The Controversial Research on 'Desistance' in Transgender Youth
Thomas Steensma, a gender clinician and researcher at the Center of Expertise on Gender Dysphoria, VU University Medical Center, in Amsterdam. (Courtesy Thomas Steensma)
The phenomenon of transgender children "growing out of" their transgender identity by the time they are adolescents or adults is called “desistance” by gender researchers.
For decades, follow-up studies of transgender kids have shown that a substantial majority -- anywhere from 65 to 94 percent -- eventually ceased to identify as transgender.
These findings have become part and parcel of the "How young is too young?" debate over "social transitioning," the term for allowing kids to publicly live as their identified gender in every way short of medical treatment.
If most kids will eventually cease to be transgender, some clinicians have reasoned, isn’t it more prudent to take the least disruptive path in coping with a child's gender dysphoria? That way, if or when kids later stop identifying as transgender, they will have less to “undo.”
In recent years, though, a new school of thought has emerged. Many gender specialists now believe that the best course for a transgender child is often “social transition,” where kids as young as three are allowed to change their names, pronouns and style of dress to match the gender they identify with.
Looking at the Research
One reason many researchers believe it’s unnecessary to delay the social transition of a child is that they don’t think the research on desistance is valid. In other words, they think the number of children who "grow out of" their transgender identity has been vastly overblown.
This school of thought holds that because the criteria for a diagnosis of gender dysphoria (previously called gender identity disorder) was less stringent in the past, the earlier desistance studies included a large cohort of children who today would not be diagnosed with gender dysphoria, gay boys who may have been experimenting with different ways of expressing gender but who were never really transgender in the first place.
“The methodology of those studies is very flawed, because they didn't study gender identity,” said Diane Ehrensaft, director of mental health at UCSF’s Child and Adolescent Gender Clinic. “Those desistors were, a good majority of them, simply proto-gay boys whose parents were upset because they were boys wearing dresses. They were brought to the clinics because they weren't fitting gender norms.”
In Amsterdam, clinicians at the Center of Expertise on Gender Dysphoria are much more cautious about recommending social transitions because of the statistics on desistance. Thomas Steensma, a researcher and clinician at the center, acknowledges these studies probably included some kids who would not be diagnosed with gender dysphoria today. Nevertheless, despite the problems with the way they classified children, "the only evidence I have from studies and reports in the literature ... is that not all transgender children will persist in their transgender identity," Steensma said.
In 2013, Steensma co-authored an oft-cited study that examined 127 adolescents, all of whom had displayed various levels of gender dysphoria as children. The researchers found that 80 of the children had desisted by the ages of 15 and 16. That works out to 63 percent of kids who basically stopped being transgender -- a lower rate than in previous studies, but still a majority.
Some clinicians criticize this study, however, on methodological grounds, because the researchers defined anyone who did not return to their clinic as desisting. Fifty-two of the children classified as desistors or their parents did send back questionnaires showing the subjects' present lack of gender dysphoria. But 28 neither responded nor could be tracked down.
“You can't do that in scientific studies,” Ehrensaft said. “You have to have your subjects in front of you and know who they are. You can't just assume somebody is in a category because you don't see them anymore.”
In addition, 38 of the 127 kids were originally designated “subthreshold” for gender identity disorder, meaning they did not fulfill all the criteria for meeting the official diagnosis.
This, according to Erica Anderson, a gender clinician at UCSF, makes the desistance findings even more suspect." [It] begs the question of whether these kids were actually divergent [in their gender identity] before the study selected them,” she said.
Steensma stands by the study’s methodology. But interestingly, he added that citing these findings as a measure of desistance is wrongheaded, because the study was never designed with that goal in mind.
“Providing these [desistance] numbers will only lead to wrong conclusions,” he said.
Rather, he says, the researchers wanted to see if they could find predictors of persistence. Which they did: The study found that transgender children who were older, born female, and reported more intense gender dysphoria were more likely to stick with their transgender identity than younger children, natal boys and those with less pronounced gender dysphoric traits.
Steensma and colleagues also culled one very specific indicator of future persistence: When asked when they were children, “Are you a boy or a girl?” those who answered the opposite of their birth sex were found more likely to have retained their gender identity in adolescence. The desistors, on the other hand, tended to merely wish they were the opposite sex.
“(E)xplicitly asking children with GD (gender dysphoria) with which sex they identify seems to be of great value in predicting a future outcome for both boys and girls with GD,” the study says.
Today, Steensma cautions that this question is not a litmus test for which children will persist in their transgender identity. He believes that gender identity in kids is still developing, and that it’s responsive to what occurs at different life stages. He also says it’s possible that a social transition could lead to persistence where it otherwise might not have occurred.
“That's not something we can answer,” he said. “It's something we have to study and find out.”
‘It’s Time to Teach Society’
Another contentious topic in the transgender community is what the literature calls “detransitioning,” or reverting back to one's natal gender.
The current Standards of Care written by the World Professional Association for Transgender Health cautions that “a change back to the original gender role can be highly distressing” The guidelines use that assertion as a reason to be cautious about early social transitioning.
But the cautionary language, Ehrensaft points out, is based on one qualitative study, coauthored by Steensma, which looked at the dilemma of just two Dutch girls who’d transitioned when they were in elementary school and wanted to switch back. She doesn’t think it’s particularly relevant.
“The stress [of detransitioning] comes from microaggressions and lack of acceptance in the environment,” she said. “If we offer social support and opportunities for children over time, we don’t have any evidence that [detransitioning] will be damaging for them.”
Ehrensaft believes the conventional treatment of transgender children has been based, for the most part, on traditionally negative views of gender nonconformity. So, she believes, the burden is now on the culture to see transgender children as they really are.
“Why are we asking a child to conform to something that is not them because society hasn't done its learning yet?”she says. “It's time to teach society.”
Toward the Nonbinary
One of the more interesting takes I heard on persistence and desistance came from UCSF gender clinician Erica Anderson, who is transgender herself. She views the very notion of measuring persistence/desistance as something of a fool’s errand, because such definitions are mediated by changing cultural norms, the self-perceptions of children and the ways that researchers interpret them.
“We’ve got kids of varying sophistication levels of language trying to explain to other people who have no experience [being transgender]," Anderson said, "and it’s being driven by shifting professional understanding or consensus and culture. You’ve got moving parts. In that context we’ve got a dynamic situation where kids who might say ‘I’m a girl’ might have said five years ago ‘maybe I’m a girl.’ ”
Ehrensaft herself doesn’t even like to use the terms persistence and desistance. Those words imply something fixed — a binary state of yes or no. But younger generations of transgender people — and even younger generations in the general population — see gender as more protean, even customizable. Of nearly 28,000 respondents to the 2015 U.S. Transgender Survey, more than one-third said they were some form of nonbinary. That means they may identify as both male and female, neither male nor female, or sometimes male, sometimes female.
This, in theory, could solve a lot of problems. After all, if the gender fluidity trend continues, perhaps many people will have no unitary gender to "persist" or "desist" from.