Dr. Stephen Levine and the Plot to Police America’s Gender (part 1)

In case after case, an anti-trans expert witness promotes the same baseless theory: permitting social transition for trans youth will prevent them from later adopting a cisgender identity. But his own sources reveal how implausible that is.

Zinnia JonesPsychiatrist Dr. Stephen Levine, chair of WPATH’s standards of care committee from 1997-98, has long been a preferred expert witness for state corrections departments defending against lawsuits from trans inmates seeking medical transition care. His evaluations of incarcerated trans patients nearly always recommend against surgical care, frequently contradicting the findings of other clinicians and unduly sexualizing trans women by terming their gender an expression of sexual fetishes. In the past few years, he’s also begun offering testimony in a number of cases involving trans youth and laws regarding their participation in school sports, use of their name and pronouns in schools, access to gender-affirming medical care, and protection from anti-trans conversion therapy.

In these cases, Levine repeatedly advances a tenuous chain of reasoning for why adults recognizing a trans child’s social transition by correctly gendering them is an actual act of harm to them, likely to influence the course of their gender identity development away from the cisgender outcome he considers more desirable – a form of unnecessary medical treatment enacted by unqualified faculty and others. He argues that the personal choice of social transition, the non-medical element of transgender expression such as adopting a certain name and pronouns, haircut, and style of presentation, is an essentially medical decision first requiring informed consent to be obtained. And in his estimation, truly informed consent – for so much as social transition only – could be impossible to obtain even from a child’s parents, or from an adult trans person themselves.

Levine consistently argues for a strictly medicalized regulatory regime of public gender identification and expression, under which parents may not even be able to “consent” to the act of not misgendering their own trans child, a 23-year-old trans woman living independently lacks the capacity to decide to present as a woman and pursue HRT, and a youth coach who allows a trans 6-year-old to play on the girls’ tee ball team is practicing medicine without a license. His model of requirements for transition would entail a far-reaching infringement on the basic civil liberties and free expression of not just trans and gender-questioning people, but any cis person who doesn’t want to ask us for a doctor’s note before calling us by our name. And his claim that social transition changes gender identification outcomes in trans youth is based entirely on his misunderstanding of statistical methodology and models used in his sources. Dr. Stephen Levine is wrong to make these substantially incorrect arguments repeatedly in his testimony, and anti-trans defendants should not rely on these arguments.

Levine’s “social transition causes persistence” argument and its recent legal appearances

Stephen Levine’s telling of this argument is similar in structure across its now-common occurrences, with large blocks of nearly identical text shared between affidavits. His expert affidavit in February 2020 in the case of Doe v. MMSD (pp. 24-27), involving schools maintaining privacy of trans children’s genders from their potentially unsupportive parents, features an early example of this claim:

In contrast, there is now data that suggests that a therapy that encourages social transition dramatically changes outcomes. A prominent group of authors has written that “The gender identity affirmed during puberty appears to predict the gender identity that will persist into adulthood.”(18) Similarly, a comparison of recent and older studies suggests that when an “affirming” methodology is used with children, a substantial proportion of children who would otherwise have desisted by adolescence—that is, achieved comfort identifying with their natal sex—instead persist in a transgender identity. (Zucker, Myth of Persistence, at 7.)(19)

Indeed, a review of multiple studies of children treated for gender dysphoria across the last three decades found that early social transition to living as the opposite sex severely reduces the likelihood that the child will revert to identifying with the child’s natal sex, at least in the case of boys. That is, while, as I review above, studies conducted before the widespread use of social transition for young children reported desistance rates in the range of 80-98%, a more recent study reported that fewer than 20% of boys who engaged in a partial or complete social transition before puberty had desisted when surveyed at age 15 or older. (Zucker, Myth of Persistence, at 7; Steensma (2013).)(20) Some vocal practitioners of prompt affirmation and social transition even claim that essentially no children who come to their clinics exhibiting gender dysphoria or cross-gender identification desist in that identification and return to a gender identity consistent with their biological sex.(21) This is a very large change as compared to the desistance rates documented apart from social transition. Some researchers who generally advocate prompt affirmation and social transition also acknowledge a causal connection between social transition and this change in outcomes.(22)

Accordingly, I agree with a noted researcher in the field who has written that social transition in children must be considered “a form of psychosocial treatment.” (Zucker, Debate, at 1.) . . . . In sum, therapy for young children that encourages transition cannot be considered to be neutral, but instead is an experimental procedure that has a high likelihood of changing the life path of the child, with highly unpredictable effects on mental and physical health, suicidality, and life expectancy. Claims that a civil right is at stake do not change the fact that what is proposed is a social and medical experiment. (Levine, Reflections, at 241.) Ethically, then, it should be undertaken only subject to standards, protocols, and reviews appropriate to such experimentation.

He goes on to make this same argument in several other cases:

  • His affidavit in Hecox v. Little in June 2020 (pp. 25-28) attempts to tie this into the question at hand of transgender participation in school sports: “In contrast, there is now data that suggests that a therapy that encourages social transition before or during puberty—which would include participation on athletic teams designated for the opposite sex—dramatically changes outcomes.”
  • In the case of Hennessy-Waller v. Snyder (pp. 23-26), a suit brought by trans adolescents against Arizona for Medicaid coverage of male chest reconstruction, Levine’s September 2020 declaration again made this argument.
  • Levine repeated this argument in April 2021 in Kadel v. Folwell (pp. 42-45), a case brought against North Carolina for exclusions of gender-affirming care from state employee health insurance plans.
  • In the case of Tingley v. Ferguson (pp. 29-33) against a Washington state law prohibiting anti-LGBT conversion therapy, Levine reiterated these claims in May 2021 and went on to call transitioning “conversion therapy”: “Given these facts, it is the cross-gender affirming methods endorsed by gender identity advocates that are changing the identity outcomes that would otherwise naturally result for the large majority of prepubertal children who suffer from gender dysphoria. It is thus these methods that could most properly be described as ‘conversion therapy.’” The plaintiff Tingley went on to argue (p. 5) that Levine’s testimony showed anti-gay conversion therapy could also be successful.
  • When Arkansas was sued over a law prohibiting gender-affirming medical care for minors in Brandt et al. v. Rutledge et al. (pp. 45-50), Levine made this argument again in July 2021, this time adding an offensive comparison of transitioning to Nazi crimes against humanity (p. 80): “Some of the most tragic chapters in the history of medicine include violations of informed consent and improper experimentation on patients using methods and procedures that have not been tested and validated by methodologically sound science. The infamous Tuskegee experimental studies, the Nazi and Imperial Japanese wartime experimental research on prisoners, the use of lobotomies, the recovered memory therapy movement, the ‘multiple personality disorder’ therapy movement, and the rebirthing therapy movement, all invite comparisons with what is happening to too many gender discordant children and adolescents.”
  • In B.P.J. v. West Virginia State Board of Education (pp. 46-48), a case brought against West Virginia’s ban on trans girls playing on girls’ sports teams in schools, Levine made this argument once again, concluding that social transition is tantamount to medical transition: “social transition cannot be considered or decided alone. Studies show that engaging in social transition starts a juvenile on a ‘conveyor belt’ path that almost inevitably leads to the administration of puberty blockers, which in turn almost inevitably leads to the administration of cross-sex hormones. The emergence of this well-documented path means that the implications of taking puberty blockers and cross-sex hormones must be taken into account even where ‘only’ social transition is being considered or requested by the child or family. As a result, there are a number of important ‘known risks’ associated with social transition.”

Levine also submitted essentially identical testimony to a March 2020 health committee hearing in the Pennsylvania House (pp. 27-31), and watered down his claims with several new caveats in an August 2020 response to Dr. Scott Leibowitz in Doe v. MMSD:

Dr. Leibowitz accuses me of confusing correlation with causation. (Leibowitz Aff. ¶ 23.) I do not. However, given the fact that the rapid spread of quickly “affirming” therapeutic practices has coincided with an extraordinarily sharp drop in “desistance” from gender dysphoria in children and adolescents (Levine Aff. ¶¶ 60-65), it is reasonable and appropriately cautious for the mental health professional to hypothesize that the adoption of a trans-sex identity by a child does indeed in many cases cause children to persist in a transgender identity on into young adulthood at least, rather than desisting. Guss et. al., whom I previously cited, take precisely this view, inquiring into the “effect of childhood social role transitioning on later persistence,” and speaking of the “possible impact of the social transition itself” on the child’s “gender identity or persistence.” Guss (2013). Other researchers in the field looking at the available data have likewise hypothesized a causal relationship. (Levine Aff. ¶ 65.)

However, his basic claim of causation has remained consistent: permitting or recognizing the social transition of a trans child makes it more likely for their gender and their dysphoria to persist into puberty and adulthood, when they would instead have later adopted a cisgender identity and resolved their dysphoria had they not socially transitioned as a child.

Levine cites a network of publications, all leading back to one source

Dr. Levine frequently refers in his testimony to “a prominent group of authors”, “a review of multiple studies”, and several supporting citations, giving the impression that his claim of causation enjoys broad endorsement as a phenomenon accepted by many others familiar with youth gender identity development. Yet each source echoing his claim ultimately refers back to one study. In Doe v. MMSD, Levine quotes those prominent authors, Guss et al. (2015), as saying:

The gender identity affirmed during puberty appears to predict the gender identity that will persist into adulthood. . . . Youth with persistent TNG [transgender, nonbinary, or gender-nonconforming] identity into adulthood . . . are more likely to have experienced social transition, such as using a different name . . . which is stereotypically associated with another gender at some point during childhood.

Guss et al., however, cite Steensma et al. (2013) in these statements. In Hennessy-Waller v. Snyder, Levine cited Zucker (2018) and claimed that “a comparison of recent and older studies suggests that when an ‘affirming’ methodology is used with children, a substantial proportion of children who would otherwise have desisted by adolescence — that is, achieved comfort identifying with their natal sex — instead persist in a transgender identity”. However, Zucker makes this prediction based on Steensma et al. (2013):

With the emergence in the last 10–15 years of a pre-pubertal gender social transition as a type of psychosocial treatment – initiated by parents on their own (without formal clinical consultation) or with the support/advice of professional input (e.g., Ehrensaft, 2014; Vanderburgh, 2009; Wong & Drake, 2017) – it is not clear if the desistance rates reported in the four core studies will be “replicated” in contemporary samples. Indeed, the data for birth-assigned males in Steensma et al. (2013a) already suggest this: of the 23 birth-assigned males classified as persisters, 10 (43%) had made a partial or complete social transition prior to puberty compared to only 2 (3.6%) of the 56 birth-assigned males classified as desisters. Thus, I would hypothesize that when more follow-up data of children who socially transition prior to puberty become available, the persistence rate will be extremely high.

And in B.P.J. v. West Virginia, Levine cites Singh et al. (2021), saying:

Another researcher observed that a partial or complete gender social transition prior to puberty “proved to be a unique predictor of persistence.” (Singh et al. 2021 at 14.)

But Singh et al. were also referring to Steensma et al. (2013):

From Wallien and Cohen-Kettenis (52) and Steensma et al. (51), one predictor of outcome, therefore, was the distinction between being threshold or subthreshold for the GID diagnosis in childhood. Dimensional measures of gender-variant behavior have also proven useful. In both Wallien and Cohen-Kettenis and Steensma et al., dimensional measures of sex-typed behavior in childhood also significantly discriminated between the persisters and desisters, with the former group having, on average, more severe gender-variant behavior at the time of the childhood assessment. Steensma et al. found two other predictors of persistence: boys who were assessed at an older age and boys who had made either a partial or complete gender “social transition” [see (68–70)]. . . . The study by Steensma et al. (51), which found the highest rate of persistence, included some patients who had made a partial or complete gender social transition prior to puberty and this variable proved to be a unique predictor of persistence (see the Introduction).

Levine consistently refers to this group of sources when making this claim of causation in testimony, acting as though he is citing four sources to support his argument when he is actually only citing one: Steensma et al. (2013).

Next: Part 2 – How Steensma et al. can’t support Levine’s claim that social transition causes persistence.

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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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