Dr Fiona Bisshop

There is an oft-quoted claim that 85% of children with gender dysphoria will “desist”, that is they will stop feeling dysphoric and accept their gender assigned at birth, by the time they reach adolescence.  In other words, the claim is that gender dysphoria is just a passing phase for the majority of children.  This figure is frequently trotted out to defend conservative “wait and watch” approaches to managing gender dysphoria in children, and is proclaimed with gusto by those transphobic zealots who seek to block any attempts to allow pre-pubertal children to socially transition and live as their affirmed gender.

The problem with this 85% figure is that it isn’t actually based on reliable data.  It is based on a small body of data involving cohorts of patients in both Canada and the Netherlands, much of it collected in the 1970’s and 1980’s, and there are a number of valid criticisms of the conclusions.

First of all, let’s look at the group of young people who form the cohort.  There was no strict diagnostic criteria applied to this group.  Rather, they were selected because they had been referred to a paediatric service about concerns over gender nonconformity.  Now being gender nonconforming is not necessarily the same as being gender dysphoric – parental concerns over a child’s preference for certain clothing, toys or activities are relatively common, and many of these children do not have confusion or dysphoria regarding their gender.  A significant number of children in the cohort were simply gay or gender nonconforming, had not expressed a strong desire to transition in the first place, and would never have been diagnosed with gender dysphoria according to the current DSM-V criteria.  Grouping these kids in with those who were truly dysphoric was clearly going to invalidate the results of any analysis of outcomes.  And one thing the studies agreed upon was that children who were more extreme and persistent in their dysphoria were much more likely to persist with their trans identification into adolescence.

Secondly, let’s examine the psychotherapeutic practices that these children were subjected to – remember that this was several decades ago, in what we could kindly call a less enlightened time when it came to gender theory and practice, and conversion therapy for homosexuality and gender identity disorder (as it was then known) was still  advocated by many in mainstream psychiatry.  The less permissive environment that surrounded these children may have had some influence on their comfort in expressing their gender identity.

Finally, there were a large number of children who were either lost to follow-up or refused to continue participating in the study.  These children were counted among the desistors, and yet there was no record of what their outcome was at all.  It’s not at all safe to assume that they did not go on to transition at a later stage.  We simply don’t know.

So we have a figure based on very unreliable data – how can anyone work out the desistance rate when we don’t know how many of these children had true gender dysphoria, and we don’t know how many actually did end up transitioning?

There are so many problems with this data, and it astounds me that people who claim to be experts still quote these studies over and over again as evidence of a high rate of desistance.  Unfortunately once something’s been published, even if it’s been discredited, much like the now infamous Lancet MMR-autism debacle, people will still use it as “evidence” to support their claims.

It is clear that the claims of a high rate of desistance are incorrect, but that there certainly will be some children who do not continue to express a desire to transition.  We desperately need new data to inform us about this, using proper validated measures, both diagnostically and in terms of outcomes and quality of life, for young people who have attended gender clinics.  Incidentally, I think the term desistance is terrible – it sounds like something a judge might say in court pertaining to criminal activity – we need a better way of describing this phenomenon.

Recently, in Australia, Dr Michelle Telfer from the Royal Children’s Hospital Gender Service in Melbourne provided expert witness testimony in the Family Court for the landmark Re: Kelvin case, and she stated that 96% of children diagnosed with gender dysphoria in her clinic continued to identify as transgender into late adolescence.  This suggests that the desistance rate is way lower than 85%, perhaps even less than 10%!

Which leads us to the question, what is the best course of action when it comes to managing gender dysphoric children?  The view taken by paediatric gender clinics around the world is that we should practice affirmative care, and allow these young children some autonomy regarding their gender, ie they should be able to choose a name and pronouns and clothing that they feel comfortable with.

More detail on how to diagnose and provide affirmative care can be found here in the recently released Australian Standards of Care and Treatment Guidelines for Trans and Gender diverse Children and Adolescents.

Let’s be clear –  the mainstay of care prior to puberty is affirmation and assistance with social transitioning.  Medical treatment is not considered until a child reaches puberty and persists in their trans identity.  At this point puberty blockers will usually be offered, and it is only later that cross gender hormones are considered.  Surgery is not offered in Australia to those under the age of 18.  Puberty blockers effectively stop development in its tracks, thus buying time and preventing irreversible events such as breast development, facial hair and deepening voice.  Not offering puberty blockers is not the same as doing nothing, it is doing harm – read this blog by transgender man Matt Ellison for more on this.

By the way, this whole idea of blocking puberty and keeping trans children in a “holding pattern” while time elapses is increasingly being seen by many as too conservative, forcing kids to miss out on going through puberty at a normal age with their peers, and instead having a delayed puberty in their late teens instead.  There is a growing movement to shorten the time of puberty blockade and allow these kids to properly hormonally transition at a more appropriate age developmentally.  This is a contentious area, with many experts cautious about having too liberal an approach to treatments that will cause irreversible bodily changes.  Nevertheless, there are many with a lot to say about this.

But let’s go back to those pre-pubertal children.  A major concern cited by critics is that psychological harm is done by allowing children to socially transition if they then later change their minds and “detransition” or desist.  Note that social transition does not involve any medical treatment whatsoever, it just means letting the child dress and use language to describe themselves that feels more authentic.  There are no puberty blockers or hormones or surgery.  Just kindness and understanding.  Affirming a child’s gender identity by allowing them to present as they prefer has not been shown to be a problem if they later decide to go back to their birth gender and name.  In fact there is no evidence that this flexibility leads to any harm in those children who desist in their transgender identity.  They simply go back to using their old name and pronouns, and eventually everyone else in their social circle (friends, family, school) moves on as well.

Another criticism of affirmative care is that it somehow encourages children to be more transgender, that by giving them permission to express themselves we will cause them to become inauthentic and feel pressured to pursue transition even if they’re not truly trans.  There is absolutely no evidence for this.

In contrast, great harm is done when a child with gender dysphoria is prevented from expressing and living as their affirmed gender – the risk of serious mental health problems, self-harm and suicide is very high.  From the treatment guidelines – “withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including depression, anxiety and suicidality, social withdrawal”

Therefore it is clear to me that if we as medical professionals are to uphold the principle of primum non nocere (first, do no harm) we must carefully assess these children and support them in their gender identity until such time as it becomes apparent that they fully intend to transition, and we should look to recent properly collected and analyzed data to inform our decision-making now and in the future, and not rely on outdated claims.

Parents may be interested in the following links to support organizations and resources: Parents of Gender Diverse Children

The Gender Fairy a book for children and their families by Jo Hirst, parent of a trans child

Archer Magazine interview with Jo Hirst

Dr Fiona Bisshop MBBS FRACGP