When “desisters” aren’t: De-desistance in childhood and adolescent gender dysphoria

The progression of childhood gender dysphoria has historically been characterized by two known developmental pathways: persistence, in which dysphoria and cross-gender identification continue into adolescence and typically lead to social and medical transition, and desistance, in which the dysphoria abates and adolescents go on to identify and live as their assigned gender. While studies have found that anywhere from 2-27% of children diagnosed with gender dysphoria will persist in feeling dysphoric (Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013), these findings have crucial limitations and have been widely misconstrued in the public discourse.

One issue is that until recently, diagnoses of gender identity disorder in childhood were made using criteria in the DSM-IV and earlier editions. These criteria were so broad that they allowed for gender-nonconforming children to be diagnosed with childhood gender identity disorder even when they did not identify with another gender or want to live as another gender. For that reason, most samples of “gender-dysphoric children” likely included large numbers of children who did not actually experience gender dysphoria in the first place – meaning that their dysphoria did not “desist” at adolescence, but rather was never present. Regarding changes from the DSM-IV-TR to the DSM-5, the American Psychiatric Association has stated:

For children, Criterion A1 (“a strong desire to be of the other gender or an insistence that he or she is the other gender . . .)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conservative.

Steensma & Cohen-Kettenis (2015) further noted:

What should be emphasized is that these studies did not use the fairly strict criteria of the DSM-5, and children could receive the diagnosis based only on gender-variant behavior. With DSM-5 criteria, the persistence rate probably would have been higher.

Additionally, there is a tendency among the public to misunderstand claims such as “80% of gender-dysphoric children will desist in their dysphoria at adolescence” (already called into question by the aforementioned diagnostic issues) as meaning that any individual child with gender dysphoria can, all else being equal, be assumed to have an 80% likelihood of desisting. But these are two distinct claims, and the latter claim does not accurately represent what is known about the developmental course of childhood and adolescent gender dysphoria.

In recent years, the specific factors associated with persistence or desistance of childhood gender dysphoria have been studied in increasing detail. Steensma, Biemond, de Boer, & Cohen-Kettenis (2011) identified a number of key differences between those whose dysphoria persisted or desisted after childhood, including strength of identification as another gender and desire for a different sexed body configuration:

Although both persisters and desisters reported cross-gender identification, their underlying motives appeared to be different. The persisters explicitly indicated they felt they were the other sex, the desisters indicated that they identified as a girlish boy or a boyish girl who only wished they were the other sex. . . .

With regard to body satisfaction, both the persisters and desisters indicated that, around the age of 5, they rarely experienced hatred or aversion towards their own bodies. Only later on they did start to feel more uncomfortable with their bodies. A marked difference between the reports of persisters and desisters was that the persisters reported that the discomfort was caused by the fact that their bodies did not conform to their feelings, whereas the desisters did not report this. The persisting girls reported primarily desiring a penis, the persisting boys in contrast wished to get rid of their penis.

Steensma et al. (2013) summarized the current findings on associations between gender-related traits in childhood and the likelihood of persistence of gender dysphoria into adolescence, noting that more prominent symptoms of dysphoria and cross-gender behavior were associated with greater persistence:

Prospectively, 1 study by Wallien and Cohen-Kettenis, reporting on the outcome in adolescence and early adulthood for 77 clinically referred children with GD (21 persisters and 56 desisters), found that the percentage of a complete childhood GID diagnosis was higher for children with persisting GD than for children with desisting GD. Furthermore, compared to the desisters, the persisters showed more gender-variant behavior and a higher intensity of GD in childhood. In line with these findings, Drummond et al. showed that girls with persisting GD recalled significantly more gender-variant behavior and GD during childhood than the girls classified as having desisting GD. More recently, another study by Singh in 139 natal boys with GD confirmed the link between the intensity of childhood GD and adolescent and adult persistence of GD.

The study went on to confirm that intensity of gender dysphoria in childhood, explicitly verbalized cross-gender identification, and socially transitioning in childhood were all associated with a greater likelihood of persistence into adolescence.

In light of these numerous factors known to be linked to persistence or desistance, it is not accurate to conceptualize “gender-dysphoric children” as a homogeneous group where any given member has a roughly 80% likelihood of desisting in their dysphoria. Instead, an individual member of this combined group should instead be understood as either falling into one group that is very unlikely to persist, or falling into another group that is very likely to persist.

Nonetheless, one very persistent phenomenon is the continued prevalence of bombastic claims in the media and by many uninformed individuals that gender-dysphoric adolescents are ultimately likely to be cis and gay, and will likely regret transitioning, with allegedly catastrophic consequences ranging from regret to detransition to suicide. These claims are utterly unsupported by evidence. In present diagnostic processes, gender-dysphoric children are allowed to experience the initial stages of their natal puberty, as their response to this and presence or absence of distress is taken as indicative of whether they should go on to receive puberty blockers (de Vries & Cohen-Kettenis, 2012). There are no reports in medical literature of consistent regret among any individuals who transitioned in adolescence, and one report of an adolescent who was illicitly given estrogen by a family member without any medical supervision and now regrets this.

However, one phenomenon of gender identity development in youth is far more substantiated than these concerns about transition regret, while receiving far less attention: cases of de-desistance (or “re-persistence”). These youth express gender dysphoria in their childhood, report that their dysphoria desists in adolescence, but later find that their dysphoria has not desisted and go on to seek out transition treatment. At least 7 of these cases are known to have been reported in the medical literature and in the media.

Zucker & Bradley (1995, p. 292) include one case report of an adolescent trans girl who initially went to their clinic in Toronto at age 10 and claimed to have desisted at age 15, later returning at 16 to explain that she had lied about desisting because of embarrassment and now wanted to transition:

José was initially assessed at age 10 (IQ = 104). Although he [sic] did not meet the full DSM-III criteria for gender identity disorder, he was markedly cross-gender-identified. He had been referred by school authorities because of his effeminacy and the attendant social ostracism that he experienced. His parents, who did not speak English, denied that he had any problems and refused to receive feedback. José was referred again by school authorities at age 13 because of similar concerns. At this time, both José and his parents were more receptive to receiving help, but they did not follow through. When José was seen for an initial follow-up at age 15, he reported no gender dysphoria and an exclusively heterosexual [gynephilic] orientation. He claimed that he had just been elected class president and that he had received A’s in his schoolwork; however, he could provide no documentation of these claims. A year later, José requested an interview. At that time, he was cross-dressing and passing socially as a female. He had dropped out of school and run away from home, and he was abusing recreational drugs and engaging in prostitution. He reported an exclusively homosexual [androphilic] orientation and urgently requested sex reassignment surgery. He stated that in the initial follow-up he had “lied” about his feelings because he had been “embarrassed.”

The Globe and Mail reported in 2016 that another trans girl attending Zucker and Bradley’s clinic first claimed to be male and gay at 13 after extensive pressure from clinicians to behave as male, and later came out as trans at 15, admitting to having concealed her true gender:

When Trish’s son was seven years old, he declared that God had made a mistake and he was meant to be a girl. He had always liked to dress up like his sisters in princess costumes and not shown much interest in traditional boy activities. “God doesn’t make mistakes,” his mom told him. “You are perfect.”

But his parents, who lived in Toronto, were worried about him, and after doing some research, they were referred to Dr. Zucker. They met with him four times, but never brought their son. They felt it wouldn’t be a good match, but they were reassured by what Dr. Zucker was telling them: Their son would likely grow up to be gay. Trish, who asked that her family not be identified, says Dr. Zucker told them “it was important to encourage our child to feel more comfortable with the gender matching their biology.” At the same time, Trish recalls, “we wanted our son to be a boy. So we jumped at any suggestion. … When we heard he is probably gay, you can’t imagine the relief we felt.”

By age 10, however, he was still struggling, so they returned to CAMH; this time, they didn’t see Dr. Zucker at the clinic, but went to see another clinician about their son’s anxiety. That clinician, they recall, consulted with Dr. Zucker. The advice they received was to normalize male behaviour and reduce female diversions. So they went home and removed the princess costumes and his father tried to interest him in karate.

Their son didn’t say much – he didn’t forcefully insist he was a girl – and his parents didn’t talk to him about it. Based on how they’d interpreted the advice at CAMH, they were worried about putting the idea in his head. But Trish would continue to find clothes hidden away. At night, her son would pull his hair out while he slept. Trish and her husband knew this couldn’t go on. At 13, when their son came out as gay, they thought, thankfully, that Dr. Zucker had been right.

A year later, their child told them what she had been feeling for years: She was transgender. This time, her parents took her to Toronto’s Hospital for Sick Children, where the truth spilled out and she was given hormone blockers to slow puberty.

She finally told them: “Every birthday, every time I blew out the candles, I wished to be a girl.” She admitted to hiding costumes and wigs so she wouldn’t get in “trouble,” and expressed anger that her parents had not asked her more about how she was feeling, and that they had waited so long to start the hormone treatment.

Most notably, Steensma & Cohen-Kettenis (2015) posited that these de-desisters could indeed constitute a third developmental pathway of childhood gender dysphoria. Out of the cohort of the first 150 children to attend their child and adolescent gender identity clinic, 40 went on to persist from childhood into adolescent gender dysphoria, while 110 initially appeared to desist. However, of those 110 apparent desisters, 5 re-entered the clinic at an average age of 24:

Four (3 natal males and 1 natal female) tried to live as gay or lesbian persons for a long time, and 1 natal male had autism spectrum disorder. He reported that he needed to solve other problems in his life before he could address his GD. The others reported not having any problems with being homosexual. Yet, after having intimate and sexual experiences with same (natal) sex partners, they came to realize that living as a homosexual person did not solve their feelings of GD, and they felt increasingly drawn toward transitioning. All also mentioned that they were somewhat hesitant to start invasive treatments, such as hormone therapy and surgeries.

The authors conclude:

The individuals with GD who were seen in childhood are still rather young. Studies encompassing much longer follow-up periods might show a prevalence higher than 16% if individuals with persistence-after-interruption are included.

Given these reports, it’s worth considering whether widespread notions that dysphoric children will become gay adolescents and adults may be harmful to these youth, placing inappropriate pressure on their development and understanding of their gender. It is disconcerting that hypothetical cases of transition regret among trans youth continue to receive outsized attention from the media and the public, even as actual observed cases of regret for not transitioning in adolescence appear to be far more common. ■

Have you regretted not transitioning earlier in life? Tell us about it in the comments!

References

• 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. [Abstract]
• 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. [Abstract]
• Steensma, T. D., & Cohen-Kettenis, P. T. (2015). More than two developmental pathways in children with gender dysphoria? Journal of the American Academy of Child & Adolescent Psychiatry, 54(2), 147–148. [Abstract] [Full text]
• Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 582–590. [Abstract]
• Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York, NY: Guilford. [Google Books]