Newhook et al. (2018) have recently published a review in the International Journal of Transgenderism of the state of the research on “desistance”, the finding that a possible majority of children diagnosed with gender dysphoria will no longer be dysphoric by adolescence. The authors identify numerous issues with desistance-related studies published since 2008 and how these findings have been used to inform clinical care for trans and gender-nonconforming youth. Key points include:
- The importance of children’s self-reports of gender identity. The studies reviewed affirm that a child’s intensity of cross-gender identity is usefully predictive of the likelihood that their gender dysphoria will persist into adolescence:
Drummond et al. (2008) found that the two participants classified as gender dysphoric at follow-up “recalled significantly more crossgender identity and role behavior in childhood than participants classified as having no gender dysphoria” (p. 41). Wallien and Cohen-Kettenis (2008) reported that “all participants in the persistence group were given a complete GID diagnosis in childhood, whereas half of the group of desisting children was subthreshold for the diagnosis” (pp. 1420–1421). Finally, Steensma et al. (2013) reported that “explicitly asking children with GD with which sex they identify seems to be of great value in predicting a future outcome for [children diagnosed with gender dysphoria].” (p. 588). Both media and scientific discussion of this research have tended to downplay what is suggested here—the value of asking a child about their gender identity.
- The possibility that non-dysphoric youth were wrongly classified as trans youth who had “desisted”. Editions of the DSM prior to DSM-5 contained less stringent criteria for the diagnosis of gender identity disorder in children, whereas the DSM-5’s diagnosis of gender dysphoria requires identification with a gender other than one’s birth sex. Prior definitions may have inadvertently included children who displayed some gender non-conforming behaviors, but did not exhibit a cross-gender identity or persistent stress over their assigned sex:
Due to such shifting diagnostic categories and inclusion criteria over time, these studies included children who, by current DSM-5 standards, would not likely have been categorized as transgender (i.e., they would not meet the criteria for gender dysphoria) and therefore, it is not surprising that they would not identify as transgender at follow-up. Current criteria require identification with a gender other than what was assigned at birth, which was not a necessity in prior versions of the diagnosis. For example, in Drummond et al. (2008) study (Table 1), the sample consisted of many children diagnosed with GIDC, as defined in the DSM editions III, III-R, and IV (American Psychiatric Association, 1980, 1987, 1994). Yet the early GIDC category included a broad range of gender-nonconforming behaviors that children might display for a variety of reasons, and not necessarily because they identified as another gender. Evidence of the actual distress of gender dysphoria, defined as distress with physical sex characteristics or associated social gender roles (Fisk, 1973), was dropped as a requirement for GIDC diagnosis in the DSM-IV (American Psychiatric Association, 1994; Bradley et al., 1991). Moreover, it is often overlooked that 40% of the child participants did not even meet the then-current DSM-IV diagnostic criteria. The authors conceded: “…it is conceivable that the childhood criteria for GID may ‘scoop in’ girls who are at relatively low risk for adolescent/adult genderdysphoria” and that “40% of the girls were not judged to have met the complete DSM criteria for GID at the time of childhood assessment… it could be argued that if some of the girls were subthreshold for GID in childhood, then one might assume that they would not be at risk for GID in adolescence or adulthood” (p. 42). By not distinguishing between gender-nonconforming and transgender subjects, there emerges a significant risk of inflation when reporting that a large proportion of “transgender” children had desisted. As noted by Ehrensaft (2016) and Winters (2014), those young people who did not show indications of identifying as transgender as children would consequently not be expected to identify as transgender later, and hence in much public use of this data there has been a troubling overestimation of desistance.
- Inadequate timeframe of follow-up. The studies included in the review listed an average age at follow-up ranging from 16 to 23 years. This may fail to capture a large number of individuals who come out as trans at a later point in their life and would be wrongly classified as “desisting” in these studies:
As noted in Table 1, only a minority of the young people who consented to be re-studied were diagnosed in adolescence with gender identity disorder in adolescents or adults (GIDAA) and/or chose to undergo certain trans-affirming surgeries in early adulthood. Yet in these four studies (Table 1), the mean age at follow-up ranged from 16.04 (Steensma et al., 2013) to 23.2 years (Drummond et al., 2008) and included adolescents as young as 14 years (Steensma et al., 2011). It is important to acknowledge that this represents a very early follow-up point in an individual’s life, and that a trans person might assert or reassert their identity at any point in their life. An assumption has been made that young people not diagnosed with GID (or Gender Dysphoria in the current DSM-5) by late adolescence and/or not pursuing medical transition by a relatively early age, can then by default be “correctly” categorized as cisgender for their lifetime. However, this conclusion is contradicted when an unknown number of those counted as “desisters” may transition later, after the point of follow-up. Research has found that many trans-identified individuals come out or transition later in adulthood (Reed, Rhodes, Schofield, & Wylie, 2009).
- Classifying youth who do not return to a particular clinic by a given time as “desisters”. In multiple studies reviewed, those youth who did not participate at follow-up are assumed to be desisters who no longer identify as trans. This assumption is questionable for a number of reasons:
In other words, desistance was assessed based on whether or not participants re-engaged with this specific clinic by a specific time. This methodological choice neglects a number of important considerations: (1) the fact that not all transgender people wish to medically transition, yet still identify as trans; (2) the socio-economic or cultural factors that may influence whether an adolescent seeks psychological or medical treatment; (3) the possibility of a negative perception of the initial clinic experience, which might discourage a youth’s return; (4) the possibility of a youth moving out of the country, being institutionalized in a mental health facility or even the possibility of death (including suicide), none of which negate a trans identity; and, (5) the possibility that some young people might repress their gender identity for a period of time, due to societal transphobia, family rejection, safety, employment and housing security, or pressure from therapies designed to discourage trans identity (Kennedy & Hellen, 2010). The phenomenon of realizing one’s gender identity long before expressing it to others has been illustrated in the Trans PULSE study conducted in Ontario, Canada. While 59% of participants had socially transitioned within the four years prior to study, the majority of participants first realized that they were trans before the age of 10 years (Scheim & Bauer, 2015).
The authors continue and provide further criticism of the assumptions embedded in persistence and desistance research. Those interested can read the full review here. ■
