Gracie, 7, poses for a picture in her room. Gracie is transgender; she socially transitioned to a girl at the age of 4. (Lauren Hanussak/KQED)
Gracie is the youngest transgender person I've ever met. She's so young, she still likes to tack on "and-a-half" when giving her age, which is six. One day last summer, bouncing all over the grounds at day camp, she looked as delighted as you'd expect any kid would on "Water Day.”
This is Rainbow Day Camp, in the East Bay town of El Cerrito. It was created specifically to be a safe place for transgender kids, and in fact, being transgender is so unremarkable here, when I asked Gracie what makes it “special," she shrugged and said:
“You get to do fun stuff.”
Her mother, Molly, tried to coax a reporter-friendly answer out of her.
“What is special about you, and the same as everybody else in the camp?” she prompted.
“I don’t know,” Gracie said.
“You’re transgender and there’s other kids that are transgender, too...”
“I’m transgender and there’s other kids that are transgender, too.”
Ah, kids. ... But when I asked Gracie how she used to feel, when other people thought she was a boy, she got straight to the point.
“It was not right to me, and I didn’t want people to say that, but they said it,” she said. “It hurted my feelings a lot."
Did it make her angry?
“No, it just made me sad.”
How about now?
“It feels happy to me.”
And that, in a child’s nutshell, sums up one side of a contentious debate about the right age for transgender children to begin what gender clinicians call “social transitioning.”
When I met Gracie, she was a few months out of kindergarten — pretty young for a transgender kid, I thought. Gracie lives with her parents and younger brother in a small city in the East Bay. She is already two years into her transition, having started her public life as a girl at four. The family began by discarding her boy name and referring to Gracie as “she” and “her.” She was also allowed to wear girl clothes outside the home, and her parents changed the gender on her birth certificate to avoid confusion at school.
Steps like these make up the “social” aspects of social, not medical, transitioning. The distinction is important: According to Endocrine Society guidelines, patients who want to begin medical treatment like puberty blockers, hormones or surgery should be old enough to give “informed consent,” which the organization says is usually attained by 16.
Diane Ehrensaft, the San Francisco Center’s mental health director and a leading proponent of early social transitioning, acknowledges this approach has been controversial.
“There are some people that think folks like myself, and the people at our clinic, have fallen off the deep end,” she told me. She wasn’t just talking about the religious right, either. She was referring to other mental health professionals.
I myself experienced a fair bit of surprise when Ehrensaft told me how young these kids are. My first, reflexive comment was a simple, "Wow." This was not an uncommon reaction when I discussed this story with people in my own life, even in the progressive Bay Area.
Yet, when I spoke with Gracie’s mom, Molly (the family didn't want their last name used for reasons of privacy), nothing about the decision to allow her then-son to publicly make the switch to a girl, at an age when many kids are still sucking their thumbs, sounded in the slightest bit rash.
We spoke at Rainbow Day Camp, in a classroom set aside for interviews. The children’s art adorning the walls, the shrimpy seats — it felt like a place to talk about kickball, not the gender identity of first graders.
Yet here we were.
“What if we do this?” Molly recalled asking a gender therapist, back when they were debating the pros and cons of letting Gracie transition. “What if we let our son walk into the world in a dress with fairy wings, and crowns, and high heels, and even just in regular girl clothes … and then he changes his mind?”
"That's not the question,” the therapist told Molly. “The question is, what if you don't do it?”
It was only semi-rhetorical. Some gender therapists say there are serious potential dangers if adults suppress a child’s desired transition. On surveys, American transgender adults have reported attempting suicide at the startling rate of around 40 percent.
The stakes couldn’t have been higher, Molly knew.
At Rainbow Day Camp, recalling that time, she started to cry.
“As soon as I knew there was even a chance that my kid could feel ashamed of who they are, there was no way … ” Her voice cracked into a higher register. “I had to support, I had to listen, and I had to let her steer, a little bit, the ship. Period. No matter what.”
‘I’m a Girl’
Ehrensaft calls children like Gracie “persistent, consistent, and insistent” in their declarations of cross-gender identity. For Gracie, this manifested through words, wishes, and, well, practically everything.
Gracie was her parents' first child. From toddlerhood on, Molly said, their son had displayed a “constant obsession and fixation on all things girl. As soon as she could tell us, it was, ‘I'm a girl. I'm a sister. I'm a daughter. I'm that girl on that show. I'm that girl in that book.’”
Gracie's parents weren’t on board at first.
“We filled her world with trucks, and dinosaurs, and superheroes, and we refused girl things,” Molly said. “Like, ‘No, you can't be Elsa for Halloween. You have to be Superman. No, you can't have the dolls for Christmas. We're going to get you a pirate ship.’”
They also made a rule: No girl clothing outside the house.
Molly tells me: “That’s the part I’m ashamed of now.”
'These Kids Do Come Forward'
Molly and her husband finally relented — they just could not deny how much happier their child felt when recognized as a girl.
I asked: Has Gracie ever looked back?
“If you think of gender as a spectrum, she is like a full, all-the-way girl.”
It’s not rocket science, Ehrensaft explained, if you really listen to the children. “A child will say: ‘Stop calling me Jane. Let me wear my dresses. Please call me she.’ That's a child making a clear statement.”
Kristina Olson, a University of Washington gender researcher, said parents do not always listen to what their kids are telling them.
“The ones that are most likely to transition are kids who for many years are very consistently saying this is who they are,” she said. ”We often see this happen for years before parents socially transition their kids.”
UCSF gender specialist Erica Anderson recently treated a five-year-old who had reached a point of desperation.
“In the bathtub, he would compare himself to his younger sister, and really start getting upset. At one point he went in the bathroom with a pair of shears — he was going to cut his penis off.”
“This child has been so clear for a couple of years,” Anderson said. “These kids do come forward.”
Gender clinicians who recommend social transition at such an early age call their model “gender affirmative,” and they believe their approach is now ascendant. Historically, clinicians more commonly treated transgender kids by discouraging cross-gender identity. The method was most famously practiced by longtime gender researcher Ken Zucker.
Zucker is now an extraordinarily controversial figure in the transgender community. He believed that an outcome in which a child becomes transgender should be avoided, if possible. You can get a glimpse of his methods in this NPR story from 2008. Zucker is counseling the family of a young boy he’d diagnosed with gender identity disorder, the term used for gender dysphoria before 2013.
Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. He explained that unless Carol and her husband helped the child to change his behavior, as Bradley grew older, he likely would be rejected by both peer groups.
Other researchers and transgender activists have criticized this approach as too close to the “conversion therapy” inflicted on gay and lesbian youth, a practice that is now illegal in a number of states, including California.
Get the best of KQED’s science coverage in your inbox weekly.
Thanks for signing up to the newsletter.
The World Professional Association for Transgender Health's guidelines for clinicians, called the Standards of Care, states that “treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth” is “no longer considered ethical.”
Zucker was the psychologist-in-chief and head of the gender identity clinic at a Toronto mental health hospital before administrators shut down the clinic in 2015, after a review of his practices. That was also controversial, and Zucker is suing his former employer for defamation. (Zucker declined to comment for this article. For a defense of his work, you can read Jesse Singal’s reporting from 2016.)
Zucker’s approach aside, there is another alternative to gender affirmative therapy. It’s the approach taken by the Center of Expertise on Gender Dysphoria in Amsterdam, and gender specialists commonly refer to it as the “Dutch Model.”
This treatment sometimes involves the social transition of young children, according to Thomas Steensma, a researcher and clinician at the center. But for the most part, its counseling incorporates the idea that the vast majority of gender dysphoric children will eventually stop identifying as transgender.
The research literature calls these individuals “desistant.” The kids who retain their transgender identity as they grow up are dubbed “persistent.”
The Desistance Controversy
Nothing roils the world of transgender research like the topic of desistance. Brynn Tannehill, a transgender activist who follows the research closely, said the concept is often used by anti-LGBT groups to make the case that rejecting children’s transgender identity is in their best interests.
“It is used primarily as an attack on the validity of transgender identities, which usually quickly disintegrates into a debate on whether we should exist,” Tannehill said.
And yet, the fact is that just about every published study on the topic to date has found that a majority of children who once reported various degrees of gender dysphoria ended up eventually giving up their transgender identity.
To grasp the implications of this, remember Molly’s anxious questioning of the gender therapist: What if we go through all this, and it turns out to be just a phase? Shouldn’t we wait?
The gender affirmative camp says no. That’s because it doesn’t believe that the body of research on desistance, some of it conducted by Zucker and his associates, is valid.
Many gender researchers maintain that the current criteria for diagnosing gender dysphoria are much more stringent than in the past. Therefore, many of the studies that found so many kids had "grown out" of their transgender identity were actually measuring children who were never really transgender in the first place.
“Some of those studies are decades old,” said gender researcher Kristina Olson. “So if you had a son in the early 1980s who liked playing with dolls and wanted to occasionally wear a dress, even today maybe you would think to bring that child to talk to a doctor about it. But that child wouldn't necessarily be transgender, because that kid doesn't necessarily think of himself as a girl."
Ehrensaft said that her San Francisco clinic sees “a tiny, tiny proportion” of clients who stop identifying as transgender after transitioning.
Even the Amsterdam clinic’s Thomas Steensma, who firmly believes most gender dysphoric kids will not grow up to be transgender, acknowledged the earlier studies probably included “milder cases” that are “hard to compare with the clinical samples we see now in our clinics.”
Nevertheless, he said, “The only evidence I have from studies and reports in the literature ... is that children who struggle with gender incongruence … will not all persist into adolescence."
Talking to Steensma over Skype, he seemed bemused by the fact that the “Dutch model” is now considered conservative compared to what has taken hold in America. After all, his Amsterdam clinic had been a pioneer in the medical treatment of transgender youth, especially in the use of puberty blockers, which delay the onset of secondary sex characteristics.
But what about the social transitioning of young kids?
"It's not a 'yes' or a 'no' in our opinion, but a 'maybe,' Steensma told me.
I wondered if there was any real argument between him and Ehrensaft, after all. So I described to him the case of persistent, insistent, consistent Gracie.
A slam dunk for social transition?
Steensma said no.
“We would counsel them ... that it's okay to express your feelings, your interests, to show your behaviors. But with certain steps like a name change, or a pronoun change, with a result that maybe others will only perceive you as a girl — that's somewhere where we say, ‘Okay, maybe you should explore things without taking steps that are hard to reverse.’”
There are mental health professionals in the U.S. who agree. Dr. Jack Drescher is a clinical professor of psychiatry at Columbia University; he served on the American Psychiatric Association's committee that revised the diagnosis of gender identity disorder in 2013. He said gender affirmative therapists have never proven they can successfully identify those kids who will stick with transgender identity.
He also says there’s no evidence to back a corollary belief, that kids who might later need to “detransition” back to their original gender will not suffer any long-lasting psychological effects.
“This is what they believe, but it's not based on research,” he said of gender affirmative clinicians. “This is a meme, not really a piece of scientific finding.”
Steensma concurred: “If a child transitions, it is not just, ‘Oh, we do the transition and we go on with our life.’ It has a huge impact on the child, on the family and their environment.’”
The current Standards of Care, issued by the World Professional Association of Transgender Health in 2011, are more or less in accordance with this view, as even Ehrensaft acknowledges. The guidelines describe “relatively low persistence rates” as “relevant” to helping parents weigh the decision to socially transition. The standards also state that “a change back to the original gender role can be highly distressing.”
The one thing everyone in the field agrees on is more research is needed. Almost every gender specialist I spoke with cited Kristina Olson’s longitudinal study at the University of Washington as critical to answering some of these hotly debated unknowns. Olson recently received a $1 million grant from the National Science Foundation, which she's using to expand the study.
Preliminary research coming out of the project has already provided good news for the families of transgender kids. In a pair of studies published over the last several years, Olson and her colleagues found that socially transitioned children and adolescents between the ages of 3 and 14 did not experience any more depression than separate control groups of peers and siblings, as well as the general population.
The transgender health association is now gearing up to revise the Standards of Care. Both Steensma, known for “watchful waiting,” and Ehrensaft, of the gender affirmative school, are on the committee in charge of the section about children. The jockeying to influence the direction of the committee has already begun, as evidenced by the critical commentaries now appearing in academic journals.
“My prediction is that there will be more endorsement of social transitions at earlier ages, without the cautionary tales,” Ehrensaft said of the upcoming revision.
Not Just Numbers
When it comes down to it, when we talk about the controversy over socially transitioning young kids, we are talking about risk analysis. Which is more disruptive and potentially harmful: to deny children their genuinely felt gender identity in the present moment, until the adults are absolutely sure it will stick? Or to validate a child’s persistent, consistent and insistent protestations that ‘Hey, someone has made a terrible mistake here,’ even if they eventually decide they no longer feel that way?
Ehrensaft, at least, is clear on the answer:
“Why would we deny for the vast majority of kids something that is basically suicide prevention?”
As a parent, I wonder: If my daughter became incandescently happy when allowed to change her name and take on other aspects of being transgender — as happy as Molly describes Gracie becoming when recognized as a girl — what would I do? If some statistics indicated my child might one day switch back, but my deepest parental instincts told me to trust her joyfulness, could I ignore the latter?
At Rainbow Day Camp, I spoke to James, a 9-year-old transgender boy who’d transitioned during second grade. He told me matter-of-factly that he’d been bullied by older kids, who’d called him an “It.”
After he transitioned, his mother said, “There was just this comfort that came about him, and comfort's something that you can't really fake. He’s [just] a happier kid.”
Similarly, before Gracie’s transition, family life was “lackluster,” Molly recalled. The constant tension drained the joy out of childhood for everybody.
“You never got to see that sort of sparkle, or that sort of magic of, like, a Christmas morning, or a Halloween, or just regular day-to-day happiness,” Molly said.
“Now she gets to really live.”
Get the best of KQED’s science coverage in your inbox weekly.