How Transgender Children Are Made and Unmade

Note that the following post discusses the sensitive topic of conversion therapy for transgender children, along with mentions of outmoded terminology and psychodynamic models, ethically questionable studies and treatment practices, and links to some sources which may misgender or mislabel transgender people.

I have also added some clarifications to my final points on 12 May 2018.

Today, a friend pointed me to a news article out of the UK covering a new study by Newhook et al. released in the International Journal of Transgenderism. The study was published a couple of weeks ago and criticizes a handful of other studies made in the last decade which bolster a myth that the vast majority (more than 80%) of children who have presented as transgender have since “desisted” (reverted to being cisgender1) as adolescents or adults. Those studies, all released in the years since 2008, analyze children who were researched in the years since 1970 up until the 2000s.

Those recent desistance2 studies might hint at a couple of interpretations of transgender children who desist. The most neutral one is that such children were “going through a phase,” playing out the vagaries of youthful whims and later changing their minds. However, these studies also permit a more sinister interpretation—one in which children were subject to external influences that “confused” them about their gender, a confusion which time and therapy later allowed them to outgrow and reject.

It stands to reason that, because each child included in the original studies had contact with researchers, it was likely they were seeking treatment which included therapy, which might seem to support the latter interpretation. The standard of care for whichever diagnosis they received, which would have varied by location and time—more on this below—would possibly have focused, in fact, on influencing the child away from transgender or homosexual behaviors. Many research studies and forms of treatment, especially in earlier years, would have taken the form of conversion therapy. That also creates interpretative concerns from the original studies—they affect their own outcome. (This is referenced below as well.)

First, I want to briefly discuss the flaws from the desistance studies so that we can begin to erode the desistance myth. The news article above sums up the critique introduced by the new study quite well.

The ‘desistance’ figure come from studies conducted between the 1970s and the 2000s in the Netherlands and Canada, which assessed whether the kids that sought services at the gender clinic turned out to be trans as adults. The new publication concludes that the figure included all kids that were brought to the clinic, many of who never experienced gender dysphoria in the first place nor saw themselves as trans. Kids that shouldn’t have been a part of the figure were therefore being used to ramp up the numbers.

The news article elaborates that, not only is there uncertainty in how many children should have been counted as transgender in the first place, the earlier studies make blanket assumptions as to what happened to those children afterward.

Another flaw is that in the follow up, all participants that weren’t included for whatever reason were simply brushed off as ‘desisters’. This was done without having any factual evidence or knowledge about the children involved.

In what should have been simple division, the numbers on both sides of the division sign have become suspect. Now the question becomes, do we have the actual figures? Here’s where the real problems start. We need to delve into the primary source, the Newhook et al. study, itself.

The study is called “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender-nonconforming children,” authored by Newhook et al.3 It contains a methodological meta-analysis of four previous studies. As it states in its introduction,

In the media, among the lay public, and in medical and scientific journals, it has been widely suggested that over 80% of transgender children will come to identify as cisgender once they reach adolescence or early adulthood. This statement largely draws on estimates from four follow-up studies conducted with samples of gender-nonconforming children in one of two clinics in Canada or the Netherlands (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Steensma, Biemond, de Boer, & Cohen-Kettenis, 2011; Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013; Wallien & Cohen-Kettenis, 2008).

The critiques in the Newhook et al. study aren’t new, and the authors take pains to mention some of their forebears in their introduction as well. They contextualize their new study by explaining that they hope to guide the eighth upcoming version of the WPATH4 standards of care, which will determine how transgender children for years to come are treated.

Newhook et al. mention older follow-up studies from before the year 2008 of gender-non-conforming children, but the authors explain those studies are tainted by methodological and sampling problems. They are also likely irrelevant since they were not cited in the meta-analysis’s contribution to the 80% figure. So they skip these earlier studies in their meta-analysis.

We recognize that numerous follow-up studies of gender-nonconforming children have been reported since the mid-20th century (e.g., Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). In that era, most research in the domain focused on feminine expression among children assigned male at birth, with the implicit or explicit objective of preventing homosexuality or transsexualism.

(I’d like to draw your attention for a moment to the fact that Kenneth Zucker was an author both in the 1995 study above and in the later 2008 study mentioned earlier. We’ll return to him later.)

Now, the Newhook et al. critical commentary study notes that the four desistance studies arrive at a figure of over 80% desistance. Then it begins to note what abilities and limitations these studies have. The methodological concerns center around what we can know and can’t know, given what information was collected at the time and afterward.

What I found was that because the studies used children from times spanning from 1970 onward, the basis for diagnosis itself seeded the flaws in mis-categorization, both in mis-categorizing children as transgender in the first place and then again on follow-up.

Back in 1970, no formal diagnosis for gender identity disorder or gender dysphoria existed. Doctors and researchers had only informal descriptions. As Newhook et al. explain,

However, the plain-language meaning of gender dysphoria, as distress regarding incongruent physical sex characteristics or ascribed social gender roles, has been established since the 1970s (Fisk, 1973). When these four studies refer to gender dysphoria, they are referring to this plain-language context of distress, and not the newer DSM-5 diagnostic category.

The DSM-III5 would not exist until 1980, so the meanings applied here may vary from person to person, as experience and prejudice allow.  I do not know all the criteria which were applied. (I have been unable to locate the Fisk source, but he appears to be the source of the term “gender dysphoria.”)

Then, in the 80s and 90s, the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR each included a “gender identity disorder” diagnosis which came with a “GID/Children Transsexualism” or “gender identity disorder in children” category. The symptomatology of these were similar in general shape and included distress (a gender dysphoria component) but also certain behaviors (e.g., crossdressing), timeframes (e.g., six months), and so on. This is a very definite case of moving the goalposts, where the diagnostic criteria shifted. In some ways, they became more lax. Diagnostic criteria often state that only a certain number out of all of the above need be satisfied over a period of time, so if every component but gender dysphoria is present, the diagnosis of gender identity disorder can still apply.

At the same time, the standards of care also were shifting, evolving through time to match the competing typologies6 and psychosexual models of the providers. Adults learned to conform to expectations (such as crossdressing for a year before receiving treatment or professing attraction to men where no such attraction existed).

Children who may not have been aware of these standards and criteria, acting on their needs and wants, might have very well fallen in and out of the categorizations changing around them. Through no fault of their own, the category of transgender might one day have landed upon a child and then another day slipped away from them.

The Newhook et al. study describes the problem this way:

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 […] 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 gender-dysphoria” 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-non-conforming 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.

Because of the meaningful shifts in diagnostic criteria over the last fifty years, there’s little hope of reconstructing the true figures of desistance, such as they may be. We would need both detailed notes (interviews, etc.) from the original cohorts to attempt to assess the children’s self-reported identities7 and then those same cohorts’ adulthood identities, assessed the same way from follow-ups, to compare. I suspect the paucity of detailed qualitative data from the original studies would undermine such an effort, due to the primacy of researchers’ diagnoses over self-described experiences and identities.

In most studies, it appears we do not have such detailed notes and the like available. Newhook et al. do cite Steensma et al. (2011)8 as having some unique qualitative research, but quantitative data are very limited—there are only two interviews mentioned.

The Newhook et al. study also brings up many ethical concerns, and here I turn back to the problem of Zucker in particular. The authors identify three ethical concerns, of which the second is particularly insidious—the questionable goals of treatment itself.9

In describing their second concern, the authors write,

A second ethical concern is that many of the children in the Toronto studies (Drummond et al., 2008; Zucker & Bradley, 1995) were enrolled in a treatment program that sought to “lower the odds” that they would grow up to be transgender (Drescher & Pula, 2014; Zucker, Wood, Singh, & Bradley, 2012; Paterson, 2015). Zucker et al. (2012) wrote: “…in our clinic, treatment is recommended to reduce the likelihood of GID persistence” (p. 393).

As I write, Zucker’s words are only six years old. To be clear: he is both espousing and practicing conversion therapy of children.

Zucker is not a marginalized figure in the world of psychiatry. He is not only respected and accepted; he was the head of the “Sexual and Gender Identity Disorders” group that revised the DSM-5, appointed by the American Psychiatric Association. A heartbreaking account of his attempt at conversion therapy may be found in this NPR story (with some misgendering).

He was not the only person in the group to favor controversial theories, either. Blanchard (who favors an outmoded typology of transgender people based on sexual attraction and also attempts conversion therapy) and Lawrence (who has expressed the belief that transgender people have a kind of body integrity identity disorder) also formed part of the group.

Why do I mention their role in shaping the DSM-5? Well, they believe children should be dissuaded from transgender identities, which they regard as pathological or maladaptive. Under their influence in shaping the diagnostic criteria for children and adults, they moved the goalposts for fitting the model. That then allowed studies to tally up how past children fit current, different diagnostic criteria to determine that they have “desisted.” In turn, these fudged figures can be used to justify further conversion therapy, resist affirmative care models of treatment, and influence the WPATH standards of care to inhibit access to treatment and personal safety.

I therefore question whether—after influencing or directly authoring new diagnostic standards for gender dysphoria—advocates for conversion therapy then revisited older studies to make follow-ups, aware of how the results would skew toward their desired outcome: an interpretation of a seeming tendency toward desistance, which marks transgender identities as “unnatural” aberrations which only emerge later in life and which can be headed off earlier in childhood. Buried underneath this interpretation is an implicit assumption about how children form transgender identities due to extrinsic influences. They conclude that they can prescribe a model of care which essentially counteracts those influences with their own.

Wiser people than I have already explained why better models of care, such as the affirmative care model, practiced in most North American clinics, provide better outcomes.10 The news article I began with also concludes with some great sources on treatment outcomes, which I cannot possibly outdo, so I’ll leave you to revisit Owl’s article.

Denying children bodily autonomy and agency over their identity is a form of abuse. The long-lasting confusion may result in self-denial, withdrawal, self-harm, or even suicide later in life. Unlike many forms of abuse, which happen privately, transgender conversion therapy coopts institutions toward its own ends by shaping the standards of care for treatment (via its influence on the WPATH with influential studies) and by writing the diagnostic manual itself. The prevalent myth of desistance of childhood gender dysphoria has been a powerful tool used to abuse children. It must be dismantled. To do so, we must expose pernicious and specious studies, using critical meta-analysis such as Newhook et al.’s.

I am grateful to Zuzu O. for feedback on this post.