Gender identity develops, forms and matures through the interaction of biological, physical, psychological, mental and social processes, which are different dimensions of sexuality. "Gender", "gender" and "gender roles", "sexual behavior", "sexual intimacy" Although many concepts such as "", "sexual orientation" are sometimes confused with each other or used interchangeably, they are concepts that explain sexual identity.
Gender identity is the individual's perception and acceptance of his/her own body and self within a certain gender. orients his emotions and behaviors accordingly. For example, a man's perception and acceptance of himself as a man; The tendency towards the female in his motivations, senses and behaviors indicates that a sense of sexual self has settled in the person and the existence of a male sexual identity.
The child begins to acquire his sexual identity and role in the first years of life. The mother's and father's gender expectations of their children as boys or girls, the name given to the child, attitudes towards the child, and the behavior expected from the child depending on whether it is a girl or a boy, play an important role in the development of sexual identity. Appropriate biological development is undoubtedly necessary for the development of an appropriate sexual identity. However, being biologically a boy or a girl, having sexual organs in place and in a normal structure, and secreting internal secretions in accordance with this gender are not sufficient for a healthy sexual identity. Experiences in the first years of life have a great impact on the development of sexual identity. Learning during childhood, especially modeling experiences and first identifications, affect and shape the development of sexual identity. For example, a boy can be raised as a girl. A girl may adopt masculine behavior. The presence or absence of appropriate identification and modeling examples is one of the most important factors in the development of sexual identity. The father of the boy or a man who is in the father's place; It is imperative for the development of a healthy sexual identity that the girl child has the opportunity to identify with her mother or a woman who replaces her mother, that the boy adopt the father, and that the girl adopt the mother. Extreme attitudes towards sexual issues within the family may negatively affect sexual identity development. high-level accusations, excessive supervision, pre-puberty and Not allowing the child or young person some privacy in the post-natal age may lead to the development of a sexual identity loaded with stimulating and provocative attitudes, giving false information, a feeling of grave sin, concerns about being caught red-handed, sexual fears and inhibitions, or exaggerated sexual behavior.
Gender defines the characteristics that determine whether a person is biologically male or female. The first seeds of sexual identity are planted during the biological fertilization process. Biological characteristics are chromosomes, sexual hormones, external and internal sexual organs, tissues in which reproductive cells develop, and secondary sex characteristics. At birth, our physical gender is determined. All children are born with male or female sexual organs. One of the most important factors that determine the upbringing attitudes towards the child from the moment he is born is his gender. Raising attitudes differ between genders in accordance with the values of culture and society.
Parents learn the gender of their children from the people who help the birth occur. In healthy children, the gender declared at birth is the first step in determining which gender the person will be perceived to belong to throughout life. Very rarely, there may be those who are born with both male and female organs.
In children with ambiguous genitalia, intersex, gender is determined. Uncertainty may be noticed at the time of birth or at any time thereafter. Questionable sexual structure means that the development of the external sexual organs is abnormal and this creates problems in gender determination. Sexual organs develop from Wolf and Müller canals. Sexual development is basically female, and to ensure male development, special factors are required that form the testes, regress the Müller ducts, and masculinize the internal and external sexual organs. While estrogens are not necessary for the development of the female phenotype, high androgen levels are required for differentiation in the male direction.
Parents' gender expectations, which affect the sexual identity development of normal healthy children, are more important in babies born with unknown gender. It is noteworthy that in such cases, parents tend to raise children in line with their own expectations. For example; evaluated in a scientific study The following information is given about a young person who was adopted as a male: It was reported that an androgynous young person, who was raised as a boy until he was fifteen years old, developed serious mental problems as a result of the family making him wear girls' clothes and telling him to behave in accordance with the girl's gender when he started menstruating. As seen in such cases, the later the gender change is made, the more psychological problems occur and the more difficult it is for the individual and the family to adapt.
The most suitable gender, which was pioneered by John Money (1957) and dominated the literature until recent years, increases. The optimal gender policy approach argues that parental attitudes are decisive in the development of the child's sexual identity. In recent years, especially longitudinal studies reveal that parental attitudes are not sufficient to maintain the sexual identity decided in infancy. Although they are few in number, the studies that enable these discussions are based on databases conducted in Western countries, where the problem is largely detected at birth and the etiology is determined in early infancy. For example, in the longitudinal study of Slijper et al. (1998), it was observed that the gender determination process was completed at the end of the first year at the latest. It suggests that in our country, a certain amount of time passes before the problem is noticed and, after it is noticed, until the diagnosis and gender determination is made. During this period full of uncertainty, there are difficulties in the adoption of the child's gender by the family and in reflecting and reinforcing it on the child through attitudes.
Childhood sexual identity disorder is a condition that is assumed to be quite rare and is relatively new to current classification systems. The first clinical data regarding this disorder are the product of a process that began with the examination of the sexual development of hermaphrodite individuals, passed through the sexual development of monozygotic twins, and resulted in the formation of the concept of gender identity disorder. The following data were obtained from retrospective evaluations of adult homosexuals and transsexuals. All these data have led to different hypotheses regarding the etiology of sexual identity disorder in children. childhood gender identity disorder The first symptoms appear at a very early age, after different processes in girls and boys. Rather than a single factor, a combination of different factors plays a role in the emergence of the disorder.
Children with ambiguous sexual identity are born with incomplete genitals. The family environment is important here because it is the first and most permanent environment that shapes the child's sexual orientation and determines his sexual behavior. In such cases, the family may ask the physician to provide detailed information about their child. They should also share their feelings, thoughts and concerns about their child's condition with the physician. Parents will need information on important points such as the gender of the child to be raised, taking the mother or father as a model, sexual identity and roles, and how to handle these children with appropriate attitudes during the upbringing process. It would be appropriate for them to consult a child mental health specialist to obtain this information and have the child evaluated psychologically. In children with gender uncertainty, early consultation with a physician to determine the most appropriate gender for the child can eliminate future gender reassignment problems.
In patients with ambiguous genitalia, appropriate gender selection should be made as early as possible, preferably in the neonatal period. After the baby's gender is announced, its name is given, and sexual identity is developed, choosing the opposite gender will cause irreversible social and psychological problems in the future. When choosing gender in a patient with ambiguous genitalia, it is of primary importance to ensure that the patient maintains normal sexual activity in adult life and, if possible, to preserve the reproductive function. Karyotype has no importance in gender selection. The anatomical structure of the external genitalia appears as one of the determining factors. Subjects who will be raised as males must have an androgen-sensitive phallus that is large enough to have sexual intercourse and contains cavernous tissue. In cases of female pseudohermaphroditism, it is most appropriate to assign female gender. In male pseudohermaphroditism, gender selection depends on the length of the phallus and its response to androgens. It is not recommended to choose male gender in cases that do not respond to testosterone. Fusion, vaginal reconstruction, gonadectomy in children who will be raised as girls (if they belong to the opposite sex or are dysgenetic); becomes a man In children who will be raised together, hypospadias repair, prosthetic testicle placement, gonadectomy (if belonging to the opposite sex or dysgenetic), and removal of Müllerian structures are included in the surgical treatment plan. In cases where necessary, hormone replacement is performed during puberty. Gender change is not possible in patients who apply late after the development of sexual identity.
Increased psychiatric problems may be observed in cases with ambiguous external genitalia. Diamond and Watson (2004) report that people's first reaction when they learn the diagnosis is denial, followed by a depression that almost reaches the point of collapse in some people. In their study of 59 cases, Slijper et al. (1998) found that 39% of the children developed major psychopathology, despite the fact that gender determination and genital repair were performed immediately after birth, psychological support was given to the parents, and intensive psychotherapy was applied to the affected children. For these reasons, regardless of the underlying reason, it becomes important that children and families with ambiguous external genitalia should be monitored until their sexual identity is established in adolescence and that the family should receive counseling (Sobel and Imperato-McGinley 2004).
Gender determination, It is recommended that it be done as soon as possible and at the youngest age in order to shorten the period of gender uncertainty as much as possible. In cases where gender needs to be redetermined after early infancy, the answer to the question of what is the latest time that will not increase the risk of conflict in the development of the child's sense of sexual identity is not clear (Carrillo et al. 2003). In such cases, when redetermining gender, the development of the child, the sexual roles and behaviors adopted by the child, the sexual roles attributed by the family and the environment, the beliefs and cultural environment of the family, as well as the biological basis and anatomical structure, should be taken into consideration. In order to minimize possible risks and to make the healthiest decision for both the child and his family, it is recommended that these children be handled with an approach model in which mental health professionals, pediatric endocrinologists and other health professionals cooperate. (Money and Danon 1996).
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