The Atlantic published the article “When Children Say They’re Trans” by Jesse Singal in its July/August edition not too long ago. In this article, the author wrote about the increasing availability of treatments for affirming one’s gender identity and the rising concerns about the risks surrounding those treatments.
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A key issue in the article is the concept of desistance. Desistance is a phenomenon in which individuals no longer feel that their gender identities are incongruent with their physical appearance. Highly related to desistance is detransitioning, a phenomenon in which transgender individuals no longer take the steps (e.g., hormone therapy) to affirm their gender identity. Singal highlights the concern surrounding starting medical treatments to affirm an individual’s gender identity, considering that the changes are irreversible and that it is possible for children to change their minds. Implied in the article is a call for a cautious approach for treating children who identify as transgender because it will be difficult to predict what one’s final gender identity is; however, I believe that a better approach is to support the child in the journey in affirming the gender identity.
The evidence on the rate of desistance may not be accurate
One argument for the cautious approach is the often cited statistic that 80% of children with gender nonconforming behaviors do not identify as transgender when they are adults. This is derived from four published studies that track the gender identity of individuals with gender nonconforming behaviors in childhood.1-4 These estimates may not be accurate, mainly due to these studies’ methodological shortcomings. For example, those who were lost to follow-up were assumed to be cisgender as adults and no efforts were made to verify these individuals’ gender identity.2-4 I do not intend to thoroughly critique these studies in this column. This is best left to peer-reviewed commentaries (a good example is one written by Newhook et al. 2018).5 I worry, however, that some clinicians may dismiss a child’s gender identity based on these studies and recommend to the parents to delay supporting a transition until the child “knows for sure.” The problem with this approach is that it may worsen the health and well-being of transgender youth, as there is growing evidence that transgender children who are supported by their parents are less likely to have mental health problems.6,7
The reasons for desistance are far more complicated
The common narrative of desistance is that the individuals simply change their minds because they were “confused” during adolescence. However, the truth is more complicated. Children can identify their own gender as early as 2 years old;8 however, when a child’s gender identity matches the assigned sex at birth, this is often reinforced. In contrast, if a child’s gender identity does not match the assigned sex at birth, it often is challenged by peers and adults. This challenge by peers, their families, and medical providers may be one of the reasons why transitioning is so difficult for many transgender youth – and many do give up.3,9 In these cases, some people wait for years, if not decades, to come out again and start transitioning when they finally feel supported and safe – even in their 90s! Other transgender people realize that their gender identity is not on the binary (neither male nor female), so they no longer need cross-sex hormones or surgeries to affirm their gender identity. Finally, others are concerned about the side effects, such as infertility, and feel that the risks for those side effects are not worth it, so they find other, nonmedical or nonsurgical ways to affirm their gender identity or manage their gender dysphoria.