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.

Fact-checking transgender treatment myths, Part 2 – the David Reimer fallacy

In my last post, while discussing an inaccurate claim about transgender treatment recently made by Lenny Esposito on the Come Reason blog, I promised to come back to his past post Today’s Snake Oil Includes A Scalpel: The Damaging Treatment of Transgenderism for some much-needed fact-checking. In that post, Esposito claims that gender reassignment therapy is ‘a dangerous falsehood that many times proves deadly to the patients that should have been helped’, and goes on to cite various pieces of evidence to make a superficially convincing case for this claim. However, this is extremely misleading; Esposito’s post not only contains several significant errors and fallacies, it also ignores all the research that actually shows gender reassignment therapy to be beneficial overall for nearly all the people who opt for it. Some proper fact-checking is clearly sorely needed here and, with apologies for the delay in getting back to it, here we go.

There’s quite a bit in his post to discuss, so I plan to break it down into several short posts dealing with each point separately. First up, his discussion of David Reimer’s story.

[I]n 1967 he [Dr John Money] sought to change a two-year-old boy whose genitals had been damaged by a botched circumcision into a girl, reassuring the parents that the child would grow up never knowing the difference. But, as the Los Angeles Times reported, “the gender conversion was far from successful. Money’s experiment was a disaster for Reimer that created psychological scars he ultimately could not overcome.” David Reimer committed suicide at the age of 38.

While it’s not clear to what extent Reimer’s suicide was a response to his history of gender surgery and to what extent it was related to other significant problems in his very troubled life, there is no doubt at all that the gender conversion attempts performed on Reimer were, indeed, psychologically disastrous for him and contributed hugely to the distress in his life, and it is very likely that they played at minimum a significant role in his final tragic end. However, there’s a big problem with using that as an anti-gender reassignment argument: Reimer wasn’t transgender.

As Esposito himself states, Reimer was a boy who was reassigned to be raised as female after a badly botched circumcision operation destroyed his penis and John Money (who was hugely influenced by his wish to prove his particular theory about gender fluidity) convinced his family that raising him as a girl was the best way to salvage the matter. There were never any claims that Reimer was transgender. From a very early stage he clearly knew he was male and wanted to be male.

Now, of course, Reimer’s situation was unique and there are limits to how much of a conclusion we should draw from that one story; but it does strike me as notable that what we have in Reimer’s story is the story of a person being raised as female who knew all the time, on some level, that he should actually be male.  In other words, the experience that a transgender man [a person born into a female body but with an inner gender of male] grows up with. And he found it devastating and destroying. That really doesn’t strike me as a good argument for trying to convince someone who identifies with one gender that they’re actually the other.

Of course, I have little doubt that Esposito and his followers would argue that a transgender man’s experience of distress over growing up in the wrong body shouldn’t be treated in the same way because he isn’t ‘really’ a male (by which they would mean that he’s not chromosomally male, or possibly that he wasn’t born with a penis – I’m not quite sure what, specifically, their criterion is). But, whichever way you look at it, it strikes me as pretty illogical to take an example of someone who found it deeply distressing to grow up with an assigned gender that his own inner certainty was telling him to be wrong, who could not refuse his need to live as the gender that matched his inner knowledge of himself – and use that to bolster your claim that people who are deeply distressed at growing up with an assigned gender that their inner certainty tells them is wrong should not be allowed to live as the gender that matches their own inner knowledge of themselves.

Misinformation about gender reassignment therapy (part 1)

One topic that’s shown up on Christian blogs a lot lately (because it’s been in the mainstream news a lot lately) is that of transgender people and gender reassignment surgery. I’ve been reading a lot of dubious claims from these sorts of articles, which have been ringing my Fact Check Alert bell big-time. I don’t know a great deal about transgender issues, but, as a GP, I do know that medical opinion supports the availability of gender reassignment as a treatment for gender dysphoria. So, when non-medical groups with a heavy religious-based agenda in the matter try to claim that gender reassignment is bad for transgender people and we should be banning it in their interests, that rings alarm bells for me and I want to look at the evidence.

The latest such post that I saw was Bloodletting and the Modern Trans Movement, on the Come Reason blog by Lenny Esposito. Esposito argues that because doctors once used to believe in treatments such as bloodletting which are now discredited we should therefore assume that medical advice to provide gender reassignment therapy for transgender people is similarly incorrect. Or something like that, anyway. That of course is just a logical fallacy (by the way, if anyone knows the official name for that logical fallacy feel free to shout out – I don’t keep track of logical fallacy names myself) but the bit that hit my Fact Check Alert button in this post was this:

I’ve pointed out before how we have fifty years of data under our collective medical belts on gender reassignment surgery and we know that the suicide rate for those suffering from gender dysphoria is as high after sexual reassignment surgery (SRS) as it is prior to transitioning.

The link Esposito gave there is to a post he wrote last year titled Today’s Snake Oil Includes a Scalpel: The Damaging Treatment of Transgenderism, which rang my Fact Check Alert bell several more times and needs a post or several of its own to discuss, which I fully plan to do. In the interest of speed and clarity, I’m going to leave that to further posts rather than try to cover everything here. What it did not do, even with the cherry-picked and misleading evidence it cites, was support Esposito’s statement that suicide rates are as high after gender reassignment therapy as before. The post cited one study showing much higher suicide rates among transgender people post-reassignment than in the general population (though without pointing out that these high suicide rates were seen a few decades ago when anti-transgender bias was worse than it is now, and that they don’t show up in recent years), but nothing comparing rates of suicide in transgender people pre- and post-gender reassignment. So, whatever Esposito may have convinced himself he ‘knows’, he hasn’t in fact demonstrated anything of the kind.

So, I did a bit of digging around to see whether any such statistics do exist, and, as far as I can find out, they don’t. I did find this report on rates of suicide attempts in the transgender population overall, which is frightening; transgender people were almost ten times as likely as the general population to have attempted suicide at some point. Not surprisingly, this was strongly linked with experience of discrimination, bullying, rejection by family, or even outright violence, making it clear that, for those of us concerned about suicide risk among transgender people, one of the most important things we can do is to work to increase transgender acceptance. (Which, frankly, doesn’t seem to be a strong point among conservative Christians such as Esposito.) And this article cited studies also indicating markedly increased suicide rates in the transgender population (and, again, cited evidence that showed this to be linked to experiences of discrimination and family rejection).

However, I couldn’t find anything giving comparative figures for suicide rates, or suicide attempt rates, in pre-transition and post-transition transgender people. Which isn’t too surprising, by the way, since it’s the sort of question on which it’s hard to get data; but it does mean that it is not correct to state that we ‘know’ the suicide rates to be as high after gender reassignment as before. We know nothing of the kind.

So what information is available on how gender reassignment affects transgender people? Looking, I found this article reviewing the existing evidence as to how gender reassignment affects the mental health and quality of life of transgender people overall. According to the abstract, the authors of this summary found 28 studies that followed transgender people through gender reassignment therapy (surgical and/or hormonal) comparing their mental health after the procedure with before. What they found was that, psychologically, the majority of people were better off after gender reassigment.

Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%).

So, no matter how hard conservative religious groups or other anti-transgender groups try to spin evidence to make it look as though it supports their cause, the evidence is in fact that the best thing to do to help transgender people is a) to eliminate prejudice and discrimination against them, and b) to make gender reassignment available for those who, after counselling, want it.