Sandra Collins first had an inkling that her son wasn't a typical boy at 20 months, when Ezra started coming home from preschool dressed as a girl.
By age 3, her son wanted to dress in only pink and sparkly clothes, wear girls' underwear, and grow out his hair. He wore the clothes to an ever-widening circle of places -- to and from preschool, at his older brother's soccer games, out in the community.
"I did have the conversation" with him, she says, "that some people may not be used to seeing a boy in a dress or wearing pink. But we will just let them know that these are clothes and colors for all kids." If anyone asked, Ezra told them he was a boy who liked girl things.
But when Ezra was 5, he told his parents he didn't just want to wear girl clothes. He wanted to have a girl's name and live as a girl.
The summer before 1st grade, Ezra's parents helped their child socially transition to being a girl, changing her name to Scarlett and using female pronouns to reflect the identity she felt in her head and her heart.
What Transgender Means
Many children experiment with dressing and playing in ways that challenge typical gender norms. A boy might like sparkly clothes and dolls, or a girl might ask to be called "Jack" for a few weeks. Experts use terms like "gender expansive," "gender creative," or "gender non-conforming" to describe these kids.
But sometimes, a boy will insist he's "really a girl," or a girl will say, "my mind tells me I'm a boy" -- no matter what other people tell them. When your basic sense of being male or female doesn't match your body, it's called transgender.
"If a child is gender expansive, they're going to be content as long as they're allowed to wear what they want to wear, play with who they want to play with, and what they want to play with," says Darlene Tando, author of The Conscious Parent's Guide to Gender Identity. "A transgender kid is not going to be happy with that. Even if they're allowed to wear what they want, if someone is categorizing them -- if they have to line up boys vs. girls -- it's going to bring up distress."
Some kids are sure of it from the time they can talk. Others come to the realization as they're thinking about puberty. A third group of kids come out after high school.
There's no simple test to tell if a child is transgender. Experts often use the concept of "insistence, consistence, and persistence" to gauge if the behavior is more than a phase. The longer and more insistently a child states they're a different gender, the less likely they are to change their mind.
How persistent they are depends on their temperament, says Tando, a licensed clinical social worker. Kids who sense that their parents don't accept their identity may shut down and stop talking about it.
How Can You Tell?
Your child may want to wear their hair or dress like the gender they identify with, including underwear and bathing suits. In role-playing games, they'll pretend to be the other sex.
A boy doesn't say "I wish I was a girl," but "I am a girl." And vice versa.
They may take on the bathroom behavior of the opposite sex (insisting on sitting down or standing up to pee). Transgender children may be unhappy with their boy or girl body parts, asking "When will I get a penis?" or "How can I get rid of it?"
Supporting Your Child
It can be scary for some parents to even imagine taking their son out in public wearing a dress, or to send their precious baby out in the world to risk being shunned, teased, or tormented. But therapists, medical providers, and researchers are emphatic that transgender children need their home to be a sanctuary of love, support, and acceptance.
"We're trying to do two things: Preserve a child's confidence and freedom to authentically be who they are, and make sure they do not get too many bumps and bruises from the outside world," says Diane Ehrensaft, PhD, author of The Gender Creative Child.
"A child who is really confident -- no matter what anyone says, they're OK with how they dress and are -- is going to be much better than someone who doesn't get support at home," she says. When families pressure children to conform to the gender they were born with, kids are much more likely to end up dealing with depression, drug abuse, suicide attempts, and HIV.
Minneapolis mom Leslie Lagerstrom, author of the Transparenthood blog, cringes when she thinks of all the times her daughter Samantha would tell her, "I'm a boy," and Lagerstrom would correct her: "You're a tomboy." "I would buy Sam books like It's Great to Be a Girl, and books talking about girl inventors throughout the ages," she says. "To his credit, he pushed back."
While some kids have an innate sense that they were born in the wrong body, other children need to know that it's possible to not be the gender that everyone else is calling them. Tando recommends reading books together that show different types of families and identities, and letting your child know you welcome their questions. You might ask them, "Do you feel like a boy or a girl? Both? Or neither?"
"I had to do my own research to understand gender expression and gender identity," Collins says. "This is about children understanding who their core selves are." She started a Bay Area day camp and monthly playgroups for kids like Scarlett.
When to Decide
Doctors recommend you find a therapist who specializes in gender issues as early as possible if you sense gender is a source of conflict for your child. "A lot of parents don't seek treatment because they're hoping this is a phase, or they don't want to do treatment that will cause harm for their child. [But] there's harm in doing nothing as well," says Jennifer Rehm, MD, co-medical director of the Pediatric and Adolescent Transgender Health Clinic at the University of Wisconsin. The clinic sees children of all ages.
It's critical to set up medical care well before puberty, because for transgender children, knowing that it's coming can be intensely upsetting, she says. "It's important to sit down with your kid, sit down with a therapist, and together as a family come up with the best plan for your child to keep them safe and address their mental health concerns as well as their body."
Scarlett is now 8. In a couple of years, she can choose to start on reversible puberty-suppressing medications that will stop her voice from deepening and other changes that come with male puberty. In the future, she can take cross-sex hormones to trigger puberty as a girl. Surgery is an option much later.
A therapist can help your family decide which changes to make at which time. And parent support groups can be helpful places for you to share your fears and confront your own attitudes about gender, away from your child.
"I should have been listening," Lagerstrom says. "We finally listened when he was 8. Today parents are listening at age 3 and 4."