An individual’s awareness of gender identity, and the emergence of a range of gender-typical behaviours, is usually established by the age of two to three years. The earliest features of gender incongruence may start to become apparent around this age.
By the age of five years, children will spontaneously characterise others by sex (boy or girl). Negative reactions by children to gender diversity in others, which may include teasing, ridicule and social exclusion, often become stronger as children grow older. Boys exhibiting behaviours characteristic of female gender are more likely to experience negative reactions, than girls exhibiting behaviours characteristic of male gender. Such negative reactions may result in psychological distress for the recipient and heighten any gender dysphoria that they might experience.
From the age of seven years, children become more flexible in how they apply gender stereotypes and begin appreciate that there are differences between individuals in how they express their gender identity. Pre-school children typically have a preference for same-sex friends that tends to strengthen until adolescence; subsequently, boys are more likely to engage in group activities and girls in activities in dyads (groups of two). The formation of same-sex groups is typical of young adolescents; in mid- to late-adolescence, more cross-sex interactions evolve, a prelude to the emergence of romantic and couple sexual relationships. These changes in relationship dynamics may be distressing and contribute to the experience of gender dysphoria by gender-diverse individuals.
In addition to social and behavioural changes, adolescence is usually accompanied by the secondary sex characteristic developments that follow puberty; these changes (growth of body hair, facial hair, external genitalia and deepening of the voice in boys, and breast development and the onset of menstruation in girls) can be deeply distressing to individuals whose gender identity is not congruent with their sex development, again contributing to any experience of gender dysphoria.
There is considerable variation in individual’s need for interventions, and the timing of those interventions. Not everyone needs or wants hormone therapy or surgery, and their needs and wants may develop over time, just like everybody else’s. Each individual’s needs are unique, and their care pathway, what it includes and when it is needed, is different; the clinical team work with them to agree a care pathway that helps them achieve their treatment goals.
Finally, family and friends should respect the wishes of transgender people in how they should be addressed or described. What transgender people find acceptable as titles and pronouns varies considerably. When speaking of a trans, non-binary or agender person, it is correct and courteous to ask them their preference of pronoun (he, she, they, per), title (Mr, Mrs, Miss, Ms, Mx) and description of their transgender nature (trans man or woman, man or woman, non-binary, Genderqueer, agender, etc.)