Sammy: gender identity concerns in a 6-year-old boy.

CASE Sammy, a 6-year-old new patient, came to his pediatrician for a health supervision visit. He had moved recently with his mother and two siblings, after a stormy marital separation. His mother felt that Sammy and his two younger siblings had weathered the events that led to the separation reasonably well. His birth and developmental history were uneventful. He had a good year in kindergarten, developed several friendships, and was responsive to early learning skills. His past medical history did not include any hospitalizations or chronic illness. The pediatrician recognized the potential importance of the parents’ separation. Focused questions to his mother revealed that the father remained in their old home, in a city 300 miles away; the children had not seen their father for 6 months, although he called them approximately once a month. The mother was living with a man with whom she had a close relationship. She stated that the children enjoyed the company of her friend, although Sammy seemed to play with him less than the younger children did. Marital discord had been ongoing for 2 years before the separation. Although heated verbal arguments had occurred frequently between the parents, Sammy’s mother denied either child abuse or spousal abuse. The pediatrician asked Sammy to draw a picture of his family doing an activity together. She used this opportunity to talk to his mother alone. In response to the question, “Is there anything else you would like to tell me about Sammy?”, Sammy’s mother said that she was concerned about his tendency “to do things like a girl.” He frequently asked his mother if he could dress in her clothes; on a few occasions, she found Sammy with one of her dresses on. He preferred to play with his sister’s girlfriends rather than with boyfriends. At one time, he put on his mother’s makeup. Sammy’s mother described him as “effeminate, with manners and body movements more like a girl than a boy his age.”