A thematic analysis of the experiences of prepubertal transgender and gender-diverse children in Sweden

Abstract

Knowledge of prepubertal transgender and gender diverse (TGD) children is limited. This study fills a gap in the research literature by exploring the lived experiences of prepubertal TGD children related to gender identity, centering their voices. Interviews with 10 TGD Swedish children 4–12 years old were analyzed through Thematic Analysis. The analysis resulted in two main themes: (1) “The journey of gender exploration,” with subthemes Discovering me and The joys, and challenges of being me; (2) “Meeting the outside world,” with subthemes Can I belong? and Staying me: my tips, tricks and help from others. The children’s evolving gender identity was traced, emphasizing emotional aspects and pivotal milestones like affirmed names. Even though the children had supportive environments, challenges of misgendering and the need for continual self-assertion were exposed. Despite struggles for recognition, the study highlights TGD children’s resilient coping and well-being. Still, cisgender norms were observed to challenge their prevalent pride and positive self-images, emphasizing the need for enhanced knowledge of gender diversity for a broader societal change. This study expands the literature on TGD children’s gender identity development, informs professionals and a broad audience and provides an enhanced understanding of TGD prepubertal children through their own words.

Keywords:

• Transgender
• children and youth
• gender diverse
• gender identity
• thematic analysis

Introduction

A growing number of transgender and gender diverse (TGD) children (Coleman et al., 2022) are socially transitioning, aligning their name, pronoun, and gender expression with their gender identity (Ehrensaft et al., 2018). However, there is limited research on the experiences of TGD youth under the age of 13 (Tyni et al., 2024). Further research is needed to understand the experiences of prepubertal TGD children, considering children’s dependence on family and school environments (Ehrensaft et al., 2018; Olson-Kennedy et al., 2016; Tyni et al., 2024).

Previous research with TGD children has described diverse developmental paths (Medico et al., 2020; Pullen Sansfaçon et al., 2020; Rae et al., 2019; Steensma et al., 2011). Just like cisgender children, TGD children have been shown to strongly identify with their gender group (aligning with their gender identity) (Gülgöz et al., 2019), but also seem to interpret gender as more fluid than their cisgender counterparts (Gülgöz et al., 2021). In a 5-year follow-up study, Durwood et al. (2022) found that the initially binary transgender children who had socially transitioned between the ages of 3 and 12, experienced additional transitions. Some retransitioned to a cisgender identity while others expressed a nonbinary gender identity or briefly experimented with it before retransitioning to a binary (boy/girl) transgender identity. Still, 97.5% identified as TGD after these retransitions. The TGD children seemingly felt free to openly process their gender identity in their families which contrasts with previous research indicating tension and concealment of gender identity before coming out (Budge et al., 2018; Catalpa & McGuire, 2018; Clark et al., 2020; Pullen Sansfaçon et al., 2020). Notably, the parents of these children viewed their children’s gender identity journeys as an ongoing process, refraining from favoring any specific path over others (Durwood et al., 2022). Allowing children to explore and express their gender identity freely without familial pressure has proven beneficial in clinical work with Swedish TGD youth (Kindstedt & Wurm, 2023).

Research on prepubertal TGD children is limited (Tyni et al., 2024), making it unclear whether these children experience elevated negative psychological health issues, such as depression and anxiety, like their older counterparts (Bränström, 2019; Chodzen et al., 2018; Tankersley et al., 2021). Within a US–Canadian longitudinal project where families with TGD children were recruited not only from gender clinics but also publicly, a study of socially transitioned TGD youth (n = 63; 9–14 years) showed no difference in their reporting of depression or self-worth compared to matched non-related cisgender youth or siblings (Durwood et al., 2017). The study suggested that when TGD children’s social transition(-s) are supported, levels of sadness and how they feel about themselves become comparable to those of cisgender controls (Durwood et al., 2017). Yet, a study in the same project showed that when TGD children (n = 265; 3–15 years) were supported in their transitions not only by their families but also by peers and schools, parents reported even better well-being in their children (Durwood et al., 2021). In another study, involving a community-based sample of caregivers to 45 TGD children 6–12 years (Kuvalanka et al., 2017), the results showed internalizing, externalizing, and total behavior problems within a range of avarage (non-clinical) populationdata, though a sub-group of TGD children (n = 45) identifying outside the gender binary was closer to cutoff for diagnostic (clinical) symptom levels than the ones identifying as girls or boys. The degree of gender conformity, the caregiver’s level of anxiety, and the children’s peer relations were correlated with the children’s well-being (Kuvalanka et al., 2017).

In studies with older TGD youth than in ours, family, peer, and school support, community connectedness, and a sense of belonging have been associated with enhanced mental health and well-being (Johns et al., 2018; McGowan et al., 2022; Veale et al., 2017; Weinhardt et al., 2019). Further, the use of TGD youth’s chosen name (Russell et al., 2018), the positive feelings of gender identity pride (Conn et al., 2023), and gender euphoria that may arise when feeling like your body aligns with your gender identity or when being correctly gendered by others (Beischel et al., 2021; Skelton et al., 2023) are crucial factors for enhancing resilience. Experiences of minority stress through invalidation, bullying, and internalized transphobia, where negative societal attitudes become internalized, are linked to negative mental health outcomes in TGD youth (Bränström, 2019; Chodzen et al., 2018; Eisenberg et al., 2019; Tankersley et al., 2021). Ilan Meyer (2003) extensively describes this phenomenon in his well-known Minority Stress model. To counteract the effects of minority stress, Meyer (2015) underscores the importance of studying resilience factors within a social context. An exclusive focus on individual risks may lead to overlooking societal injustices, emphasizing the need for a comprehensive view of resilience that spans individual to collective levels (Meyer, 2015). Beyond exposure to adverse events or the worry thereof (Bränström, 2019), daily microaggressions (Nadal et al., 2012), such as strange looks or inappropriate personal questions, can contribute to continous low-key stress. The concept of emotional labor (Hochschild, 1979) aids in understanding the emotional toll for TGD individuals facing the daily consequences of cisnormativity, involving the emotional work of hiding, explaining, and seeking recognition of their gender identities and pronouns (Lundberg et al., 2023), as well as finding safe places in daily life (Linander et al., 2019). Managing emotions to align with social expectations in stressful environments can exacerbate the strain (Jeung et al., 2018). Adaptive coping strategies, a supportive environment, and a psychological sense of belonging can alleviate emotional labor and enhance well-being (Linander et al., 2019; Lundberg et al., 2023; Tankersley et al. 2021).

In conclusion, there is limited research on prepubertal TGD children. Therefore, this study aims to gain deeper insights into their lived experiences related to gender identity. The following research question will be explored: What are the lived experiences of Swedish prepubertal TGD children as they internally and externally navigate and express their gender identity?

Methods

Epistemological stance and positionality

Following Braun and Clark (2021), this study employed Thematic Analysis, within a critical realist framework (Bhaskar, 2008). Critical realism seeks to uncover the complex interplay between individual agency and broader social structures, providing a more comprehensive understanding of phenomena. In recognizing that reality is indirectly accessible, the observable and narrated experiences of TGD children in relation to gender identity were explored in the context of deeper psychological, social, and cultural influences. As researchers and clinical psychologists, the authors of this study adopt the position that transgender and gender diversity is a phenomenon that exists, acknowledging and affirming the gender identities of TGD children. We believe that various contextual factors, such as family dynamics, school environments, and societal norms, shape the expressions and individual experiences of TGD children. Our focus on centering prepubertal TGD children’s voices and experiences throughout the study is in line with the Convention on the rights of the child (1989) which is legally binding in Sweden and states that all children are unique individuals with the right to be heard. In Sweden, everyone has the right to their own gender identity, and according to The Swedish Discrimination Act (2008), it is illegal to treat someone unfairly or inferior because of it.

Additionally, we have a diverse representation of gender and sexual identities within the research group, coupled with clinical experience of working with youth and their families and conducting research with transgender individuals. Researchers identify as a cisgender, bisexual woman; as nonbinary, queer; and as a cisgender, heterosexual woman.

Ethics

Ethical approval was granted by the Swedish Ethical Review Authority (Dnr 2020-01854).

Context

The study used first-hand interview data from prepubertal Swedish TGD children to emphasize their voices. We aimed to capture real-time experiences related to gender identity, not solely relying on retrospective accounts. Focusing on the children’s experiences before and outside of gender-affirming care, we recruited publicly rather than from gender clinics. Despite our intention for intersectional recruitment as well as contacting both critical and affirming online groups of parents with TGD children, the children in this study were predominantly from white, middle-class families that supported their children’s gender identities.

Procedure

Participants aged 4 to 12 years were recruited through various channels, including social media (specifically Facebook groups for parents of trans children, Swedish LGBTQ organizations, a municipality site for LGBTQ youth activities, and the authors’ social media networks). To be eligible for the study, the child and at least one parent had to participate. Interested families contacted the first author (KT), and upon expressing interest, they received age-appropriate information by e-mail. Participants confirmed their involvement by returning a signed informed consent (with a happy or unhappy smiley to indicate consent for younger children). During the scheduled meeting, held at an agreed-upon date and location chosen by the participants, they received a verbal recap of the information before proceeding with the interviews.

Participants

Ten TGD children, aged 4–12 years participated. Eight children identified as girl/trans girl (n = 4), or boy/trans boy (n = 4), and two children (both assigned boy at birth), had nonbinary (n = 1) and gender fluid (n = 1) identities. All children had to some degree started a process of social transitioning supported by their parent(s). Geographically diverse, the participants lived in various settings, including large cities, smaller towns, and rural areas across Sweden. Nine children were white, and one child was adopted from an Asian country. Considering the participants’ anonymity and security in the relatively small trans community in Sweden, these factors have not been specified for individual children (Table 1).

Data collection

The first author (KT) conducted the semi-structured, individual interviews. According to the wish of the participants, the interviews took place in the families’ homes, but one child was interviewed digitally (Zoom), due to great distance, with the parents present during the interview by the child’s choice. Interviews were tape-recorded, transcribed verbatim, and anonymized to protect the children’s confidentiality. They were conducted between 2020 - 2023 and lasted between 17 and 50 min (M: 33). The interview questions were related to three areas: 1) name and pronoun, 2) gender identity, and 3) social areas, with flexible follow-up questions on the children’s reactions and concrete situations (Appendix A).

Table 1. Features of the included 10 children.

Nr	Assigned gender at birth	Self-identified gender and preferred pronoun	Age at interview	Age when coming out	Social transition	Gender affirmative care
1.	Girl	Boy; he/him	4	2-3	Some gender expressions, but not name/pronoun.	No contact was initiated.
2.	Girl	Boy; he/him	5	3	Yes, in all aspects and contexts. A full social transition at 5 years.	No contact was initiated.
3.	Boy	Trans girl; she/her	6	2-3	Yes, in all aspects and contexts. A full social transition at 5 years.	No contact was initiated.
4.	Intersex, assigned boy	Boy, he/him - but binary changes daily, why we have decided to use “gender fluid” (though a word not known to the child).	6	3	Some gender expressions, but not name/pronoun.	No contact was initiated.
5.	Boy	Girl; she/her	7	2-3	Yes, in all aspects and contexts. A full social transition at 5 years.	No contact was initiated.
6.	Boy	Girl; she/her	8	2-3	Yes, in all aspects and contexts. A full social transition at 6 years.	No contact was initiated.
7.	Girl	Boy; he/him	9	2-3	Yes, in all aspects and contexts. A full social transition at kindergarten.	No contact was initiated.
8.	Girl	Boy; he/him	10	5	Yes, in all aspects and contexts. A full social transition at 8 years.	Yes, on a waiting list for the first appointment.
9.	Boy	Girl; she/er	11	10	Yes, in all aspects and contexts. A full social transition at 10 years.	Yes, a time for the first appointment was scheduled.
10.	Boy	Nonbinary; they/them	12	5	Yes, in all aspects and contexts. A full social transition at 9 years.	No contact was initiated.

To address interview inequalities, we empowered the children by creating a safe environment. Meetings began with family gatherings, sharing a casual “Swedish fika” (i.e. a cup of coffee/juice and something sweet to eat, e.g. cookies or ice cream) enhancing the child’s comfort through familiarizing before interviews. The child then chose weather they or their parent(-s) began the individual interview and the child also had the option to keep the door slightly open during their interview for parental proximity. The interviewer provided drawing materials, allowing children to distract themselves from the intimacy of the interview situation. Careful attention was paid to children’s nonverbal cues to discern their comfort and preferences during the interview.

Data analysis

The interview data was analyzed through inductive Thematic Analysis in six phases (Braun & Clark, 2021). An iterative process gave rise to a series of codes, further developed into themes and sub-themes. In the first phase, the researchers familiarized themselves with the data by reading and re-reading transcripts. In the second phase, relevant text sections were coded. These were gathered into potential themes and sub-themes in the third phase. In the fourth phase, themes were refined using the initial codes and the whole dataset. Themes including all codes, were defined, and labeled in the fifth phase to convey their essence. This step also involved selecting citations exemplifying the main content of themes, showing their grounding in data. In the last sixth step, a comprehensive narrative was constructed. The analysis, conducted independently by the first (KT) and the third author (ASB), included regular meetings to ensure the trustworthiness and credibility of the data analysis.

Results

The analysis resulted in two main themes regarding the TGD children’s experiences related to gender identity: 1) “The journey of gender exploration,” with the subthemes Discovering me and The joys, and challenges of being me, and 2) “Meeting the outside world,” with the subthemes Can I belong? and Staying me: My tips, tricks, and help from others.

The journey of gender exploration

In the first main theme, “The journey of gender exploration,” the children’s gender identity journeys and related feelings were explored. The first subtheme, Discovering me, detailed the children’s ongoing process of recognizing and being recognized in their gender identities. The second subtheme, The joys, and challenges of being me, recounted the children’s positive versus negative emotions about their gender identity.

Discovering me

Most children could not recall when they became aware of their gender identities, indicating an early awareness. A 5-year-old trans boy said: “I have forgotten. It was a long time ago.” Most children referred instead to milestones like being called their affirmed name or changing their gender expression, allowing them to truly express themselves. A 7-year-old girl described a gradual awareness of her current gender identity, emphasizing her name change as a “game-changer”: “I think it was like, little girl and little boy, like a little bit of both, but then I only felt like a girl. I know because before I was five, my name was X [a traditionally male name].” Older participants reflected more deeply over time:

At school, at the end of second grade, I began thinking more like - well, thinking more about it - that I’m ‘they.’ Because previously, I had another name, and everybody used another pronoun, and I didn’t correct anyone. But there, between 2^nd and 3^rd grade, something started happening. I felt like this: ‘No, but I’m not this, I’m they.’ I felt like I couldn’t relate to myself that way. It didn’t, like, feel good. I didn’t want to be a guy. And then, I changed my name to one that I felt was more gender-neutral. (12-year-old nonbinary child)

This 12-year-old nonbinary child first recognized themselves in the nonbinary Swedish pronoun “hen” already at kindergarten and told their parents about it, but it was not until the age of 8 that they really started to reflect on their gender identity on a deeper level.

All children could express their gender identity verbally, though not all the youngest were familiar with the term “trans” during their interviews. The ones who were, defined “trans” in relation to their own, personal experience, like this 5-year-old trans boy: “It’s being a boy and having a girl’s genitalia.” Others expressed that they had imagined growing up as the gender they identified themselves as for as long as they remembered.

The youngest children struggled to explain to the interviewer how a person knows if they have a different gender than their sex assigned at birth. They initially referred to external cues like the length of the hair or gender-typical clothing. When instead asked about their own experience of knowing their gender identity, they described it as an internal, psychological matter. A 7-year-old stated, “I felt it inside,” echoing others. Some mentioned the heart, and the youngest pointed to their hearts to show where they felt it in their body. A 6-year-old child, who referred to herself as a trans girl, expressed her current positive feelings about being trans through her drawing:

Child: I feel like this [drawing a heart upside-down] when I think about how it was being a boy. It wasn’t so good. An upside-down heart means it wasn’t good.

Interviewer: It wasn’t good? So, how does it feel to be a girl?

Child: It feels like this [trying to draw a heart correctly but failing, now having two hearts upside-down]. It is – [reassessing the drawing]. If two hearts upside-down, then I don’t like it, but when it’s one, then I like it. It feels good. (6-year-old trans girl)

Most children had traditionally gendered interests (e.g. gaming or dancing), gender expressions and preferences (colors, toys, and posters in their room, clothing, hairstyle), and friends aligned with their gender identities. They knew themselves what they liked and how they wanted to express themselves, but to be recognized by others in their gender identity was equally important. All children had come out to their families, initially to parents, and in one case, to an older sibling supporting the child’s coming out to parents. A 4-year-old child, who talked about his desire to change his name to a boy’s and cut his hair short, explained joyfully that his parents had told him that he could express his gender identity at home, emphasizing that it was “perfect.” Another child aged 6, with a male name and pronoun, described their gender identity as fluid, some days boy, some days girl, which was also fine for their parent, indicating parental attitudes as following their child’s lead. All children described feeling confident of their families’ approval, either through previous knowledge of parents supporting LGBTQ issues or simply, as a 9-year-old boy said, “because I know them well.” A child who came out when she was 10 years old described her experience, as “a relief not having to keep it inside anymore,” indicating an emotional tension of keeping such an experience a secret.

The joys, and challenges of being me

All children described various joyful feelings related to their gender identity, first and foremost, as the 12-year-old nonbinary child explained, “It feels good to be yourself.” The experience of being able to truly “be themselves” was intimately intertwined with being able to express themselves and be recognized as their gender identity by others. Joyful feelings were related to “passing” as their self-identified gender in social contexts, fostering a sense of belonging with their current gender group. A 10-year-old boy, assigned girl at birth, described the great satisfaction of passing when he realized that the boys in his class perceived his gender-neutral name as male. He also expressed delight of being on the boys’ team in school sports without being questioned.

Discovering there were other trans kids was described as joyful but also as a calming relief. A few children had previously thought they were the only ones identifying as another gender. For example, a 10-year-old boy said: “I had no clue that- when I was eight, I thought that I was the only one in the world.” Some children had never met anyone feeling similarly but still felt a connection just by hearing about the existence of other trans people. Events like Pride parades or TGD children camps facilitated enjoyable connections and friendships, allowing shared experiences without gender being an issue. The safe community had a calming impact, or as this 11-year-old girl put it: “I don’t actually talk so much about it [gender identity], but it just feels good to know someone who feels the same way as myself.” Consequently, the children described being able to engage freely in activities without worrying or having to cope with other people’s reactions or inappropriate questions.

More difficult aspects related to the children’s own gender identities were mentioned by the older children approaching puberty, expressing various worrying thoughts. The thought of no longer being able to recognize themselves due to bodily changes felt like a threatening dilemma, raising questions about their identity, expressed by the 12-year-old nonbinary child as, “Who will I become?” Unlike cisgender teenagers, TGD youth confront physical changes going in the wrong direction of their gender identities. Some participants coped by avoiding thoughts about the forthcoming changes to minimize emotional distress, possibly due to the difficulty of coping with a fear associated with contemplating the abstract. Dealing with the unknown can prove more challenging than facing concrete, immediate situations. Other negative emotions related to the forthcoming puberty were fear of exclusion from cisgender peers when not being able to share puberty-related experiences, such as having a period. The thought of growing up with a physical body incongruent with their gender identity was unimaginable for the children. None had undergone medical interventions in gender-affirming care, even if two had initiated contact, being on a waiting list. One child expressed a desire to halt puberty using puberty blockers but feared this option might not be available due to recent policy restrictions. The possibility of seeking solutions abroad if necessary was discussed in the family.

Meeting the outside world

In the second main theme, “Meeting the outside world,” the children’s various experiences of exclusion and social exposure were explored through the subtheme Can I belong? The other subtheme, Staying me: my tips, tricks, and help from others, highlighted the support received and the children’s coping strategies but also touched on their reactions to belonging to a minority group.

Can I belong?

In kindergarten, the children’s clothing and play with gender roles were met with open-mindedness from adults. All children expressed that they enjoyed (or had enjoyed, if school-aged) kindergarten, but information about this period was limited, possibly due to difficulties remembering. The children emphasized the importance of being called their chosen name and pronoun, but all described reactions when they were not. The 4-year-old child, assigned girl at birth, said: “At kindergarten, they call me girl even though I want to be a boy.” Still, the younger children in the study seemed more casual about it than the older ones. An 8-year-old girl said:

Interviewer: How does it feel if someone says the wrong name to you? Have you experienced that sometimes?

Child: Yes. That is if - I didn’t have any reaction, like anger or such, I felt nothing. I just said, ‘You happened to say the wrong name.’

Interviewer: OK, and then - what did they do when you said that?

Child: ‘Oops, I meant X [the right name].’ (8-year-old girl)

The young children seemed more confidently assertive, possibly strengthened by their early experience of being confirmed in their self-identified gender or simply because they had not experienced misgendering so often. Despite this, all children regularly had to correct people. For the older children, the experience of correcting others was negative, causing unease, worry, sadness, and annoyance. It was also draining their energy. Some chose not to correct in less emotionally significant relationships or to avoid attention and conflict, such as at school when teachers misgendered them, even if it felt upsetting. An understanding was expressed toward those struggling with correct pronouns, as exemplified by a child with their grandparents:

Like, they’re a bit old-fashioned, you could say. My grandma and grandpa aren’t so good at using the right pronoun, but they’re getting better (…) I think it’s mostly that they’re not used to it, and it’s all quite new, so to speak. (12-year-old nonbinary child)

The children described encountering challenging situations related to the reactions they faced in response to societal gender norms. One 6-year-old trans girl described being sad when she shared her desire to change her name to one associated with girls at kindergarten and was faced with ridicule from the other children. Proudly identifying herself as a trans girl, she later also expressed confusion when peers at school did not believe that she was assigned male at birth, being unfamiliar with TGD identities:

It felt weird that they didn’t believe me. They usually do believe me, but maybe they never have- maybe they don’t know what trans is-. I might have to, I have to tell the teachers to tell them what trans is. (6-year-old trans girl)

The children identifying outside the traditional gender binary of girl/boy were particularly affected. The 12-year-old nonbinary child expressed anxiety about the increasing pressure to choose a binary gender identity but also about being perceived as binary by others. The genderfluid young child also hinted about the challenges of having to choose to identify as only a girl or a boy, revealing how gender norms affect young children as well:

Interviewer: Is there something bad about being a boy?

Child: That you can’t be – [changes subject].

Interviewer: What did you say -, you were beginning to say something. That you can’t be-?

Child: [with a lowered voice] That you can’t be both [boy and girl].

(6-year-old genderfluid child)

Regarding gendered rooms and activities at school, the young children described being free to choose the group and dressing room aligning with their gender identity at school sports (and in public baths). Still, they had to make a binary gendered choice with the consequences of having to come out or possibly being questioned if their gender identity was not, for example, sufficiently known by teachers, as described by this 10-year-old boy:

You were supposed to place yourself- the girls were supposed to stand here and the boys there, and I thought it was really hard. I said to a classmate there that I wanted to be a boy, or that I was one, and then he said to me, ‘But come here then!’ but it was really difficult because the teacher didn’t know about it, so I didn’t know what to do. (10-year-old boy)

Knowledge about gender diversity and practical arrangements that fit all children regardless of gender identity was often missing at school. Parents had to “make room” for their children by informing school staff not just about their own children’s chosen names, pronouns, and individual needs but sometimes also basic knowledge about gender identity and diversity. Since standardized gender-neutral dressing rooms and toilets were rarely an option, this became a challenge for the older or nonbinary children, having to ask for a room of their own. The school’s solutions could sometimes be ill-suited, for example, far off or too small for changing clothes or without a shower. The children also argued for diverse choices irrespective of gender identity, for example, in clothing stores, arguing that gendered sections perpetuate the narrow societal norms and alienate those of other gender identities.

The TGD children faced more stressful challenges related to their gender identity than most cisgender youth must face, belonging to the majority norm. Despite support from peers and teachers, the school environment felt unsafe for the older children in the study. They experienced gender-based negative treatment, including disrespectful comments, harassment, and bullying by peers, especially in less supervised areas like the schoolyard. One child was, for example, repeatedly being called “trans bastard” by peers, which caused distress. Even the classroom could sometimes feel as un unsafe place as teachers did not always protect the TGD children, leaving them to cope with challenging situations alone. Especially nonbinary identification led to questioning, ridicule, or on the contrary, to invisibility. The 12-year-old nonbinary child described a situation were they were harassed:

Then I got some hard questions, like “Can you identify as a fridge?” It was very annoying, and they- we explained and, like, very thoroughly, but they wouldn’t listen and continued asking the same questions. So, it was quite hard because it was like- the teachers didn’t say much. It was me mostly who had to face it. It was a bit difficult. Then, at lunch break, there were still some, with whom I have quite good relationships, who are quite good friends, who continued the discussion and like, “I saw on TikTok someone identifying as a cat” and just kept going on like that. (12-year-old nonbinary child)

The older children reported experiencing negative health effects, such as stomach aches, sleeping disturbances, and fatigue, following gender-based incidents. Additionally, they expressed feelings of depression and worry about potential new incidents, which led to difficulties in attending and concentrating. Despite these challenges, with encouragement from their parents, they still made efforts to attend school.

Staying me: my tips, tricks and help from others

The support from home and trust in most adults at school encouraged the children to seek help when needed, like telling a teacher or their mentor (i.e. a contact person for the child and its parents meeting up regularly for information exchange and checking in on how the children are doing at school) if something bothered them or a bad incident happened. As it demands trustful experiences and courage to reach out to others for help, the children showed many signs of good self-esteem and confidence. Some children used humor as a strategy, as this 10-year-old, who defended himself by a counterquestion in a humoristic maneuver, making the intrusiveness of a teacher’s questions visible:

She just asked many questions about name changes, and I thought, “Okay, why should I answer that?” So, I once asked her - I don’t really know why, but I asked, “What was your first name?” and asked if she had changed hers. I don’t know why she would’ve, but I just tried to be a bit funny. (10-year-old boy)

Trustworthy teacher relationships at school were vital. All children described being affirmed in their gender identities, although exceptions existed. Supportive actions from school staff were described as crucial for bringing about change regarding maltreatment in the school environment. Although school policies were essential, individual teachers’ support and taking responsibility for effectively addressing harassment made the biggest difference according to the children.

At first, he only got an e-mail home, and then we had a kind of small conversation: me and my mentor, and he and his mentor. Then it got like “If you do that,” or then the other teacher said that “If you do that one more time then we’re going to call your parents and her parents to come here to school so we can talk about it,” and he just like “No. No, no, no.” So, then he quit. (11-year-old girl)

The significance of supportive friends was mentioned by all children, but it increased with age and less dependence on parents for communication and practical arrangements. Friends actively defended them if being mistreated by peers and corrected misgendering by teachers, creating a supportive environment that was both empowering and joyful for the children:

Interviewer: OK, so how is it for you when she [teacher] says the wrong pronoun?

Child: But then my friends correct her (giggles).

Interviewer: What do they say?

Child: They shout ‘HE’! (laughs)

Interviewer: How does that feel for you?

Child: It’s fun. They’re funny (smiles). (10-year-old boy)

The children displayed diverse and active coping strategies for managing difficult emotions and situations. The youngest found solace in cuddling their favorite stuffed animals when feeling sad or lonely. In response to teasing, they walked away or sought distraction with friends, as described by this 6-year-old trans girl: “I try not to be sad, and I find someone to play with, then I’m not sad anymore. That’s my little trick.”

In the face of misgendering, some children took an educational approach when they considered that it was caused by a lack of knowledge. Raising awareness could happen in the situation directed toward the person misgendering, or indirectly by, for example, getting the teacher to inform the other children (if young) or (if older) by initiating a lecture about LGBTQ issues in cooperation with a teacher. A few also used advocacy in public areas, for example, by pointing out the need for gender-neutral facilities at a local bath, demonstrating empathy and courage beyond their years in trying to improve conditions for trans people.

The study revealed early awareness of inequality issues arising due to the children’s diverse experiences when comparing their living conditions to other trans kids. They expressed gratitude for having a supportive gender identity environment. A 10-year-old boy shared:

I know many [trans kids] who have a hard time and many who have a great time. I don’t know, but I have a great time and don’t know why I became me. It’s kind of all done for me. […] but if someone had said that “you can’t be that [trans],” I would have- [looks angry], but my parents say I can, so I guess I’m doing quite fine. I haven’t any problems at school, and I’m not being teased. Yeah, I’m fine that way. (10-year-old boy)

The children’s awareness and experiences made several of them reflect upon the need for societal change. Some highlighted the importance of greater visibility of TGD people and positive role models. Another child described how children at school behaved nicer when they learned more about transgender issues and emphasized increased knowledge about gender diversity for public attitude change. Several children also expressed a desire to make a difference in the future by working toward improving conditions for LGBTQ people, possibly triggered by the early awareness of inequalities. The 12-year-old nonbinary child echoed the other children:

People who are against LGBTQ, for example, think it’s strange to strengthen and protect them and- I want it [LGBTQ] to continue to be accepted and normalized in society, that it should be more visible, yeah, more dressing rooms for transgender people, for example, and-, all kinds of small things like that make a huge difference and more education for people who don’t know so much. I think foremost at teachers and such because it’s very important, I think, that teachers know about these things. (12-year-old nonbinary child)

Discussion

This study describes the lived experiences of prepubertal TGD children as they navigate and express their gender identities, highlighting two main themes. The first, “The Journey of gender exploration,” explored TGD children’s evolving gender identity from early childhood to adolescence, revealing emotional and psychological dimensions. Milestones such as affirmed names, pronouns, and gender expression changes played pivotal roles, as well as the joyful feelings of recognition. The second main theme, “Meeting the outside world,” revealed persisting challenges with misgendering and the need for continual self-assertion despite positive living conditions. Supportive teacher relationships and peer alliances were crucial in navigating the school environment, where the older children experienced incidents of gender-based bullying with direct negative physical and mental health effects. The TGD children exhibited resilience through coping strategies such as seeking support, utilizing humor, and actively engaging in education initiatives. Nevertheless, the children had to struggle for recognition, underscoring the need for increased knowledge about gender diversity in schools and society.

While most participants became aware of their current gender identity early on, the study highlights individual variations and unique developmental paths aligning with previous research on TGD children (Medico et al., 202; Pullen Sansfaçon et al., 2020; Rae et al., 2019; Steensma et al., 2011). All the children spoke of identification with some other gender identity than their assigned sex and had begun a social transition to some degree, even if the youngest ones were not able to develop their narratives on experiences as much as the older children could. However, it is unclear from the children’s own words whether all of them also demonstrated clear and pronounced adherence to normative gender expressions early on, as the children who made early social transitions described by Rae et al. (2019) did. Cultural aspects may influence what are considered normative gender expressions in different countries. Gender-nonconforming expressions regarding, for example, clothing and hair length are generally quite accepted for all kids in Sweden. The fact that language and gender norms are predominantly binary though, might make it more complicated and time-consuming for children with nonbinary or fluid identities to find what feels right for them.

The participants in our study actively displayed confidence, and resilience in facing challenges, without concealing their identities. This contrasts with previous research with TGD youth, older than our sample, who have often reported hiding their gender identity due to fear of people’s reactions both at home and in school environments (Budge et al., 2018; Catalpa & McGuire, 2018; Clark et al., 2020; McGowan et al., Pullen Sansfaçon et al., 2020). In line with Meyer (2015), we could place resilience factors within a wider social context. All the children in our study were supported by their parents and, mostly, also at school, which might be crucial for developing resilience against the negative effects of minority stress. The parents had a positive approach to gender exploration, allowing the children to exhibit their unique paths while affirming them. This attitude has been shown in research (Durwood et al., 2022) and clinical work (Kindstedt & Wurm, 2023) to facilitate openness, easier (re-)transitions and enhance TGD children’s well-being. Besides possible variations in parental attitudes at home, the reports of nondisclosure in previous research might be a result of an increase in harassment in middle and high school, as the studies on TGD youth’s school experiences include older participants than ours (Eisenberg et al., 2019; Kelley et al., 2022; McGowan et al., 2022). The school environment emerged as the most challenging for all the children in our study, despite good relationships with teachers or mentors and supporting peers. However, the older children experienced increased adverse events and grappled with challenges to their physical and mental health and well-being such as stomach aches, fatigue, and depressive feelings after incidents. The burdens of emotional labor (Hochschild, 1979) described in research with adult transgender individuals (Linander et al., 2019; Lundberg et al., 2023) were evident also for the older children in our study, with worries about future incidents or misgendering, experiences of gender-based bullying, and feelings of unsafety making life challenging. This also corresponds with previous research on TGD adolescents, showing negative mental health effects due to minority stress (Bränström, 2019; Chodzen et al., 2018; Eisenberg et al., 2019; Tankersley et al., 2021), and even more if identified as nonbinary (Kuvalanka et al., 2017). The importance of supportive actions from parents, peers, and school staff, as highlighted in this study, is consistent with the Minority Stress model (Meyer, 2003) and the emphasis on protective factors such as social support and recognition from family, school, and community (Durwood et al., 2021; Johns et al., 2018; McGowan et al., 2022; Veale et al., 2017; Weinhardt et al., 2019). We believe that the children’s experience of secure places where they can be themselves without gender identity being an issue is not highlighted enough in minority stress theory in line with Lundberg et al. (2023). Lowering neurobiological stress levels due to the psychological and existential well-being of experiencing belongingness could be a major factor in enhancing physical recovery (Linander et al., 2019; Lundberg et al., 2023). If the feeling of belonging can add to resilience even when direct social support is absent, as Meyer (2015) suggests, the knowledge of the existence of other trans people is of great importance, also for young TGD children, to ease possible tension and build resilience. Using coping strategies, such as active engagement (Budge et al., 2018) through assertiveness, advocacy, education, and activism to fight for change can also strengthen a sense of pride, self-esteem, and resilience. On the other hand, it can also be experienced as an exhausting obligation, as was described by some children in our study, triggering dysphoria if not being heard when, for example, trying to educate others.

The joyful experience of gender euphoria (Beischel et al., 2021; Skelton et al., 2023) adds a positive dimension to the understanding of TGD children’s experiences. Most of the TGD children in our study described good mental health and well-being, positive self-worth, and self-confident assertiveness, in line with the study by Durwood et al. (2017). Highlighting the existing positive experiences is important since these narratives can affect self-image, future visions, and societal attitudes, giving hope and nuance to the often narrow and pessimistic transgender narratives. The children’s joyful emotions were intertwined with being recognized by family, friends, and at school, emphasizing the need for support during crucial developmental phases. The results underscore the importance of using TGD children’s chosen names and pronouns, confirming previous research showing that it mitigates mental health risks on a group level (Russell et al., 2018) and affects well-being in the TGD adolescent demographic (Kelley et al., 2022).

Cisgender norms were present in the children’s narratives, even if not consciously reflected upon. Even the youngest showed signs of potential awareness that their preferences, marked by joy, diverged from societal gendered expectations. This awareness manifested through hesitation and lowered voices as if they were disclosing something deemed shameful. Additionally, the narratives reflected a perception of TGD identity as a “wrong otherness” compared to cisgender friends. This tendency may signify a gradual, ongoing internalization of society’s negative views of TGD identities, potentially leading to the incongruent self-image and conflictual emotions manifested through gender dysphoria. Research suggests that an antidote mitigating the association between internalized transphobia and depressive symptoms is fostering a sense of pride in one’s gender identity (Conn et al., 2023). This underscores the importance of societal attitude change for increased inclusiveness through mirroring and addressing TGD youth correctly to enhance gender identity pride, joy, and belongingness. Aspects of belonging to a minority became visible in some children’s narratives as they expressed gratitude for their supportive environments compared to other TGD children’s living conditions. This comparison evoked various emotions and prompted an early reflection on circumstances often taken for granted when in a majority position.

In previous studies (Linander et al. 2017; Malmquist et al., 2023), TGD participants have mentioned turning abroad for hormonal treatment due to the lengthy waiting time for the diagnostic assessment in gender-affirming care in Sweden or to signal the seriousness of their gender dysphoria to evaluators, possibly shortening the waiting time. Likewise, one child in our study mentioned discussions in the family to turn abroad for hormonal treatment (due to the 2021 restrictions of hormonal treatment for minors) should the suffering from gender dysphoria worsen during puberty. Even if this subject was not a major part of the children’s narratives these signals are alarming, as medication outside the official gender-affirmative care comes with expensive economic burdens and health risks.

Strengths and limitations

This study has both strengths and limitations. It is the first qualitative research study with prepubertal TGD children in Sweden., As societal conditions may differ geographically it is also an important complement to the limited previous qualitative studies with this population, predominantly conducted in the US and Canada. Despite an intersectional intention, as well as trying to recruit TGD children with parents from both critical and affirming online groups, the TGD children in this study were predominantly from white, middle-class families, supporting their children’s gender identity journeys as also in most previous studies. The sample was diverse in other aspects though, such as the children’s gender identities, their sex assigned at birth, age of coming out, and geographical locations in Sweden. The study still faces sample bias limitations which affect qualitative generalizability in that the prepubertal TGD children’s lived experiences might not be as varied as they could have been with a more diverse population.

The use of first-hand interview data from prepubertal TGD children to emphasize their voices and capture real-time experiences related to gender identity is a strength, compared to retrospective accounts. Also, two researchers independently analyzed the data, and regular discussions in the research group enhanced the study’s credibility. The research group’s diverse gender and sexual identities and clinical and research experience enhance the study’s depth and perspectives through all phases.

Conclusions

In summary, this is one of few conducted qualitative studies, and the first Swedish, to center prepubertal TGD children’s voices. It expands the literature and comprehensive understanding of TGD children’s identity development, coping, and well-being. The importance of fostering gender identity pride and joy to counteract internalized transphobia is underlined, as well as the role of supportive and affirming environments where children can explore their gender identity freely but also relax from having to think about gender at all. Despite struggles for recognition, the study highlights TGD children’s resilient coping and well-being. Nevertheless, cisgender norms were a challenge to the children’s prevalent pride and positive self-images, emphasizing the need for enhanced knowledge of diversity for a broader societal change. This study informs professionals and a broad audience and provides an enhanced understanding of TGD children through their own words.

Implications for future research

Future research should prioritize the voices of prepubertal TGD youth underrepresented in research. A focus on positive experiences and protective factors should be emphasized for developing relevant support and interventions but also to nuance the commonly pessimistic transgender narratives. Further research on diverse samples of TGD youth’s experiences in various contexts is needed for an enhanced understanding of gender identity development and the impact of societal gender norms on their well-being and the emergence of gender dysphoria.

Acknowledgments

First and foremost, the authors wish to thank the TGD child participants and their families for their important contributions to this research. The authors also wish to thank the reference group for feedback on language appropriate for trans people, the TGD youth volunteering for pilot interviews, and the young children for giving feedback on age-appropriate language in participant information, as well as the organizations and persons who assisted in spreading the recruitment ad.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research received no grant from public, commercial, or not-for-profit funding agencies.

Notes on contributors

Kristiina Tyni

Kristiina Tyni is a PhD student in clinical psychology and a lecturer. Her thesis deals with the lived experiences of transgender and gender-diverse minors and their parents, focusing their voices. Additionally, she is working as a clinical psychologist/psychotherapist.

Matilda Wurm

Matilda Wurm is a senior lecturer with a PhD in health psychology where they’ve explored factors influencing the development of (ill-) health. Their research has focused on LGBTQ people’s minority joy and minority stress, their coping and resilience, as well as how to counteract the negative impact minority stress may have on people’s quality of life and health.

Anna Sofia Bratt

Anna Bratt is an associate professor in psychology and a senior lecturer. In addition to her role as a clinical psychologist, her research focuses on LGBTQ studies from a lifespan perspective, delving into the unique challenges and experiences faced by individuals within the LGBTQ community at different stages of life. Bratt’s work also explores aspects of children’s development and mental well-being.

Appendix A.

Interview guide

1. Name

2. What is your name?

3. Have you ever changed your name? If so, can you tell me about it? (Why? Thoughts/feelings related to name and name change? How did the name come about/who chose it? etc.)

Pronoun

• What do you want me to say about you - he, she, they, or something else?

• Has someone sometimes said the wrong name or thing [pronoun] about you? (If yes, where/who? how did that feel? What did you do?)

• Gender identity

• What word do you use about your gender? (boy, girl, something else?)

• How does one know that someone is X [the gender the child identifies as] (compared to other gender identities)?

• How do you express your gender – does it show in some way that you are X (describe!)? (How does it feel?)

• Best/worst thing about being X? (how does it feel? How do you cope with X?)

• Do you remember when you first became aware of being X [self-defined gender identity] – can you tell me about it? (how did you notice? Feelings/thoughts?)

• Did you know there are others feeling the same way [gender identity]

• Have you heard the word trans [if not mentioned before]? (where? Who told you? What does it mean?)

• What makes you feel good? (related to gender identity)

• What makes you feel bad?

• How do you cope with it?

• Social areas

• Did you tell anyone when you knew that you are X – if yes, to whom did you first tell? How did X react? How was that for you (thoughts, feelings)?

• Do they know about your gender identity in preschool/school/leisure activities? If yes, how did it happen (who told? Positive/negative reactions received? How did/do you feel about that?

• What do other people think about or react to you being X? (parents, siblings, relatives, friends, at preschool/school, etc. – describe situations/examples! How does that make you feel?)

• Good/bad incidents? Coping with them?

• How do you cope with X [different negative/positive feelings]? (what do you do if you feel X (examples/situations!)? what makes it feel better?)

• Have you met other children/people who identify as some other gender than their sex assigned at birth? (who, for example, feels they are a boy/girl even though they were called girl/boy at birth? If yes, when, where? Feelings/thoughts/activities?)