“Conveyer belt” fallacy against youth transition is missing a crucial piece: all the off-ramps before transitioning

Zinnia JonesAnti-trans advocates have spent years attempting to popularize a folk notion of the process by which trans youth pursue transition, a dramatic picture that scarcely resembles the clinical reality of evaluation and possible treatment for transgender children and adolescents. In this telling, the protocol of GnRH agonists to reversibly delay puberty prior to any decision about HRT is little more than a formality, with puberty blockers actually serving as a “conveyor belt” that universally leads those who take them to continue on to cross-sex hormone therapy. Because of this alleged inevitability, the choice of whether to continue or discontinue transitioning is painted as no choice at all in practice. Arch-transphobe Paul McHugh has long promoted the inevitability argument:

The lack of data on gender dysphoria patients who have withdrawn from puberty-suppressing regimens and resumed normal development raises again the very important question of whether these treatments contribute to the persistence of gender dysphoria in patients who might otherwise have resolved their feelings of being the opposite sex. As noted above, most children who are diagnosed with gender dysphoria will eventually stop identifying as the opposite sex. The fact that cross-gender identification apparently persists for virtually all who undergo puberty suppression could indicate that these treatments increase the likelihood that the patients’ cross-gender identification will persist.

And a cursory search for “puberty” “conveyor belt” locates several representative examples of this widespread assertion:

Rather than helping children embrace their bodily sex – male or female, many hospitals, doctors and therapists have shifted toward helping children “transition” to living as the opposite sex. In the process, they’re placing these children on a fast-moving conveyor belt toward dangerous and life-altering drugs, hormones and surgeries. . . . Cretella said that in the one study where children were first socially transitioned and then placed on puberty blockers – as is CHLA’s general practice – “100% went on to request cross-sex hormones.” (Focus on the Family, 2019)

She argued that when she entered their care as a gender-dysphoric young woman who had become convinced that she should have been born a boy, the service should have challenged her more. Instead, she stepped onto a conveyor belt of “affirmation” that led to puberty suppressants, cross-sex hormones, and ultimately a double mastectomy. All this she regrets. . . . Here is Transgender Trend on the court findings: “Puberty blockers are not ‘fully reversible’. Puberty blockers do not ‘buy time’, they are the first stage of a medical pathway very few children come off. (Caroline Ffiske, 2020)

For one, it would have made it difficult for GIDS to maintain the delusion that puberty blockers and cross-sex hormones are separate treatments. . . . It is rather harder to defend that claim when 98 per cent of those mentioned in this latest study remained on a conveyor belt from one to the other. (Debbie Hayton, 2020)

The specific assertion that use of puberty blockers by gender-questioning trans youth universally leads to transition has bled over into broader accusations of haste and heedlessness on the part of clinicians evaluating even very young children. These supposedly irresponsible clinicians have allegedly taken the slightest hint of gender-nonconforming behavior by cisgender youth as a sure indication of transgender identity, with misdiagnosis and transition treatment following soon after – simply an extension of the same conveyor belt, with cisgender children needlessly transitioning en masse under the inadequate and harmful stewardship of gender clinics.

We do not live in that reality. The fundamental claim that puberty blockers for trans and gender-questioning youth are always followed by progression to cross-sex hormones is false: one study found 3.5% of gender-questioning youth on puberty blockers chose to discontinue treatment without transitioning. It’s also a double bind: a large proportion of these youth continuing on to transition is taken as evidence of an uncritical “conveyor belt” protocol, yet if only a small proportion continued to transition, this would be taken as evidence of widespread misdiagnosis and ineptitude on the part of gender clinicians. And it makes an unfounded claim of causation: use of puberty blockers is asserted to cause these youth to progress to hormone therapy when they otherwise would not have. There is no known mechanism by which puberty blockers, also used in cis youth and adults for various conditions, have an effect on an individual’s gender identity. Such a claim neglects the far more plausible and obvious locations of cause and effect – use of puberty blockers and use of hormone therapy are both caused by these youth having correctly diagnosed gender dysphoria and requiring treatment for this condition. Progression from puberty blockers to hormone therapy can hardly be taken as evidence that these youth aren’t trans; if anything, it’s strongly indicative that they are.

The “conveyor belt” construct itself is deeply flawed in its claims, but equally notable is what this argument neglects to address: everything that does or doesn’t happen long before any trans or gender-questioning youth begin taking puberty blockers. And it couldn’t be further from the misleading depiction of a yet longer conveyor belt of immediate (mis)diagnosis of any girl who plays with trucks and any boy who picks up a Barbie.

Wagner et al. (2021) examined the health records from 2006 to 2014 of a cohort of 958 children who had exhibited gender-diverse behavior, quantifying how many of these gender-nonconforming youth went on to receive a diagnosis of gender dysphoria or begin medically transitioning. The “conveyor belt” prediction would estimate that this is approximately all of them. But it wasn’t: at an average followup time of 3 years, only 29% had received a diagnosis of gender dysphoria, and 25% had been prescribed puberty blockers and/or hormone therapy. Notably, even among those who were diagnosed with gender dysphoria, only 58% were recorded as having later received treatment with puberty blockers or hormones.

The breakdown by age also reflects what is already known about the disjunction of childhood gender dysphoria at the onset of puberty, which may manifest as either persistence of dysphoria into adolescence or the resolution of dysphoria (“desistance”). Compared to children whose gender-diverse behavior was first noted at 3-9 years, those aged 10-14 were 2 times as likely to receive a diagnosis of gender dysphoria, and those aged 15 and over were 2.7 times as likely to be diagnosed with gender dysphoria. Crucially, this does not support longer delays of transition treatment for transgender adolescents under the assumption that with time, they will become less likely to identify as trans or pursue transition. Instead, the opposite trend is seen: gender-diverse youth who present at older ages are more likely to be gender-dysphoric. These are the persisters.

The supposed “conveyor belt” is ultimately a much less frightening series of off-ramps. An outcome of not identifying as trans or transitioning is not some mere theoretical option never actually taken up by these youth – that is the outcome for the majority of gender-diverse youth of any age. This pours cold water on the flagrant leaps of reasoning offered by critics including Debra Soh, Julie Bindel, and J. K. Rowling, who are quite sure that any gender-nonconforming behaviors they exhibited in their childhood would nowadays have led to their misidentification as transgender. In depicting this as if it were a real risk, they propose certainty after certainty after certainty, with the likelihood of their inevitable transition standing undiminished at the conclusion. The reality is that for gender-diverse children, who are indeed mostly not trans, the likelihood of this outcome is dramatically pared down at every step.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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