Welcome to the very last thing I’m ever going to write about the science of gender-affirming care. Here’s what we’ve done so far:
All of this is well and good, but won’t somebody think of the children?
From the New York Times to Newsmax, the message is consistent and clear: kids are being transed younger and younger, they say, and it’s a problem. What if they would have changed their minds when they got older? What if these young children now going under the knife regret transitioning later?
Firstly, I encourage you to dig deeper into literally any of the pearl-clutching reports about prepubescent children getting hormones and surgery. What I have found, every single time, is that these articles conflate social transition, puberty blockers, hormonal transition, and medical transition. Yes, very young children are being allowed to socially transition. No, no one is operating on 8-year-olds or pumping them full of drugs. People are letting them choose their name and pronouns and what they’d like to wear.
Also, these standards of care have been in a place for a while now, so where’s the wave of transition regret? Here’s a quote from Erin Reed, who, seriously, is the person you should actually be listening to on this stuff:
If these extremely high rates were accurate, we'd expect to see around 1.2 million detransitioners. Therapist offices would be slammed with people wanting to “change back,” hearing rooms would be packed to the brim with detransitioners, and prime time news-hour specials would feature… well, people other than Chloe Cole on a regular basis.”
Still, as children have access to gender-affirming care earlier and earlier, some people worry that, left to their own devices, most of these self-identified trans children would desist and return to identifying as their assigned gender. Providing gender-affirming care before that happens dumps kids into the gender pipeline and dooming them to a lifetime of regret.
If children are being transed into genders they aren’t, that would be very bad! Let’s find out whether that’s true.
Yet More Bad Science
Gender Criticals sometimes claim that almost 90% of trans children desist, a number that comes from from a 2021 study by Devita Singh, Susan J Bradley, and Kenneth Zucker. We have already talked about Zucker in the first Criticizing Gender Critical article–click through and do a name search to find out why I don’t find him to be a credible authority. Susan Bradley is often portrayed as a politically unaligned doctor with years of experience treating trans children, but only the second part of that sentence is true: she co-founded CAMH with Zucker—the Canadian gender clinic discussed in the first article that pushed children to accept their assigned gender identity through therapy. As for Singh, Zucker is her co-author on all her academic work since 2009. These people have an agenda.
The study itself, conducted in 2021, looks at 139 children assigned male (the paper uses the term “boys”) who were referred to CAMH between 1979 and 2009. The children were either recruited for follow-up after being seen at the clinic or recruited when families called the gender clinic for follow-up services. So far, so good. It’s not the best sample size, but it’s not criminally small. Unlike the ROGD studies we talked about last time, they didn’t recruit from gender critical websites. Cool.
Here’s where this paper starts getting less cool. During their initial appointment, only 63.3 percent of the children met DSM criteria for “Gender Identity Disorder” (GID) The other 36.7 percent did not meet the threshold, but it’s OK–they had some indicators, and if they’d been asked earlier they would have had more indicators, so, you know. Whatever.
Here’s why I don’t think that having over a third of your sample size not fully qualify to be part of the sample is not, in fact, “whatever”:
“People who did not have Gender Identity Disorder as children usually don’t have it as adults” is something I could have told you for free
We don’t call it Gender Identity Disorder anymore
That last thing might sound like woke semantics. It isn’t. The DSM V, which came out in 2013, removed Gender Identity Disorder from their “sexual dysfunctions and paraphilias” section, renamed it Gender Dysphoria, and revised the diagnostic criteria. Here’s a side-by-side comparison:
Regardless of how you feel about the changes, these two diagnoses are not the same. GID focuses on stereotypically feminine or masculine behaviors, Gender Dysphoria focuses on subjective experience (as do diagnoses of things like depression and anxiety). It’s not the paper’s fault that the data was all collected before 2013, but the fact that the diagnosis is out of date should have us questioning the applicability of the results. Starting with bad assumptions often leads to bad outcomes.
Both GID and Gender Dysphoria require that the condition involve “clinically significant distress,” which means that some kid who’s perfectly happy wearing dresses and playing with dolls at recess would not reach the threshold for GID. They would, however, “have some indicators.” So that 36.7 percent of kids who don’t qualify might just be gender nonconforming which, considering that it’s over a third of a fairly small sample size, seems to me like a problem. Unfortunately, the study does not say which indicators these non-disordered children had, so I guess we’ll never know.
Flash forward to the follow-up research between 1986 and 1993, and from 2009 to 2011 (this paper was originally Singh’s 2012 dissertation). Of the 139 people recruited for the study, 19 participants (14.3 percent) could not be contacted. Which makes the following excerpt from the article really interesting:
“Of the 139 participants, 17 (12%) were classified as persisters and the remaining 122 (88%) were classified as desisters.”
In other words, some people who failed to respond to the survey were not excluded from the study but instead counted as desisting. Trans people, I have really bad news: if you have ever not picked up your phone, or missed a survey you received in the mail, you’re cis now. I’m sorry you had to find out this way.
I might be overstating things. The study authors did not automatically classify the non-responders as trans. Instead, they made a decision based on “clinical interview, parent-report or chart data”: three very different methods, one of which is highly suspect (I don’t care if a parent has decided their child is not trans, I care what the child thinks)
To review, here are the people classified as desisters for shady, weird reasons:
36.7% of participants who didn’t have GID as children
14.3% of participants who didn’t answer their phone
Which means that as much as 51 percent of the study’s data might be garbage. And the other 49 percent of experiential data is based on standards that conflate cross-dressing with being trans.
What I’m saying is that further research is needed, and I’m going to need to see these results replicated before, you know, denying people healthcare.
I didn’t cherry-pick a bad paper, either—the other studies that suggest high desistance rates for children are somehow even worse. You can largely find them here. What you’ll notice about all of these is that they all come from before 2013, when DSM-V came out. Some of them came out in the 80s. The sample sizes tend to be very small. The only one that has a sample size over 100 determined persistence vs desistance based on whether the children returned to the gender clinic to pursue gender transition when they were older. Because the clinic studied was the only available clinic in the country, the study authors “assumed that for the 80 adolescents (56 boys and 24 girls), who did not return to the clinic, that their GD had desisted.” This is a fascinating assumption, since it suggests that no other factors could POSSIBLY influence people to not pursue gender-affirming care (pressure applied by society generally, and gender-critical family and friends specifically, comes to mind).
One study Gender Criticals usually don’t cite is that Amsterdam Gender Identity Clinic study we talked about in the last article. 548 of the 6,793 participants in that study first came to the clinic when they were younger than 12 years old. When these children became old enough to return for puberty blockers, only 40 percent did so, suggesting a 60 percent desistance rate.
This 60 percent desistance rate has the same problem as the other rates we’ve talked about so far: how many of these children actually decided they were the gender assigned to them at birth, and how many gave into societal or familial pressures and returned to the closet? We can’t know.
A 2022 American study that followed up with trans-identified children 5 years after they began their social transition found very different numbers. Of the 317 study participants, only 7.5% decided to socially transition back to their assigned gender.
One big difference between these two studies is that the American subjects had started social transition, while we do not know whether the desisters from the Amsterdam study chose to socially transition or not. Another difference, though, might be age-related. I cannot find good information on how old the Amsterdam cohort was when they began to receive puberty blockers. However, here’s what the American study says about timing:
“The endocrinologists helped families identify the onset of Tanner 2 (the first stage of puberty) and prescribed puberty blockers within a few months of this time; therefore, the onset of puberty blockers is used as our proxy for the onset of puberty in youth who received blockers.”
Things are about to get uncomfortable. I’m sorry.
It’s possible that one of the reasons we see such dramatically higher rates of desistance in the Amsterdam study than in the American one is that the children in the American study received puberty blockers earlier. It is possible that the onset of puberty may also change gender identity in some percentage of trans-identified kids. We cannot say for sure. We don’t know.
We should probably find out. More research is needed.
In any kind of decent world, that statement would not be fraught with political meaning. Doctors and scientists would do more research and find out. But we don’t live in a decent world. We live in this one, where statements like that almost always mask a TERF agenda, where almost no one is really “just asking questions.” Trans people are fighting for their right to exist. The battle lines have been drawn. Anything that crosses them feels like exposing the flank to the enemy, because that’s exactly what it is. Gender Criticals will hold up your out-of-context quote and say “EVEN LEFTISTS THINK TRANSING CHILDREN HAS GONE TOO FAR” and now suddenly you’ve set trans rights back which was truly not your intention. The politicization of gender cuts both ways. It really, really sucks.
This is probably a good place to talk about Kinnon MacKinnon.
MacKinnon is, emphatically, not Gender Critical. He is an associate professor at York University with a BA in gender studies and a PhD in Public Health Sciences. His large body of work focuses on ensuring that trans people get adequate healthcare, very much including gender-affirming care. He has written about how pre-transition screenings create healthcare inequities. He is, himself, trans.
MacKinnon also worries that we are not paying enough attention to the phenomenon of detransition. Rare or not, people who detransition deserve just as much support and gender-affirming care as trans people. When we avoid talking about detransition or dismiss it, he says, we are degrading our ability to provide a high standard of care to the human beings at gender clinics. This is the goal, right? To treat people and help them live their best lives, no matter what that looks like?
Unfortunately, that’s not the goal at all. The goal is to establish and defend the rights of trans people to receive gender-affirming care, to use the bathroom, to work in education, to exist at all—because that’s the fight we’re in. Whether we like it or not, trans healthcare is now a civil rights issue, not a healthcare issue. Science cannot defend someone’s right to exist. That’s what politics are for.
Transphobes have chosen the battlefields of politics and media because this is the only way they can possibly win. These people cannot do science worth a damn. They do not operate on facts and logic. They operate on flawed studies and gut instinct. The sooner we hand this question back to science, the better care children and adults with gender dysphoria will receive. That’s how you make sure the standards of care are as good as they can be. That’s how you actually save the children.
That’s it. That’s all. Go subscribe to Erin In The Morning. I’m off to pack my bags for the Motor City, where the UAW is flexing its long-dormant muscles and Biden and Trump both plan to make an appearance. Will Biden challenge a UAW worker to a push-up contest? Will Trump pretend to be pro-union despite his consistent track record as an anti-union president? Will my media credentials be approved and, if not, how convincingly can I impersonate a Detroit line worker at the door? Who knows? Let’s find out.
(Edit: as soon as I pressed send, my press credentials were denied. Guess I’m going proletariat style)
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Your coverage on this topic has been thorough, thoughtful, and well, superb actually. Good on you.
Great article. Good luck on Motor City.