Read on for new (as yet unpublished) ‘desistance’ statistics from Australia (Spoiler: it may be as low as 4% ‘desistance’).

The 85% ‘desistance’ myth

Anyone with even a cursory awareness of issues relating to transgender children will have heard the 85% ‘desistance’ myth. Some old and flawed research studies, that lumped together large numbers of gender non-conforming cisgender children with transgender children, claimed astonishingly high levels of supposed ‘desistance’, ie children who held a cisgender (not transgender) identity after puberty. These studies are flawed in many ways, including in their analysis, where they assumed that children who could not be contacted or declined to be interviewed were all so called ‘desisters’. These statistics often relied upon older data from the 1970s and 1980s, a period in which societal acceptance for transgender people in the West was a long way behind where it is today. The 85% ‘desistance’ myth has been widely criticised:

See here from Zac Ford;

See here from our own ‘growinguptransgender’ blog;

See here from Brynn Tannehill;

See here and here from Kelley Winters;

See here from Julia Serano;

See here from Kristina Olsen and Lily Durwood;

Nevertheless, it is difficult to get rid of an old statistic, no matter how discredited, when there is not a better one available. Hence many of us have been eagerly awaiting new figures from the United States, where longitudinal research on a cohort of transgender children is currently underway.

The myth that will not desist

Despite the clear evidence and analysis that the research studies underpinning the 85% ‘desistance’ statistic are deeply flawed and unreliable, academic paper after academic paper on transgender issues continues to repeat this old discredited 85% figure. It is easier to present the mistakes of the past than to engage in this topic, especially where the research is not specifically focused upon gender dysphoria in children, and where the author is required to discuss persistence only as part of a wider survey of the literature. However discredited the 85% ‘desistance’ figure is, it keeps getting published as there is not (until now), a better ‘desistance’ statistic to put in its place.

Endocrine society continues the myth

The 2017 Endocrine Society guidelines still refer to the 85% figure, though they do at least note that  non-conforming children may be included in those older studies and acknowledge that persistence rates may well be different in future studies.

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (Source: Steensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013; 64(2):288–297.”

“Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.”

The above paragraph is disappointing from the Endocrine Society. If a statistic is known to be useless then it is better to have no statistic at all than a wrong one.

In the words of Brynn Tannehill:

“the 84 percent desistance figure is meaningless, since both the numerator and denominator are unknown, because you have no idea how many of the kids ended up transitioning (numerator), and no idea how many of them were actually gender dysphoric to begin with (denominator).

Scottish Gender Recognition Act (GRA) Consultation

The newly released Scottish Gender Recognition Act consultation has taken an even more disappointing approach than the Endocrine Society – they do not make it clear that the 85% ‘desistance’ rate is widely discredited and they combine it with other statements about gender changes at around puberty that are based on fundamentally flawed research (see below).

In the section 4 “What research evidence is available” the Scottish GRA consultation document states:

4.1 There is evidence that children can experience incongruence between their assigned gender and their gender identity early in life. One study indicates the average age was 8.

4.2 There is a limited evidence base about whether children will continue to experience these feelings in the longer term. Follow-up studies indicate overall that for 85.2% of the children, their distress discontinued either before or early in puberty.

However, the rates in the individual studies varied widely. For instance, a 2008 study indicated that in 39% of children the feelings did continue beyond the onset of puberty whereas older studies from before 2000 had very much lower rates for children continuing to experience distress after the onset of puberty. It is thought that pre-2000 studies have included children who would not now be considered to be experiencing gender dysphoria. The studies may also be affected by the small clinical population of children with gender dysphoria – studies looking at whether gender dysphoric feelings persisted had a total population of 317 people.

4.3 There is also evidence that the more extreme a child’s gender dysphoria was before puberty, the less likely it was that their feelings will recede with the onset of puberty. For those who have reached puberty and continue to experience distress, evidence indicates that their distress then tends to intensify and that depression or self-harming behaviours are also more common in ages 12 and over. It is understood that physical changes caused by puberty may intensify the levels of distress experienced.

4.4 Available evidence suggests that factors arising around the ages of 10 to 13 may help explain changes in how a child feels about their gender: · the changes in social roles between boys and girls as their gender role become more distinct; · the anticipation or experience of physical changes as a result of puberty; and · their first experience of experiencing falling in love and discovering their sexual identity. “

The references (evidence base) for point 4.2 in the Scottish GRA consultation relies on the two deeply flawed and uncredible studies of Wallien and Cohen-Kettenis (2008) and Ristori and Steensma (2016), two papers whose multiple weaknesses we have previously addressed.

Point 4.4 also refers solely to another Steensma study (2010) that we demonstrate to have multiple flaws. The ‘evidence’ is outrageously weak and fundamentally unreliable, and should not have been quoted in the Scottish GRA consultation document.

This false information forms a key part of the information upon which Scottish stakeholders are to make decisions on the appropriateness of rights to legal identity recognition for under 16s. Stating 85% ‘desistance’ has the risk of influencing Scottish stakeholders away from supporting the rights of transgender children and adolescents.

The UK NHS Children’s Gender Identity Service continues the myth

Dogged adherence to the discredited 85% ‘desistance’ figure on the behalf of the UK Children’s Gender Identity Service continues to have serious and damaging effects on transgender children in the UK. A recent publication (Costa 2016) by two experts at the UK Gender Service, makes it clear that belief in this flawed ‘desistance’ rate is the key factor underpinning their insistence on a ‘watchful waiting’ (also known as delayed transition) approach.

“Treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults”

“The percentage of children initially diagnosed with gender dysphoria who display persistence of the condition ranges from 12–27%, indicating that the majority of children meeting gender dysphoria criteria do not have persistence of the condition by the time they have entered puberty.”

“Most importantly, this approach is based on the evidence is that only a minority of those with untreated childhood gender dysphoria will identify as transsexual or transgender in adulthood, while the majority will become comfortable with their natal gender over time”

“A second approach considers it crucial not to interfere with the child’s development. ….the basis of this strategy is the absence of clear-cut predictors of gender dysphoria persistence in adulthood and the evidence that a substantial percentage of gender-variant behaviour in childhood will not culminate in adult gender dysphoria”

The service continue to quote this statistic to parents of insistent, consistent and persistent transgender children, telling them that their specific children will almost certainly shift to a cisgender identity at puberty – statements that have the risk of discouraging parents from listening to, accepting and loving their child.

Many of us have been hopefully looking to the United States for some better figures on ‘desistance’. But as we have looked West, some new figures have emerged from Australia.

November 2017 game changer: landmark Australian court case on transgender rights

A recent landmark court case in Australia described as “the greatest advancement in transgender rights for children and adolescents in Australia”, successfully removed a requirement for court approval for the prescription of cross sex hormones for gender dysphoric adolescents.

As part of the multiple court proceedings for that case, a “battery of reports from experts” were commissioned by the court. Dr Michelle Telfer, a world leading specialist in transgender children’s health,  of the Royal Children’s Hospital in Melbourne (and one of the authors of the new Australian Guidelines) was one of the key expert witnesses called to produce evidence from the Australian Gender Service. This evidence is summarised in the publicly available court report for the case titled ‘Re: Kelvin’ that was released this week:

FAMILY COURT OF AUSTRALIA RE: KELVIN

“The fifth intervenor, the Royal Children’s Hospital Gender Service in Victoria is a specialist unit comprising of a team from multiple disciplines including Paediatrics, Psychiatry, Psychology, Endocrinology, Gynaecology, Nursing and Speech Pathology. Since its commencement in 2003, the Gender Service has received 710 patient referrals including 126 between 1 January 2017 and 7 August 2017. 56. 96 per cent of all patients who were assessed and received a diagnosis of Gender Dysphoria by the 5th intervenor from 2003 to 2017 continued to identify as transgender or gender diverse into late adolescence. No patient who had commenced stage 2 treatment had sought to transition back to their birth assigned sex. No longitudinal study is yet available.” <page 8 points 55 and 56>

“Senior counsel continued: In addition, we have evidence from Dr Telfer which has made its way into the case stated at paragraph [55] about the experience of the gender service of the Royal Children’s Hospital over a period from 2003 to 2017, which also encompasses, therefore, new medical knowledge and, in particular, at paragraph [56] Dr Telfer’s affidavit – I’m sorry the case stated, picking up from Dr Telfer’s affidavit, the case stated records as a fact that 96 per cent of patients treated for gender dysphoria at the Royal Children’s Hospital continue to identify as transgender into late adolescence and so one sees some evidence there about persistence of gender dysphoria. Again, we would say that data is new. (Transcript, 21 September 2017, p 66, l 37 – 45)” <page 33 point 160>

Let’s focus on the the critical line:

“From 2003 to 2017 96 percent of all patients assessed and diagnosed with Gender Dysphoria continued to identify as transgender or gender diverse into late adolescence”.

This evidence is stating is a 96 percent ‘persistence’ rate into late adolescence. This implies a 4% ‘desistance’ rate. This may mean that only 4 percent of children diagnosed with Gender Dysphoria might shift to a cisgender (not transgender) identity. This represents a wildly divergent statistic than the 85% ‘desistance’ myth, and much closer to the anecdotal findings of those who have experience parenting, working with and supporting transgender children.

Here’s the words of Marlo Mack, a parent of a trans child:

“As the mother of a young trans daughter who has spent the past six years interacting with hundreds of families with kids like mine, the notion that detransition is rare strikes me as a statement of the obvious. In fact, the “80 percent of these kids change their minds” statistic feels a lot like Trump’s inauguration crowd size claims. If 80 percent of these kids are really desisting, where the hell are they? You’re telling me they’re there, but I’m just not seeing them. I’ve actually never met one.”

What would a 4% ‘desistance’ mean in practice? 

The Australia statistic refers to persistence “until late adolescence” (they can’t yet have longer term data – and we will have to wait until this cohort of young people grow into middle age). However, given that even many of the flawed studies on ‘desistance’ acknowledge that those who are transgender at late adolescence will almost all persist through adulthood this provisional 4% ‘desistance’ figure should cautiously be taken as an important data point.

This has potentially huge implications for policy. For how our society listens to, respects and supports transgender children. For how the media portray transgender children. For how specialists, including the UK Children’s GIDS talk to parents about transgender children. Remember the UK NHS website still looks to the outdated, flawed research and says:

“Across all studies approximately 16% continue with their gender identification”

It is time to put the 85% ‘desistance’ myth in the bin where it belongs.

The Australian 4% ‘desistance’ figure has not yet been formally published, and until we have peer reviewed analysis they should be treated cautiously. It is however derived from data collected from the 710 individuals who have been seen from the inception of the Melbourne gender service in 2003 and has been provided as evidence in legal proceedings. It should be treated as the most representative  data point we have to date for likely outcomes of gender dysphoric children.

While we await data from the longitudinal studies being led by Kristina Olsen and others in the United States, let us discard the 85% desistence figure that is known to be junk science. We know how much damage the 85% ‘desistance’ figure causes. Let’s call an end to this harm.

Let’s start with the upcoming UK Gender Recognition Act consultation.

To the Women and Equalities Select Committee, to the Secretary of State for Equality, and to all engaged in planning the UK GRA consultation document: – do not repeat the failings of the Scottish consultation document – do not use the discredited ‘desistance’ figure that is not only unreliable, but is shown by this new Australia data to be grossly inaccurate and misleading.

To stakeholders in Scotland: It is not acceptable that the consultation documents include this junk 85% ‘desistance’ statistic, without fair acknowledgement that it is widely discredited. If the real ‘desistance’ figure in the UK is even remotely close to the 4% ‘desistance’ provisionally found in Australia, the 85% figure is not just junk science, it is grossly misleading and actively harmful. It is not hard to see that ill-informed stakeholders across Scotland are much less likely to support the rights of transgender under 16 if they are told that 85% will shift to a cisgender identity. If those same stakeholders had been told that the latest findings demonstrate only as few as 4% of transgender children may later shift to a cisgender identity, it is feasible the consultation would come up with very different results. It is incumbent upon those in Scotland to make up for this disgraceful error, and make sure the rights of transgender under 16s are respected in the forthcoming revised Scottish GRA.

To Michelle Telfer and colleagues from the Australian Gender Service: thank you for providing this data and for providing evidence based advocacy on behalf of transgender children. The 85% ‘desistance’ myth causes so much damage in so many spheres. Please can you publish your data, even in its raw form, within a peer reviewed journal. Please give more information on the sample size, how many were pre and post adolescence, the ages of your sample group; It is crucial to ensure the 85% ‘desistance’ myth is not repeated in WPATH Standards of Care 8, dooming another generation of transgender children to disbelief, delay and denial of care.

To Gail Knudson and Board Members of WPATH: Please consider how you can ensure WPATH SOC 8 does not continue to perpetuate discredited statistics like the 85% ‘desistance’ myth. This causes real harm. Where evidence is flawed it must be discarded. To include statistics that are unreliable, and that in light of initial findings from Australia, may be wildly incorrect, is unethical and causes extensive harm.

To the UK NHS Tavistock Children GIDS. Please adapt and learn from the example of Australia where a specialist from the Australian children’s gender identity service is advocating, including in court proceedings, for the rights of transgender children.

Please consider publishing the data that has been collected. We need more information and analysis on how the UK figures compare to Australia and other children’s gender identity services worldwide. Publish your data.

To parents of transgender pre-pubertal children who have been repeatedly told that your specific insistent, consistent, persistent transgender child will almost certainly shift to a cisgender identity at puberty, despite the clear lack of examples of this happening with any enormous frequency. Now is the time to listen to your children. Now is the time to demand better from those who are meant to care for and support them.

References

Costa, R. Carmichael, P., Colizzi, M. (2016) To treat or not to treat: puberty suppression in childhood-onset gender dysphoria Nature Reviews Urology 13, 456–462

FAMILY COURT OF AUSTRALIA RE: KELVIN (2017)

Ford, Z. (2017) Think Progress: ‘The pernicious junk science stalking trans kids‘

Growing up Transgender, A plea for better transgender research on the perpetual myth of ‘desistance’ and the ‘harm’ of social transitioning; 2017. 

Growing up Transgender, Australian Gold Standard of Care for Trans Children; 2017

Growing up Transgender, Diagnostic importance of starting puberty; 2017.

Hembree, W., Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen; Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903,

Mack, M. (2017) ‘Hit by trans friendly fire‘

Olsen, K. & Durwood, L. (2016) ‘What alarmist articles about transgender children get wrong‘

Ristori, J and Steensma T.D (2016) “Gender dysphoria in childhood” in International Review of Psychiatry, Gender dysphoria and gender incongruence, Vol 28, 2016 Issue 1.

Scottish Government (2017) Review of the Gender Recognition Act 2004 A Consultation,

Serano, J. (2016) ‘Placing Ken Zucker’s clinic in historical context‘.

Steensma T.D et al (2010) “Desisting and persisting gender dysphoria after childhood; A qualitative follow up study”, Clinical Child Psychology and Psychiatry Vol16 issue 4

Tannehill, B. (2016) Huffington post: ‘The end of the desistance myth‘

UK NHS Gender Identity Service Website, ‘Continuing and not continuing studies; accessed November 2017

Wallien and Cohen-Kettenis (2008) study “Psychosexual outcome of gender-dysphoric children” Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423 study

Winters, K. (2016) transadvocate.com: ‘The New York Magazine Lies to Parents about trans children‘

Winters, K. (2017) Australian ’60 Minutes’ report Misrepresents Trans Youth Medical Care

 

 

Post script: Risks of not providing treatment

The Australian court transcripts also include this section on Risks:

Risks of not Providing Treatment

17. Failure to provide gender affirming hormones results in the development of irreversible physical changes of one’s biological sex during puberty or the development of changes that lead to the need for otherwise avoidable surgical intervention such as chest reconstruction in transgender males or facial feminisation surgery in transgender females.
18. The prolonged use of puberty blockers (stage 1 treatment) has long term complications for bone density (osteopenia) namely osteoporosis and bone fractures in adulthood. Best practice is to limit the time an adolescent is on puberty blockers and then commence oestrogen or testosterone. Delaying stage 2 treatment for those on puberty blockers also results in psychological and social complications of going through secondary school in a pre-pubertal state which is inconsistent with the child’s peers. [2017] FamCAFC 258 Reasons Page 5
19. The distress caused by Gender Dysphoria can lead to anxiety, depression, selfharm and attempted suicide.
20. Individuals with Gender Dysphoria who commence cross sex hormone therapy generally report improvements in psychological wellbeing. An affirmation of their gender identity coupled with improvements in mood and anxiety levels typically results in improved social outcomes in both personal and work lives.
21. For a transgender male, manifestations of increased body hair and deepening of the voice are generally considered by them as positive.
22. For transgender females if stage 2 treatment is not administered another risk is linear growth beyond their expected final height.
23. Some patients receiving treatment for Gender Dysphoria have reported purchasing hormones over the internet or illegally obtaining hormones through prescriptions written for other people. They have also reported that oestrogen and testosterone are cheap and freely available over the internet or through friends or acquaintances. Accessing hormones in this way is dangerous for several reasons including the risks of complications from blood borne viruses such as Hepatitis B, Hepatitis C and HIV contractible with shared use of needles and syringes and the taking of inappropriate dosages of hormones which can be life threatening.