Should a boy who grows out his hair, likes to wear pink, and prefers to jump rope at recess rather than play football be raised as a girl instead of a boy? Several recent pieces in prominent media outlets would have us believe that this is a major issue in North America. In the latest such piece, “The Transgender Battle Line: Childhood,” an op-ed that appeared in the Wall Street Journal on Jan. 4, doctoral student of sexual neuroscience Deborah Soh raises alarm that many feminine boys and masculine girls are being encouraged by their parents and therapists to undergo social transitions, changing their names and pronouns to live full-time in the other gender. Soh characterizes these transitions as premature and in contradiction with established research, citing studies showing that most children who are gender nonconforming do not grow up to be transgender adults.
The central problem with this often-made argument is that it treats all children who violate cultural gender norms as a single category, when in fact there is a wide range of such children in the world. On one end of the spectrum are children who enjoy toys and clothing that are stereotypically associated with the opposite sex (imagine a girl who loves G.I. Joes and rough-and-tumble play or a boy who love Barbies and ballet). In the middle are children who express a lot of unhappiness about being a member of their gender group. For example, a boy who says he wishes he were a girl because then no one would tease him about his preference for nail polish or the fact that he only plays with girls. At the other end of the spectrum are children who consistently, persistently, and insistently assert that they are members of the opposite sex and who are beside themselves when they are not allowed to live as such. Such children sometimes resort to self-harm or become anxious and depressed that others will not recognize their gender identity. Importantly, while some children in the last group undergo social transitions, we see no evidence that anyone believes that children elsewhere on the spectrum should do so. We believe these recent articles, whose authors, to our knowledge, do not work with transgender children, overlook key differences within the spectrum of children who do not conform to gender norms, misinterpret past research, and misconstrue interventions to help transgender children.
In describing her own childhood gender dysphoria, Soh praises her parents’ approach to her dysphoria. She explains:
I myself was a gender-dysphoric child who preferred trucks and Meccano sets to Easy-Bake Ovens. I detested being female and all of its trappings. Yet when I was growing up in the 1980s, the concept of helping children transition to another sex was completely unheard of. My parents allowed me to wear boys’ clothing and shave my head, to live as a girl who otherwise looked and behaved like a boy. I outgrew my dysphoria by my late teens. Looking back, I am grateful for my parents’ support, which helped me work things out.
Soh implies that if only parents weren’t so rigid about gender norms, so stuck on the idea that only boys can do boy things and only girls can do girl things, then their children wouldn’t feel the need to socially transition. We see the appeal of this argument, and we admit that at least one of us had this view as recently as a few years ago. In the intervening years, we have recruited and studied more than 150 families across the United States and Canada who have supported their children in social transitions. These families are participants in our study, the TransYouth Project, a longitudinal study that aims to track the gender development and mental health of these children, as well as children who would better be described as “gender nonconforming” (children like Soh), through adolescence and young adulthood. After three years of traveling around the country to meet with these families in their homes, in support groups, at camps, and at conferences, our beliefs have changed. Most parents of children who ultimately socially transitioned describe spending months or years doing exactly what Soh praises her parents for doing—explaining to their children that they can play with whatever toys they want and wear whatever clothing they want without having to become the other gender. Unlike the young Deborah Soh, these children were decidedly not satisfied with this solution.
In contrast to Soh, a prominent subset of researchers have recommended a more decisive approach, in what they hope will prevent children from ultimately identifying as transgender, than the one Soh describes—to simply limit or even forbid gender nonconforming behaviors in the home and to encourage gender conforming ones instead. At the TransYouth Project, we know many families who employed one or both of these strategies at various points in their child’s lives—trying to convince their child that that he can play with whatever toys he wants without needing to be a girl, or simply forbidding the child from any expression of gender nonconformity. Still other families tried to ignore the gender nonconforming behavior and pleas altogether. These families were ultimately persuaded by the child’s persistence—and, oftentimes, by the child’s obvious suffering and even self-harm—to try something new, in this case a social transition.
Nearly every piece that raises the issue of social transitions among transgender children cites what we call “the 80 percent statistic,” which refers to a 1995 study by Zucker and Bradley that found that, within a group of 45 gender nonconforming children, 80 percent were not transgender at follow-up (usually in the high-school years). Historian Alice Dreger described this finding in a June 2015 article in Wired:
The data we have indicates that a large percentage of boys who act statistically more “feminine” as children—who dress up in girlish clothing, prefer social role-play games to contact sports, are highly attentive to their mothers and aunts, and feel budding sexual attraction towards male—will end up not as transgender women, but as gay men, at least in our culture. Only a small number will grow up to be straight transgender women.
These findings are used to argue that social transitions should not be encouraged, because according to the logic, around 80 percent of these children who are identified as gender dysphoric will not ultimately be transgender if left alone or given proper therapy. Here, again, the distinction between transgender children and the rest of the spectrum of gender nonconforming children is critical to acknowledge. The studies that found this 80 percent number (or similar numbers) included a broad range of gender nonconforming children. The authors of this particular study, Zucker and Bradley, wrote that it is actually quite rare for children who are brought to gender clinics to believe themselves to be the other gender. Much more common were children who showed cross-gender behaviors, who may have wished they were the other gender at times but still saw themselves as members of their original gender group. Thus, most of the children who are argued to have grown out of their gender dysphoria never claimed a transgender identity to begin with.
Perhaps the clearest evidence that most children in these samples were never transgender to begin with is that, when they were directly asked “are you a boy or a girl” as part of a battery of intake questions, an overwhelming percentage (more than 90 percent) of children in these clinics provided the answer that aligned with their natal sex. Is it so surprising that the majority of boys who in childhood believed themselves to be boys in adulthood believed themselves to be men? As one research team based in Amsterdam concluded: “[E]xplicitly asking children with GD [gender dysphoria] with which sex they identify seems to be of great value in predicting future outcomes for both boys and girls with GD.” That is, even within samples of gender nonconforming children, the ones who say they are the other gender are the ones who are most likely to say the same thing later in life.
This is not to say that a transgender identity in childhood never desists in adulthood. The truth is that we do not know precisely how many transgender children will grow up to be transgender adults, because no long-term studies have recruited a large number of children who believe that they are members of the opposite sex nor separated the few they have included in past studies from the broader group of gender nonconforming children. Until the start of our project in 2013, we knew of no studies tracking large numbers of children who specifically identified as transgender in early childhood. Thus, while most popular articles on this topic imply that 80 percent of children with transgender identities will not grow up to be transgender adults, we believe it is more accurate to say that we have no good estimate. What little data do exist suggest that many transgender-identified young children do in fact become transgender-identified teens and adults.
What happens if transgender children socially transition and then change their minds? This is a frequent worry not only in articles on the topic but also of many parents of transgender children. Soh raises this concern:
Consider a 2011 study of 25 adolescents who had been gender dysphoric as children, published in the academic journal Clinical Child Psychology and Psychiatry. Two girls who had undergone social transitioning to boys—by taking on male-typical appearances—regretted it and struggled to detransition. One wanted to begin wearing earrings, but said she couldn’t because she “looked like a boy.” The other, hoping for a fresh start with high school, hid childhood photos at home that depicted her time living as a boy. Both feared teasing from their peers.
Importantly, the study that Soh cites here specifically notes that none of the children in the study actually socially transitioned. That is, while these two female children appeared such that strangers might have mistaken them for boys because of their haircuts, they did not change their pronouns to live as boys. (Actually, they seem to have had experiences that match Soh’s description of her own childhood.) Thus, the degree to which these two children struggled to later assume a more feminine appearance is relevant to the question of whether girls should be allowed to cut their hair short and wear masculine clothing rather than the question of whether girls should be allowed to socially transition to live as boys. From a scientific perspective, we are fortunate that today there are larger numbers of children who have socially transitioned, who can be followed to assess rates of regret and the social or psychological costs (or benefits) of “de-transitioning”—some of the many goals of our ongoing study.
Despite the focus of most of the recent articles on prepubescent children, nearly all of these pieces raise alarm about medical intervention. Our experience is that everyone gets nervous when 5-year-olds are mentioned in the same sentence or paragraph as hormones and surgery—and for good reason. Once again, though, care is needed in interpretation. First, and most critically, the only intervention that is being made with prepubescent transgender children is a social, reversible, non-medical one—allowing a child to change pronouns, hairstyles, clothes, and a first name in everyday life. No one in mainstream medicine (or elsewhere, to our knowledge) is performing surgery on or providing hormones to prepubescent transgender children. Thus, sentences such as Soh’s, “We don’t allow children to vote or get tattoos, yet in the name of progressive thinking we are allowing them to choose serious biomedical interventions with permanent and irreversible results” are simply irrelevant to the discussion of social transitions and prepubescent children.
Adolescents and adults—the very people for whom there is agreement about the persistence of gender identity—are the ones receiving the “permanent and irreversible” medical treatments. As Soh and Dreger both note in their criticisms of early social transitions, best-treatment practices include the possibility of hormones and surgery for adolescents and adults, and these interventions “can be lifesaving,” as Dreger put it.
One final point is relevant here as well: Just because children identify as transgender—and even if they continue to identify that way through adolescence and adulthood—there is no reason to assume that they will necessarily opt for hormones and surgery. Large numbers of transgender adults do not pursue these medical interventions, and we have met adolescents, even ones who have socially transitioned before puberty, who are making that same decision. So even the argument that allowing early social transitions will lead to an inevitable use of hormones and surgery is misleading.
Despite the recent alarmist calls about movements to persuade parents to socially transition their children to another gender and worry that doing so sets them up for a lifetime of hormone and surgical treatment, we know of no evidence suggesting that this is an issue. There are no calls to encourage social transitions among children who merely show preferences for objects, clothing, or hairstyles that are associated in our culture with the other gender, nor for children who sometimes wish they were the other gender. Such children are typically quite content to live in the gender assigned to them at birth, especially if they are allowed to express themselves in a safe environment, with family and peer support.
The consideration of social transitions for transgender children is a different discussion entirely. These children, who at first glance might appear similar to other gender nonconforming kids, and who for years were not differentiated within research samples, are actually distinct within the broader group. Transgender children believe themselves to be members of the other gender, and researchers, clinicians, and parents can ascertain this information by getting to know these children, and, once trust is gained, asking them. Many transgender adults recall having had this knowledge as children, and many suffered through years of therapy in which they were told they weren’t who they knew they were. The causal influence of denial of a deeply held identity and the staggeringly high levels of depression, anxiety, and suicidality observed in unsupported transgender young people—punctuated by the suicides of teens like Leelah Alcorn and Skylar Lee—remains untested, though correlational studies indicate that support is related to better outcomes. This new generation of parents of transgender children—who see statistics on these outcomes and have decided to try social transitions to avoid them—are pioneers.
We do not yet know what the outcomes of social transitions in childhood will be, but this is where people like Soh, the future generation of researchers and clinicians, as well as those who publicly write about these issues, such as Dreger, and those of us studying transgender children can hopefully all agree. By systematically studying the impact of social transitions in transgender children, and by studying outcomes in transgender children whose families make a wide array of decisions, we can best discover what is in the best interest of the transgender child.