As anyone who has read much about the subject can attest, the discussion about kids with gender dysphoria — that is, discomfort with their body and the feeling that they should have been born the other sex, or that they are the other sex — can get extremely heated and tricky. Much of the controversy stems from questions of age: How young is too young to help a child socially transition — that is, to change their name and pronoun, and possibly the way they present themselves? To prescribe them cross-sex hormones to begin the process of physically transitioning?
For children with persistent gender dysphoria who are approaching adolescence, current best practice is to prescribe them so-called puberty blockers. Delaying the onset of puberty both forestalls the sometimes very uncomfortable experience of a child going through puberty in a body they aren’t comfortable in, and buys them and their families time to figure out what to do. Sometimes, this eventually leads to the prescription of cross-sex hormones, and sometimes it leads to surgery after that.
Some people, though, are arguing that kids — particularly those who have socially transitioned at a young age — shouldn’t have to wait that long. Recently in the Guardian, for example, Kate Lyons reported on the current state of this debate in Britain: specifically, whether children who identify as transgender should be given access to cross-sex hormones, or possibly even surgery, at younger ages than what is current practice.
“He had been on puberty blockers since the age of 9,” Helen Webberly, a general practitioner, told Lyons, discussing a 12-year-old patient to whom she prescribed cross-sex hormones. “He would have to now wait until 16 to get testosterone. This child has always been a boy, never worn a dress, always played with boys. He was so ready, his mates are starting puberty and he’s desperate to start puberty. I felt and the mother felt and the child felt it was the right time, so that child’s now on cross-sex hormones.” As the article explains, Britain’s National Health Service does have guidelines stating that cross-sex hormones shouldn’t be prescribed until age 16, but these guidelines only apply to public clinics — doctors in private practice, like Webberly, have a fair amount of leeway to take the approach they feel is best for their patients.
One doctor quoted near the top of the piece had some qualms with the idea of prescribing cross-sex hormones at a young age, though:
Dr James Barrett, a consultant psychiatrist at the Charing Cross clinic, the oldest gender identity service in the UK, said he had concerns about treating children with cross-sex hormones.
“If you wait until puberty has got a little way along, a fair proportion of the children change the clinical presentation and feel more like straightforward lesbian and gay kids,” said Barrett. “They don’t seek social role change any more and will end up with no need for lifelong medical intervention, surgery and with no loss of natural fertility should they want children.”
Here Barrett is referring to the so-called desistance literature, and another doctor sounds a similar note toward the bottom of the article. “Desistance,” in this context, means the tendency for gender dysphoria to resolve itself as a child gets older and older. All else being equal, this research suggests that the most likely outcome for a child with gender dysphoria is that they will grow up to be cisgender and gay or bisexual. Researchers don’t know why that is, but it appears that in some kids, nascent homo- or bisexuality manifests itself as gender dysphoria. In others, gender dysphoria can arise as a result of some sort of trauma or other unresolved psychological issue, and goes away either with time or counseling. And in still others, of course, it is a sign that the child will identify as transgender for their whole adult life. While the actual percentages vary from study to study, overall, it appears that about 80 percent of kids with gender dysphoria end up feeling okay, in the long run, with the bodies they were born into.
Desistance doesn’t even come up by name in the Guardian article, but it’s an absolutely vital concept. Anyone thinking or writing about trans kids, in fact, should be familiar with exactly what this body of research does and doesn’t say, and how it applies to the early, evolving science of helping kids with gender dysphoria feel better.
Part of problem is that some people don’t accept the desistance findings at all — they argue that the studies demonstrating high levels of desistance in gender-dysphoric kids are fatally flawed, and further that the very concept of desistance itself is really just a pretense for allowing bigots to deny the reality of trans people’s identities. This is understandable, in light of the very real discrimination trans people face every day and past misdeeds committed by the mental-health Establishment, but it’s also unfortunate: We can’t have an intelligent, informed discussion about these tricky issues if we’re going to ignore what is, at the moment, a solid scientific consensus.
So what does that consensus say, exactly? According to a very helpful January blog post from James Cantor, a sex researcher at the Centre for Addiction and Mental Health, or CAMH, in Toronto, there have been 11 studies, going back to 1972, examining the question of how often kids with gender dysphoria end up identifying as transgender in the long run. Given how far back these studies stretch, and how small several of them are, I’m going to focus on the two most recent studies, which together have a larger sample size than the rest of the literature combined. One, “Factors Associated With Desistance and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study,” was lead-authored by the gender-dysphoria specialist Thomas Steensma and published in 2013 in the Journal of the American Academy of Child and Adolescent Psychiatry. The other one, the clinical psychologist Devita Singh’s 2012 dissertation, is unpublished, but you can read it in PDF form here.
Both studies sought, among other things, to track down a bunch of people who were patients at gender-dysphoria clinics as children and/or adolescents to see whether they ended up identifying as trans in the long run. Steensma is affiliated with the Center of Expertise on Gender Dysphoria at VU University Medical Center, a famous gender clinic in Amsterdam that has pioneered progressive treatments for gender dysphoria, including the use of puberty blockers (the so-called “Dutch Protocol”), and he and his colleagues drew their sample from there, while Singh drew her sample from the Gender Identity Clinic at CAMH, where she did her dissertation research. (As Science of Us reported in February, the GIC was shuttered late last year and its director, the sex researcher and gender-dysphoria specialist Kenneth Zucker, fired, largely a result of false accusations leveled against him, after a lengthy campaign from a segment of LGBT activists who accused him — wrongly, in light of the available evidence — of harming his clients by practicing “conversion therapy” on them.)
The Amsterdam study reported on 127 adolescents, 79 of them boys, and found that 80 of those adolescents, or about two-thirds, had desisted — that is, now identified as cisgender — at the time of followup. Singh, meanwhile, found that of the 139 former GIC patients she got in touch with, all of them natal males (that is, born with a penis), 122, or 88 percent, had desisted.
And when you combine these two studies with the other, admittedly earlier and smaller ones Cantor lists, all of which find the same thing, the case grows even stronger. While the numbers vary from study to study, as you would expect to between research conducted at different times in different places, the basic storyline is always the same: If a kid has gender dysphoria, the most likely outcome is that he or she will grow up to be a cisgender, gay or bisexual adult.
If you accept the studies, that is. A lot of people don’t, and their critiques deserve to be heard. So let’s go through a couple of the most prominent ones.
Perhaps the meatiest criticism of these studies is the claim that they didn’t really examine kids who had gender dysphoria. Rather, some critics argue, the studies lumped in a bunch of kids who were merely gender nonconforming: girly boys and tomboyish girls who exhibited some behaviors stereotypically associated with the other sex, but who weren’t truly dysphoric in the sense of feeling unease with their body, stating a desire to be the other sex or an insistence that they are the other sex, or some combination of the above.
To see why this would matter, imagine I have a rather old-fashioned view of gender relations, and I see a little boy with long hair. “A boy with long hair? No way!” I say to myself, knowingly. “This kid must have gender dysphoria.” If I checked back in ten or 20 years, found that that kid identified as cisgender, and declared that Whoa, I guess he desisted, that would clearly be false: He never really had gender dysphoria in the first place.
This claim has been made many times about Zucker’s clinic — that he and his colleagues were “treating” kids not for gender dysphoria, but for gender nonconformity (think Robin Williams trying to teach Nathan Lane to walk like John Wayne in The Birdcage). Two smart trans writers and advocates, Brynn Tannehill and Julia Serano, have made this argument. In her Huffington Post article “The End of the Desistance Myth,” until recently (I’ll explain in a moment) Tannehill claimed that “when investigators reviewed the files of children admitted to CAHM, 72 percent of them never met the clinical criteria for juvenile gender dysphoria in the first place … 90 percent of the kids Dr. Zucker claimed to ‘cure’ were never transgender in the first place.”
And when I emailed Serano for the Zucker story, she made the same argument (as an aside, you should read her Daily Beast article about navigating the dating scene as a trans woman in San Francisco). I didn’t end up quoting from Serano’s response, but she posted it online afterward, and it reads, in part: “These children [at Zucker’s clinic] are not necessarily brought in for “gender dysphoria” but for gender non-conformity. I’ve already conceded (as most trans activists & advocates would), many of these gender non-conforming kids will not grow up to be cross-gender-identified.”
If Tannehill, Serano, and other critics of the desistance literature like Kristina Olson and Lily Durwood in Slate are correct and the kids at the GIC and the Amsterdam clinic were really just gender nonconforming — if they were little boys who liked to do ballet and play with dolls, for example, but didn’t otherwise express any discomfort with being boys — then these critics would be right to suspect that the desistance literature is misleading. It would be garbage-in, garbage-out thing: If you aren’t studying kids who really had gender dysphoria in the first place, your followup data about them isn’t going to tell you much.
But is that really what was happening? At the time of Singh’s dissertation and her subjects’ treatment at the GIC, gender dysphoria was captured by the DSM-IV entry for what was then called “gender identity disorder,” which has since been renamed, in the DSM-5, to the less pathologizing “gender dysphoria.” Singh notes that of the 139 participants she successfully contacted for followup, “88 (63.3%) met diagnostic criteria for GID in childhood and the remaining 51 (36.7%) were subthreshold for the diagnosis,” which is close to the 70 percent figure Zucker and his colleagues have noted when describing the GID’s patient population overall. (I Twitter DMed Tannehill to ask where she got her “72 percent” and “90 percent” numbers from. She said she was extrapolating from a set of 12 random patient charts examined during the investigation of Zucker’s clinic. But there’s no need to extrapolate like this, since we have the actual percentages for both Singh’s study and the broader patient population. Tannehill has since removed those figures from her article.)
In a short appendix starting on page 275, Singh helpfully includes the diagnostic criteria for this condition from the DSM-IV. It’s long, but worth reading in full:
A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex. AA In children, the disturbance is manifested by four (or more) of the following:
1. Repeatedly stated desire to be, or insistence that he or she is, the other sex.
2. In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing.
3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex.
4. Intense desire to participate in the stereotypical games and pastimes of the other sex.
5. Strong preference for playmates of the other sex.
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following: In boys: assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.
In girls: rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate or marked aversion toward normative female clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Some of the items listed above, of course, aren’t, on their own, a sign of gender dysphoria. If a little boy likes playing with little girls, that alone offers zero evidence he’s gender dysphoric. But the overall criteria are much more stringent than that, and include as a requirement “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” It’s hard to imagine a kid meeting all the necessary criteria in the DSM-IV and not “actually” being gender dysphoric, if the term is going to mean anything.
Since 63 percent of the subjects in Singh’s study met these criteria, this really wasn’t a sample of children who were “just” gender nonconforming. Plus, as Singh points out in her dissertation, there wasn’t even a statistically significant difference in the desistance rates between those who did and didn’t meet the criteria — subthreshold kids were just as likely to eventually identify as trans. In the Steensma study, meanwhile, about 70 percent of the patients got a GID diagnosis as kids. (In that sample, a GID diagnosis did predict persistence to a certain extent — an interesting, unexplained difference between the two sets of findings that may come down to cultural differences between the two countries and/or other factors.) Overall, however you slice it, both studies really did look at children who had legitimate gender dysphoria.
Tannehill also levels an important critique against the Steensma study in her HuffPo article: that the
80 24 subjects in that study who were lost to followup were counted by the researchers as having desisted from their gender dysphoria, despite the fact that the researchers couldn’t actually check because they were, well, lost to followup. She claims this artificially inflated the study’s reported desistance rate.
But the researchers explain exactly why they did this: “As the Amsterdam clinic is the only gender identity service in the Netherlands where psychological and medical treatment is offered to adolescents with GD, we assumed that for the 80 adolescents (56 boys and 24 girls), who did not return to the clinic, that their GD had desisted, and that they no longer had a desire for gender reassignment.” This isn’t a bulletproof assumption, of course — maybe some of those patients moved to another country, or something — but every research article involves approximations, and it would be hard to come up with a storyline in which this group had enough persisters in it to nudge the overall numbers all that much. (Update: The truth here is actually a bit more complicated. The researchers were able to get in touch with 56 of the 80 kids who stopped coming to the clinic, or their parents, and obtain enough information to determine whether they were still gender dysphoric. Either zero or one of them qualified as gender dysphoric at followup, depending on the scale used. I’ve posted an in-the-weeds explanation here, but the key takeaway is that it’s accurate to say that 24 lost-to-followup kids were assumed to no longer have dysphoria without the researchers knowing for sure, not 80 as Serano and I initially reported — this research is stronger than I initially presented it to be. This was my mistake for not reading the study more carefully.)
Again: Every study that has been conducted on this has found the same thing. At the moment there is strong evidence that even many children with rather severe gender dysphoria will, in the long run, shed it and come to feel comfortable with the bodies they were born with. The critiques of the desistance literature presented by Tannehill, Serano, Olson and Durwood, and others don’t come close to debunking what is a small but rather solid, strikingly consistent body of research.
That said, it’s completely understandable why the concept of desistance makes some trans people as well as some of their allies uncomfortable. A huge part of the challenge of being transgender, after all, is having your identity — your very sense of self — endlessly, exhaustingly critiqued, invalidated, and disregarded by people who couldn’t possibly understand where you’re coming from. In addition to the well-established threats they face in the form of physical violence and legislation aimed at ostracizing them, trans people are constantly dealing with the psychological threat of being told that they aren’t really what they say they are, that they’re just crazy or broken or delusional.
So when they and their allies encounter claims that many gender-dysphoric kids aren’t really trans, or won’t be in the long run, they hear in those claims some loud and uncomfortable echoes. And the fact that these claims often come from the psychiatric Establishment, which does not have a good track record when it comes to treatment of sexual minorities, only exacerbates matters: Why should trans people trust institutions that have treated them so poorly over the years?
There aren’t really any good answer to these questions — how can you begrudge anyone whose very identity is at stake their suspicion or their unease? All we can do is look at and closely critique the most recent studies that have been done on this subject. And those studies continue to find what has always been found: There is something about the complexities of kids’ identity formation — both their gender identity and their nascent sexuality — that makes this stuff really, really complicated. If a kid is gender dysphoric, it may or may not mean that they will grow up to be trans. To say so isn’t to indict trans people, and anyone who uses the desistance data as a cudgel against them is missing the point entirely: Adolescents and kids are different from adults in vital ways. We recognize this in every other conversation about human behavior, and we should recognize it here.
It’s worth pointing out that the desistance percentages may change over time. As I noted in my GIC article, more and more clinicians are embracing what is known as the “gender-affirming” approach. In this model, if young children’s claims about their gender identity are “insistent, persistent, and consistent,” these claims are taken as face-value evidence that the child is actually trans, and should be socially transitioned with little delay. Zucker and his colleagues’ view was that since, in their theoretical model at least, gender is partly a matter of behavior and identity being learned and reinforced over time, socially transitioning a young kid is likely to reinforce their dysphoria. “I have predicted that we would see rates of persistence increasing overtime as more children engage in social transitioning in childhood,” Singh told me in an email. In other words, if kids who begin socially transitioning shortly after their first appointment at a gender-affirming clinic are more likely to persist and come to permanently identify as trans, and more and more gender-dysphoric kids find their ways into these clinics, the overall desistance rate may well drop over time.
In the long run, we’ll be better at this stuff — we’ll be better at understanding how to best help gender-dysphoric kids grow up to be confident, happy adults, whether they end up trans or cis, gay or straight or bi. The Steensma and Singh studies, for example, both provide early evidence that the severity of a child’s gender dysphoria predicts the likelihood they’ll identify as trans in the long run. But it’s a probability thing — it can simultaneously be true that severe dysphoria makes it more likely that a kid will end up identifying as trans, but also that many kids who are very dysphoric do desist in the long run. “Some of the children who desisted were just as extreme [in their gender dysphoria] as some of the children who persisted,” Singh said, referring to her dissertation.
But cycling back to the questions raised in the Guardian article and in this discussion overall — when should kids be put on hormones? How young is too young for surgery? — given the scientific uncertainty at the moment, it’s vital children be asked thoughtful, respectful questions about why they feel the way they do, that clinicians understand that gender dysphoria can mean any number of different things. “What’s happening is our society is moving faster than the evidence base,” one expert told Lyons, and it’s a sentiment worth keeping in mind.
Childhood gender dysphoria, in short, is complicated and deserves a nuanced public conversation. The increasingly popular belief that gender dysphoria must mean a child will identify as trans in the long run has the opposite effect: It renders a complicated subject simple; it makes it harder to ask the questions that need to be asked. That doesn’t help anyone.