Parents of transgender children search high and low for evidence to guide them on how to best support their child. Clear evidence is rare, with the majority of the available research being of dubious quality.

Despite the poor quality, and low relevance, of much of the older academic literature, writers continue to refer to  this and use it as evidence for sweeping and unjustified claims relating to transgender children, particularly relating to ‘persistence’ and to the potential harm of early social transition.

A new paper on this topic was published in 2016 (Ristori and Steensma – Gender Dysphoria in Childhood).

This paper, at first glance, looks to be a very recent overview of the evidence. However the article is based on no new research, instead it uses a number of older studies on which to base its conclusions and recommendations on transgender children.

As a parent of a transgender child, I’m familiar with the older studies that are summarised in this new paper.

The majority of the listed studies (whose conclusions inform this 2016 paper) were published prior to 1988, namely Bakwin 1968; Lebowitz 1972; Zuber 1984; Money and Russo 1979; Green 1987 etc. These papers were based on data from even earlier (50’s, 60’s, 70’s), collected at a time and in a social context so very different from the present, in an era when the day to day experience of being a transgender child was unrecognisably different to how it is in contemporary Britain.

These studies were undertaken in a context where transgender identities were viewed as ‘pathological and delusional illnesses’ to be ‘cured’ and in a context where any form of gender non-conformity was rejected (e.g. the focus on ‘the sissy boy syndrome’). Significantly these studies made no effort to distinguish between gender non-conforming and transgender children.

For these reasons, studies on children published prior to 1988 are not a strong guide for how to best support transgender children three decades later and can be discarded as evidence.

Only three of the listed studies were conducted post 1988.

Two of these were Canadian studies conducted under the leadership of Zucker: Drummond et al 2008 – Zucker is one of the co-authors – and Singh 2012.  Singh is a protégé of Zucker and based this publication on data collected by Zucker.

https://www.ncbi.nlm.nih.gov/pubmed/18194003

https://tspace.library.utoronto.ca/bitstream/1807/34926/1/Singh_Devita_201211_PhD_Thesis.pdf

If you’ve done even cursory reading on the subject of transgender children you’ll probably be aware that Zucker’s approach, once the accepted mainstream, is now widely discredited. Those of us who care deeply for the well-being of transgender children have significant reservations about anything he has shaped. His recent statement “if your 4 year old said they were a dog would you feed them dog food”, has done nothing to help us feel our child’s best interests are his concern. At long last even the academic establishment have begun to turn their backs on him. At the recent US-WPATH convention, Zucker’s first speaking slot was disrupted by a protest and walk-out, and the second was cancelled, with the US-WPATH organising committee apologising for having invited him in the first place.

There are many, many problems with Zucker’s approach and his data, and it is clear even from his own publications that his studies lumped together children who were non-conforming and those who were transgender (with Zucker not distinguishing between the two, as he did not, and does not, really believe in the existence of transgender pre-pubertal children). Many children in his samples were below threshold for diagnosis of Gender Identity Disorder (GID).

Zucker’s data is highly suspect, and not useful in guiding parents on how to best support transgender children. It can safely be discarded as evidence.

A brief note on Gender Identity Disorder, or GID. This was a measure that was used to diagnose children and distinguish them from those who had no discomfort with their sex at birth. Note that Gender Identity Disorder is itself a contested concept. For many, being transgender is not a disorder, and increasingly it is being removed from psychological text books – these papers use the term GID, and it makes sense to use the same terminology here, if only as  useful shorthand, however that doesn’t mean we like or support the acronym or the concept of diagnosis -in fact the opposite.

In this new Ristori and Steensma 2016 paper we are therefore left with just one study post 1988 that does not rely on Zucker’s data, namely Wallien and Cohen Kettenis 2008. https://www.researchgate.net/publication/23449293_Psychosexual_Outcome_of_Gender-Dysphoric_Children

Like many fellow parents, I have read this Wallien and Cohen Kettenis 2008 study closely (and also much of Steensma’s PhD which looked at the same data available at http://dare.ubvu.vu.nl/handle/1871/40250). The abstract for the 2008 paper states that the study found a 27% persistence rate. I like to look through the actual data (presented in a clear summary table in the main article of the Wallien and Cohen Kettenis 2008 paper). I was surprised by what I read.

They started with a sample of 77 children.

19 of these children were not classified as reaching the criteria for GID to begin with.

Interestingly zero of the children from this non-GID group (not transgender to begin with group…) were transgender at follow up. It is not at all surprising to me that children who were referred to a gender clinic for non-conformist behaviour but did not meet the criteria for GID would not end up transgender later on. It is surprising however that this conclusion, that is clear in the data table (zero percent of non-GID children end up as transgender), is not mentioned once in the paper or in the abstract. Seemed strange to me to omit this obvious finding. The only reason I could think of to avoid mentioning this clear finding is if the author wanted to lump together non-GID children with GID children in their analysis.

There were 58 children in the original sample who were assessed as meeting criteria for GID at the start. From this sample, 16 were not contacted, leaving 42 children who could be traced. 6 were unwilling to be interviewed but allowed their parents to be interviewed – the study adds these to the desistance group based on very unsound reasoning (it states that since the demographic of this sample of 6 matches the demographic of the desister sample (in terms of nationality, family income) these 6 can be added to the desister category. This assumption lacks both logic and research ethics, so these 6 need to be omitted.  That leaves 36 children (both with GID at the start and willing to be interviewed later on) upon which the study needs to rely.

From these 36 children, 21 were counted as persisters. 15 were counted as desisters. We can do some very basic math on this. 21/36 persisters, 15/36 desister. This study shows that for children reaching criteria for GID, 21 (58%) persist and 15 (42%) desist. Yet this 58% persistence figure, that appears very clearly in the data table, is not mentioned anywhere in the paper or the abstract. Nor is this 58% persistence statistic mentioned at all in the recent 2016 paper that uses this paper as evidence.

In a later follow up study on the same cohort, researchers found that some of the supposed ‘desisters’ had re-entered the service at a later point and so were not really desisters and that the persistence rates found ‘would likely be higher in reality’. So this study itself suggests a persistence rate of higher than 58%.

Given how clearly the two above conclusions are in the data table (zero persistence rate amongst children who were not classified as GID to begin with, and 58% persistence rate in children who were classified as GID to begin with) I was astonished that this paper could be published in a reputable journal without the peer reviewers or editor asking the author why they omitted these two findings and instead reported a 27% persistence rate (which can only be deduced if you include the children who were not GID to begin with in the sample and if you assume the children who were not contacted or unwilling to be interviewed were all desisters). Perplexed by this I looked up the journal, and saw that this article appeared in a special edition with the editorial by Zucker. You couldn’t make it up.

Certainly these studies listed in the 2016 paper provide no conclusive evidence that consistent, persistent, insistent transgender children are likely to desist. In fact the best of these bad studies does not support desistance at all, but instead clearly showed a 58% persistence rate).

Yet this 2016 paper does indeed use the percentages in this range of outdated and unreliable research studies to draw strong conclusions stating confidently that “the conclusion from these studies is that childhood GD is strongly associated with a lesbian, gay, or bisexual outcome and that for the majority of the children (85.2%; 270 out of 317) the gender dysphoric feelings remitted around or after puberty”.

For children who are consistently, insistently and persistently stating a clear transgender identity, the available research simply does not show “that for the majority gender dysphoric feelings remitted around or after puberty”. This is very poor research and analysis – our transgender children deserve better.

The best that an ethical and responsible researcher should conclude from the available studies is that there is a lack of effective research data available, and further research (that clearly distinguishes gender non-conforming from transgender children) is desperately needed.

Another subject that this 2016 paper focuses upon is the different options for how to best support transgender children, including consideration of a gender affirmative approach (the approach clearly endorsed by the leading US pediatric organisation). Here the 2016 paper quotes a finding that appears time and again in recent academic publications – the concern that socially transitioned children (who haven’t had permanent medical interventions) would be traumatised if they needed to later transition to a natal gender identity. The 2016 paper states that “the fact that transitioning for a second time can be difficult was indeed shown in the qualitative study by Steensma et al. (2011) where children who transitioned early in childhood reported a struggle with changing back to their original gender role when their feelings desisted, with the fear of being teased or excluded by their peers reported as the main reason for this”. This conclusion, which is the key listed reason to avoid a gender affirmative approach, is based on a single study.

This study by Steensma, included discussion of two natal girls who had not at any point socially transitioned to male – the two girls had changed their gender role and adopted less feminine clothing, but neither had changed their name, neither had changed to a male pronoun, they had not told their classmates they identified as male, they had not told classmates to call them a boy – in short they had clearly not socially transitioned. The trauma that is reported occurred when they changed their behaviour or gender role back to a more stereo-typically female behaviour/role/clothing and was not linked to ‘transitioning’ back to a female identity (they could not transition back since they did not socially transition to male in the first place).

It is unethical for the original piece of research (again by Steensma) to quote this as an example of the harm of social transition, and it is lazy and unethical of later researchers (like this 2016 paper) to quote Steensma’s finding without re-examining the original case. There are now hundreds (or thousands perhaps) of socially transitioned children, and parents are regularly being told that our children would be harmed if they needed to later (before medical intervention) transition a second time. This advice is based on the irrelevant conclusions of a tiny sample within a study made up of flawed data. The conclusion simply has no relevance on social transitioning.

Caring parents of transgender children are desperate for clear evidence on the pros and cons of different approaches, and are of course interested in issues including the likely persistence rate (for children who are consistently, insistently and persistently stating a transgender identity to start with) and also the potential harm if socially transitioned children needed to later (pre-permanent medical intervention) transition again. On these issues families with transgender children are greatly let down by the available academic research.

Criticisms of often mentioned 80% desistence figures have been written numerous times in blogs, presentations, conference seminars and non-academic publications.

http://www.huffingtonpost.com/brynn-tannehill/the-end-of-the-desistance_b_8903690.html

https://gidreform.wordpress.com/

http://transadvocate.com/the-new-york-magazine-lies-to-parents-about-trans-children_n_18875.htm

http://juliaserano.blogspot.co.uk/2016/02/placing-ken-zuckers-clinic-in.html

http://www.slate.com/blogs/outward/2016/01/14/what_alarmist_articles_about_transgender_children_get_wrong.html

However correct and damning, these critiques in non-academic publications appear to hold little influence on those medical professionals whose opinion shapes the care that transgender children receive (at least in the UK context).

We need a clear critique of the current evidence (and how it has been and should be interpreted) to be written by an academic and published in a respected peer reviewed journal. Until that happens, parents of trans children will continue to have deeply flawed ‘evidence’ (like this 2016 paper) foisted upon us.

I know some researchers out there are very aware of the lack of effective evidence on persistence and outcomes for transgender (as opposed to non-conforming) children. Such researchers are undertaking much needed new research – which will be extremely useful to families in future decades.

To help parents and families right now, we would much appreciate a peer-reviewed journal article clarifying why this new research is so very much needed, and why the studies listed in this 2016 paper are not an effective evidence base on which to ground strong conclusions on likely desistence and harm of social transition.