 500 to 1000 “friends” on a social media account. A video was recently posted on social media of a complex game that several people spent several hours creating in the couple’s home, simply to display 1 outcome: Is the infant a boy or a girl?
Although these cultural traditions seem fun-filled and innocent, we should pause to ask, why is sex, or gender, so important? Are these traditions truly harmless? By celebrating this single “fact” several months before an infant’s birth, are we risking committing ourselves and others to a particular vision and a set of stereotypes that are actually potentially harmful? Beyond decorating the nursery, choosing a name, and filling the drawers with pink or blue, what other familial and/or societal expectations are being created for this infant just based on sex and implied gender? What are the implications if and when those expectations are unfulfilled? In situations in which the “right” gender assignment is not clear, is it possible to wait and let a child decide?
Decades ago, the terms sex and gender were not viewed as distinct. Children learned in health class that boys and girls could be distinguished by 46, XY versus 46, XX chromosomes in addition to their internal and external genitalia. In pediatrics, we now know that this is not always the case. Currently, it is estimated that 1 in 4500 to 5500 infants are born with a difference of sex development, congenital conditions within which the development of chromosomal, gonadal, and anatomic sex is atypical.2 The approach to decisions surrounding gender assignment, and medical and surgical interventions, has evolved to implement a shared decision-making model, in which parents and health care providers are ideally equal partners in the process.3 Although all the predictors of gender identity have not been defined, many factors are considered when making a gender assignment, including appearance of external genitalia, assumptions of future sexual function and fertility potential, presumable degree of pre- and postnatal androgen exposure to the brain, and predictions of gender identity as an adult.3,4 The majority of these conditions are rare, thus few longitudinal research studies have been done; given this lack of high-quality evidence, parents are often left wondering, “What if we chose wrong?” Because many adolescents and young adults with these conditions have reported psychosocial difficulties and stigma, experts have recommended age-appropriate disclosure starting at a young age, in addition to ongoing psychosocial support.3 In addition, several groups have advocated for deferring any decisions that are not medically urgent until the child’s perspective can be considered.
Aside from differences of sex development, an increasing number of otherwise healthy youth are presenting to pediatric clinics because their birth-assigned gender is discordant from their affirmed or identified gender. Gender identity development is influenced by biological, environmental, and cultural factors; the exact explanation for incongruence remains unclear, and in many cases leads to gender dysphoria.4–6 Unfortunately, these children have strikingly high rates of mental health concerns; they are also frequently victimized by peers, and authors of studies have shown that half of transgender youth consider suicide and 25% to 35% make an attempt.5,7 Notably, these risks decrease if families are supportive, as recent studies among transgender adolescents revealed that parental support was associated with higher life satisfaction and fewer depressive symptoms.8
Most expectant parents are not aware that any or all of these scenarios exist. Ultrasound technicians and obstetricians do not typically say, “Just so you know, we may be wrong. Ultrasounds aren’t perfect. Also, some infants have a condition in which genital anatomy is atypical and gender assignment may be changed.” Furthermore, one rarely says, “Regardless of gender assignment at birth, some kids may later identify as the opposite gender.” Parents have shared the trauma they have experienced moments after their infant was delivered, and instead of hearing the anticipated “It’s a girl,” providers crowded around mumbling that it may not be a girl after all. Parents of transgender adolescents have said, “I have to mourn the loss of the daughter I have raised before I can move forward with my son.”
Although some of these challenges are natural and cannot be avoided, we must assess how medical practices and cultural traditions may actually be contributing to potential for future distress among children and their families. Although within the vast majority of cases, an infant predicted to be a boy or girl on prenatal ultrasound will identify that way for life, we cannot ignore the vulnerable youth in whom that does not transpire. As medical and mental health professionals work together to increase awareness, improve outcomes, and reduce health care disparities for sexual and gender minorities, perhaps a wider net should be cast. Physicians, nurses, and staff in general pediatrics clinics, as well as teachers and staff at schools, should be aware that gender is just 1 aspect of a child’s identity, and not the defining aspect; particular attention should be given to preferred names and pronouns. These individuals can then provide anticipatory guidance to parents who may be struggling with these issues, so that they, in turn, can support their children.
We should educate obstetricians and the delivery room and newborn nursery staff about the implications of overemphasizing the importance of sex of the infant during pregnancy (and informing parents that sex assignments on prenatal testing may be inaccurate) and after birth. Perhaps, instead of, “It’s a boy,” the first proclamation after delivery should be, “Congratulations, you have a beautiful infant!” Although expectant parents may continue to share their joyful anticipation with close family and friends, as a society, we should question what we are truly celebrating in a gender reveal, and whether the nature of that celebration has the potential to lead to distress. Ultimately, the goal is to deliver, raise, and support a healthy and happy child, regardless whether the child is boy or a girl.
- Accepted July 11, 2017.
- Address correspondence to Leena Nahata, MD, Nationwide Children’s Hospital, Endocrinology and Center for Biobehavioral Health, 700 Children’s Dr, Columbus, OH 43205. E-mail:
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics