Gender dysphoria in children – replacing myth with fact, Part One


There is a widespread and pervasive myth that children are frequently being pushed into gender transition therapies. It’s a dangerous myth, because the pushback against it is contributing significantly to the problems that transgender youth have in actually getting appropriate, evidence-based support and therapy. Unfortunately, doctor and blogger Harriet Hall’s recent post Gender Dysphoria in Children appears to have been heavily influenced by this myth, with clumsily researched and pervasively scaremongering results.

There are a lot of highly misleading statements in the post that I’d like to debunk if possible. I’m realistic about my rate of blogging, however; if I get time to reply to other statements in her post then I will, but, for this post, I’m going to concentrate on the central myth here.

(Hat tip to FTB blogger Hj Hornbeck, who mentioned Hall’s post to FTB. His own reply to it is here, so do check that out as well, for a lot more information on the subject.)

I’m going to reply, here, to one particular quote from early in Hall’s post which is not in fact from Hall herself; it was a comment she found on this post. I chose this particular paragraph to reply to because I think it quite well encapsulates the groundless fears that swirl muddily around this topic. (Hall, unfortunately, seems to have chosen the quote so that she can echo these fears, rather than in order to examine them and see whether they’re actually justified.)

At about the age of 5, I was convinced I was a boy who had mistakenly been born in the body of a girl. This was in the 1950s, so there was never any discussion of my feelings, and obviously I never heard of “gender dysphoria.” By the time I was an adolescent, these feelings had disappeared. Parents who rush to allow children to “transition” when they are young may be harming their children more than if they just waited to see if the child still felt that way when they got a little older.

It’s not totally clear what this commenter thinks would have happened if she had attended one of today’s gender dysphoria clinics; in fact, I suspect the commenter isn’t clear herself on what she thinks would have happened. However, she does clearly have some kind of significant concern about the possibility that she would somehow have ended up rushing, or even being rushed, into an overly hasty decision to transition that would have then turned out to be the wrong decision for her. And this is the concern that normally comes up in these discussions.

So let’s look at what actually does happen.

Let’s imagine for a moment that gender identity and gender dysphoria research had been seventy years ahead of where it actually was, so that the guidelines and clinics we have today were available in the ’50s. Let’s imagine that this woman’s feelings about her gender, back when she was 5, had led to her referral to the kind of gender identity clinic that’s available to transgender people now, where she could have been assessed and managed under the guidelines that exist for children with gender dysphoria in the present day. What could we expect her experience there to be?

To answer this, I turned to the international guidelines on gender dysphoria management; the World Professional Association for Transgender Health’s Standards of Care. They can be downloaded for free here; the sections which I drew on for this post are on pages 14 to 19. My other main source was the study Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study (Steensma et al., Clinical Child Psychology and Psychiatry, 2011; 16(4): 499 – 516). This is a key study on the topic of children who do lose their initial ‘wrong gender’ feelings after childhood, and factors that differentiate them from children with gender dysphoria that persists into adulthood. The abstract is available online at that link; the full study can also be downloaded for free there.

Based on the above information, here is what actually would have happened for this commenter if she’d visited a well-run modern-day gender identity clinic in her childhood.

First of all, she’d have had the chance to meet with supporting and non-judgemental professionals who would have explored her feelings about gender with her, without trying to push her one way or the other. They’d have taken a full and detailed look at what was going on in her life generally; at how her family life, her school life, and her social life were going, and whether there were problems there. They’d assess her for signs of mental health problems such as depression or anxiety, and, if such were found, treat them appropriately. They’d have provided support for her and her family, as well as pointing her in the direction of other resources that could help.

They’d have discussed whether or not she wanted to try any parts of what’s known as ‘social transitioning’ – living as one gender without making any physical changes. For example, she might want to try having clothes, haircuts or toys that were traditionally viewed as ‘for boys’, or maybe even move on to being called by a boy’s name and/or referred to as ‘he’ instead of ‘she’. If so, there would have been some careful discussion of what implications this might have in terms of how other people would react and treat her, and it would also have been made clear to her that this was an experiment, not the start of an irreversible journey; if she tried these changes and found that they made her more uncomfortable rather than less, it would be absolutely fine for her to reverse them at any point. She might have been offered the option of trying these changes only on holiday, where it would be easy for her to stop them without pushback from people who knew her. Of course, on discussion it might have emerged that she didn’t feel comfortable with trying any of these changes; that would also have been fine. The goal over this time would be to help her explore her feelings about her gender in ways that would be fully reversible should those feelings change.

It’s not clear from her comment when her beliefs about having the wrong-gender body faded, although clearly it was at some point between age 5 and when she hit puberty. If those feelings did persist over the next few years, the clinic would have been particularly on the lookout for how she reacted to the run-up to/early stages of puberty. This is because, in the Steensma et al study I linked to above, this showed up as the stage that differentiated persisters (those children whose gender dysphoria feelings continued) from desisters (those children who grew out of them). Desisters reported that, during this stage, they found themselves coming more to terms with their bodies, and that pubertal changes were, overall, a positive factor that helped reconcile them with the idea of being their birth gender. Persisters reported the exact opposite; their feelings of gender dysphoria became much stronger, and pubertal changes were extremely distressing for them.

This woman, of course, was clearly a desister. From her wording (‘By the time I was an adolescent, these feelings had disappeared’), it sounds as though, in her case, the initial feelings of gender dysphoria faded before she reached puberty. When that happened, her family would have been able simply to discharge her from the clinic.

That’s it. That’s what would have happened. That’s what happens to children today who are referred to gender identity clinics with feelings that turn out to be temporary; they get to talk those feelings over with supportive and non-judgemental medical professionals who also do their best to find out about any other problems in the child’s life that may need help, they’re supported in reversible ways of experimenting with gender identity if and only if they so wish, and they can stop follow-up whenever they feel the feelings have faded.

All this business about letting children wait a bit longer/not rushing them into transitioning/being aware they might feel differently as they get older? These are not mysterious extraordinary concepts that have somehow never occurred to the doctors who work in this field. These are fundamental principles of good care for children with gender dysphoria. This is what is already happening for children with gender dysphoria. So, when next you hear someone raising concern about how young children with gender dysphoria should be allowed to just wait a little longer, or whatever the concerned phrase is… then be aware that this is exactly what’s already happening.

Comments

  1. Siobhan says

    I’m glad you elaborated on the 80% desistance talking point. The vast majority of commentary relies on the assumption that this probability is random, scattershot, equally likely for all patients that enter into care. But the reaction to Tanner Stage 2 is a differentiating point which provides illustrative data. Once you’ve narrowed your focus to people who experience elevated distress to puberty, rates of regret drop to 0%, because the outcome to Stage 2 is actually predictive.

    Of course, most of this is about profiting off a moral panic, not seriously assessing the research.

    • Dr Sarah says

      @Siobhan: Also, as you probably know, the other important differentiating point that came up in the Steensma et al research was that the desisters typically described their childhood gender non-conformity as wishing they were the gender that didn’t match their birth gender, while the persisters typically described their experience as feeling they were the other gender. I believe this is now part of the DSM criteria.

      Of course, most of this is about profiting off a moral panic, not seriously assessing the research.

      While writing this post, I came across a post on a Christian apologetics blog about how gay/transgender issues had to be their line in the sand, because if they agreed that transgenderism existed and was a problem then that would mean that the ‘male and female created he them’ line in Genesis was wrong and that would mean that their Bible wasn’t true and… Seriously, this was the hill that blog author wanted to die on. It really brought it home what’s behind the propaganda (not that I didn’t realise there were huge religious motivations involved, but this really brought the point home.) I mean, I know that most of the people who believe this stuff have just read the myths, honestly believe that there’s a problem with people trying to rush children into transitioning, and are genuinely if misguidedly concerned… but this sort of religious extremism and literalism is where the propaganda originates.

  2. Hj Hornbeck says

    All this business about letting children wait a bit longer/not rushing them into transitioning/being aware they might feel differently as they get older? These are not mysterious extraordinary concepts that have somehow never occurred to the doctors who work in this field. These are fundamental principles of good care for children with gender dysphoria. This is what is already happening for children with gender dysphoria.

    That’s the part that floored me back then: Harriet Hall is a doctor, writing on Science-Based Medicine, and yet she doesn’t know the current treatment methodology?

    What’s bothering me now is that we’re the only two bloggers who’ve called her out on this. There are a number of commentors on her post who beat both of us to the punch, and deserve kudos for putting up with the flood of transphobia that appeared under it, but I have yet to see anything from bloggers associated with the skeptic community. Do they not read FtB, or know less about gender dysphoria than Dr. Hall, or don’t want to push back against a respected member of the community, or something else? Meanwhile, when I search “gender dysphoria skeptic” in Google Dr. Hall’s article is the first on the list. Her misinformation remains up, her credentials give it some weight, and her article will be used to harm people.

    • Dr Sarah says

      That’s the part that floored me back then: Harriet Hall is a doctor, writing on Science-Based Medicine, and yet she doesn’t know the current treatment methodology?

      That much is actually plausible – this isn’t at all Hall’s specialty, and, believe me, no doctor is going to know every protocol for every possible medical problem – but what she certainly should know is how to look into the matter properly. Or, at least, to stay the hell out of the subject if she doesn’t know much about it, rather than latching onto crank or extremist views.

      Although she’s superficially tried to cite comments from both sides, it’s in a way that doesn’t look as though she’s put any real effort into researching the matter, comparing evidence for each side, or weighing up who might be right. It’s an approach that makes her look more like a journalist in search of sensationalism than a medical professional actually trying to understand the evidence.

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