ternative gender, provided that it differs from the individual’s assigned gender. 
Gender dysphoria manifests itself differently in different age groups. Prepubertal natal
girls with gender dysphoria may express the wish  to be a boy, assert they are a boy, or as-
sert they will grow up to be a man. They prefer boys’ clothing and hairstyles, are often
perceived by strangers as boys, and may ask to be called by a boy’s na me. Usually, they dis-
play intense negative reactions to parental attempts to have them wear dresses or other
feminine attire. Some may refuse to attend sc hool or social events where such clothes are
required. These girls may demonstrate marked cr oss-gender identification in role-playing,
dreams, and fantasies. Contac t sports, rough-and-tumble pl ay, traditional boyhood games,
and boys as playmates are most often preferred. They show lit tle interest in stereotypically
feminine toys (e.g., dolls) or activities (e.g.,  feminine dress-up or role-play). Occasionally,
they refuse to urinate in a sitting position. Some natal girls may express a desire to have a
penis or claim to have a penis or that they will  grow one when older. They may also state that
they do not want to deve lop breasts or menstruate.
Prepubertal natal boys with gender dysphoria may express the wish to be a girl or as-
sert they are a girl or that they will grow up to be a woman. They have a preference for
dressing in girls’ or women’s clothes or ma y improvise clothing from available materials
(e.g., using towels, aprons, and scarves for lo ng hair or skirts). These children may role-