A 14-year-old boy is brought to the office by his mother for a well-child visit. Before entering the room, the mother takes the physician aside in private and says, "My son does really well in school and helps out at home, but I'm concerned that he doesn't play sports like other boys and has started wearing makeup. I don't know whether that's normal or not." When interviewed alone, the patient says, "I'd rather spend my time on clothes and makeup than sports, but that doesn't make me less of a boy. My friends don't mind, but I think my mom does." The patient reports no depressed mood, bullying at school, or difficulty at home, other than occasional disagreements with his mother about how he dresses. He is not sexually active. Medical history is noncontributory. Vital signs are within normal limits; the patient's height and weight are tracking adequately on growth curves. He is dressed in colorful clothes and is wearing eyeliner and nail polish. Tanner stage is 4. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate response to the mother's concerns?

Question

A 14-year-old boy is brought to the office by his mother for a well-child visit.  Before entering the room, the mother takes the physician aside in private and says, "My son does really well in school and helps out at home, but I'm concerned that he doesn't play sports like other boys and has started wearing makeup.  I don't know whether that's normal or not."  When interviewed alone, the patient says, "I'd rather spend my time on clothes and makeup than sports, but that doesn't make me less of a boy.  My friends don't mind, but I think my mom does."  The patient reports no depressed mood, bullying at school, or difficulty at home, other than occasional disagreements with his mother about how he dresses.  He is not sexually active.  Medical history is noncontributory.  Vital signs are within normal limits; the patient's height and weight are tracking adequately on growth curves.  He is dressed in colorful clothes and is wearing eyeliner and nail polish.  Tanner stage is 4.  The remainder of the physical examination is unremarkable.  Which of the following is the most appropriate response to the mother's concerns?

Quizplus · Accepted Answer

Gender identity is a person's internal sense of being male, female, a combination of both, or neither. Gender expression is how a person chooses to express gender to the outside world. When gender identity or gender expression differ from social norms and/or expectations, it is referred to as gender variance or gender nonconformity. Gender expression is influenced by social and cultural norms, with some appearances or activities considered to be more typically masculine or feminine in nature. In this case, the patient chooses to wear makeup, which is considered feminine in many western cultures. Although gender variance may cause distress for some due to lack of acceptance by others, there is no evidence of this in this case. This patient's mother should be reassured that it is normal for adolescents to explore and find unique ways of expressing identity and gender, which may or may not conform with typical gender norms. Her son is comfortable in his expression, without evidence of distress or impairment. (Choice A) Although a person's self-expression may change when moving through different life stages, this is not always the case. In addition, this statement is dismissive and implies that there is something wrong with how her son is choosing to express himself. (Choice B) This response prematurely recommends therapy for the mother without responding to her concerns. The initial approach should include education about gender expression in adolescence and reassurance that her son's behavior is normal. (Choice D) This statement inappropriately assumes that the patient is uncomfortable with the pubertal changes he is experiencing, which is not what he is reporting. (Choice E) Gender dysphoria is characterized by persistent distress due to a discrepancy between assigned gender and innately felt gender. This patient is not distressed by his assigned gender. Rather, he chooses to express himself in ways that do not conform with typical gender norms. Educational objective: Exploring gender expression is a normal part of child and adolescent development. Nonconformity with typical gender norms should be differentiated from an experienced gender identity that is incongruent with assigned gender. References: Understanding gender variance in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/24972420)

A 14-Year-Old Boy Is Brought to the Office by His