Debunking hypothetical arguments about youth transition (Gender Analysis)

Previously: Transgender youth fact check

There’s a particular genre of opinion piece that erroneously portrays the early treatment of children and adolescents with gender dysphoria as being subject to overdiagnosis, as forcing potentially-cisgender children to “become” inevitably transgender, or as serving as some kind of “reparative therapy” targeting gender-nonconforming gays and lesbians. These articles have been penned by feminist commentators like Julie Bindel and Sarah Ditum, and even other popular figures like actor Rupert Everett. A column by Bindel in the Daily Mail earlier this year is a representative example:

When I was growing up as a girl in the Seventies, I wanted to be a boy. It wasn’t simply that I knew I was sexually attracted to women – much more importantly, I looked around and saw boys had more power, more freedom, more fun. Of course I wanted to be a boy.

If I were a teenager today, well-meaning liberal teachers and social workers would probably tell me that I was trapped in the wrong body. They might refer me to a psychiatrist who would prescribe fistfuls of hormones and other drugs. And terrifyingly, I might easily be recommended for gender re-assignment surgery… just because I didn’t like the pink straitjacket imposed on girls.

… What is on offer is not support for a young lesbian, but the promise of a medical conversion. Any idea this is liberal, progressive behaviour is completely wrong. It pushes us back to the dark ages, to a time when lesbianism wasn’t even recognised.

And in the New Statesman, Sarah Ditum argued:

There’s a risk that increased medicalisation could be imposing permanent physical changes on children who, left to their own devices, would discover they are quite happy living with their natal sex – about 80 per cent of children diagnosed with gender dysphoria desist before adulthood, but the normalisation of medical transition could commit many to irrevocable treatments they would otherwise avoid.

Rupert Everett further hypothesized:

Everett, currently starring in the BBC1 show The Musketeers, told the Sunday Times magazine: “I really wanted to be a girl. Thank God the world of now wasn’t then, because I’d be on hormones and I’d be a woman. After I was 15 I never wanted to be a woman again.”

He believes parents who “get medical” are scary, saying: “It’s nice to be allowed to express yourself, but the hormone thing, very young, is a big step. I think a lot of children have an ambivalence when they’re very young to what sex they are or what they feel about everyone. And there should be a way of embracing it.”

These claims are sensationalized misrepresentations with no basis in fact. The current protocols for the use of puberty blockers in gender-questioning youth recognize all of these potential concerns and account for them effectively, exercising an abundance of caution in order to rule out the possibility of misdiagnosis.

Puberty blockers deliberately provide a lengthy period of time for the careful consideration of an individual’s gender identity and developmental course. These are long-acting injections or implants which temporarily prevent the development of the permanent physical changes that accompany puberty. This treatment does not have permanent effects – it is described as “completely reversible” in medical literature (de Vries & Cohen-Kettenis, 2012). Instead, this protocol delays puberty for a number of years while the child and medical professionals can consider whether more permanent transition treatments like hormone therapy or surgery are appropriate. A child or teenager has the option of discontinuing puberty blockers if they decide they don’t want to transition; their own puberty can then proceed as normal. Such cases have been described by pediatric endocrinologists (Shumer, Nokoff, & Spack, 2016):

A 12-year-old biologic male presented to the gender clinic after referral by a mental health professional. The child had been having dysphoric feelings about his male pubertal development, and was found to be at SMR rating 3. Treatment with a GnRH agonist was initiated. The child continued in therapy and by age 14 had developed a better understanding of their gender identity. The child accepts that they do not identify completely with a male or female gender identity, and begins to refer to themself as genderqueer. They prefer to be referred to using the them/they/their pronouns. After discussion with the family and mental health professional, the decision is made to withdraw the GnRH agonist medication and allow male puberty to progress with continued supportive counseling in place.

If this protocol really did inexorably guide every child into a more permanent medical transition, this period of extended consideration would not be standard clinical practice. This time specifically serves to identify those youth who will stop experiencing dysphoria and will not want to transition. While Julie Bindel and others may speculate at length about how they “might” have pursued a medical transition, there is every indication that even if they had ever received puberty blockers, they would have had ample opportunity to recognize that transitioning wasn’t what they wanted.

Contrary to these media depictions, puberty blockers and transition treatments are not delivered in a scattershot or reckless manner. While Ditum asserts that 80% of children with gender dysphoria will lose this dysphoria in adolescence, this isn’t simply a spin of the roulette wheel. During the extra time provided by puberty blockers, extended evaluations are conducted to observe the course of an adolescent’s gender identity development, reliably distinguishing those who will continue to experience dysphoria from those who will not (de Vries & Cohen-Kettenis, 2012):

During the diagnostic trajectory, information is obtained from both the adolescents and their parents to assess whether the adolescents meet the eligibility criteria. Therefore, first it is ascertained whether adolescents are suffering from a very early onset gender dysphoria that has increased around puberty, or whether something else brought them to the clinic (e.g., confusion about homosexuality or transvestic fetishism). About one quarter of the referrals in Amsterdam do not fulfill diagnostic criteria for GID and most of them drop out early in the diagnostic procedure for this reason or because other problems are prominent

There are various specific factors that are recognized as potentially related to an individual’s likelihood to persist in experiencing dysphoria (Steensma, Biemond, de Bohr, & Cohen-Kettenis, 2011). These factors can be of diagnostic value during treatment:

Starting around the age of 10, and for the subsequent years, the persisters indicated that their cross-gender preferences and behaviour and their gender identity remained stable, but that their dysphoric feelings intensified. The intensification of gender dysphoria was attributed to three factors; (1) Certain changes in their social environment, (2) The anticipation of and/or actual physical changes during puberty, (3) The first experiences of falling in love and discovering their sexual orientation.

… In desisters, the gender discomfort gradually decreased over the course of grades 7 and 8 (age 10 to 13). Both boys and girls indicated that their changing interests and friendships, and the physical changes during puberty made the gender discomfort diminish and eventually disappear. The desisters also reported that their first experience of falling in love and awareness of sexual attraction were factors that resulted in the disappearance of their gender dysphoria.

One key component of this diagnostic process is that these youth are allowed to experience the earliest stages of their original puberty, which can be critical to their developing understanding of their gender (de Vries & Cohen-Kettenis, 2012):

If the eligibility criteria are met, gonadotropin releasing hormone analogues (GnRHa) to suppress puberty are prescribed when the youth has reached Tanner stage 2–3 of puberty (Delemarre-van de Waal & Cohen-Kettenis, 2006); this means that puberty has just begun. The reason for this is that we assume that experiencing one’s own puberty is diagnostically useful because right at the onset of puberty it becomes clear whether the gender dysphoria will desist or persist.

In effect, Bindel, Ditum, and others are baselessly criticizing these medical providers for supposedly failing to do something they have in fact been doing all along. Again, even if these individuals had undergone treatment with puberty blockers, this protocol would likely correctly determine that transitioning would not be appropriate for them.

It’s also unclear what alternative course these commentators would recommend. Non-affirming, non-accepting “treatment” of gender-questioning youth is not known to affect the likelihood that youth will continue to experience dysphoria into adolescence and adulthood (de Vries & Cohen-Kettenis, 2012):

There are, however, no controlled studies that have investigated psychological interventions aimed at influencing certain types of gender dysphoria. It remains for the most part unclear if “treated” children have been “cured” through interventions or just “grew out of” their gender variance.

Modern diagnostic criteria also make a clear distinction between clinically significant experiences of dysphoria, and a simple discomfort with cultural gender roles or desire for the social privileges afforded to another gender. The American Psychiatric Association’s DSM-5 (2013) states:

Gender dysphoria should be distinguished from simple nonconformity to stereotypical gender role behavior by the strong desire to be of another gender than the assigned one and by the extent and pervasiveness of gender-variant activities and interests. The diagnosis is not meant to merely describe nonconformity to stereotypical gender role behavior (e.g., “tomboyism” in girls, “girly-boy” behavior in boys, occasional cross-dressing in adult men). Given the increased openness of atypical gender expressions by individuals across the entire range of the transgender spectrum, it is important that the clinical diagnosis be limited to those individuals whose distress and impairment meet the specified criteria.

The APA’s DSM-IV-TR (2000) similarly specified as part of diagnostic criteria for gender identity disorder that individuals experience “A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex)”, and further explained:

Behavior in children that merely does not fit the cultural stereotype of masculinity or femininity should not be given the diagnosis unless the full syndrome is present, including marked distress or impairment.

Professional clinical guidelines for the diagnosis and treatment of gender dysphoria explicitly warn against misinterpreting gender nonconformity alone as an indication that dysphoria is present. The speculation that these treatments serve to target gender-nonconforming cisgender gays and lesbians is completely unfounded and contrary to modern medical practice.

Bindel and others imagine that they would have been guided toward transition if they were children today, and while this is vanishingly unlikely under current practices, suppose that all of these individuals ultimately did transition during puberty. What would the outcome be for them? Multiple studies have found no cases of persistent regret among youth who were treated with puberty blockers and later went on to transition (Cohen-Kettenis & van Goozen, 1997; de Vries et al., 2014). It’s also been found that after treatment, this group experiences psychiatric symptoms such as depression and anxiety at a rate no higher than that of their cisgender peers. These commentators must invent hypothetical cases of regret because of the lack of any actual cases of regret that would support their argument. But what is supposed to be regrettable about this outcome – that a happy and well-adjusted transgender person exists?

It’s also worth considering what gender-nonconforming youth did often experience in decades prior to the adoption of gender-affirming therapy. “Treatment” for these children and teenagers was known to include experimental behavior modification to train them in social gender stereotypes, use of antipsychotic drugs, institutionalization, and even electroconvulsive therapy (Burke, 1996). At times, gender identity diagnoses were deliberately misapplied to cisgender gay and lesbian youth – not to guide them toward transition, but to serve as a pretext for ineffective and harmful “reparative therapy” intended to change their sexual orientation. How are these treatments in any way preferable to the cautious protocol of using reversible puberty blockers as part of “watchful waiting”, an approach which is known to lead to positive and healthy outcomes?

Both historically and today, the idea that there exists some cultural norm of blindly pushing children toward transition – that adults would actually want a cisgender child to “become” transgender – is absurd. Transgender teenagers experience catastrophic rates of homelessness, precisely because they’ve been failed by their families, their schools, and other cultural institutions that should be protecting them (NHCHC, 2014). This fact-averse tabloid fearmongering over safe and effective medical treatment is a disservice to these already vulnerable youth. ■

References

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Burke, P. (1996). Gender shock: Exploding the myths of male and female. New York, NY: Anchor.
• Cohen-Kettenis, P. T., & van Goozen, S. H. (1997). Sex reassignment of adolescent transsexuals: a follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 36(2), 263–271.
• de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality, 59(3), 301–320.
• de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704.
• National Health Care for the Homeless Council. (2014). Gender Minority & Homelessness: Transgender Population. In Focus: A Quarterly Research Review of the National HCH Council, 3(1).
• Shumer, D. E., Nokoff, N. J., & Spack, N. P. (2016). Advances in the care of transgender children and adolescents. Advances in Pediatrics, 63(1), 79–102.
• Steensma, T. D., Biemond, R., de Boer, F., & Cohen-Kettenis, P. T. (2011). Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clinical Child Psychology and Psychiatry, 16(4), 499–516.

Further reading

• “Supporting & Caring for Transgender Children” by the Human Rights Campaign, American Academy of Pediatrics, and American College of Osteopathic Pediatricians (2016).
• “Gender Non-Conforming & Transgender Children” by the American Academy of Pediatrics (2015).
• Book review: “Becoming Nicole: The Transformation of an American Family” (2016).