gender assignment examples

Understanding Gender, Sex, and Gender Identity

It's more important than ever to use this terminology correctly..

Posted February 27, 2021 | Reviewed by Kaja Perina

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Representative Marjorie Taylor Greene hung a sign outside her Capitol office door that said “There are TWO genders: MALE & FEMALE. ‘Trust the Science!’” There are many reasons to question hanging such a sign, but given that Rep. Taylor Greene invoked science in making her assertion, I thought it might be helpful to clarify by citing some actual science. Put simply, from a scientific standpoint, Rep. Taylor Greene’s statement is patently wrong. It perpetuates a common error by conflating gender with sex . Allow me to explain how psychologists scientifically operationalize these terms.

According to the American Psychological Association (APA, 2012), sex is rooted in biology. A person’s sex is determined using observable biological criteria such as sex chromosomes, gonads, internal reproductive organs, and external genitalia (APA, 2012). Most people are classified as being either biologically male or female, although the term intersex is reserved for those with atypical combinations of biological features (APA, 2012).

Gender is related to but distinctly different from sex; it is rooted in culture, not biology. The APA (2012) defines gender as “the attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex” (p. 11). Gender conformity occurs when people abide by culturally-derived gender roles (APA, 2012). Resisting gender roles (i.e., gender nonconformity ) can have significant social consequences—pro and con, depending on circumstances.

Gender identity refers to how one understands and experiences one’s own gender. It involves a person’s psychological sense of being male, female, or neither (APA, 2012). Those who identify as transgender feel that their gender identity doesn’t match their biological sex or the gender they were assigned at birth; in some cases they don’t feel they fit into into either the male or female gender categories (APA, 2012; Moleiro & Pinto, 2015). How people live out their gender identities in everyday life (in terms of how they dress, behave, and express themselves) constitutes their gender expression (APA, 2012; Drescher, 2014).

“Male” and “female” are the most common gender identities in Western culture; they form a dualistic way of thinking about gender that often informs the identity options that people feel are available to them (Prentice & Carranza, 2002). Anyone, regardless of biological sex, can closely adhere to culturally-constructed notions of “maleness” or “femaleness” by dressing, talking, and taking interest in activities stereotypically associated with traditional male or female gender identities. However, many people think “outside the box” when it comes to gender, constructing identities for themselves that move beyond the male-female binary. For examples, explore lists of famous “gender benders” from Oxygen , Vogue , More , and The Cut (not to mention Mr. and Mrs. Potato Head , whose evolving gender identities made headlines this week).

Whether society approves of these identities or not, the science on whether there are more than two genders is clear; there are as many possible gender identities as there are people psychologically forming identities. Rep. Taylor Greene’s insistence that there are just two genders merely reflects Western culture’s longstanding tradition of only recognizing “male” and “female” gender identities as “normal.” However, if we are to “trust the science” (as Rep. Taylor Greene’s recommends), then the first thing we need to do is stop mixing up biological sex and gender identity. The former may be constrained by biology, but the latter is only constrained by our imaginations.

American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist , 67 (1), 10-42. https://doi.org/10.1037/a0024659

Drescher, J. (2014). Treatment of lesbian, gay, bisexual, and transgender patients. In R. E. Hales, S. C. Yudofsky, & L. W. Roberts (Eds.), The American Psychiatric Publishing textbook of psychiatry (6th ed., pp. 1293-1318). American Psychiatric Publishing.

Moleiro, C., & Pinto, N. (2015). Sexual orientation and gender identity: Review of concepts, controversies and their relation to psychopathology classification systems. Frontiers in Psychology , 6 .

Prentice, D. A., & Carranza, E. (2002). What women should be, shouldn't be, are allowed to be, and don't have to be: The contents of prescriptive gender stereotypes. Psychology of Women Quarterly , 26 (4), 269-281. https://doi.org/10.1111/1471-6402.t01-1-00066

Jonathan D. Raskin, Ph.D. , is a professor of psychology and counselor education at the State University of New York at New Paltz.

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Article contents

Gender identity and gender expression.

• Jama Shelton Jama Shelton Hunter College, City University of New York
• https://doi.org/10.1093/acrefore/9780199975839.013.1324
• Published online: 21 June 2023

Gender identity and gender expression are aspects of personal identity that impact an individual across multiple social dimensions. As such, it is critical that social workers understand the role of gender identity and gender expression in an individual’s life. Many intersecting factors contribute to an individual’s gender identity development and gender expression, as well as their experiences interacting with individuals, communities, and systems. For instance, an individual’s race, geographic location, disability status, cultural background, religious affiliation, age, economic status, and access to gender-affirming healthcare are some of the factors that may impact experiences of gender identity and gender expression. Gender identity and expression are dimensions of diversity that social workers will interact with at all levels of practice. As such, it is important for social work educational institutions to ensure their students are prepared for practice with people of all gender identities and expression, while also understanding the historical context of the social work profession in relation to transgender populations and the ways in which the profession has reinforced the sex and gender binaries.

• gender binary
• gender equity
• gender identity
• gender expression

What Are Gender Identity and Gender Expression?

Every individual has a gender identity, and every individual expresses their gender (see Table 1 ). Gender identity and gender expression are often referenced in relation to transgender, nonbinary, and gender-expansive people, yet one’s gender and the expression of gender are dimensions of identity that every individual possesses. Gender identity can be understood as an individual’s internal sense of self as it relates to gender. One’s gender is a deeply felt, personal sense of self as a girl/woman, boy/man, both a girl/woman and a boy/man, neither a girl/woman nor a boy/man, or a combination of a girl/woman and a boy/man. Additional words people may use to describe their gender include (but are not limited to): nonbinary, gender expansive, agender, multigender, two-spirited, gender-fluid, genderqueer, and muxe. Importantly, there is no external source that can dictate an individual’s gender identity.

Gender expression refers to the ways in which an individual expresses their gender outwardly. Gender expression may include an individual’s dress, hairstyle, mannerisms, and behaviors. These are typically based on stereotypes about gender within a particular cultural context. An individual’s gender expression may or may not conform to social norms that are typically associated with an individual’s gender or with gendered assumptions based on an individual’s assigned sex. Importantly, an individual’s gender presentation may or may not reflect their gender identity. Issues such as personal safety and access to accurately gendered items may impact an individual’s ability to express their gender in a way that aligns with their gender identity.

Table 1. Additional Relevant Terms

The sex and gender binaries.

The terms gender and sex are often used interchangeably. While these terms may be related in some instances, they are not the same. An individual’s sex is connected to their chromosomes, hormones, and anatomy. Typically, an individual is assigned a sex at birth, if not prior to birth. A sex assignment is most often made based on the appearance of a baby’s genitals. The options for sex assignment have historically been either male or female, which is then listed on an individual’s birth certificate. This is still often the case in the United States, even though evidence demonstrates that sex is not a binary construct ( Fausto-Sterling, 2018 ). Some states in the country allow an additional option (X) for the classification of sex on the birth certificate. While it is beyond the scope of this article to examine the category of intersex (discussed in “XXX”), intersex people cannot be overlooked in discussions of sex and gender. The binary construction of sex assumes the existence of only two sexes. This is an inaccurate and limiting construct that ignores human variability. Not only is it inaccurate and limiting, it is also harmful. Intersex babies and children often undergo surgical procedures that they do not consent to, and are required to take hormones in order to make their bodies fit within a binary that their bodies directly challenge.

An individual’s gender is most often presumed based on their sex assignment, and is presumed to fall within the binary gender categories of girl/woman and boy/man. For instance, if a baby is assigned female, the assumption is that the baby is a girl and will grow up to be a woman. With this assumption comes a set of gendered norms and expectations, societally reinforced in myriad ways including options for grooming and dress, presumptions about appropriate behavior and presentation, and even the choice of language used to praise or discipline (“such a pretty girl” or “that’s not ladylike”). However, an individual’s assigned sex does not always predict their gender; gender identity is more strongly linked to an individual’s experience of gender than to assigned sex ( Olson et al., 2015 ). Yet, the connection between an individual’s sex and their gender and the binary constructions of both sex and gender are so widely taught that this misperception is pervasive in the United States and in many Western countries despite the fact that “defining gender as a condition determined strictly by a person’s genitals is based on a notion that doctors and scientists abandoned long ago as oversimplified and often medically meaningless” ( Grady, 2018 ). In addition to the limitations of these binary categories, sex and gender are often viewed as immutable and stable over time. The lived experiences of intersex, nonbinary, transgender, and gender-expansive people demonstrate the inaccuracy of the binary system of sex and gender categorization.

It is important to note that an individual’s identification within the gender binary is not itself problematic. Because many laws and policies in the United States are based on a binary construction of sex and/or gender, it is the classification system itself that is flawed. Binary classifications are problematic when identification with the gender binary and associated gender expressions are required for entry within social and legal systems.

Beyond the Binary: Reconceptualizing Gender Identity and Gender Expression

Some think about gender identity and gender expression as a continuum, with binary classifications marking the endpoints and a range of identities and expressions in between. More contemporary understandings assert that gender identity and gender expression exist more as a “galaxy” rather than a continuum ( Action Canada for Sexual Health and Rights, n.d. ). This thinking is more in alignment with moving beyond binary conceptualizations of gender altogether and situates all gender identities and gender expressions as equally viable, without relying on the containment of binary categories.

Moving beyond the gender binary not only improves the lived experiences of transgender, nonbinary, and gender-expansive people but also opens up possibilities for everyone . The construct of gender carries with it prescribed ways of being ranging from what is “appropriate” physical and behavioral gender expression to what are appropriate fields of study and career choices. Truly moving beyond the gender binary can liberate all people from the constraints inherent in presumptive and prescribed notions of what is deemed socially, culturally, and politically appropriate.

How could moving beyond the gender binary be operationalized within the social work profession? Prior to discussing suggestions for moving beyond the binary in social work education, practice, and research, it is important to first examine the history of the social work profession as it relates to gender identity and gender expression.

Social Work, Gender Identity, and Gender Expression: A Brief History

Historically, the social work profession is rife with demands that nonconforming gender expressions and bodies adapt to mainstream gendered expectations. Examples include the profession’s support for the assimilative Native American Residential Schools, electroconvulsive therapies intended to “cure” homosexuality, and a host of welfare eligibility requirements that serve to police Black families for their deviation from White heteronormative standards ( Bowles & Hopps, 2014 ). Thus, common practices centered around promoting access to resources through acclimating and gaining membership to the status quo. As such, the profession of social work has been complicit in the policing of gender and the maintenance of the gender binary. It is important for the profession to reckon with this disciplinary approach to gender identity and expression in the past, while also developing equitable frameworks for the future.

The primary formal mechanism for the policing of gender and, thus the reification of the gender binary, is the Diagnostic and Statistical Manual of Mental Disorders (DSM). Gender identity disorder was first included in the DSM-III in 1980 , and included the diagnoses “gender identity disorder of childhood” and “transsexualism.” When updated in 1987 , the new DSM-III-R included gender identity disorder of adolescence and adulthood, nontranssexual type ( Drescher, 2009 ). Gender identity disorder of adolescence and adulthood, nontranssexual type, was removed from the DSM-IV and replaced with the category gender identity disorder, a diagnosis encompassing both gender identity disorder of childhood and transsexualism ( Shelton et al., 2019 ). The most recent version of the DSM (the DSM-5) replaced gender identity disorder with gender dysphoria. This shift in diagnostic terminology signifies a change in the understanding of the root causes of the challenges individuals face when their gender identity and gender expression fall outside of the dominant societal norms prescribed to the gender associated with their assigned sex. Namely that societal definitions of and expectations surrounding gender do not accurately reflect people’s lived experience of gender. However, the fact that a mental health diagnosis remains in the DSM is considered problematic by many, as gender related dissonance continues to be constructed as individual pathology.

The DSM solidified the notion of a gendered norm any deviation from which required correction. For decades, the remedy was to fit an individual into a gender that aligned with the expectations associated with their assigned sex. Through modern medicine, a new type of “correction” emerged for those who could gain access, through hormone treatment and affirming surgeries. Though these interventions are medical in nature, the psychiatric diagnoses remain a driving force in accessing these treatments. Further, gender-affirming treatments have reinforced the necessity of binary gender conformity, by supporting an individual in their transition from one gender to the other gender. It is important to note here that these treatments have been and continue to be life-saving for many individuals, and that identifying with the gender binary is not in itself problematic. As already stated, the gender binary is problematic when a binary classification is imposed and/or presumed and is not in alignment with an individual’s stated gender and understanding of their own body ( Ansara & Hegarty, 2012 ), and when identification or categorization within the gender binary is required for entry into and acceptance within social and legal systems ( Shelton et al., 2019 ).

The National Association of Social Workers released a position statement denouncing the continued inclusion of gender identity related diagnoses in the DSM-5, stating that diagnoses such as gender dysphoria should be approached from a medical model rather than a mental health model. Because of the authority that the DSM holds in social work and related professions, the inclusion of gender dysphoria perpetuates the notion that the variability of gender is a psychiatric condition, reinforcing cisnormativity and the binary gender system. Advocacy organizations argue that until gender related diagnoses are removed from the DSM, transgender and gender-expansive people will continue to suffer from stigma, discrimination, and the invalidation of their identities and experiences.

Social workers may find themselves in a gatekeeping role when working with individuals whose gender identity and/or gender expression expand beyond binary classifications or stretch the boundaries of what is typically considered appropriate gendered behavior based on an individual’s sex assignment. For instance, according to the Standards of Care put forth by the World Professional Association for Transgender Health ( WPATH, 2012 ), in order to access gender-affirming care (such as hormone treatment or surgery), an individual must obtain a letter of recommendation from a qualified mental health professional diagnosing their persistent gender dysphoria and indicating their readiness for care ( Coleman et al, 2022 ). Thus, the notion that individuals whose gender identities expand beyond the binary cisgender norm are not only pathologized but also viewed as incapable of owning their own bodily expertise. The same requirements are not expected from cisgender individuals seeking body altering surgeries, such as breast augmentation, hair implants, or facelifts.

Notably, not every nonbinary, gender-expansive, or transgender individual desires gender-affirming medical procedures. There is no single way to be nonbinary, gender expansive, or transgender, just as there is no single way to be a girl, woman, boy, or man. Each individual person experiences and expresses their gender in their own unique way.

Social Work and Gender Equity

Social workers are charged with confronting injustice; social justice is a core value of the profession. In recognition of the social worker’s responsibility to work toward social justice, the Council on Social Work Education (CSWE) (2015 ) generated accreditation standards requiring social workers to understand diversity and difference in the context of privilege, power, oppression, and marginalization to eliminate biases (Competency 2). Because gender identity and gender expression are included as dimensions of diversity that professionals must understand and value, social workers have an ethical commitment to advance gender equity in all professional practice, education, and research activities. The National Association of Social Workers (NASW) Code of Ethics ( 2017 / 1996 ) includes gender identity and gender expression as specific categories to include when confronting discrimination. The Code of Ethics ( 2017 / 1996 , p. 21) states that “social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of ... sexual orientation, gender identity or expression.”

In order to meet CSWE’s Competency 2—that social workers must understand diversity and difference in the context of privilege, power, oppression, and marginalization to eliminate biases—it is important that the profession broadens its analysis from individual and interpersonal acts of discrimination to include social systems and institutions that permit individual and interpersonal acts of discrimination. In other words, the role of structural discrimination in the oppression of people based on their gender identity and/or gender expression must be addressed. Structural discrimination can be understood as “the policies of dominant race/ethnic/gender institutions and the behavior of the individuals who implement these policies and control these institutions, which are race/ethnic/gender neutral in intent but which have a differential and/or harmful effect on minority race/ethnic/gender groups” ( Pincus, 1996 , p. 186).

To engage from within a structural framework would require social workers to address the structural conditions that marginalize people on the basis of their gender identity and/or gender expression. For example, rather than working with people to cope with the gender identity and expression based marginalization they face, social workers would also address the systems and structures that produce and reinforce marginalization. This may include challenging policies and practices within institutions of social work practice and education that rely on a binary classification of gender as a way to organize and categorize people. It may include insisting that all gender restrooms are accessible to all clients in one’s agency, or becoming involved in advocacy efforts aimed at removing gender identity based diagnoses from the DSM.

Social workers can begin to move beyond the gender binary by taking an inventory of the policies and practices within their organizations, critically examining the ways in which they may be inadvertently marginalizing clients and communities based on gender identity and gender expression. By centering transgender and nonbinary people in their examinations of policy and practice, social workers can intentionally assess their inclusion of and impact on transgender, nonbinary, and gender-expansive people. Because societal systems and services were built on the premise of binary sex and gender, they are rooted in the presumption that every individual who comes into contact with them can be categorized within these binary constructions. Public restrooms provide a concrete example. Social norms around restroom use necessitate that males and females are separated in different rooms, even with the physical separation of locked and partitioned stalls. In instances when public restrooms are single occupancy, they are most often still labeled male and female. The rationale for this separation is often safety and privacy. As Davis (2014 , p. 53) asserts, “If privacy and safety are the main reasons for sex-segregated restrooms, then might alternative physical designs such as floor-to-ceiling stall partitions do an even better job of meeting that goal than the current design of most American public restrooms?”

With regard to social work education, Shelton and Dodd (2020 ) outline key strategies for challenging cisnormativity and moving beyond the gender binary, including:

Use all gender pronouns (they and them) when speaking and writing rather than only including she and he or his and hers, an example of binarizing ( Blumer et al., 2013 ).

Examine and review course syllabi for implicit cisnormativity. Include your name and pronouns, ensure gender identity and expression are a part of classroom nondiscrimination standards, avoid binarizing language, and identify any all-gender restrooms available in the building.

Examine and review content on course syllabi. Ensure readings by and about transgender people are included. Transgender topics and authors should appear in a unit on gender identity. When planning a session about parenting, for instance, include a reading about transgender, gender-expansive, genderqueer, or nonbinary parents.

Be intentional when planning classroom introductions. Some students may not use the names indicated on your class roster or on school records. Plan introductions in such a way that enables students to introduce themselves first (before reading names from the provided class roster).

Model the sharing of pronouns and give students the option to include their pronouns when introducing themselves. For example, you could say, “Please share your name and your pronouns if you would like to do so.”

When utilizing case examples in the classroom, make sure transgender people are included/represented.

When including transgender people in case examples, make sure they are included in a way that does not perpetuate negative stereotypes and misinformation. For instance, a case example including a transgender person does not need to be focused solely on gender dysphoria and does not need to be related to their transgender identity.

Engage students in nuanced discussions about the history of the pathologization of gender and sexual minorities and the role of social work in this history.

Social work researchers can concretely work toward gender equity throughout the research process, helping to ensure all gender identities and gender expressions are acknowledged as valid. From the design of demographic questions to the reporting of results, researchers can intentionally include participants with a range of gender identities and expressions. Demographic questions can include additional options for sex and gender beyond the binary categorizations of female/male, woman/man, or girl/boy. When analyzing quantitative data, researchers can opt out of collapsing sex and/or gender into a dichotomous variable. Though this may make the process of analysis less simple, making these variables dichotomous erases the lived experiences of participants. When reporting results, researchers can include the experiences of participants across a range of gender identities and gender expressions. In reporting only statistically significant findings, critical data about frequently marginalized and underrepresented populations is lost. Recruitment strategies should include specific outreach to individuals and communities of diverse gender identities and gender expressions. This will require community engaged research and a willingness to extend recruitment timelines to ensure adequate representation. A 2021 study from the Williams Institute reported that 1.2 million adults in the United States are nonbinary ( Wilson & Meyer, 2021 ). Expanding beyond binary conceptualizations of gender within social work research is imperative in order to address the health and well-being of nonbinary individuals and communities.

In summary, gender identity and gender expression are dimensions of identity that are relevant to and impact all people. Thus, it is important for social workers to understand the ways in which gender identity and gender expression impact the individuals and communities with whom they work, as well as the ways that systems and institutions may perpetuate bias and marginalization based on gender identity and gender expression. Although the profession of social work has a fraught history with regard to policing and pathologizing individuals whose gender identities and expressions exist outside of or in between the gender binary, contemporary practice charges social workers with confronting injustice, including dimensions of diversity such as gender identity and gender expression.

Further Reading

• Bilodeau, B. , & Renn, K. (2005). Analysis of LGBT identity development models and implications for practice. New Directions for Student Services , 111 , 25–39.
• Burdge, B. (2007). Bending gender, ending gender: Theoretical foundations for social work practice with the transgender community. Social Work , 52 (3), 243–250.
• Butler, J. (2004). Undoing gender . Routledge.
• James, S. E. , Herman, J. L. , Rankin, S. , Keisling, M. , Mottet, L. , & Anafi, M. (2016). The report of the 2015 U.S. transgender survey . National Center for Transgender Equality.
• Kroehle, K. , Shelton, J. , Clark, E. , & Seelman, K. (2020). Mainstreaming dissidence: Confronting binary gender in social work’s grand challenges. Social Work , 65 (4), 368–377.
• Sanger, T. (2008). Queer(y)ing gender and sexuality: Transgender people’s lived experiences and intimate partnerships. In L. Moon (Ed.), Feeling queer or queer feelings? Radical approaches to counselling sex, sexualities and genders (pp. 72–88). Routledge.
• Action Canada for Sexual Health and Rights . (n.d.). Gender galaxy .
• Ansara, Y. , & Hegarty, P. (2012). Cisgenderism in psychology: Pathologising and misgendering children from 1999 to 2008. Psychology & Sexuality , 3 (2), 137–160.
• Blumer, M. L. C. , Ansara, Y. G. , & Watson, C. M. (2013). Cisgenderism in family therapy: How everyday clinical practices can delegitimize people’s gender self-designations. Special Section: Essays in Family Therapy. Journal of Family Psychotherapy , 24 (4), 267–285.
• Bowles, D. D. , & Hopps, J. G. (2014). The profession’s role in meeting its historical mission to serve vulnerable populations. Advances in Social Work , 15 (1), 1–20.
• Council on Social Work Education . (2015). Educational policy and accreditation standards .
• Coleman, E. , Radix, A. E. , Bouman, W. P. , Brown, G. R. , de Vries, A. L. C. , Deutsch, M. B. , Ettner, R. , Fraser, L. , Goodman, M. , Green, J. , Hancock, A. B. , Johnson, T. W. , Karasic, D. H. , Knudson, G. A. , Leibowitz, S. F. , Meyer-Bahlburg, H. F. L. , Monstrey, S. J. , Motmans, J. , Nahata, L. , Nieder, T. O. , … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 . International journal of transgender health, 23(Suppl 1), S1–S259.
• Davis, H. (2014). Sex-classification policies as transgender discrimination: An intersectional critique. Perspectives on Politics , 12 (1), 45–60.
• Drescher, J. (2009). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual. Archives of Sexual Behavior , 39 , 427–460.
• Fausto-Sterling, A. (2018, October 15). Why sex is not binary. The New York Times .
• Grady, D. (2018, October 2). Anatomy does not determine gender, experts say . The New York Times , 10A.
• National Association of Social Workers . (2017). The NASW code of ethics (Rev. ed.). (Original work published 1996)
• Olson, K. R. , Key, A. C. , & Eaton, N. R. (2015). Gender cognition in transgender children. Psychological Science , 26 (4), 467–474.
• Pincus, F. (1996). Discrimination comes in many forms: Individual, institutional, and structural. The American Behavioral Scientist , 40 (2), 186–194.
• Shelton, J. , & Dodd, S. J. (2020). Beyond the binary: Addressing cisnormativity in the social work classroom. Journal of Social Work Education , 56 (1), 179–185.
• Shelton, J. , Kroehle, K. , & Andia, M. (2019). The trans person is not the problem: Brave spaces and structural competence as educative tools for trans justice in social work. Journal of Sociology and Social Welfare , 46 (4), 97–123.
• World Professional Association for Transgender Health . (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7 th Version].
• Wilson, B. D. M. , & Meyer, I. (2021). Nonbinary LGBTQ adults in the United States . The Williams Institute.

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A review of the essential concepts in diagnosis, therapy, and gender assignment in disorders of sexual development

• Vivek Parameswara Sarma   ORCID: orcid.org/0000-0001-9484-7090 1  

Annals of Pediatric Surgery volume  18 , Article number:  13 ( 2022 ) Cite this article

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The aim of this article is to review the essential concepts, current terminologies and classification, management guidelines and the rationale of gender assignment in different types of differences/disorders of sexual development.

The basics of the present understanding of normal sexual differentiation and psychosexual development were reviewed. The current guidelines, consensus statements along with recommendations in management of DSD were critically analyzed to formulate the review. The classification of DSD that is presently in vogue is presented in detail, with reference to old nomenclature. The individual DSD has been tabulated based on various differential characteristics. Two schemes for analysis of DSD types, based on clinical presentation, karyotype and endocrine profile has been proposed here. The risk of gonadal malignancy in different types of DSD is analyzed. The rationale of gender assignment, therapeutic options, and ethical dimension of treatment in DSD is reviewed in detail.

The optimal management of different types of DSD in the present era requires the following considerations: (1) establishment of a precise diagnosis, employing the advances in genetic and endocrine evaluation. (2) A multidisciplinary team is required for the diagnosis, evaluation, gender assignment and follow-up of these children, and during their transition to adulthood. (3) Deeper understanding of the issues in psychosexual development in DSD is vital for therapy. (4) The patients and their families should be an integral part of the decision-making process. (5) Recommendations for gender assignment should be based upon the specific outcome data. (6) The relative rarity of DSD should prompt constitution of DSD registers, to record and share information, on national/international basis. (7) The formation of peer support groups is equally important. The recognition that each subject with DSD is unique and requires individualized therapy remains the most paramount.

The aim of this article is to review the essential concepts, current terminologies and classification, management guidelines, and the rationale of gender assignment in different types of differences/disorders of sexual development (DSD). The basics of the present understanding of normal sexual differentiation and psychosexual development were reviewed. The current guidelines, consensus statements along with recommendations in management of DSD were critically analyzed to formulate the review. The classification of DSD that is presently in vogue is presented in detail, with reference to old nomenclature. The individual DSD has been tabulated based on various differential characteristics. Two schemes for analysis of DSD types, based on clinical presentation, karyotype, and endocrine profile has been proposed here. The risk of gonadal malignancy in different types of DSD is analyzed. The rationale of gender assignment, therapeutic options, and ethical dimension of treatment in DSD is reviewed in detail.

The normal sexual differentiation

The normal pattern of human sexual development and differentiation that involves specific genetic activity and hormonal mediators [ 1 , 2 ] is explained by the classical Jost’s paradigm; the essence of which is narrated below [ 3 ].

The establishment of chromosomal sex (XX or XY) occurs at the time of fertilization. The variations in sex chromosome include XO, XXY or mosaicism as in XO/XY.

Chromosomal sex influences the determination of the gonadal sex, thus differentiating the bipotential gonadal ridge into testis or ovary. (Variations in gonadal sex include ovotestis and streak gonad.) The SRY gene (referred to as the testis-determining gene) on the short arm of Y chromosome directs the differentiation into testes, with formation of Leydig and Sertoli cells [ 4 , 5 ].

The sex phenotype (internal and external genitalia) is determined by the specific hormones secreted by the testes, which translates the gonadal sex into phenotype. Testosterone secretion by Leydig cells promotes Wolffian duct differentiation into vas deferens, epididymis, and seminal vesicles. The Wolffian ducts regress in the absence of androgenic stimulation. Testosterone is converted to dihydrotestosterone (DHT), by 5-alpha reductase, which results in masculinization of external genitalia, closure of urethral folds, and development of the prostate and scrotum. In the absence of influence of SRY gene, the development of bipotential gonad will evolve along the female pathway. Thus, the Mullerian ducts develop (even without any obvious hormonal input) into the uterus, fallopian tubes, and the proximal 2/3 of vagina. DHT is also important for the suppression of development of the sinovaginal bulb, which gives rise to the distal 1/3 of vagina. The fact that internal duct development reflects the ipsilateral gonad (due to the paracrine effect of sex hormones) is an important consideration in the understanding of specific types of DSD. The anti-Mullerian hormone (AMH) from Sertoli cells of Testis is vital for the regression of Mullerian structures. Therefore, Wolffian structures will develop on one side, along with Mullerian duct regression, only in the presence of a fully functional testis. But, Mullerian duct structures develop on one side even in the presence of an ipsilateral streak gonad. The genital tubercle develops as a clitoris, the urethral folds form the labia minora, and the labioscrotal swellings form the labia majora [ 1 , 2 , 4 , 5 , 6 ].

The concept of psychosexual development was added to the above sequence by Money et al. [ 7 ]. The brain undergoes sexual differentiation consistent with the other characteristics of sex. It is proposed that androgens organize the brain in early development and pubertal steroids activate the same, leading to masculine behavior. The sexual differentiation of genitalia occur in first 2 months of pregnancy, while sexual differentiation of brain occurs in the second half of pregnancy, and hence these processes can be influenced independently. Therefore, the extent of virilization of genitalia may not reflect the extent of masculinization of brain [ 8 , 9 ].

Psychosexual development is a complex and multifactorial process influenced by brain structure, genetics, prenatal and postnatal hormonal factors, environmental, familial, and psychosocial exposure [ 10 , 11 , 12 ]. Psychosexual development is conceptualized as three components: (1) gender identity is defined as the self-representation of a person as male, female or even, neither. (2) Gender role (sex-typical behavior) describes behavior, attitudes and traits that a society identifies as masculine or feminine. (3) Sexual orientation denotes the individual responsiveness to sexual stimuli, which includes behavior, fantasies, and attractions (hetero/bi/homo-sexual).

Psychosexual development is influenced by various factors such as Androgen exposure, sex chromosome genes, brain structure, family dynamics and social structure. With reference to altered psychosexual development, two conditions are important to be recognized and differentiated. (1) Gender dissatisfaction denotes unhappiness with the assigned sex, the etiology of which is poorly understood. (With respect to subjects with DSD, it has to be remembered that homo-sexual orientation or cross-sex interest is not considered an indication of incorrect gender assignment.) (2) Gender dysphoria (GD) is characterized by marked incongruence between the assigned gender and experienced/expressed gender, which is associated with clinically significant functional impairment. (It can occur in the presence or absence of DSD) [ 12 , 13 , 14 ].

The term “disorders/differences of sex development” (DSD) is defined as congenital anomalies in which development of chromosomal, gonadal, or phenotypic sex (including external genitalia/internal ductal structures) is atypical. In a wider perspective, DSD includes all conditions where chromosomal, gonadal, phenotypical, or psychological sex are incongruent. The three components of psychosexual development also may not always be concordant in DSD [ 15 , 16 ].

A greater understanding of underlying genetic and endocrine abnormalities has necessitated refinement in terminologies and classification of DSD. The newer classification of DSD aims to be more precise, specific, flexible, and inclusive of advances in genetic diagnosis, while being sensitive to patient concerns (Table  1 ). Terms such as intersex, hermaphrodite, pseudohermaphrodite, and sex reversal are avoided, to this end, in diagnostic terminologies. Presently, a specific molecular diagnosis is identified only in about 20% of all DSD. The majority of virilized 46 XX infants will have CAH, but only 50% of 46 XY DSD will have a definitive diagnosis [ 16 , 17 ].

For the purpose of understanding of the basic pathology and ease of comprehension, DSD can be classified as follows:

Sex chromosomal DSD: here, the sex chromosome itself is abnormal. This includes XO (Turner syndrome), XXY (Klinefelter’s syndrome), mosaic patterns of XO/XY (Mixed Gonadal Dysgenesis and Partial Gonadal Dysgenesis), XX/XY (Ovotesticular DSD), and even SRY-positive XX in 46 XX testicular DSD (de la Chapelle syndrome). These are essentially genetic anomalies characterized by a varying degrees of gonadal dysgenesis/abnormal gonadal differentiation secondary to the sex chromosome defect and in certain situations, associated systemic abnormalities and increased risk of malignancies. The phenotypic sex (internal ductal structures and external genitalia) reflects the gonadal sex.

Disorders of gonadal development: these are characterized by abnormal gonadal development, in the absence of any obvious sex chromosomal abnormality, i.e., Karyotype is either 46 XX or 46 XY. It includes 46 XY complete gonadal dysgenesis (Swyer syndrome), 46 XY partial gonadal dysgenesis, 46 XY ovotesticular DSD, 46 XX pure gonadal dysgenesis (Finnish syndrome) and 46 XX ovotesticular DSD. Here also, the phenotypic sex reflects the gonadal sex (streak or dysgenetic gonads/ovotestis).

Abnormalities in phenotypic sex secondary to hormonal defects: these are characterized by normal chromosomal sex (46 XX or 46 XY) and gonadal sex (testes/ovaries), but abnormal phenotype (internal ductal and/or external genital) due to defects in hormonal function. In 46 XY DSD, this can be due to defects in synthesis or action of androgens or less commonly, AMH. In 46 XX DSD, this is due to androgen excess, as in Congenital Adrenal Hyperplasia, or less commonly, gestational hyperandrogenism.

Primary endocrine abnormalities: These are characterized by a severe underlying endocrine abnormality, as in congenital hypogonadotropic hypogonadism or pan-hypopitutarism.

Malformation syndromes: these are characterized by the presence of genital abnormalities due to severe congenital anomalies including persistent cloaca, cloacal exstrophy, Mullerian agenesis/MRKH syndrome, or vaginal atresia.

The common pattern of correlation of gonadal sex with internal duct structure development is summarized in Table  2 . The cardinal characteristics of chromosomal, gonadal, and phenotypic sex in the individual types of DSD is summarized in Table  3 .

The genetic testing in DSD

For a sex chromosome DSD, no further genetic analysis is required. However, a DSD with 46 XX or 46 XY karyotype, the underlying etiology may be a monogenic disorder where the candidate gene has to be analyzed. The algorithm of genetic analysis of DSD is defined according to the results of sex chromosome complement (karyotyping/array CGH or SNP array) and presence of regions of Y chromosome (FISH/QFPCR). The next step is to study specific genes involved in gonadal development by techniques including Sanger sequencing combined with MLPA to assess specific genetic defects. Further analysis includes evaluation for causes of monogenic DSD or analysis of copy number variations (CNV) or both. Panels for candidate genes (CYP21A2 in CAH, AR in androgen insensitivity syndrome) provide rapid and reliable results. The evolving use of whole exome sequencing (WES) and whole genome sequencing (WGS) aim to identify previously unrecognized genetic etiology of DSD.

The further characterization of 46 XY DSD

The further characterization of individual types of 46 XY DSD based on endocrine and genetic evaluation is summarized in Table  4 . The selective use of the following investigations is required in 46 XY DSD to arrive at a specific diagnosis of the subtype:

Assay of serum testosterone, LH and FSH.

hCG stimulation test, to assess response in testosterone levels.

Assay of AMH, to detect the presence of functioning testicular tissue.

Testosterone: dihydrotestosterone (DHT) ratio.

Testosterone: androstenedione ratio.

ACTH test, for the diagnosis of testosterone biosynthesis defects.

Specific substrates like progesterone, 17-OHP, and 1-OH pregnenelone, for typing of Androgen biosynthesis defects.

Ultrasound scan/MRI and laparoscopy for the detection of Mullerian structures.

Gonadal biopsy for the diagnosis of ovotesticular DSD and gonadal dysgenesis.

Genetic testing including screening of androgen receptor gene for mutations, Molecular testing for 5-alpha reductase-2 gene mutations, androgen receptor expression, and androgen binding study in genital skin fibroblasts.

The further characterization of 46 XX DSD is summarized in Table  5 . The classification of the major types of DSD based on the different clinical manifestations is summarized in Table  6 .

Gonadal dysgenesis syndromes

There are five common patterns of gonadal dysgenesis syndromes, in addition to the dysgenetic ovotestis which is found in 46 XX or 46 XY ovotesticular DSD.

46 XY complete gonadal dysgenesis (Swyer syndrome)

46 XY partial gonadal dysgenesis (Noonan syndrome)

45 XO/46 XY mixed gonadal dysgenesis

46 XX pure gonadal dysgenesis (Finnish syndrome)

45 XO Turner’s syndrome.

Gender assignment in DSD

The classical “optimal gender policy” involved early sex assignment and surgical correction of genitalia and hormonal therapy, with the objective of an unambiguous gender of rearing, that will influence the future gender identity and gender role [ 7 , 11 ]. The genital phenotype (characteristics of genitalia) has historically been the guide for gender assignment, considering esthetic, sexual, and fertility considerations. This perspective, which assumes psychosexual neutrality at birth, has been challenged now, with the present focus shifting to the importance of prenatal and genetic influences on psychosexual development. In addition to the progress in the diagnostic techniques and therapeutic modalities, there has been greater understanding of the associated psychosocial issues and acceptance of patient advocacy [ 19 , 20 , 21 ].

Factors to be considered for gender assignment in DSD

The most common gender identity outcome, observed incidence of GD, and requirement of gender reassignment in the specific type of DSD from available data.

The most common pattern of psychosexual development in the particular DSD, consistent with established neurological characteristics.

The requirement of genital reconstructive surgery to conform to the assigned sex.

The estimated risk of gonadal malignancy and need for gonadectomy (Table  7 ).

The requirement, possible response, and timing of HRT.

The expected post-pubertal cosmetic and functional outcome of genitalia, after reconstruction where required.

The potential for fertility, even with the presumed aid of assisted reproduction techniques.

Though GD in patients with DSD influences, the choice of gender assignment (and reassignment), sexual orientation, and gender-atypical behavior do not affect the decision-making process in gender assignment of DSD [ 22 ].

Gender assignment in neonates should be done only after expert evaluation. The evaluation, therapy, and long-term follow-up should only be done at a centre with an experienced multidisciplinary team. The multidisciplinary team for management of DSD should include pediatric subspecialists in endocrinology, surgery/urology, genetics, gynecology, and psychiatry along with pediatrician/neonatologist, psychologist, specialist nurse, social worker, and medical ethicist. The core group will vary according to the type of DSD. All individuals with DSD should receive the appropriate gender assignment [ 22 , 23 , 24 , 25 ]. The patient and family should be able to have an open communication and participation in the decision-making process. The concerns of patients and their families should be respected and addressed in strict confidence.

The rationale of gender assignment in different clinical conditions of DSD

The usually recommended gender assignment guidelines in different clinical types of DSD is summarized in Table  8 .

46 XX DSD—congenital adrenal hyperplasia (CAH)

In CAH, female gender identity is the most common outcome despite markedly masculinized gender-related behavior. Patients diagnosed in the neonatal period, particularly with lower degrees of virilization, should be assigned and reared as female gender, with early feminizing surgery. GD is rare when female gender is assigned. Those with delayed diagnosis and severely masculinized genitalia need evaluation by a multidisciplinary team. Evidence supports the current recommendation to rear such infants, even with marked virilization, as females [ 18 , 19 , 22 , 23 , 26 ]. A psychological counseling for children with CAH and their families, focused on gender identity and GD, is recommended.

46 XY complete gonadal dysgenesis

It is recommended to rear these children as female, due to following considerations: (a) these patients have typical female psychosexual development. (b) Reconstructive surgery is not required for the external genitalia to be consistent with female gender. (c) Hormonal replacement therapy (HRT) is required at puberty as streak gonads should be removed in view of high risk of gonadal malignancy. (d) Pregnancy is feasible with implantation of fertilized donor eggs and hormonal therapy [ 19 , 22 , 23 ].

Complete androgen insensitivity syndrome (CAIS)

It is recommended that subjects with CAIS should be reared as female, due to the following considerations: (a) they have well documented female-typical core psychosexual characteristics, with no significant GD, in accordance with the proposed absence of androgenization of the brain. (b) Surgical reconstruction of the genitalia is not required for consistency with female gender, though vaginoplasty may be necessary. (c) HRT is required with estrogens after gonadectomy, but testosterone replacement is untenable due to androgen resistance [ 18 , 19 , 22 , 23 , 26 ].

5-alpha reductase deficiency

Male gender assignment is usually recommended due to the following considerations: (a) the genital tissue is responsive to androgens. (b) The potential for fertility. (c) The reported high incidence of subjects requesting female-to-male gender reassignment after puberty*. (d) HRT is not required at puberty for patients reared as male, if testes are not removed. (e) As the risk of gonadal malignancy is low, testes can potentially be retained. (f) They are very likely to have a male gender identity.*(As most neonates with this disorder have female external genitalia at birth, they are reared as females. Profound virilization occurs at puberty, with a gender role change from female to male during adolescence in up to 63% cases.) About 60% of these patients, assigned female in infancy and virilizing at puberty, and all who are assigned male, live as males. When the diagnosis is made in infancy, the combination of male gender identity in the majority and the potential for fertility, should be considered for gender assignment [ 19 , 22 , 23 ].

17-beta-HSD-3 deficiency

Classical features are that of an undervirilized male. Some of the affected patients with feminine genitalia at birth are reared as females. Virilization occurs at puberty, with gender role change from female to male in up to 64% cases. They are highly likely to identify as males. Male gender assignment is recommended in partial defects. But there is no strong data to support male gender assignment, as in 5-alpha reductase deficiency. The other considerations against male gender assignment are the lack of reported cases of fertility and the intermediate risk of germ cell tumors. Hence, regular testicular surveillance is required for those reared as male, with retained testes. Therefore, gender assignment should be made considering all the above factors [ 18 , 19 , 22 , 23 , 26 ].

Partial androgen insensitivity syndrome (PAIS)

Infants with PAIS are assigned to male/female gender, depending partially on the degree of undervirilization. The virilization at puberty is also variable and incomplete. The response to hCG stimulation test/testosterone therapy can serve as a guide to the possible sex of rearing. The phenotype is highly variable in PAIS, which is correspondingly reflected in the sex of rearing. The gender identity has considerable fluidity in PAIS, though gender identity is usually in line with the gender of rearing. Though fertility is possible if the testes are retained, it should be remembered that there is an intermediate risk of gonadal germ cell tumors. Hence, gender assignment in these patients is a complex, multifactorial process [ 18 , 19 , 22 , 23 , 26 ].

47 XXY Klinefelter’s syndrome and variants

They usually report a male gender identity, but with a putative high incidence of GD, which needs to be elaborated in larger series.

Mixed gonadal dysgenesis

The genital phenotype is highly variable. The prenatal androgen exposure, internal ductal anatomy, testicular function at and after puberty, post-puberty phallic development, and gonadal location have to be considered to decide the sex of rearing.

• Ovotesticular DSD

These entities were previously referred to as “true hermaphroditism”, signifying the presence of both testicular and ovarian tissue, though dysgenetic, in the same subject. The three patterns seen are as follows:

46 XX/XY–33% of ovotesticular DSD, with testis and ovary/ovotestis.

46 XX–33% of ovotesticular DSD, with dysgenetic ovotestis.

46 XY–7% of ovotesticular DSD, with dysgenetic ovotestis.

This is characterized by ambiguity of genitalia or severe hypospadias at birth, with secondary sexual changes at puberty, corresponding to the relative predominance of ovarian/testicular tissue. The management depends on the age at diagnosis and anatomical differentiation. Either sex assignment is appropriate when the diagnosis is made early, prior to definition of gender identity. The sex of rearing should be decided considering the potential for fertility, based on gonadal differentiation and genital development. It should be ensured that the genitalia are, or can be made, consistent with the chosen sex [ 19 , 22 , 23 , 24 , 25 ].

General guidelines for surgery and HRT in DSD

Feminizing genitoplasty.

Surgery for correction of virilization (clitoral recession, with conservation of neurovascular and erectile structures, and labioplasty) should be carried out in conjunction with the repair of the common urogenital sinus (vaginoplasty). The current recommendation is to perform early, single-stage feminizing surgery for female infants with CAH. It is opined that correction in first year of life relieves parental distress related to anatomic concerns, mitigates the risks of stigmatization and gender identity confusion, and improves attachment between the child and parents. The current recommendation is the early separation of vagina and urethra, the rationale of which includes the beneficial effects of estrogen for wound healing in early infancy, limiting the postoperative stricture formation and avoidance of possible complications from the abnormal connection between the urinary tract and peritoneum through the Fallopian tubes. Surgical reconstruction in infancy may require refinement at puberty. Vaginal dilatation should not be undertaken before puberty. An absent or inadequate vagina, requiring a complex reconstruction of at high risk of stricture formation, may be appropriately delayed. But, the need for complete correction of urogenital sinus, prior to the onset of menstruation, is an important consideration [ 19 , 22 , 23 , 24 , 25 , 26 ].

Male genital reconstruction

The standard timing and techniques of operative procedures for correction of ventral curvature and urethral reconstruction, along with selective use of pre-operative testosterone supplementation is advised when male sex of rearing is adopted. The complexity of phallic reconstruction later in life, compared to infancy, is an important consideration in this regard. There is no evidence that prophylactic removal of discordant structures (utriculus/pseudovagina, Mullerian remnants) that are asymptomatic, is required. But symptoms in the future may mandate surgical removal. In patients with symptomatic utriculus, removal can be attempted laparoscopically, though it may not be practically feasible to preserve the continuity of vas deferens [ 19 , 22 , 23 , 24 , 25 ].

Gonadectomy

The gonads at the greatest risk of malignancy are both dysgenetic and intra-abdominal. The streak gonad in a patient with MGD, raised male should be removed by laparoscopy in early childhood. Bilateral gonadectomy (for bilateral streak gonads) is done in early childhood for females with gonadal dysgenesis and Y chromosome material, which should be detected by techniques like FISH and QFPCR. In patients with defects of Androgen biosynthesis raised female, gonadectomy is done before puberty. The testes in patients with CAIS and those with PAIS, raised as females, should be removed to prevent malignancy in adulthood. Immunohistochemical markers (IHM) that can serve to identify gonads at risk of developing malignancy include OCT 3/ 4, PLAP, AFP, beta-Catenin and CD 117. Early removal at the time of diagnosis (along with estrogen replacement therapy) also takes care of the associated hernia, psychological problems associated with the retained testes and risk of malignancy. Parental choice allows deferment until adolescence, in view of the fact that earliest reported malignancy in CAIS is at 14 years of age. A scrotal testis in gonadal dysgenesis is at risk of malignancy. Current recommendations are surveillance with testicular biopsy at puberty to detect premalignant lesions, which if detected, is treated with local low-dose radiotherapy (with preliminary sperm banking). Also, patients with bilateral ovotestes are potentially fertile from the functioning ovarian tissue. Separation of ovarian and testicular tissue, though challenging, is preferably done early in life [ 19 , 22 , 23 , 24 , 25 , 26 ].

Hormonal therapy/sex steroid replacement

Hormonal induction at puberty in hypogonadism should attempt to replicate normal pubertal maturation to induce secondary sexual characteristics, pubertal growth spurt, optimal bone mineral accumulation together with psychosocial support for psychosexual maturation. Treatment is initiated at low doses and progressively increased. Testosterone supplementation in males (initiated at bone age of 12 years) and estrogen supplementation in females (initiated at bone age of 11 years) is given accordingly for established hypogonadism. In males, exogenous testosterone is generally given till about 21 years, while the same in females is variable. Also, in females a progestin is added after breakthrough bleeding occurs, or within 1–2 years of continuous estrogen. No evidence of benefit exists for addition of cyclical progesterone in females without uterus [ 22 , 23 , 24 , 25 ].

The advances in molecular diagnosis of DSD

The advent of advanced tools for genetic diagnosis has enabled specific diagnosis to be made by molecular studies. WES and WGS represent evolving translational research that help to identify novel genetic causes of DSD. The techniques for identification of novel genetic factors in DSD have evolved from the use of CGH and custom array sequencing to the use of next generation sequencing (NGS) which mainly includes polymerase-based and ligase-based techniques. The importance of molecular diagnosis in DSD lies in the guidance of management in relation to possible gender development, assessment of adrenal and gonadal function, evaluation of the risk of gonadal malignancy, assessment of the risk of familial recurrence, and prediction of possible morbidities and long-term outcome. Hence, the advances in molecular diagnosis of DSD constitute a rapidly evolving frontier in the understanding and therapy of DSD.

The ethical dimension in DSD

The predominant ethical considerations in management of DSD are twofold. Firstly, when the components of biological sex (the sexual profile of genome, gonads, phenotype, endocrine and neurological status) align strongly, prediction of gender identity and recommendations for sex assignment can be made accordingly. The more discordant the determinants of biological sex, more variation in subsequent components of psychosexual development. Secondly, irreversible anatomic and physiologic effects of surgical assignment of sex have to be avoided, especially when the components of biological sex do not strongly align. The objective in such situations should be to delay such treatment till the appropriate age [ 24 , 25 , 26 ].

The arguments favoring recognition of DSD as an alternate gender, with delayed sex assignment and deferred surgical therapy has gained ground over the past decades, highlighted by certain judicial interventions across the globe. In this regard, it has to be emphasized that a transgender state, without incongruity of biological sex, has to be clearly distinguished from a DSD. Though differences in psychosexual development can occur in DSD, the vast majority of clinically diagnosed DSD (CAH, MGD, 46 XY DSD) have the anatomic and physiological consequences of altered components of biological sex. The issues in these subjects are not only confined to the genitalia, but also include problems that can include life-threatening cortisol deficiency, features of hypogonadism and urogenital sinus, and even the risk of gonadal malignancy. The early identification and correction of each issue is vital, and the best available window for the same is limited and usually, early in life. It is some of the less frequently encountered types of DSD (ovotesticular DSD, 17-BHSD deficiency, PAIS) that invariably require a more complex decision-making process. The diagnostic and therapeutic approach in the majority of clinically encountered DSD requires a structured scientific approach, with due consideration of the intricacies of psychosexual development.

The optimal management of different types of DSD in the present era requires the following considerations: (1) establishment of a precise diagnosis, employing the advances in genetic testing and endocrine evaluation. (2) A multidisciplinary team is required for the diagnosis, evaluation, gender assignment and follow-up of these children, and during their transition to adulthood. (3) Deeper understanding of the issues in psychosexual development in DSD is vital for therapy. (4) The patients and their families should be an integral part of the decision-making process. (5) Recommendations for gender assignment should be based upon the specific outcome data. (6) The relative rarity of DSD should prompt constitution of DSD registers, to record and share information, on national/international basis. (7) The formation of peer support groups is equally important. The recognition that each subject with DSD is unique and requires individualized therapy remains the most paramount.

Availability of data and materials

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Abbreviations

Disorders of sexual differentiation

• Congenital adrenal hyperplasia

Complete androgen insensitivity syndrome

Partial androgen insensitivity syndrome

Follicular stimulating hormone

Leutinizing hormone

Human chorionic gonadotropin

Fluorescence in situ hybridization

Quantitative fluorescence polymerase chain reaction

Comparative genomic hybridization

Multiplex ligand-dependent probe amplification

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Sarma, V.P. A review of the essential concepts in diagnosis, therapy, and gender assignment in disorders of sexual development. Ann Pediatr Surg 18 , 13 (2022). https://doi.org/10.1186/s43159-021-00149-w

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• Disorders of sexual development
• Ambiguous genitalia
• Gonadal dysgenesis
• Psychosexual development
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Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma

• Published: 10 June 2016
• Volume 39 , pages 1207–1224, ( 2016 )

Cite this article

• A. D. Fisher 1 ,
• J. Ristori 1 ,
• E. Fanni 1 ,
• G. Castellini 1 , 2 ,
• G. Forti 3 &
• M. Maggi 1  

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Introduction

Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development.

(1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis.

A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors’ expertise.

A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD.

Conclusions

Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.

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Advances in diagnosis and care of persons with DSD over the last decade

A review of the essential concepts in diagnosis, therapy, and gender assignment in disorders of sexual development.

Psychosexual Development in Individuals with Disorders of Sex Development

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Fisher, A.D., Ristori, J., Fanni, E. et al. Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma. J Endocrinol Invest 39 , 1207–1224 (2016). https://doi.org/10.1007/s40618-016-0482-0

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• Disorders of Sex Development
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Can sex or gender be ‘assigned’?

• Post author By Pat and Stewart
• Post date September 18, 2020

Q: The terms “gender assignment” and “sex assignment” give me pause. The use of the verb “assign” and noun “assignment” in this sense strikes me as off-pitch. Assigning is what the Sorting Hat does in sending a Hogwarts student to one of the school’s four Houses. Is there an interesting story here?

A: The use of the terms “sex assignment” and “gender assignment” for designating the sex of a newborn child is relatively rare, though an etymological case could be made for this sense of “assignment.”

We’ve found only 42 examples of “sex assignment” and 100 of “gender assignment” in recent searches of the News on the Web Corpus, a database of newspaper and magazine articles from 2010 to the present.

None of the 10 standard dictionaries that we regularly consult have entries for “gender assignment” and only one includes “sex assignment.” Dictionary.com , based on the old Random House Unabridged , defines it as “the determination or assignment of a baby’s sex, based on the appearance of external reproductive organs, and, sometimes, chromosomal testing.”

The Oxford English Dictionary , an etymological dictionary based on historical evidence, doesn’t include either term, though it has examples dating back to the 14th century of the verb “assign” used to mean determine, designate, specify, classify, categorize, and so on. Here are a few examples:

“And til seynt Iames be souȝte þere, I shal assigne / That no man go to Galis” (“And till Saint James be sought there, I shall assign [specify] that no man go to Galicia” ( Piers Plowman , 1377, by William Langland). We’ve expanded the OED citation.

“Folke whom I neyther assigne bi name, nor as yet knowe not who they be” ( The Debellacyon of Salem and Bizance , 1533, by Thomas More).

“Who all assign its Altitude to be but about 27 inches” ( Experimental Philosophy , 1664, by Henry Power).

And here are a few examples from contemporary standard dictionaries:

“assigned the new species to an existing genus” ( American Heritage ).

“However, further investigations are needed before assigning these Mexican specimens to a new status” ( Lexico , the former Oxford Dictionaries Online ).

“Though assigned male at birth, she appears most comfortable and in her element wearing a skirt and high-heeled sandals when riding a big-wheel or playing with a tea set” ( Merriam-Webster ). The dictionary includes this among examples in which “assign” means to “fix or specify.”

The use of “sex assignment” or “gender assignment” for determining the sex of a newborn is relatively new. And the subject can be controversial, especially when the evidence is ambiguous, as in the earliest example we’ve found. This passage was published in the 1950s in a medical paper on intersexuality, having both male and female sexual organs or characteristics:

“Equally clearly the medical practitioner and the paediatrician need to be helped to form a correct opinion in the first place on the sex assignment and rearing of the intersexed infant.” From “Psychosexual Identification (Psychogender) in the Intersexed,” by Daniel Cappon, Calvin Ezrin, and Patrick Lynes, in the Canadian Psychiatric Journal, April 1959.

The first example we’ve seen for “gender assignment” uses the phrase in the linguistic sense—that is, in reference to languages that use gender to classify nouns, pronouns, and related words:

“Of course there may be dialect differences in the gender assignment of nouns” (from Plains Cree: A Grammatical Study , by the linguist H. Christoph Wolfart, published in Transactions of the American Philosophical Society, November 1973).

And here’s the earliest example we’ve seen of “gender assignment” used in the sense you’re asking about: “Gender assignment is based on the existing anatomy and a full understanding of the pathologic and endocrinologic reasons for the ambiguity” ( Practical Gynecology , 1994, by Allan J. Jacobs and ‎Michael J. Gast).

By the way, all but one of the standard dictionaries we consult have entries for “sex reassignment” or “gender reassignment,” commonly known as “sex change.” Some add the word “therapy” or “surgery” to the term.

The OED defines “gender reassignment” as “the process or an instance of a person adopting the physical characteristics of the opposite sex by means of medical procedures such as surgery or hormone treatment.”

The earliest Oxford example is from the late 1960s: “After gender reassignment surgery, some previously rejecting fathers become very affectionate” (“The Formation of Gender Identity,” by Natalie Shainess, Journal of Sex Research, May 1969).

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Chapter Systems of Gender Assignment

by Greville G. Corbett cite

In Chapters 30 and 31 we have seen how we as linguists analyze gender systems, and establish how many genders there are. The remaining question is how the speaker assigns nouns to those genders. In other words, if a speaker of Russian uses the word kniga   ‘book’ or djadja   ‘uncle’, how does he or she "know" the gender? Clearly speakers must know the gender in order to be able to make the appropriate agreements. A model of the way in which speakers allot nouns to genders is called a gender assignment system.

1. Defining the values

Assignment may depend on two sorts of information about the noun: its meaning and its form. We start with what we shall call strict semantic systems. In some languages the meaning of a noun is sufficient to determine its gender, for all or almost all nouns. This type is found in Dravidian languages like Kannada (Karnataka, southern India ; Sridhar 1990 : 198). In Kannada , nouns denoting male humans are masculine, those denoting female humans are feminine. There are also deities, demons and heavenly bodies in these genders. All remaining nouns, including those denoting infants and animals, are neuter. Thus appa   ‘father’, and candra   ‘moon’ are masculine, amma   ‘mother’ is feminine, and na:yi   ‘dog’ is neuter.

Many languages have semantic assignment rules which do not cover the noun inventory as completely as do the rules of Kannada . We shall call these predominantly semantic assignment systems . An example is found in Bininj Gun-Wok , which was introduced at the beginning of Chapter 31 . The semantic categories found in each gender are given in Table 1.

This table is from Evans et al. (2002) , and full details of gender assignment in Bininj Gun-Wok can be found there; the items in square brackets represent categories which have moved into the vegetable gender from the neuter in the speech of younger speakers. The important points for our typology are that the semantic assignment rules are considerably more complex than those of Kannada , and yet the coverage is less good. For example, lower animates are split between the masculine and feminine genders, and it is hard to be more specific; nouns denoting reptiles, birds, fish are found in both categories. There may well be principles of categorization here of which we are still unaware, but it seems likely that for at least some nouns there is no longer a principle for assignment which is still "live" for current speakers. 

The genders of Bininj Gun-Wok have a semantic core, like those of Kannada . However, the rules of Bininj Gun-Wok are more complex, and still leave more nouns unaccounted for. This typological distinction applies equally well to languages where the dominant semantic principle involves animacy rather than sex. We noted in Chapter 31 how Eastern Ojibwa ( Algonquian ; Ontario, Canada ) assigns nouns to gender according to animacy, but how some nouns do not fall readily under the rule. Thus in languages with semantic assignment systems, the meaning of the noun determines gender. In the strict assignment systems, the rules are obvious and cover (virtually) the entire noun inventory. In the predominantly semantic systems, there is a minority of exceptions; these exceptions have been claimed to be largely only apparent in some languages, once the cultural setting of the language is taken into account. When we ask which are the semantic criteria on which semantic systems can be based, we see recurring patterns and occasional surprises ( Corbett 1991 : 30-32). For the present map we treat strict semantic and predominantly semantic systems together.

In many languages, however, assignment by semantic rules would leave many nouns without an assignment to a gender. In languages like Kannada , the nouns not assigned by the semantic rules (the "remainder" or "semantic residue") all belong to a single gender. In the languages we consider next, these residue nouns are distributed over more than one gender. Here we find additional rules for assigning nouns to genders according to their form. There is a significant asymmetry: languages may base their assignment system on semantic rules, or on semantic and formal rules, but not just on formal rules. Formal assignment rules may in turn access two types of information: phonological and morphological. There may be combinations of such rules. We shall take a clear instance of each, considering languages from the sample.

A good example of assignment depending on phonological information is provided by Qafar ( Eastern Cushitic ; north-eastern Ethiopia and Djibouti ; Parker and Hayward 1985 ). In Qafar the semantic assignment rules are fairly standard, namely, for sex-differentiable nouns, those denoting males are masculine and those denoting females are feminine. It is the nouns which fall outside these semantic rules, the residue, which are of interest. For them there are the following phonological assignment rules: nouns whose citation form ends in an accented vowel are feminine (for example, karmà   ‘autumn’), while all others are masculine (for example, gilàl   ‘winter’, which does not end in a vowel, and tàmu   ‘taste’, which does end in a vowel, but not an accented one). These rules operate with few exceptions. Moreover, nouns denoting males and females typically accord with them too (for example bàqla   ‘husband’ and barrà   ‘woman, wife’). It might seem that we could dispense with semantic rules for Qafar . However, while the phonological rules give the right result in almost all cases, there are some nouns which show the role of the semantic rules. We find abbà   ‘father’, which is masculine, even though it ends in an accented vowel. Conversely, gabbixeèra   ‘slender-waisted female’ is feminine, though the accent is nonfinal. In such cases of conflict, the semantic rules take precedence (as is the normal situation in gender assignment systems). Qafar has remarkably simple phonological assignment rules, which assign semantically heterogeneous nouns to the appropriate gender by reference to their form.

The second type of formal assignment rule accesses morphological information. Here Russian is a good example. Once again for sex-differentiables, nouns denoting males are masculine and those denoting females are feminine. But unlike the situation in languages like Kannada , the residue is shared between the three genders, with the neuter gender not even receiving the majority. We might think that further semantic rules would be sufficient, but this turns out to be at best highly unlikely; see the data in Table 2, where the nouns in each row are semantically similar yet belong to three different genders. 

Thus the nouns of the semantic residue are scattered across the three genders in Russian . This situation is presented in table 3. 

In order to see how the remaining nouns are assigned, rather than looking at their meaning we should look instead at their morphology. There are four main inflectional classes in Russian , each with several thousands of nouns (for justification of this view see Corbett 1982 : 202-211). There are six cases and two numbers (though no paradigm has twelve distinct forms because of various syncretisms). We give just the singular forms in Table 4. 

Given information about the inflectional class of nouns, the assignment rules are straightforward. Nouns in class I are masculine, those in classes II and III are feminine, and those in IV are neuter. (Further rules are required in Russian for indeclinable nouns, like taksi   ‘taxi’, which is indeclinable and neuter; however, indeclinability is itself a morphological property.) In view of the coverage of these rules, we might be tempted to think that we could dispense with the semantic assignment, since mal´čik   ‘boy’ is in class I, while sestra   ‘sister’ is in class II, and mat´   ‘mother’ is in class III. In other words, many of the sex-differentiable nouns would be assigned to the appropriate gender by the morphological assignment rules. But there are also instances where this is not so, for instance, djadja   ‘uncle’, which denotes a male but is in class II, whose nouns are typically feminine. Djadja   ‘uncle’ is masculine. Nouns like this confirm, once again, that we do not find languages where formal assignment rules are sufficient.

Of course, there are languages where the rules are more complex than these, but for languages where careful research has been undertaken, gender is always predictable from a set of assignment rules, for at least 85% of the noun inventory and usually for a substantially larger proportion than that. For more details on these assignment systems see Corbett (1991 : 7-69). For the purposes of the map we shall treat phonological and morphological assignment together. Thus the division will be between languages which have semantic assignment rules on the one hand, and those which have semantic and formal assignment rules on the other. The values are as follows: 

2. Geographical distribution

Of the languages in our sample with gender systems, there is a roughly even split between the two types of assignment system: 53 have semantic assignment while 59 have semantic and formal assignment. The distribution is interesting. Semantic and formal assignment is found mainly in Eurasia and Africa, in the Indo-European , Afro-Asiatic and Niger-Congo families. The convincing accounts of the rise of gender systems provide paths leading to systems with semantic assignment. And there are ways in which such systems may further develop into systems with semantic and formal assignment. Note that there is no necessity for this development to occur: the Dravidian systems have remained as semantic systems for a substantial period. However, one might reasonably expect that if a system is of the semantic and formal assignment type, this is likely to indicate an “old” gender system, since there must have been sufficient time for the system to develop from an earlier semantic assignment system. By contrast, if the system is of the predominantly semantic type we can make no prediction, as such systems can arise at any time. It would follow that “old” gender systems are found in Eurasia and Africa. 

3. Theoretical issues

There are several theoretical issues which arise. Given the typology of assignment systems, it is natural to ask what other features might be correlated with the assignment system. There have been several instances of modelling assignment systems, particularly those of the more difficult types, where it is helpful to be able to demonstrate that the proposed system does indeed account for the vast majority of the nouns in the lexicon (see Fraser and Corbett 1995 on Russian , Fraser and Corbett 1997 on Mountain Arapesh , both discussed in Corbett and Fraser 2000 , and Evans et al. 2002 on Bininj Gun-Wok ). Since it has been shown that gender is always largely predictable, this raises an interesting issue for lexicologists: what is the status of a lexical feature which is predictable? Psycholinguists too are beginning to tackle the issue of the place of gender in lexical entries. There has been some interesting work on how children acquire gender systems, for example, Mills (1986) and Müller (2000) . Such studies may also help us to see how such systems change over time, as shown by the work of Polinsky and Jackson 1999 , on Tsez ; see also Comrie and Polinsky 1998 ; for development of the work on modelling change in assignment systems see Polinsky and van Everbroeck 2003 . There are interestingly different gender systems to investigate, and so it is important that we are careful about definitions, in order to ensure that our comparisons are valid. 

Related map(s)

• Systems of Gender Assignment
• Sridhar 1990
• Evans et al. 2002
• Corbett 1991
• Parker and Hayward 1985
• Corbett 1982
• Fraser and Corbett 1995
• Fraser and Corbett 1997
• Corbett and Fraser 2000
• Muller 2000
• Polinsky and Jackson 1999
• Comrie and Polinsky 1998
• Polinsky and van Everbroeck 2003

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Gender identity: A psychosocial primer for providing care to patients with a Disorder/difference of Sex Development and their families [Individualized Care for Patients with Intersex (Disorders/Differences of Sex Development): Part 2]

Michelle m. ernst.

a Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA

b Differences of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH45229, USA

Barry A. Kogan

c Albany Medical College, Albany NY 12208, USA

Peter A. Lee

d Penn State College of Medicine, Hershey, PA 17033, USA

Introduction/background:

Many parents of infants born with a DSD describe the process of initial sex assignment at birth as highly stressful. Parents of children with a DSD also note high distress when their children engage in behaviors that are not considered typical for their gender.

The goal of this article is to provide members of the health care team a brief overview of psychosocial facets of gender and gender identity particularly relevant to DSD for the purposes of enhancing shared decision-making and optimizing support for individuals with a DSD and their families.

Discussion:

Gender identity is a multidimensional construct involving related but distinct concepts such as gender typicality, gender contentedness and felt pressure for gender differentiation, and can be assessed via standardized measures. Gender dysphoria is associated with poor psychological adjustment, and is mitigated by family and peer support. Family influences on gender identity include parental modeling of gender behavior and family composition (e.g., same-sex children vs both sons and daughters in a family). Cultural factors that may influence sex assignment include societal views on gender, and gender-related differential resource allocation within a society. In addition, religious beliefs and the presence of a “third-sex” category within a culture may also influence parental gender ideology.

Clinical application:

Health care providers who work with patients with a DSD must have a strong grasp on the construct of gender identity, and must be able to clearly and consistently communicate with patients and families about gender beliefs in order to optimize family support and gender-related decisions.

For the vast majority of humans, being labeled a boy vs girl at birth is straightforward, based on genital anatomy, and is experienced as “obvious” - without need for a “choice”. Similarly, for many diagnoses that fall within the Disorders/Differences of Sex Development (DSD) umbrella, clear recommendations for male versus female assignment can be made on the basis of outcome data, even when genital anatomy is atypical. However, for some DSD diagnoses, recommended sex assignment at birth 1 is less clear, and a “choice” must be made in terms of which gender label (boy vs. girl) a child is to be assigned [ 1 ]. Parents of children with a DSD identify uncertainty about initial gender assignment as very stressful; as children grow older, parents also experience considerable distress if their child displays behaviors they deem typical of the “other” gender [ 2 , 3 ]. Parents also note high stress related to reconciling what they perceive to be conflicting information about their child’s DSD [ 2 ]. To promote optimal decision making and child/family adjustment, both the health care team and families must have a shared, accurate understanding of both biological sex features and gender identity, as well as how they differ. [ 4 ]. To that end, this article provides 1) a concise overview of the construct of gender identity, 2) proposes terminology and definitions to promote consistent and accurate communication (see Table 1 ), and 3) reviews psychosocial contextual factors to enhance conversations about gender with families.

Gender terms

Note: There are numerous terms to describe a myriad of gender categories. These terms are constantly changing. When individuals or families reference a specific gender term, asking for clarification of what the term means to them is advisable. Many websites offer lists of terms and definitions (e.g., https://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf ).

Gender identity review

DSD refers to conditions in which the biological sex features that typically distinguish males from females are discordant or have developed atypically. Biological sex features are usually consistent with a person’s gender identity [i.e. their sense of themselves as a boy/man or girl/woman (if binary)]. In other words, most children with a penis (biological sex feature) think of themselves as a boy (gender identity).

Gender identity is a “lived experience” – only a person themselves can know what their gender identity is. Thus, the “boy” or “girl” label given prenatally or at birth (and celebrated at gender reveal parties), does not actually reflect a gender identity – it is the “best guess” (and usually a really good guess, based typically on genital appearance) that parents and health care providers have as to a person’s future gender identity. The formation of gender identity is the result of complex interactions between biological and social factors, and relies on cognitive development [ 5 , 6 ]; by age 2 years children understand gender labels, by age 3 years children typically will label themselves a particular gender (“I am a girl!”), and by age 4 years the gender label is typically being expressed consistently. Gender atypical behavior is often first recognized in early childhood, and can range from interests/activities culturally atypical for a particular gender (e.g., a boy wearing a dress) to expressed desire to be a different gender or insistence that one is actually a different gender [ 7 ]. The best predictor of gender identity is sex assignment at birth.

In many societies, there has been a paradigm shift in gender identity expression in recent years. In the US, 15 states offer non-binary ID options, and legislation has recently been proposed that adds a 3 rd gender option to US passports [ 8 ]. 35% of youth categorized as “Gen Z” report personally knowing someone who uses gender-neutral pronouns, and nearly 60% support the availability of non-binary gender options on form or online profiles. Of note, these percentages are higher compared with older generations; e.g., for Millennials, 25% reported knowing someone who uses gender-neutral pronouns, and 50% supported non-binary options on forms/online profiles [ 9 ]. Thus, increased exposure to and acceptance of a range of gender identity expression may continue into future generations.

Gender identity has been conceptualized as a multidimensional construct including aspects such as gender typicality (whether behaviors/interests conform to gender stereotypes), gender contentedness (the degree to which a person feels glad to be their gender), and felt pressure for gender differentiation (i.e., pressure to conform to stereotypes)[ 6 ]. These concepts are distinct, albeit related constructs [ 10 ], and are important to distinguish for patients and, in particular, families. In DSD, children may express a high level of gender atypicality , while at the same time having high gender contentedness (e.g, a child with CAH who strongly aligns with a female gender identity but likes to do more boy-typical activities). The multi-dimensional model of gender identity has recently been extended to include the potential for determining the degree to which an individual feels similar or dissimilar to both genders [ 6 ]. Both gender contentedness and gender typicality have been shown to be related to positive adjustment for children; felt pressure for gender differentiation is noted to have a particularly negative impact on adjustment, particularly in the context of gender discontentment or atypicality. Several measures assessing children’s gender identity have been developed, including the Parent-report Gender Identity Questionnaire for Children (for children 2.5 to 12 years of age) [ 11 ], the Gender Identity Interview for Children (for children 2.5 to 12 years)[ 12 ], and the Multidimensional Gender Identity Scale (for children 8 years of age and older) [ 13 ].

Careful consideration of sex assignment based on prediction of future gender identity is important, but it must be realized that it is impossible to predict with certainty so parents must be prepared to respond when gender identity does not develop as assigned. Ideally this can be recognized before gender dysphoria occurs. The rate of gender dysphoria is higher in several DSD diagnoses compared with the general population [ 14 ]. Gender dysphoria is diagnosed when there is 1) “marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration”, and 2) this incongruence is associated with clinically significant distress [ 15 ]. In prospective studies of children with gender dysphoria in the general population (i.e., non-DSD samples), gender dysphoria remits in the majority of children [ 16 ]. Youth with gender dysphoria present with high rates of anxiety, depression and suicidal ideation [ 17 ]. Youth with non-binary gender identities (presumably initially raised with a binary gender assignment) also demonstrate poor mental health outcomes [ 18 ]. “Not choosing” a gender until the child declares their own gender identity is a path recently taken by some families [ 19 ]– it is unclear what the psychosocial ramifications of this approach will be given the rarity of the experience. Protective factors that mitigate the risk conferred by gender variance include healthy self-esteem and positive relationships with parents and peers [ 20 ].

Consideration of gender must consider the family influences on gender identity [ 21 ]. In addition to genetic transmission of biological factors from parent to child, the family provides formative gender-related experiences to a child. For example, parents provide a model for gender typical behavior (through their own interests and activities), create opportunities for gendered behavior through their control of the environment, shape the gendered behavior of their children through attention and consequences, and verbally share their own beliefs about gender with their children. Siblings may also play an important influential role in gender identity development and gender-related parenting (e.g., less gender-stereotypical parenting in families with same-sex siblings vs both sons and daughters). And, as noted previously, family acceptance and support of gender variance (when it is present) appears to be important for positive adjustment [ 20 ]. More broadly, parental self-efficacy (a parent’s belief that they can influence their child toward successful outcomes) and parental coping both positively predict better child adjustment [ 22 ].

Other cultural factors that contextualize sex assignment (both initial assignment and openness to change) include societal views on gender, which can change over time [ 23 ]. In most societies, expressed gender plays a role in resource allocation, including income and inheritance. Gender also often impacts division of labor, rules of conduct, educational attainment, health, political empowerment, and initiation of and freedom in relationship building (particularly, marriage) [ 24 , 25 ]. The influence of gender on these arenas likely depends on a number of factors, e.g. the rigidity of the gender binary in a society; societal variations in these gendered facets impact the gender ideologies that parents and health care providers bring to the discussion of gender assignment. For example, Joseph and colleagues [ 26 ] observed family preference for male sex assignment in their case series of DSD in India, interpreting this preference in light of the social advantages male gender confers in that society, and difficulty in arranging marriage for infertile girls. It is also important to understand whether there is an understood “third” (or more) gender category in the family’s culture – while binary sex is the dominant sex categorization across societies, many cultures have specific terms recognizing people who identify outside the binary (e.g., Indian “hijras”, Hawaiian and Tahitian “māhū“, Samoan “fa’afafine”, Indigenous North American “two-spirits”). Families from these cultures may be interpreting information related to their child’s DSD through the lens of their cultural experience of “intersex.” These culturally recognized categories differ widely in the roles and social status that they hold in their respective societies, and are often quite stigmatizing; the assumptions that families from these cultures bring into the DSD context must be voiced and understood [ 26 – 28 ]. Even within one nation, geographical differences in gender ideology may exist. For example, in a recent large US study, gender diverse youth in rural settings had higher rates of gender-related harassment relative to youth in urban settings (50.6% vs 41.4%, respectively). Of note, the positive influence of protective factors such as supportive families and teachers was similar across geographical locations [ 29 ].

Religious background also may posit a strong influence on a family’s perspective related to sex assignment and change. In some faith traditions, gender influences access to spiritual activities, and some religions have very strong negative views on sex assignment change [ 24 , 25 , 30 ]. Furthermore, some religions include systems of law that will influence sex reassignment. For example, families from Islamic countries may be influenced by their awareness of fatwas (formal legal opinions from experts in Islamic law) relating to sex assignment and reassignment [ 31 ].

Clinical implications

Every attempt should be made to determine a specific etiologic diagnosis that, when possible, is verified by molecular genetics, evidence of fetal androgen exposure, and extent of internal and external reproductive system virilization. Even then, the fact remains that there are variations and complexities even within a specific diagnosis. When there are sufficient diagnostic information and outcome data to guide sex assignment at birth, health care providers must provide these data to family and advocate strongly for a sex assignment that is most likely to align with future gender identity. However, the limitations of outcome data must be acknowledged. And, for any specific child and family, psychosocial contextual factors may be so distinctive that consideration of an alternative sex assignment at birth may be warranted. Families deserve to have 1) complete and accurate counseling of sex versus gender, 2) an understanding of the gender identity outcomes relevant to their child’s DSD, and 3) their personal and cultural gender ideologies understood by the health care team. It is also critical that medical teams use language that is understandable to and respectful of individuals and families, and to seek clarity on what families actually mean when using their terminology [ 32 ]. From this mutual understanding, clear and consistent communication related to gender concerns can enhance decision making and optimize quality of life outcomes individuals and families.

This is the 2 nd article in a series regarding care of children born with a DSD for whom gender assignment at birth is a primary consideration due to ambiguous genitalia. This article provides a concise overview of some of the important psychosocial facets of gender and gender identity. Our goal in presenting this information is for affected individuals, their families, and multidisciplinary care providers to develop a shared and accurate language related to gender identity, and for health care teams to have enhanced knowledge in order to provide culturally sensitive family-centered care.

Acknowledgements

M. Ernst gratefully acknowledges the mentorship and clinical support of the DSD-Translational Research Network, funded by grant RO1 HD093450 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Funding sources

Conflict of interest statement

None of the authors have any conflicts of interest

Ethical approval

Approval not required

1 Both sex assigned at birth and gender assigned at birth are terms that have been used within DSD. Most recently, sex assigned at birth has been favored; this recognizes that gender identity cannot actually be assigned by others.

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Assignments Are Critical Tools to Achieve Workplace Gender Equity

Work assignments can be a powerful means of propelling employees’ growth but — unless managed deliberately — they can also undermine efforts to build a diverse workforce.

• Workplace, Teams, & Culture
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Facing unprecedented levels of employee burnout and historic quit rates , how can companies lead with a model that attracts and retains talent? This period of transition, and the lessons learned from the pandemic, offer organizations a unique opportunity to improve and refine their diversity, equity, and inclusion (DEI) strategies. 1 It is imperative that leaders consider the landscape of work assignments at their companies as a foundation for greater workforce equity.

“Assignments” can comprise work tasks, activities, or projects. Scholars have long identified a gender gap in access to the kinds of assignments — large in scope, highly visible, and strategically important — that are seen as essential to career advancement. An estimated 70% of leadership development occurs through experiential learning , especially the kind offered by these challenging stretch assignments.

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Yet women are largely overlooked for challenging work assignments. One factor is that women typically have fewer ties to influential decision makers who connect people to assignment opportunities . Biased performance evaluations also may play a role, with women seeing no gains in their performance scores for the very behaviors (such as “taking charge”) for which men are rewarded. 2 One study showed how promotability depends on having had challenging past projects — setting up a vicious cycle in which women never get ahead. 3 Women of color, tasked with the additional burden of “fitting in” at predominantly White organizations, may find channels to career-advancing work blocked entirely. 4

Historically, companies have not tracked assignment processes. In one 2010 report, when HR leaders were asked the percentage of “business-critical/important” assignments held by women, the top two responses were “1% to 10%” and “not measured.” Both career-advancing work and meaningful work are cornerstones of positive professional experiences. But leaders may know little about who has access to significant assignments, or they may be unaware of how a lack of access drives burnout, turnover, and dwindling diversity on the leadership bench. 5

These many unknowns about assignments drive an information gap that grows riskier as countless organizations head into new hybrid work arrangements. To quantify this risk, our team at the Stanford VMware Women’s Leadership Innovation Lab ran a study of assignments, using data that many companies collect and managers review at least yearly: employee engagement survey (EES) data. We examined pre-pandemic EES results for a midsized global technology company. 6 Only one question on the survey asked about employees’ perceptions of access to career-advancing assignments.

The company did not track assignments by gender, but our analysis showed a statistically significant gender difference. Relative to men, women were 15% less likely to report opportunities for career-advancing assignments. 7 This gender difference held even after we adjusted for employee and job characteristics. That is, women were less likely than men to perceive their assignment opportunities as having career value. This was the case even among women and men in the same department and role.

We then supplemented this analysis with a descriptive look at two related survey questions on our case company’s EES: one about making meaningful contributions, and another about receiving recognition for one’s work. Of women, 39% saw greater contribution opportunities than recognition opportunities, compared with 34% of men. While this particular gender gap may seem small, limited opportunities can accumulate over the course of a career and contribute to the persistent underrepresentation of women in leadership. Imagine how these results could inform today’s leaders in an economy recalibrating during an ongoing global pandemic.

An Equity-Minded Assignment Framework

Unseen assignment disparities can destabilize efforts to build a diverse workforce all the way up the ladder, so we propose an equity-minded assignment framework for leaders and managers to implement in the short, medium, and long terms, starting today . The purpose of this framework is to better identify and strengthen the role of work assignments in meeting DEI goals.

In the short term, embed assignment conversations in the “return to office” tools for managers. Many companies are deploying managerial tools to support employees and teams in their decision-making about hybrid work arrangements. These one-on-one meetings offer a promising context for managers to discuss assignments with their direct reports. These discussions are critical, as will be the consequences of not talking about assignments: Hybrid work arrangements, where some employees are in the office while others are working from home, run the risk of creating inequality in employees’ visibility to leaders and thus who might be seen as the right person for a particular assignment.

These conversations present a unique opportunity to explore assignments and have a forward-looking career discussion. Managers may ask, for example:

• What are you currently working on that you see as critical to your career development and advancement? What work do you find especially meaningful? How do these areas overlap?
• As we return to the office, how can we align your work with your career advancement goals and your sense of fulfillment? Which assignments do you need in order to get there, and to whom do you need to be visible?
• How will your hybrid work arrangement give you exposure to the right people and workstreams?

These questions will encourage managers and employees to think through not just the where of the hybrid workplace, but the what and with what career outcomes . Answering them can push employees to think beyond work-life factors in their ideal hybrid design — and can nudge everyone in the organization to view assignments as a core tool in employee development.

In the medium term, develop a broader view of the assignments landscape in the organization. In the wake of workforce disruption and heightened attention to racism, sexism, and inequality, leaders have been called on to accelerate their DEI efforts. To achieve real change, assignments need to be embedded in DEI strategy. The first step is to get a better handle on the baseline landscape of assignments by identifying the most important assignments for career advancement and meaning. Conducting focus groups with employees across all organizational functions can help inform the strategy by identifying common assignment-related themes and persistent problems to tackle.

Once the landscape is understood, leaders can create accountability mechanisms for more equitable assignment allocations and outcomes. Leaders need to ensure that top assignments are made available across organizational functions and that supports are in place for people to execute them successfully. For example, the former CEO of Jamba Juice, James White, changed how high-profile work was assigned by deliberately giving defined strategic projects to people who were rarely selected for them and providing them with dedicated time to meet project goals. Rethinking these channels diversified the internal pipeline of people ready to advance to leadership roles .

In performance evaluation and talent calibration meetings, leaders must explicitly account for assignments — those assigned to employees who are promoted and, just as importantly, to employees who are not. Managers should consider whether promotion gaps between women and men, for instance, would shift if assignments were changed. Internal audits and assignment dashboards, which visually clarify who on which teams is doing what, can inform data-driven managerial decision-making about assignments. The goal is not to decrease managerial autonomy but rather to empower managers with a broad view of the landscape, to increase assignment transparency and build opportunities for connection.

Finally, the range of assignments needs to be balanced fairly within units and across different roles. In mapping and building on this landscape, leaders must not overlook “low-promotability” work. Linda Babcock and colleagues have shown that women are more often asked to volunteer for lower-leverage assignments than are men, and they agree to do this work more often, too. 8 Expectations about women’s propensity to volunteer for tasks that everyone wants completed but no one wants to do themselves can route women away from career-advancing work and ultimately deepen gender stereotypes and inequity in the workplace. Leaders must engage managers, HR professionals, and staff members focused on DEI efforts in building a more equitable assignment space to support the advancement of all workforce groups.

Over the long term, make assignments a core part of your employee engagement surveys, and link the results to your talent strategy. The EES has long been a tool for organizations to take the temperature of their workforces by collecting engagement data and identifying employee needs. But work assignments are rarely measured on EESs, despite their significance for motivation, engagement, and equitable advancement. (In examining EESs at four large multinational companies in various sectors, we found that, of nearly 200 total questions, only five explicitly mentioned work assignments.) Including even a few questions about assignments will allow for new insights, and running gap analyses that integrate EES data can lead to even more significant change. (A gap analysis is a tool that allows an organization to diagnose gaps between an organizational goal and an actual outcome.)

Questions included on a survey define what information leaders can know about their workforces. “What is not measured is critically important to consider,” said Molly Anderson, CEO of Exponential Talent, a diversity and inclusion consulting firm. She also noted that “companies often draw the wrong conclusions … through an error of omission.” We suggest using one question as a starting point for study: “To what extent do you have sufficient opportunities to work on assignments that are important to your career development?” Gathering information about access to critical assignments and their connections to particular employees’ goals is a good jumping-off point that organizations can track in real time.

After you ask questions, it’s crucial to examine group differences in the responses as part of conducting a larger gap analysis into which EES data can factor directly. 9 Say, for example, that an organization sets a DEI goal to increase the representation of women and people of color in leadership roles. Collected EES data might show that these groups perceive access to leadership development assignments differently than White men do. With assignment-specific EES data, leaders can then act to meet their DEI goal, equipped with information to open dialogue, inspire interventions, and course-correct.

Assignments Looking Forward

Related articles.

The best approach to incorporating assignments in your talent strategy is multipronged. As organizations prepare for hybrid work arrangements, assignments should be discussed in managers’ one-on-ones with their direct reports; embedded in DEI goals, performance evaluations, and promotion conversations; explored in focus groups; and measured on EESs and in gap analyses. When any of these approaches reveals potential disparities in the experiences or perceptions of assignments between groups, leaders should focus on revamping their processes.

Leaders don’t have to tackle all of these approaches at once. Any increase in understanding the state of assignments in an organization, and in beginning to act on these insights, will in fact be a talent differentiator. After the pandemic-driven exodus of women — especially women of color — from the workforce, companies cannot afford to lose more of them to the additional burnout wrought by unfairly allocated assignments. By keeping steady tabs on their workforces when change is both inevitable and highly uncertain, forward-looking leaders can quickly identify and intervene in emergent negative trends and drive positive changes to empower their workforces equitably.

About the Authors

Erin Macke is a Ph.D. candidate in sociology at Stanford University and a graduate research assistant at Stanford’s VMware Women’s Leadership Innovation Lab. Gabriela Gall Rosa is a research data analyst at the VMware Women’s Leadership Innovation Lab. Shannon Gilmartin is a senior research scholar at the VMware Women’s Leadership Innovation Lab. Caroline Simard is managing director of the VMware Women’s Leadership Innovation Lab.

1. “ Hybrid Working Is Here to Stay Post-Pandemic: Stanford’s Nicholas Bloom ,” Bloomberg TV, Dec. 30, 2020, video, 6:34, www.bloomberg.com; and J.M. Barrero, N. Bloom, and S.J. Davis, “ Why Working From Home Will Stick ,” working paper 28731, National Bureau of Economic Research, Cambridge, Massachusetts, April 2021.

2. S.J. Correll, K.R. Weisshaar, A.T. Wynn, et al., “Inside the Black Box of Organizational Life: The Gendered Language of Performance Assessment,” American Sociological Review 85, no. 6 (December 2020): 1022-1050.

3. I.E. De Pater, A.E.M. van Vianen, M.N. Bechtoldt, et al., “Employees’ Challenging Job Experiences and Supervisors’ Evaluations of Promotability,” Personnel Psychology 62, no. 2 (May 2009): 297-325.

4. T.M. Melaku, “You Don’t Look Like a Lawyer: Black Women and Systemic Gendered Racism,” (Lanham, Maryland: Rowman & Littlefield Publishers, 2019).

5. P.T.Y. Preenan, I.E. De Pater, A.E. van Vianen, et al., “Managing Voluntary Turnover Through Challenging Assignments,” Group & Organization Management 36, no.3 (April 2011): 3088-344; C. Maslach and M. Leiter, “Early Predictors of Job Burnout and Engagement,” Journal of Applied Psychology 93, no. 3 (June 2008): 489-512; and J.M. Hoobler, G. Lemmon, and S.J. Wayne, “Women’s Managerial Aspirations: An Organizational Development Perspective,” Journal of Management 40, no. 3 (March 2014): 703-730.

6. This EES data was collected in 2015 from over 4,000 respondents at this company.

7. For this analysis, we calculated predicted probabilities (57% for women and 67% for men, p<0.0001) from a logistic regression in which the dependent measure, agreement with “having opportunities,” is dichotomized into levels of agreement: “great/very great” and “very little/some/moderate.” A series of ordinary least squares regressions on a nondichotomized dependent measure yielded similar results.

8. L. Babcock, M.P. Recalde, L. Vesterlund, et al., “Gender Differences in Accepting and Receiving Requests for Tasks With Low Promotability,” American Economic Review 107, no. 3 (March 2017): 714-747.

9. It is worth noting that we could not conduct our case study analyses by employees’ race and ethnicity because this information was not collected on the company’s EES, so our analyses cannot speak to both gender and race assignment inequities. While legal and privacy considerations in different geographies may constrain what can be measured, companies should strive to examine such data by race and ethnicity, geography, and other social dimensions based on their diversity strategies.

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What Are Gender Stereotypes?

• How They Develop
• How to Combat

Gender stereotypes are preconceived, usually generalized views about how members of a certain gender do or should behave, or which traits they do or should have. They are meant to reinforce gender norms, typically in a binary way ( masculine vs. feminine ).

Gender stereotypes have far-reaching effects on all genders.

Read on to learn about how gender stereotypes develop, the effects of gender stereotypes, and how harmful gender stereotypes can be changed.

Davin G Photography / Getty Images

Meaning of Gender Stereotypes

Gender stereotypes are ideas about how members of a certain gender do or should be or behave. They reflect ingrained biases based on the social norms of that society. Typically, they are considered as binary (male/female and feminine/masculine).

By nature, gender stereotypes are oversimplified and generalized. They are not accurate and often persist even when there is demonstrable evidence that contradict them. They also tend to ignore the fluidity of gender and nonbinary gender identities.

Classification of Gender Stereotypes

Gender stereotypes have two components, which are:

• Descriptive : Beliefs about how people of a certain gender do act, and their attributes
• Prescriptive : Beliefs about how people of a specific gender should act and attributes they should have

Gender stereotypes can be positive or negative. This doesn’t mean good or bad—even stereotypes that seem “flattering” can have harmful consequences.

• Positive gender stereotypes : Describe behaviors or attributes that align with accepted stereotypical ideas for that gender, and that people of that gender are encouraged to display (for example, girls should play with dolls and boys should play with trucks)
• Negative gender stereotypes : Describe behaviors or attributes that are stereotypically undesirable for that gender and that people from that gender are discouraged from displaying (such as women shouldn’t be assertive, or men shouldn’t cry)

The attribute is undesirable for all genders but more accepted in a particular gender than others. For example, arrogance and aggression are unpleasant in all genders but are tolerated more in men and boys than in women, girls, or nonbinary people .

Gender stereotypes tend to be divided into these two generalized themes:

• Communion : This stereotype orients people to others. It includes traits such as compassionate, nurturing, warm, and expressive, which are stereotypically associated with girls/women/femininity.
• Agency : This stereotype orients people to the self and is motivated by goal attainment. It includes traits such as competitiveness, ambition, and assertiveness, which are stereotypically associated with boys/men/masculinity.

Basic types of gender stereotypes include:

• Personality traits : Such as expecting women to be nurturing and men to be ambitious
• Domestic behaviors : Such as expecting women to be responsible for cooking, cleaning, and childcare, while expecting men to do home repairs, pay bills, and fix the car
• Occupations : Associates some occupations such as childcare providers and nurses with women and pilots and engineers with men
• Physical appearance : Associates separate characteristics for women and men, such as women should shave their legs or men shouldn’t wear dresses

Gender stereotypes don’t exist in a vacuum. They can intersect with stereotypes and prejudices surrounding a person’s other identities and be disproportionately harmful to different people. For example, a Black woman experiences sexism and racism , and also experiences unique prejudice from the intersectionality of sexism and racism that a White woman or Black man would not.

Words to Know

• Gender : Gender is a complex system involving roles, identities, expressions, and qualities that have been given meaning by a society. Gender is a social construct separate from sex assigned at birth.
• Gender norms : Gender norms are what a society expects from certain genders.
• Gender roles : These are behaviors, actions, social roles, and responsibilities a society views as appropriate or inappropriate for certain genders.
• Gender stereotyping : This ascribes the stereotypes of a gender group to an individual from that group.
• Self-stereotyping vs. group stereotyping : This is how a person views themselves compared to how they view the gender group they belong to (for example, a woman may hold the belief that women are better caregivers than men, but not see herself as adept in a caregiving role).

How Gender Stereotypes Develop

We all have unconscious biases (assumptions our subconscious makes about people based on groups that person belongs to and our ingrained associations with those groups). Often, we aren’t even aware we have them or how they influence our behavior.

Gender stereotyping comes from unconscious biases we have about gender groups.

We aren’t preprogrammed at birth with these biases and stereotypes. Instead, they are learned through repeated and ongoing messages we receive.

Gender roles, norms, and expectations are learned by watching others in our society, including our families, our teachers and classmates, and the media. These roles and the stereotypes attached to them are reinforced through interactions starting from birth. Consciously or not, adults and often other children will reward behavior or attributes that are in line with expectations for a child’s gender, and discourage behavior and attributes that are not.

Some ways gender stereotypes are learned and reinforced in childhood include:

• How adults dress children
• Toys and play activities offered to children
• Children observing genders in different roles (for example, a child may see that all of the teachers at their daycare are female)
• Praise and criticism children receive for behaviors
• Encouragement to gravitate toward certain subjects in school (such as math for boys and language arts for girls)
• Anything that models and rewards accepted gender norms

Children begin to internalize these stereotypes quite early. Research has shown that as early as elementary school, children reflect similar prescriptive gender stereotypes as adults, especially about physical appearance and behavior.

While all genders face expectations to align with the stereotypes of their gender groups, boys and men tend to face harsher criticism for behavior and attributes that are counterstereotypical than do girls and women. For example, a boy who plays with a doll and wears a princess dress is more likely to be met with a negative reaction than a girl who wears overalls and plays with trucks.

The Hegemonic Myth

The hegemonic myth is the false perception that men are the dominant gender (strong and independent) while women are weaker and need to be protected.

Gender stereotypes propagate this myth.

Effects of Gender Stereotypes

Gender stereotypes negatively impact all genders in a number of ways.

Nonbinary Genders

For people who are transgender / gender nonconforming (TGNC), gender stereotypes can lead to:

• Feelings of confusion and discomfort
• A low view of self-worth and self-respect
• Transphobia (negative feelings, actions, and attitudes toward transgender people or the idea of being transgender, which can be internalized)
• Negative impacts on mental health
• Struggles at school

Unconscious bias plays a part in reinforcing gender stereotypes in the classroom. For example:

• Educators may be more likely to praise girls for being well-behaved, while praising boys for their ideas and comprehension.
• Boys are more likely to be viewed as being highly intelligent, which influences choices. One study found girls as young as 6 avoiding activities that were labeled as being for children who are “really, really smart.”
• Intentional or unintentional steering of children toward certain subjects influences education and future employment.

In the Workforce

While women are in the workforce in large numbers, gender stereotypes are still at play, such as:

• Certain occupations are stereotypically gendered (such as nursing and teaching for women and construction and engineering for men).
• Occupations with more female workers are often lower paid and have fewer opportunities for promotion than ones oriented towards men.
• More women are entering male-dominated occupations, but gender segregation often persists within these spaces with the creation of female-dominated subsets (for example, pediatrics and gynecology in medicine, or human resources and public relations in management).
• Because men face harsher criticism for displaying stereotypically feminine characteristics than women do for displaying stereotypically male characteristics, they may be discouraged from entering female-dominated professions such as early childhood education.

Despite both men and women being in the workforce, women continue to be expected to (and do) perform a disproportionate amount of housework and taking care of children than do men.

Gender-Based Violence

Gender stereotypes can contribute to gender-based violence.

• Men who hold more traditional gender role beliefs are more likely to commit violent acts.
• Men who feel stressed about their ability to meet male gender norms are more likely to commit inter-partner violence .
• Trans people are more likely than their cisgender counterparts to experience discrimination and harassment, and they are twice as likely to engage in suicidal thoughts and actions than cisgender members of the Queer community.

Stereotypes and different ways of socializing genders can affect health in the following ways:

• Adolescent boys are more likely than adolescent girls to engage in violent or risky behavior.
• Mental health issues are more common in girls than boys.
• The perceived “ideal” of feminine slenderness and masculine muscularity can lead to health issues surrounding body image .
• Gender stereotypes can discourage people from seeking medical help or lead to missed diagnosis (such as eating disorders in males ).

Globally, over 575 million girls live in countries where inequitable gender norms contribute to a violation of their rights in areas such as:

• Employment opportunities
• Independence
• Safety from gender-based violence

How to Combat Gender Stereotypes

Some ways to combat gender stereotypes include:

• Examine and confront your own gender biases and how they influence your behavior, including the decisions you make for your children.
• Foster more involvement from men in childcare, both professionally and personally.
• Promote and support counterstereotypical hirings (such as science and technology job fairs aimed at women and campaigns to gain interest in becoming elementary educators for men).
• Confront and address bias in the classroom, including education for teachers on how to minimize gender stereotypes.
• Learn about each child individually, including their preferences.
• Allow children to use their chosen name and pronouns .
• Avoid using gender as a way to group children.
• Be mindful of language (for example, when addressing a group, use “children” instead of “boys and girls” and “families” instead of “moms and dads,”).
• Include books, toys, and other media in the classroom and at home that represent diversity in gender and gender roles.
• View toys as gender neutral, and avoid ones that promote stereotypes (for example, a toy that has a pink version aimed at girls).
• Ensure all children play with toys and games that develop a full set of social and cognitive skills.
• Promote gender neutrality in sports.
• Be mindful of advertising and the messaging marketing sends to children.
• Talk to children about gender, including countering binary thinking and gender stereotypes you come across.
• Take a look at the media your child engages with. Provide media that show all genders in a diversity of roles, different family structures, etc. Discuss any gender stereotyping you see.
• Tell children that it is OK to be themselves, whether that aligns with traditional gender norms or not (for example, it’s OK if a woman wants to be a stay-at-home parent, but it’s not OK to expect her to).
• Give children equal household chores regardless of gender.
• Teach all children how to productively handle their frustration and anger.
• Encourage children to step out of their comfort zone to meet new people and try activities they aren’t automatically drawn to.
• Put gender-neutral bathrooms in schools, workplaces, and businesses.
• Avoid assumptions about a person’s gender, including children.
• Take children to meet people who occupy counterstereotypical roles, such as a female firefighter.
• Speak up and challenge someone who is making sexist jokes or comments.

Movies That Challenge Gender Stereotypes

Not sure where to start? Common Sense Media has compiled a list of movies that defy gender stereotypes .

Gender stereotypes are generalized, preconceived, and usually binary ideas about behaviors and traits specific genders should or should not display. They are based on gender norms and gender roles, and stem from unconscious bias.

Gender stereotypes begin to develop very early in life through socialization. They are formed and strengthened through observations, experiences, and interactions with others.

Gender stereotypes can be harmful to all genders and should be challenged. The best way to start combating gender stereotypes is to examine and confront your own biases and how they affect your behavior.

A Word From Verywell

We all have gender biases, whether we realize it or not. That doesn’t mean we should let gender stereotypes go unchecked. If you see harmful gender stereotyping, point it out.

YWCA Metro Vancouver. Dating safe: how gender stereotypes can impact our relationships .

LGBTQ+ Primary Hub. Gender stereotyping .

Stanford University: Gendered Innovations. Stereotypes .

Koenig AM. Comparing prescriptive and descriptive gender stereotypes about children, adults, and the elderly . Front Psychol . 2018;9:1086. doi:10.3389/fpsyg.2018.01086

United Nations Office of the High Commissioner for Human Rights. Gender stereotypes .

Hentschel T, Heilman ME, Peus CV. The multiple dimensions of gender stereotypes: a current look at men’s and women’s characterizations of others and themselves . Front Psychol . 2019;10:11. doi:10.3389/fpsyg.2019.00011

Eagly AH, Nater C, Miller DI, Kaufmann M, Sczesny S. Gender stereotypes have changed: a cross-temporal meta-analysis of U.S. public opinion polls from 1946 to 2018 . Am Psychol . 2020;75(3):301-315. doi:10.1037/amp0000494

Planned Parenthood. What are gender roles and stereotypes?

Institute of Physics. Gender stereotypes and their effect on young people .

France Stratégie. Report – Gender stereotypes and how to fight them: new ideas from France .

Bian L, Leslie SJ, Cimpian A. Gender stereotypes about intellectual ability emerge early and influence children’s interests . Science . 2017;355(6323):389-391. doi:10.1126/science.aah6524

Save the Children. Gender roles can create lifelong cycle of inequality .

Girl Scouts. 6 everyday ways to bust gender stereotypes .

UNICEF. How to remove gender stereotypes from playtime .

Save the Children. Tips for talking with children about gender stereoptypes .

By Heather Jones Jones is a freelance writer with a strong focus on health, parenting, disability, and feminism.

15 Examples of Gender Inequality in Everyday Life

Gender inequality is everywhere. According to the World Economic Forum, it could take another 131 years to achieve global gender parity. Inequality affects the treatment, rights and opportunities of women, girls and transgender and gender-diverse people the most, but everyone deals with negative effects. Crises like war, climate change and pandemics can make things worse. How does gender inequality manifest in everyday life? Here are 15 examples:

#1. Women make less money than men

The pay gap is one of the most consequential examples of everyday gender inequality. According to the UN, women make only 77 cents for every dollar men earn, even when they do comparable work. The gap widens for women who have children. Country specifics also reveal racial inequalities . In the United States, Hispanic women earned 57.5 cents for every dollar in 2022, while Black women made 69.1 cents. The Institute for Women’s Policy Research estimates that if progress doesn’t speed up, it could take 30 years for the US to reach pay equity.

#2. Girls are more likely to be out of school

Education access has improved over the years, but large gaps are still an issue. According to the World Bank, 88% of girls are enrolled in primary school on a global level, but 78% are enrolled in low-income countries. The gap widens in secondary school; only 31% of girls are enrolled in low-income countries compared to the 66% global average . Conflict plays a big role. Girls are 2.5 times more likely than boys to leave school during crises, which impacts their economic opportunities, safety, health and more.

#3. Women and girls are more likely to be murdered by people they know

While men are overall more likely to be murdered, women and girls are more likely to be killed by people they know. Family members or intimate partners commit around 55% of female homicides. That means every hour, more than five women or girls are murdered by someone in their family. Because it’s much harder to avoid violent family members or partners, everyday life for women and girls can be dangerous.

#4. Women and girls experience more sexual violence

For many women and girls, the threat of sexual violence is persistent. According to UN Women, 26% of women 15 years and older have endured intimate partner violence , which means their abuser is a romantic and/or sexual partner. Around 15 million girls 15-19 years old have experienced forced sex at some point. Men experience sexual violence, too; according to stats from the United States, around 24.8% of men have experienced unwanted sexual contact. The numbers show it’s much more common for women and girls. The true prevelance is unknown as sexual violence is significantly underreported.

#5. Women do more unpaid work

Life is more than paid work and play; people must cook, clean, do laundry, care for children and more. Women do most of this unpaid labor. According to Oxfam, the world’s women and girls complete more than ¾ of all unpaid work . That accounts for 12.5 billion hours of unpaid work every day. It’s worse for rural women from low-income countries. They can spend up to 14 hours a day doing unpaid care work. This limits their educational and economic opportunities.

Gender inequality can manifest in subtle ways. When I was in high school, the girls noticed that one of the male teachers only seemed to call on boys. We started an informal experiment where we raised our hands for every question. More times than not, he would always call on a boy if they had their hands up, too. While we could never prove he was sexist, we felt invisible and undervalued.

#6. Women cook more

Let’s look closer at one example of unpaid work: cooking. It’s an everyday task that takes significant planning, energy and time. According to one survey, women cook more meals than men in almost every country. In 2022, that totaled a little less than nine meals a week. Men cooked four meals a week. In places like Ethiopia, Egypt, Yemen and Nepal, women cooked eight more meals than men. Italy was the only place where men cooked more than women. The reasons vary, but cooking is typically considered a domestic and “feminine” job. Because of this stereotype, women end up saddled with extra unpaid work.

#7. Discrimination affects gender-diverse and transgender people more than their cisgender counterparts

Gender-diverse and transgender people don’t identify with the sex they were assigned at birth and/or traditional gender binaries. Gender inequality affects them, too. According to research, trans people are more than four times more likely than cis people to experience violence, including rape and sexual assault. Households with a trans person also have higher rates of property victimization. Discrimination extends into every area of life, including employment, housing and healthcare . According to the Human Rights Campaign, discrimination disproportionately affects young trans women of color.

#8. Women are sexually harassed at work more often

Work should be a safe place for everyone, but women deal with more sexual harassment. According to the International Labour Organization, young women are twice as likely as young men to experience sexual violence and harassment at work. Migrant women are especially vulnerable; they’re twice as likely as non-migrant women to report harassment. Not every industry is the same. According to the Center for American Progress, women who work in male-dominated fields, like warehousing and construction, are most likely to report harassment . Most people who experience harassment never report it, however, so harassment is happening a lot more often than we know.

#9. STEM jobs are gendered

The STEM field, which stands for science, technology, engineering and math, has been male-dominated for many years. Gender stereotyping is one of the main reasons why. Historically, most societies didn’t believe women were fit for these types of jobs. The consequences are still with us today. According to research from LinkedIn, women fill only 3 out of 10 STEM roles around the world. This represents an improvement, but at the pace of progress, it will take 90 years for women to make up half of the global STEM workforce.

#10. Caretaker jobs are gendered (and undervalued)

While women are underrepresented in STEM jobs, they perform most caretaker jobs. According to the International Labour Organization, women fill 88% of the personal care worker jobs , which include home healthcare assistants, while men fill 12%. Women also dominate the cleaning, food prep, teaching and clerical support fields. Their work tends to go unappreciated, however. According to the Economic Policy Institute, American home healthcare and childcare workers make just $13.81 and $13.51 an hour . That’s half of the average hourly wage for workers in general.

Gender equality jobs can help reduce inequality and empower women and girls.

#11. Women experience worse mental health

Everyone can experience mental health problems, but women and girls are at a higher risk. According to 2017 data, women are three times more likely than men to have common mental health issues. They’re also three times more likely to experience eating disorders and PTSD. The picture gets more complicated when it comes to suicide. While men are 2-4 times more likely to die by suicide, women are three times more likely to attempt suicide . Stigma could be one reason why. Because of gender stereotypes, men may be less likely to report mental health problems or seek help, which is another example of how inequality hurts everyone.

#12. Healthcare professionals take women less seriously

Everyone should be able to go into a doctor’s office and feel respected. Because of gender inequality, women face more challenges. Doctors often take women less seriously and quickly label health issues as “anxiety,” which results in worse healthcare. According to one study, women who went to the emergency room with severe stomach pain waited 33% longer than men with the same symptoms. Black women face even more discrimination. According to research, doctors are twice as likely to deny Black women pain medication during birth than white women.

#13. Taking paternity leave is stigmatized

Paternity leave used to be rare. The prevailing view was that women were responsible for childcare, while men needed to stay at work. Now, 63% of countries guarantee paid parental leave. Only seven countries – including the United States – do not. Even in countries where paternity leave is provided, families deal with stigma. A small 2020 study from the UK found that 73% of men believed there was a stigma to taking paternity leave, while 95% wanted workplaces to “normalize” taking paternity leave. Gendered stereotypes about parenting harm everyone and allow gender inequality to thrive.

#14. Products for women can cost more

People of all genders use products like razors, soap and lotion, but the ones designed for women often cost more. According to data from the World Economic Forum, personal care products marketed to American women can cost 13% more than the same products for men. This disparity is called “the pink tax.” While it’s not an official tax, cost differences affect accessories, clothing, dry cleaning, and other products and services. Women may pay thousands of dollars more over their lifetimes because of their gender.

#15. Men get in more car crashes (but women are more likely to be trapped)

For many people, driving a car is an everyday occurrence. Women could face some unique risks. According to a study of UK data, while men were more likely to be involved in serious crashes, women were twice as likely to be trapped after a car crash. Women also experienced more injuries to the hip and spine, while men were injured on their heads, face, chest and limbs. While the cause of this disparity isn’t obvious, it could be because crash test dummies are modeled after male bodies. Identifying the less clear reasons for gender inequality is essential to people’s health and safety.

Want to learn more about gender equality? Here’s our Gender Equality 101 article .

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About the author, emmaline soken-huberty.

Emmaline Soken-Huberty is a freelance writer based in Portland, Oregon. She started to become interested in human rights while attending college, eventually getting a concentration in human rights and humanitarianism. LGBTQ+ rights, women’s rights, and climate change are of special concern to her. In her spare time, she can be found reading or enjoying Oregon’s natural beauty with her husband and dog.

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The Supreme Court opens the door to more discrimination claims involving job transfers

Nina Totenberg

A view of the U.S. Supreme Court on March 26. Jemal Countess/Getty Images for Women's March hide caption

A view of the U.S. Supreme Court on March 26.

The U.S. Supreme Court on Wednesday made it easier for workers to bring employment discrimination suits over job transfers based on sex, race, religion or national origin.

At issue was a question that has produced many conflicting decisions in the lower courts over what constitutes illegal discrimination when it comes to job transfers.

The high court's answer Wednesday was that an employee must show some harm, but need not demonstrate harm that is "significant" or "material."

The case before the court was illustrative. It was brought by Jatonya Clayborn Muldrow, a police sergeant who claimed she was transferred from her job as a plainclothes police officer in the intelligence section of the St. Louis Police Department because she is a woman. Muldrow worked in the Intelligence Division from 2008 to 2017 investigating public corruption and human trafficking cases. She also oversaw the Gang Unit, served as head of the Gun Crimes Unit, and was assigned as a task force officer with the FBI.

Despite high employment evaluations, a new unit commander engineered her transfer out of the Intelligence Division. Among other things, he justified the transfer by noting that the division's work was "very dangerous." Over her objections, Muldrow was reassigned to a uniformed job in the department's Fifth District, where she supervised the activities of neighborhood patrol officers — approving arrests, reviewing reports and handling other administrative matters.

Though her pay and rank remained the same, Muldrow sued the police department, asserting that she had been harmed by the transfer. Because she was no longer in the Intelligence Division, she lost her FBI status and the car that came with it, and in the new job Muldrow often had to work nights and weekends, instead of the Monday-through-Friday workweek she had worked in the intelligence unit.

Supreme Court gives skeptical eye to key statute used to prosecute Jan. 6 rioters

A federal district court judge ruled in favor of the police department, without a trial, and the 8th Circuit Court of Appeals upheld Muldrow's transfer, declaring that because she could show no "diminution to her title, salary, or benefits," her claims of discrimination were not "significant."

But on Wednesday the Supreme Court reversed that ruling and laid out a more stringent test for lower courts to use in determining whether a discrimination claim based on altered conditions of employment can proceed to trial.

The decision was unanimous , but the reasoning was not.

Writing for the six-member majority, Justice Elena Kagan said that the federal law banning discrimination in employment includes a ban not just on economic discrimination; it includes a ban on discrimination in the "terms" and "conditions" of employment." Kagan said that covers a transfer that changed "nothing less than the what, where, and when of [Muldrow's] police work."

While the 8th Circuit and some other courts have required that such discrimination claims show "significant" or "material" harm, the Supreme Court said that is too high a bar. The anti-discrimination statute "targets practices that 'treat a person worse' " because of their sex, race, religion or national origin, the court said.

Explaining why this higher threshold is necessary, Kagan said that "whether the harm is significant" turns out to be "in the eye of the beholder." And to prove the point she cited examples that lower courts have held to be not significant:

• an engineering technician is assigned to a new job site — in a 14-by-22- foot wind tunnel;
• a shipping worker is transferred to a position involving only nighttime work;
• and a school principal is transferred to a non-school-based administrative role supervising fewer employees.

In each of those sex or race discrimination cases, the lower courts found that there was no "significant" harm to conditions of employment.

That, however, is "the wrong standard," Kagan explained. Rather, if an employee can show some harm because of sex, race, religion or national origin, that is enough. "Had Congress wanted to limit the liability for job transfers to those causing a significant disadvantage, it could have done so," wrote Kagan, adding that the court "does not get to make that judgment" by rewriting the statute.

Three justices — Samuel Alito, Clarence Thomas and Brett Kavanaugh — wrote opinions concurring with the result but not the reasoning.

Alito's was the most extraordinary. "I do not join the Court's unhelpful opinion," he wrote, adding of its reasoning: "I have no idea what this means."

Justice Thomas picked some legal nits with the majority opinion, but in the end, acknowledged that it is "unlikely" the 8th Circuit had a "stringent" enough standard in mind.

And Justice Kavanaugh wrote that he favored a different and less complicated approach. If a job transfer is based on sex, race, religion or national origin, it is discriminatory, period, whether or not it causes some concrete harm. That said, he acknowledged the court's "new some-harm requirement appears to be a relatively low bar" that ought to be easily met for anyone transferred based on their sex, race, religion or national origin.