As your child reaches preschool age, his ability to understand more information naturally grows. If your child did not ask many questions when he was a toddler, he will most likely ask you many questions as he goes from age three to age six. Although preschool-aged children are able to take in more information than toddlers, they are still not yet able to fully understand all the details of their DSD. They can, however, begin to understand the ways in which they are similar and different from their peers (“peers” means children the same age as them), and they can begin to understand simple explanations about their DSD.

Preschool children continue to mature physically. Most learn to do things like run, jump around, ride a tricycle, and hang from the monkey bars. They begin to do things they could not do when they were younger, like fastening buttons and tying their shoes.

During the preschool years many children are better able to handle being away from their parents. Preschoolers have a better memory than toddlers, and a more mature sense of time that allows them to remember that you will eventually return to them after you go away. Your child, however, may sometimes seem to go backwards in terms of behavior, becoming clingy and having a hard time saying goodbye, especially when he or she is stressed. This behavior is common and usually temporary, and may have nothing to do with the DSD.

Children with DSD often have to go through things other children don’t, like extra medical exams or the challenges of learning that they were born with their genitals looking different from most other children. Because of this, their parents sometimes become over-protective and try to limit social opportunities for themselves or their child, so that the child will not be out of arm’s reach. In the short run, this may make the parent and child feel better. But in the long run, children and parents who do this wind up with fewer chances to practice being apart. This can accidentally make added stress for the parents and the child as the need arises to be apart.

If you find yourself in this situation, you might start with thinking about whether you are mostly protecting your child or yourself when you are avoiding social settings that might put your child out of your immediate reach. Remember that all children have to learn to be away from their parents sometimes. You might also think about how you can plan to have your child away from you once in a while in a “safe” zone—in other words, in a setting you feel comfortable with because you know and trust the other parents and children. Remember that you will not always be able to be in the same room as your child, so it helps to now start working on ways you can both feel okay when you are apart.

If your child is having trouble being apart from you, know that many parents say it is helpful to do things like assure your child that you will return, and follow a clear pattern. Work out a routine for comings and goings, and, if possible, use the same care giver for your child when you are away from him. That way your child learns to feel okay when you are away, and you become used to being apart, too.

As your children mature into the preschool years, their thinking abilities increase. Compared to toddlers, preschoolers begin to understand more, remember events better, and put things into categories. Preschoolers are able to start putting together the “big picture” by understanding the parts of the world and how they fit together.

Preschool children sometimes do not know the difference between their fantasies and reality. They may, for example, think that a grandparent who has died will come back to life, because that is what they want to have happen. As preschool children mature, they begin to understand the difference between fantasy and reality. Preschool children begin to move toward an understanding of how and why things happen (“cause and effect”). They also start being able to see the world from somebody else’s point of view. Up until this point, children see themselves as the center of the world and believe that everyone feels the same way they do. Mostly through play activities, preschool children may gradually start to see things from another person’s point of view.

Preschool children work on their language and work on communicating with others. They learn how to communicate their feelings with words. They will still often communicate through action (like by “acting out”) and their play. Preschool children often talk out loud to themselves.

Preschool children are usually very interested in developing friendships with other children. At this stage, they are busy trying to figure out what it is that is important when trying to make friends. As they learn what these things are, they are figuring out how to change how they act, so that other children will want to be friends with them. This leads to being cooperative, sharing, understanding others’ feelings, and solving fights or disagreements. It also sometimes leads to copying other children’s behaviors and interests.

Preschoolers obviously do not have perfect, rosy relationships with all of the other children they meet. Almost all preschoolers, at one time at another, will keep out another peer who wants to be involved. This happens in part because children of this age begin to think in categories. When preschool children realize that some of their peers are like them and some are different, they may see some children as being in a different category and use this as a reason to keep them out of the game. This can be very painful for the child who is excluded. At this stage, children are very sensitive to how they are viewed by their peers.

As your child’s friends and classmates grow better at using language, you may worry that they are going to use that language to hurt your child; you may worry your child will be teased because she has a DSD. The first thing to know about teasing is that teasing is a normal part of human life. Parents understandably want to protect their children from teasing, but it simply is not realistic to think you can save your child from ever being teased. Most children (if not all!) get teased and called names at some point. Sometimes your first reaction to hearing that your child was teased is to immediately say something to make your child try to feel better. But it is very important to listen to the fact that your child has been hurt and to let her know that you understand that she has been hurt. Trying to make the pain go away by telling your child “sticks and stones may break my bones, but names will never hurt me” denies the fact that she really has been hurt.

Even though it is difficult to see your child in pain, it helps to sit with her and allow her to tell you about what she’s feeling. It is also important to let her decide when the conversation is done. Do not rush her to feel better, and do not make her dwell on it once she seems done talking about it (even if you do not feel done).

So the way to respond to your child if she is teased is the same way that parents of any child should respond when their child’s feelings are hurt. Here is a possible response to a child who is feeling sad or angry because of teasing or name-calling:

Parents also say that it is sometimes helpful to give your child information about teasing. Some parents tell their children that teasing comes from people’s ignorance or meanness and does not have anything to do with the person who is being teased. Your child will also be helped if you let her know you will be there to support her and help her through any painful experiences she may encounter. Reassuring her that you love and appreciate her will also help.

Some parents talk to their children about what to do or say if someone teases them or calls them names. You can ask your child what she thinks she should say if someone ever teases her again in the future. It is often comforting for children to know how they will respond if a situation like that happens again. Children may not feel as powerless or helpless if they feel prepared to face a similar situation:

It is important to let your child say what she thinks would be best to say before suggesting your own response.

Howard Devore, Ph.D., and his parents

If your child’s genitals look or work differently from most other girls or boys, your child will notice this as he gets older. Many children play doctor or explore each other’s bodies during the preschool years. Through this type of common childhood exploration, some children with DSD will become aware that their genitals do not look or work the same as their same-gender peers. Even if your child does not notice how his genitals differ from other children at this age, it is important to begin to talk about anatomy (body parts) and how your child is different from the average.

Some children may feel anxious about how their genitals look or work. They may fear being rejected by friends and become very aware of how they are different. In this case, it is important to explain in simple language why your child’s genitals appear different. Confirm what he is seeing (by saying it back to him), and let him know you accept him as he is. For example:

Again, if your child has had genital surgery, now is a good time to talk simply and gently about the surgery. Tell the child the basics of why it was done (for example, “your pee-pee didn’t have a hole for pee to come out, so the doctor had to make a hole for you so your pee could come out”) and answer his or her questions about the surgery. You might use a doll or a stuffed animal to help explain what happened.

Many parents of children with DSD say that it was helpful for them, as their children asked questions, to use the pictures in Figure 5.1 “Genital Development Before Birth” and Figure 5.2 “Genital Variation”. You can explain to your child that the first picture in the Genital Development diagrams shows a fetus at six weeks, and also explain to her that everyone’s genitals, both boys and girls, look the same at this point in growth. Then you can point out the pictures below that illustrate the changes that happen as the fetus develops. You can tell your child that at this point her genitals began to form differently. It often helps children understand more if they can see a picture. You may be able to use the Genital Variation diagrams to show your child how his or her genitals looked at birth, or how they look now.

It is common for preschool children to ask a lot of questions about how bodies work. It is important to let your child know that it’s alright to ask questions. It is common for parents to feel uncomfortable talking about genitals, sex, or reproduction with their children. Some parents say that it is sometimes helpful to use a book when you talk to your child about sex. The resource section at the end of the book lists some suggestions. Although many people feel awkward when children ask questions relating to sex, parents say that with practice it becomes much easier. Again, try to answer the child in an honest way that is at his level:

Some preschool children will be satisfied with this answer while others will ask more questions. Remember to let your child guide the conversation and to answer honestly in a way that he can understand:

Do not be surprised if your preschool child asks whether he or she will ever be a parent. Whether or not individuals with DSD are able to have biological children depends on their particular condition and medical history. It also depends on what reproductive technologies will be available in the future, when your child is deciding whether to become a parent. Although some children may now be considered infertile because of their DSD, improved technologies may make it possible for them to become biological parents years down the road.

If infertility is likely to be an issue in your child’s case, it is never too early to be honest and begin to talk to him or her about other ways to be a parent. Again, be guided by what you think your child wants to know. And as you answer your child’s questions, remember that your relationship is an emotional one, and so it is not surprising that you may feel sad or protective as you talk. Think about your own feelings and work on answering your child with honesty:

When children reach preschool age they grow in terms of seeing themselves as being boys or girls, and they may begin to copy their same-gender parent. So girls will sometimes try to act like their mothers, and boys like their fathers. Children continue this process of what is called “gender role socialization” well into their teens. Gender role socialization happens when children notice the differences between how boys and girls, men and women, behave and are expected to behave. Preschoolers begin to notice what counts as “appropriate” behaviors for their gender. In general, during play, girls will find their way to role-playing relationships (like playing mother) and boys will find ways to manipulate objects (like playing with blocks). This is not to say that little boys don’t play with dolls or that girls aren’t rough and sporty at times. However, during the preschool years, many children want to act out, through their play, the gender roles that they are acquiring.

Even while your child is doing this category-sorting, it’s important for you to remember that there is a great range in boys and girls in terms of their behavior. Today, gender roles are much less strict than they were in the past. Girls can now engage in what were once considered boys’ activities (like contact sports) and boys can now engage in what were considered girls’ activities (like primary parenting). They can do this without having to suffer the same type of ridicule as they would have in the past. As has always been true, today children of both genders express a wide range of behaviors. Some girls are calm and quiet while others are lively and daring. Similarly, some boys are very thoughtful and watchful while others are aggressive and action-oriented.

It is important to avoid using negative gender reinforcement with your child; in other words, avoid telling your daughter “You’re acting like a boy!” or telling your son “You throw like a girl!” These kinds of negative reinforcements make children feel scared and anxious about who they are.

It is not uncommon for preschool children to play at being the other gender. So a little boy may dress up as a woman, or a little girl may announce that she is a boy. Just because your child does this may have nothing to do with the fact that she or he was born with a DSD. Many children without DSD do this at this age. Although we are not saying you should ignore how your child feels and behaves, we encourage you not to think gender is so simple that you can decide, based on just a few things your child says or does, that your child was assigned the “wrong” gender.

Peter Trinkl

Preschoolers also become curious about their own sexuality during this period of their childhood, although they do not have a word for that. They may discover their genitals as sources of pleasure. Touching and playing with one’s own genitals is common, natural, and healthy for children at this stage of development. Children should not be discouraged or punished for their interest in their own genitals, though it is helpful for them to learn the difference between private and public activities. If your child wants to play with his genitals, you can explain that it is okay for him to do this when he is having some quiet time alone. Parents may also use this opportunity to let children know they should tell their parents if other people touch their genitals. Because children with DSD often go through many genital exams, they may need extra teaching when it comes to learning to protect themselves from unwanted touching. Now and then, encourage your child to tell you if anyone touches him in a way that makes him feel uncomfortable. Try not to scare him about this, but do let him know his “private parts” are his own and are for his use, not someone else’s.