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Based on a true transgender identity journey, the picture book I'm Not a Girl is an empowering story from writers Maddox Lyons and Jessica Verdi about a boy who is determined to be himself, illustrated by Dana Simpson.

Nobody seems to understand that Hannah is not a girl.

His parents ask why he won't wear the cute outfits they pick out. His friend thinks he must be a tomboy. His teacher insists he should be proud to be a girl.

But a birthday wish, a new word, and a stroke of courage might be just what Hannah needs to finally show the world who he really is.

A 2021 Rainbow Book List Recommended Reading Selection

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I'm Not a Girl: A Transgender Story [Lyons, Maddox, Verdi, Jessica, Simpson, Dana] on Amazon.com. *FREE* shipping on qualifying offers. I'm Not a Girl: A Transgender Story

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Amazon.com: My Shadow is Pink: 9780648728764: Stuart, Scott: Books

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By: Jason Rafferty MD, MPH, EdM, FAAP

There are many ways parents can promote healthy gender development in children. It helps to understand gender identity and how it forms.

What's the difference between gender and sex?

Being a boy or a girl, for most children, is something that feels very natural. At birth, babies are assigned male or female based on physical characteristics. This refers to the or "assigned gender" of the child.

Meanwhile, "gender identity" refers to an internal sense people have of who they are that comes from an interaction of biological traits, developmental influences and environmental conditions. This may be male, female, somewhere in between, a combination of both or neither.

Self-recognition of gender identity develops over time, much the same way a child's physical body does. Most children's asserted gender identity aligns with their assigned gender (sex). However, for some children, the match between their assigned gender and gender identity is not so clear.

How does gender identity develop in children?

Gender identity typically develops in stages:

Around age two: Children become conscious of the physical differences between boys and girls.

Before their third birthday: Most children can easily label themselves as either a boy or a girl.

By age four: Most children have a stable sense of their gender identity.

During this same time of life, children learn gender role behavior-that is, doing "things that boys do" or"things that girls do." However, cross-gender preferences and play are a normal part of gender development and exploration regardless of their future gender identity

The point is that all children tend to develop a clearer view of themselves and their gender over time. At any point, research suggests that children who assert a gender-diverse identity know their gender as clearly and consistently as their developmentally matched peers and benefit from the same level of support, love and social acceptance.

What parents can do:

All children need the opportunity to explore different gender roles and different styles of play. Parents can make sure their young child's environment reflects diversity in gender roles and encourages opportunities for everyone. Some ideas would be to offer:

Children's books or puzzles showing men and women in non-stereotypical and diverse gender roles (stay-at-home dads, working moms, male nurses and female police officers, for example).

A wide range of toys for your child to choose from, including baby dolls, toy vehicles, action figures, blocks, etc.

By age 6, most children spend most of their playtime with members of their own sex. They may also gravitate towards sports and other activities that are associated with their gender. It is important to allow children to make choices regarding friend groups, sports and other activities they get involved in. It is also a good idea to check in with your child to learn about their preferences and to make sure they feel included without teasing or bullying.

How do children typically express their gender identity?

In addition to their choices of toys, games, and sports, children typically express their gender identity in the following ways:

Clothing or hairstyle

Preferred name or nickname

Social behavior that reflects varying degrees of aggression, dominance, dependency and gentleness.

Manner and style of behavior and physical gestures and other nonverbal actions identified as masculine or feminine.

Social relationships, including the gender of friends, and the people they decide to imitate.

Gender expression & gender identity

A child's gender-specific behavior (gender expression) at any time seems to be influenced by exposure to stereotypes and their identification with the people in their lives. However, the internal sense of being a girl, boy, in between or something else (gender identity) cannot be changed.

How have gender stereotypes changed over time?

Our expectations of "what girls do" and"what boys do" have changed. Many female athletes excel at their sports. Girls increasingly pursue subjects traditionally thought of as"masculine." There are many famous male chefs, artists, and musicians―fields traditionally thought of as"feminine."

Over time, society has recognized that stereotypes of "masculine" and"feminine" activities and behaviors are inaccurate and limiting to a child's development. Such interests also do not determine or influence one's gender identity. Plus, our ability to predict who a child is based on early preferences is not very accurate-and may be harmful if it leads to shame or attempts to suppress their skills, talents and genuine self.

Still, when a child's interests and abilities are different from what society expects, they may face discrimination and bullying. It is natural for parents to have gender-based expectations for their children and to want to protect them from criticism and exclusion. Instead of pushing children to conform to these pressures and to limit themselves, parents can play an important role in advocating for safe spaces where their children can feel comfortable and good about themselves.

If your child doesn't excel in sports or even have an interest in them, for example, there will still be many other opportunities and areas in which they can thrive. Regardless of gender identity, each child has their own strengths that may not always conform to society's or your own expectations, but they will still be a source of current and future success.

Gender development is a normal process for all children. Some children will exhibit variations―similar to all areas of human health and behavior. However, all children need support, love and care from family, school and society, which fosters growth into happy and healthy adults.

More information

About Dr. Rafferty

Jason Rafferty, MD, MPH, EdM, FAAP, is pediatrician and child psychiatrist at Thundermist Health Centers, a Patient-Centered Medical Home in Rhode Island. He specializes in adolescent substance use disorders and gender and sexual development, and also practices in related specialty clinics at Hasbro Children's Hospital and Emma Pendleton Bradley Hospital. Dr. Rafferty is an advocate in his local community and on a national level through work with the American Academy of Pediatrics on issues including the emotional health of young men, access to care for LGBTQ youth, and prevention of childhood homelessness.

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There are many ways parents can promote healthy gender development in children. It helps to understand gender identity and how it forms.

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Children and gender identity: Supporting your child

Understand the importance of talking with your child about gender identity and expression - and how to get the conversation started.
By Mayo Clinic Staff
If your child has questions about gender identity or gender expression, you've probably got questions, too. Find out what you can do to help and support your child.

What are the basics of gender identity?

A person's sex assigned at birth, gender identity - the internal sense of being male, female, neither or both - gender expression and sexual orientation are separate things. They can happen in many combinations. Having a particular sex assigned at birth or gender expression doesn't mean a person has any specific gender identity or sexual orientation.

Is your child transgender?

In many cases children will say how they feel, strongly identifying as a boy or girl - and sometimes - neither or both. While children might go through periods of insisting that they are the opposite gender of their birth sex, if they continue to do so it was likely never a phase.

Most children typically develop the ability to recognize and label stereotypical gender groups, such as girl, woman and feminine, and boy, man and masculine, between ages 18 and 24 months. Most also categorize their own gender by age 3 years. However, because gender stereotypes are reinforced, some children learn to behave in ways that bring them the most reward, despite their authentic gender identity. At ages 5 to 6 years, most children are rigid about gender stereotypes and preferences. These feelings typically become more flexible with age.

Gender identity and expression are related, yet different concepts. A child's gender identity isn't always indicative of one particular gender expression, and a child's gender expression isn't always indicative of the child's gender identity. Diversity in gender expressions and behaviors might include:

Certain bathroom behavior, such as a girl insisting on standing up to urinate

An aversion to wearing the bathing suit of the child's birth sex

A preference for underwear typically worn by the opposite sex

A strong desire to play with toys typically assigned to the opposite sex

Don't rush to label your child. Over time your child will continue to tell you what feels right.

How can you support a gender-nonconforming or transgender child?

If your child is persistent about gender identity feelings, listen. Talk to your child and ask questions without judgment. To support your child:

Don't assume your child's gender expression is a form of rebellion or defiance.

Don't prevent your child from expressing gender in public or at family activities to avoid it making you or someone else uncomfortable.

Don't try to shame or punish the gender expression out of your child.

Don't block your child's access to gender-diverse friends, activities or resources.

Don't blame your child for experiencing discrimination.

Don't belittle or ridicule your child's gender expression or allow others in your family to do so.

Speak positively about your child to your child and to others. Show your admiration for your child's identity and expression of it. By allowing your child to demonstrate preferences and share them, you'll encourage a positive sense of self and keep the lines of communication open.

Also, try to let go of specific fantasies you might have had about your child's future and, instead, focus on what brings your child joy and security. A child living with supportive parents and caregivers is likely to be a happier child.

What kind of health care does your child need?

Your child needs a respectful, knowledgeable doctor. Talk to your child's doctor about your child's gender identity and behaviors and ask for help. Your doctor might recommend working with a specialist. If you're having trouble finding a doctor with appropriate training, seek a recommendation from a support group.

Talking to a therapist also is critical. Ask your child's doctor to help you find a counselor with training in transgender needs to work with your child.

What is gender exploration and social transitioning?

A social transition is a reversible step in which a child lives partially or completely in the preferred gender role by changing hairstyles, clothing, pronouns and, possibly, names. Limited research suggests that social transitioning might help ease a child's depression and anxiety.

It's important for parents and children to determine the extent of the transition, to whom to disclose it, and how to handle challenges such as which bathroom or locker room to use. You'll also need to consider whether transitioning at school or in the community will endanger your child. Seek the advice of a social or advocacy agency to help you make a safety assessment.

How can you advocate for your child?

You might worry that your transgender child will be shunned and experience discrimination or physical harm at school or in your community. To prevent these problems and advocate for your child:

Connect with other families who have a gender-diverse child. This can help reduce any isolation you and your child might be experiencing. Look for an in-person or online support group.

Work with your child's school and teachers. Talk to them about how to stop or prevent bias and bullying before it starts. Ask for gender training to be included in staff development. Come up with a plan for how your child will be addressed in school, which bathroom your child will use, and how to interpret rules about participation in teams, clubs and overnight activities. Choose whether you want to share information about your child's gender identity with other parents.

If your child experiences harassment or discrimination at school and the school system fails to address the problem, take action. Research your legal options and talk to school administrators about them.

Reach out within your community. Work with local institutions to make them safer for gender-diverse and transgender children. Also, consider supporting or volunteering for gender organizations to learn more and help others learn.

Whatever your child's gender identity, do your homework and seek appropriate care. Showing your love and acceptance will also help your child feel comfortable in his or her body and in the world.

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Show references

1. Brill S, et al. The Transgender Child: A Handbook for Families and Professionals. San Francisco, Calif.: Cleis Press, Inc.; 2008.

2. Gender Spectrum. Parenting and family. https://www.genderspectrum.org/explore-topics/parenting-and-family/#more-340. Accessed Dec. 23, 2016.

3. Olson KR, et al. Mental health of transgender children who are supported in their identities. Pediatrics. 2015;137:1.

4. Olson-Kennedy J, et al. Overview of the management of gender nonconformity in children and adolescents. https://www.uptodate.com/contents/search. Accessed Dec. 23, 2016.

5. The World Professional Association of Transgender Health. Standards of care for the health of transsexual, transgender and gender-nonconforming people, 7th version. http://www.wpath.org. Accessed Dec. 23, 2016.

6. Olson-Kennedy J, et al. Overview of the management of gender nonconformity in children and adolescents. https://www.uptodate.com/contents/search. Accessed Feb. 14, 2017.

7. Gonzalez CA (expert opinion). Mayo Clinic, Kasson, Minn. May 10, 2017.

8. Lteif AN (expert opinion). Mayo Clinic, Rochester, Minn. May 10, 2017.

See more In-depth

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Steps for supporting your child's gender identity

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Understand the importance of talking with your child about gender identity and expression - and how to get the conversation started. By Mayo Clinic Staff If your child has questions about gender identity or gender expression, you've probably got questions, too. Find out what you can do to help and support your child.

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Affirming Gender in Elementary School: Social Transitioning

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Find ways to help transgender and non-binary children in your school. Look at ways to affirm a child's gender identity and proactive steps your school can take. A gender inclusive school affirms all children and allows them to express their interests and find confidence in their strengths.

# data[].attributes.body
Children typically express their gender identity by:
- clothing/hairstyle
- preferred name/nickname
- manner/style of behavior and physical gestures/other nonverbal actions that are typically deemed "masculine" or "feminine"
- social relationships, and the people they decide to imiate

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- Take professional development courses over strategies to prevent and stop LGBTQ+ and gender based bullying.
- Educate yourself, and others in the school, about the complexities of gender, and the importance of a gender inclusive classroom for ALL students.
- Talk with your students about ways they can be allies when someone is being teased/bullied for any reason.
- Share/read diverse books, with many gender identities/expressions.

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Around age two: children become aware of the physical differences between boys and girls.
Before three: (most) children can easily label themselves as either a boy or a girl.
By four: (MOST) children have a stable sense of their gender identity

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Due to gender stereotypes, some children learn to behave in a way that brings them the most reward, despite their authentic gender identity.

# data[].attributes.body
Some children will exhibit variations/differences, but all children deserve love, support, and care so they can grow into happy and HEALTHY adults.

# data[].attributes.body
Diversity in gender expressions and behaviors could present as:
- bathroom behaviors (example: a girl standing up to urinate)
- an aversion to wearing a bathing suit of the child's assigned birth sex
- preference to underwear of the opposite sex
- a desire to play with toys that are stereotypically assigned to the opposite sex

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Gender expression =/= gender identity. It is not the teacher's job to assume or draw conclusions based on how the child is "presenting".

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Educators Discuss Gender in the Classroom

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Gender development is a normal process for all children.

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It is a teacher's responsibility to maintain an open mind about gender identity, as it is a complex and unique topic that changes based on each student.

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Children who claim a gender-diverse identity know their gender as confidently, and consistently, as their developmentally matched peers.

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Gender expression doesn't particularly indicate a child's gender identity, nor does a child's gender identity indicate their gender expression.

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A teacher should build a strong sense of community, with an atmosphere of acceptance.

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Reading with Ms. Nicole - "I'm Not a Girl" by Maddox Lyons & Jessica Verdi