Ever since my primary-care pediatric group practice adopted electronic records, we’ve used them to give our patients pre-visit online questionnaires that screen for various things: tuberculosis, lead exposure, developmental issues, autism, drug and alcohol use, postpartum depression, food insecurity and so on.
I started off thinking that the questionnaires were intended to save precious visit time by asking patients about these subjects before the appointment. Then I realized that our practice bills the health-insurance companies for administering these questionnaires (and some pay quite well). More recently, I’ve realized that these surveys offered another benefit as well—perhaps the most valuable of all.
For my young patient Remi’s three-year checkup, his parents completed all the recommended pre-visit online screenings. Shortly after I walked into the room, Remi’s dad asked me about one questionnaire: the Ages and Stages Questionnaire, or ASQ3.
This form, filled out by the child’s parents, is a scientifically validated instrument for developmental screening. It covers communication, gross motor and fine motor skills, problem-solving and personal-social development. To complete the questionnaire, the parents must ask the child to carry out various actions—to point to various body parts, speak a short sentence and so on.
I’ve probably reviewed thousands of ASQ3 questionnaires in the last five years, but this was the first time a patient’s parent had read it with such close, thoughtful attention.
“I’m concerned about one particular question,” Remi’s father told me. “The one where you ask the child: ‘Are you a girl or a boy?’ When we asked Remi this, he answered, ‘I’m a girl.’ ”
I’ve known Remi for his entire three years of life. I’ve known his mother even longer (as a child and as a young adult, she was my patient). I feel very close to the family, but there are times when it feels awkward to bring up certain subjects.
The first time I’d become aware of this was a few months before Remi’s three-year checkup, when he came in dressed as his favorite Disney character, Mirabel Madrigal from Encanto, wearing a colorful embroidered skirt and white ruffled top. Although at the time I didn’t feel comfortable asking about his gender identity, I did feel pleased to observe how happy he was, and how comfortable his parents felt with his choice of clothes.
Interestingly, when Remi’s mom was a student at Wesleyan University, about twenty years back (long before people routinely identified themselves by their preferred pronouns), she told me she was taking a course on gender and society: “On the first day, everyone introduced themselves with their name, gender and preferred pronouns.”
It was the first time I’d heard of the gender-neutral pronoun xe. Little did I know how important these questions would become in today’s society.
I asked Remi’s father to tell me more about his concerns.
“I was shocked, because the question seems so old-fashioned,” he said. “I’m not really sure what the question is asking.”
“I think maybe you’re interpreting the question as having a much deeper meaning than the way it was intended,” I said, a bit tentatively.
“Well, gender is a complicated subject, especially for a three-year-old,” he replied. “This either/or question is pretty incongruous with our experience raising Remi.”
Notably, that very week the New York Times ran an article entitled “The Broad Appeal of the Elsa Dress,” highlighting the fact that many children, both girls and boys, have been dressing up as Elsa. Remi was clearly not alone in enjoying dressing up.
I’m curious to see how Remi grows up. He is certainly surrounded by one of the most loving, supportive families I’ve met in my thirty-plus years in pediatric practice.
When I showed this essay to Remi’s parents, they wrote a response expressing their views, which I’m including here with their permission:
“Using these exact words, ask your child, ‘Are you a girl or a boy?’ Does your child answer correctly?” This is a question from the Ages and Stages Questionnaire, a popular children’s developmental-screening tool.
Before our child’s three-year checkup, we were surprised to find this question on an intake form among the expected questions about things like talking, jumping and drawing.
Remi was assigned male at birth, which is to say he has typical male anatomy. He knows he has a penis and the correct word for it. He knows that some people have one, and others do not. He uses the words “man,” “woman,” “boy” and “girl,” mostly in a way that matches how people present. And when we asked him the question, Remi didn’t hesitate before answering, “I’m a girl.”
Did Remi answer correctly? The makers of the ASQ would say no, and that his answer should reduce his score in the “Personal-Social” area, potentially into a range where his pediatrician should provide “learning activities” or refer him for additional assessment with a professional.
We don’t interpret Remi’s answer that way. Gender is a complicated concept, and it’s easy to imagine that a three-year-old doesn’t fully understand it yet. We’re not even sure that we fully understand it. We know that sex and gender are different, but closely related. We appreciate that much of gender is performative, but also that it’s inborn and largely fixed. We doubt Remi understands much of this nuance, but surely he understands himself. The only person qualified to say that he gave the correct answer is Remi himself.
(Note: we use he/him pronouns to refer to Remi, as he has not expressed a preference for other ones.)
For me, the take-home message is that the questions I ask my patients and their families may bring unexpected answers that are much more complex and interesting than anticipated. I need to keep my ears and my mind open for the very telling information that they offer, even if it’s not what I thought I was asking for.
5 thoughts on ““Are You a Girl or a Boy?””
Thank you, Ronna, Nina and Laurice, for the kind words.
Muriel, I think the question is non-judgmental (archaic or out-dated? yes, but judgmental? no, I don’t think so); the question is phrased: “Using these exact words, ask your child, ‘Are you a girl or a boy?’ Does your child answer correctly?” The actual answer from this patient was much more interesting and telling than the expected answer…. and if I were “grading” this patient on his response, I would give him extra bonus points for his clear answer and deep understanding of the question, but again, this standardized questionnaire doesn’t allow me to do so. Thanks for your response.
Remi is blessed to have such a supportive physician and such loving , understanding parents.
How about rephrasing the question to “how do they answer?” Makes it non-judgmental.
I agree with the above comment. What a wonderful, nurturing family, and what an amazing, nurturing physician.
What a wonderful family this is, and thank you for considering the matter so thoughtfully. Given the high suicide rate amongst gender-diverse people, Remi is really lucky to have supportive and understanding parents and an open-minded medical practitioner to rely on as he develops into whoever he needs to be to be himself.