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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.
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.
Positive outcomes are more common
Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.10 Furthermore, there is growing evidence showing that such treatments are associated with better health.11 A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.12 Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.
The key is support
I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:
- At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
- Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
- Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
- Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
- Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. Dev Psychol. 2008;44(1):34-45.
2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.
3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.
4. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23.
5. International Journal of Transgenderism. 2018;19(2):212-24.
6. Pediatrics. 2016 Mar;137(3):e20153223.
7. J Sex Marital Ther. 2010;36(1):6-23.
8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).
9. Graduate Journal of Social Science. 2010;7(2):26-43.
10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.
11. Transgend Health. 2016 Jan;1(1):21-31.
12. Pediatrics. 2014 Oct;134(4):696-704.
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.
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.
Positive outcomes are more common
Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.10 Furthermore, there is growing evidence showing that such treatments are associated with better health.11 A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.12 Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.
The key is support
I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:
- At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
- Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
- Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
- Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
- Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. Dev Psychol. 2008;44(1):34-45.
2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.
3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.
4. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23.
5. International Journal of Transgenderism. 2018;19(2):212-24.
6. Pediatrics. 2016 Mar;137(3):e20153223.
7. J Sex Marital Ther. 2010;36(1):6-23.
8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).
9. Graduate Journal of Social Science. 2010;7(2):26-43.
10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.
11. Transgend Health. 2016 Jan;1(1):21-31.
12. Pediatrics. 2014 Oct;134(4):696-704.
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.
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.
Positive outcomes are more common
Reports of youth detransitioning highlight many physicians’ fears of making a mistake; however, these reports obscure the more common – and positive – outcomes for transgender individuals who took steps to affirm their gender identity. The Report of the 2011 Transition Survey shows that 97% were satisfied with being on hormone therapy and 90% were satisfied with obtaining bottom surgery.10 Furthermore, there is growing evidence showing that such treatments are associated with better health.11 A study by de Vries et al. found that transgender youth who transitioned in adolescence had less depression and better adjustment as adults.12 Finally, there is a lack of evidence supporting the concept that someone whose gender identity is fluid over time is any less healthy than those whose gender identity is static over time. Rare outcomes should never be dismissed; however, providers should not use rare events as the primary driver for discouraging evidence-based treatment.
The key is support
I believe that every child’s gender identity should be supported and affirmed. Clinicians can provide this support and affirmation through the following actions:
- At the first visit, clinicians should ask what the child’s hopes and expectations are for pursuing gender-affirming medical treatments.
- Clinicians should allow the child the opportunity to describe and process their gender identity instead of assuming that they are on the binary.
- Clinicians must recognize the varied reasons for desistance – stigma, discrimination, shame, or need to fit within a gender binary – and find ways to address those factors.
- Clinicians should have a thorough discussion with patients and their families about the risks of not supporting the child’s gender identity versus the risk of medical or surgical treatments used to affirm one’s gender identity and process with the child and the family where the values and wishes are within the context of those risks.
- Most importantly, clinicians should emphasize support for whatever decisions the child makes to affirm their gender identity. Providing support is essential in promoting the health and well-being of any child.
Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.
References
1. Dev Psychol. 2008;44(1):34-45.
2. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90.
3. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516.
4. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23.
5. International Journal of Transgenderism. 2018;19(2):212-24.
6. Pediatrics. 2016 Mar;137(3):e20153223.
7. J Sex Marital Ther. 2010;36(1):6-23.
8. “Adolescence,” 11th ed. (New York: McGraw-Hill Education; 2016).
9. Graduate Journal of Social Science. 2010;7(2):26-43.
10. “Affirming Gender, Affirming Lives: A Report of the 2011 Transition Survey,” Gender Advocacy Training & Education, 2012.
11. Transgend Health. 2016 Jan;1(1):21-31.
12. Pediatrics. 2014 Oct;134(4):696-704.
