Rapid-onset gender dysphoria: New study recruiting parents

UPDATE August 18, 2016: The National Review is reporting this morning that the study was “launched” by 4thWaveNow. While we are very glad to see this research effort take place, the study was initiated and is being carried out by Lisa Littman, MD, MPH at Mt. Sinai in New York. Please see below for details.


Many members of the 4thWaveNow community are parents of teens who became convinced they were the opposite sex after a steady diet of social media and/or peer influence. In most of our cases, the transgender identity came on suddenly and with little warning.

Our families’ experiences haven’t been acknowledged nor reflected in the mainstream media, but now a researcher has decided to systematically investigate the phenomenon.

The survey study is being conducted by Lisa Littman, MD, MPH, Adjunct Assistant Professor, Icahn School of Medicine at Mount Sinai, New York. Dr. Littman’s survey description is below. The SurveyMonkey link at the bottom of this post contains more detailed information.

If you are–or know of–a parent in this situation, please consider participating in the survey. Note that responses are kept anonymous.


Rapid onset gender dysphoria, social media, and peer groups

GCO# 16-1211-00001-01-PD

We have heard from many parents describing that their child had a rapid onset of gender dysphoria in the context of increasing social media use and/or being part of a peer group in which one or multiple friends has developed gender dysphoria and come out as transgender during a similar time frame. Several parents have described situations where entire friend groups became gender dysphoric. This type of presentation is atypical and has not been studied to date.  We feel that this phenomenon needs to be described and studied scientifically.

If your child has had sudden or rapid development of gender dysphoria beginning between the ages of 10 and 21, please consider completing the following online survey. If you have more than one child with gender dysphoria who fits the above description, please complete one survey per child.

This survey is completely anonymous and confidential and conducted through Survey monkey, an independent third- party. There is no way to connect your name with your responses. We do not track email or IP addresses. The survey should take 30-60 minutes. Participation in this research study is voluntary, and you may refuse or quit at any time before completing the survey.

If you know of any individuals with a similar experience who might be eligible for this survey, or any communities where there might be eligible parents, please copy and paste this recruitment notice and survey link to share.

https://www.surveymonkey.com/r/SCX9RZY

Littman ressearch study

Brain sex: The jury is still out—but does it matter?

Early this morning, Think Progress (a “progressive” news outlet) posted on Facebook what was meant to be a provocative pull-quote from its latest trans-kid piece by reliable journalist propagandist Zack Ford, “It Takes A Village To Bully A Transgender Kindergartner”:

And what exactly is the “need” of this child? A boy in kindergarten would like to be accepted as “girl”? Well, as a woman, I take offense at any boy who is pretending to share my gender when he quite clearly NEVER can nor ever will. … He is not. He never can be.”

The commenter quoted is, of course, a woman (a bigoted bully, as seen through Ford’s tunnel-vision lens) who questioned the parents’ need to socially transition their 5-year-old child. The child’s transgender status has resulted in a giant kerfuffle as result of the Minnesota school’s dilemma in deciding what to do to accommodate the kindergartner.  Zack Ford paints anyone who questions the wisdom of a 5-year-old boy being assured he is really a girl as an ignorant transphobe, a bigot supported only by right-wing conservative groups.

Zack Ford Facebook
In this post, I’m not going to be writing about the fact that it isn’t just conservatives who question the trans-kid trend (obvious to anyone who reads this blog on a regular basis, or for that matter, the increasing number of blogs by left wing parents, professionals, and feminists. Check out my blogroll). Nor will I be dissecting in detail this “news” article set out as bait on the Think Progress Facebook page to incite the reliable progressive hordes.

Instead, my interest in Ford’s latest bit of Newspeak revolves around the huge number (easily 10-1) of reader comments on that Facebook post, which can be paraphrased as follows:

You stupid bigots! Go read up on the science of gender identity. Gender identity is proven, settled brain science. Little kids KNOW from the time they’re born what sex they are. Plus intersex. No one “chooses” to be transgender, they’re born that way.

 I’ve spent thousands of hours marinating in gender dogma and research studies, both pro- and con-, re: “innate gender identity.” So while it’s no surprise to me to see some people spouting as FACT the totally unproven hypothesis that gender identity is set in stone at birth, what does surprise me is the sheer numbers who have bought what, at best, is a tenuous theory, and who have thereby completely shut down even a modicum of critical thinking.

Of course, who can blame well intentioned progressives? They’re fed bittersweet mouthfuls of Innate Gender Identity gruel every single day not only by the media, but even by the President of the United States, who via his Department of Justice, baldly asserts on line 36 of the complaint against the state of North Carolina:

36. Gender identity is innate and external efforts to change a person’s gender identity can be harmful to a person’s health and well-being.

DOJ complaint

US v. North Carolina

(And it’s not just these few lines. The entire complaint reads like boilerplate trans-activist dogma, and interested readers are urged to take a look at the rest of this document).

This increasingly unchallengeable notion that gender identity, aka “brain sex,” is innate, hard-wired at birth, and thus absolutely unchangeable (despite the efforts of us horrible bigoted parents who are rooting for our kids to commit suicide) means, to the masses who now parrot it like the top graduates of a Maoist Re-Education Camp: Every toddler who claims to be the opposite sex must be agreed with by every adult who comes in contact with the child. Innate gender identity is the ironclad reason why no one is supposed to question the sudden flood of “trans kids” we hear about on a daily basis.

Given the gravity of all this—that little kids are now being ushered aboard a train that will lead inexorably from puberty blockers to cross-sex hormones (with concomitant irreversible changes) in 100% of reported cases–these brain sex/innate gender identity claims can’t just be ignored and dismissed. Not when so many  people—more every day—have swallowed them whole.

Here’s the thing. There is some research that supports a role for biological, genetic, or physiological factors in gender dysphoria. And as much as people on “my side” of this argument (the argument being: should children be “transitioned” to the opposite sex on their own say-so?) would like to simply dismiss any and all evidence for biological aspects of things like gender dysphoria, it’s not that simple.

Shunning entire lines of research because we are made uncomfortable by the findings should not be the way of truth seekers. If opening our minds to their claims changes our position, then so be it. As medical historian and intersex-rights activist Alice Dreger says in her book Galileo’s Middle Finger which chronicles (among other things) the chilling effect of activism on scientific inquiry,

[it is] a rare trait in activists: a belief in evidence even when it challenge[s] our political goals.

Human beings, in general, do not appreciate having their cherished ideas challenged. Political viewpoints tend to be set in stone, with any wavering seen by one’s allies as a dangerous and slippery slope. Evidence contrary to the ideological convictions of either side is taken as an existential threat to the fundamental integrity of the position.

For instance, people (like me) who support a woman’s right to abortion often avoid  acknowledging the fact that a fetus is not just an amorphous mass of cells, but a proto-human being. Conversely, anti-abortion advocates give short shrift to arguments about a pregnant woman’s agency over her body, and the critical importance of a baby coming into the world to a parent who is ready–and can financially afford–to raise the child.

The battle lines dividing those who support the idea that self/parent/activist-identified “trans” kids should be transitioned as young as possible, vs. those who disagree (like me) are drawn across a long-contested and hardened piece of ground: nature vs. nurture. And the opposing combatants are highly reluctant to give even an inch on the matter.

As you’ll see, this post is going to argue not for a détente or concession of territory, but rather, for a willingness of “my side”—the gender critics–to consider the evidence marshaled by our detractors, and then ponder whether it changes your mind. I’m only going to touch on a few areas of research typically used by the trans activist side; if you’re interested, you’ll want to spend some delving time yourself.

Let me cut to the punchline right now: Speaking for myself, weighing the claims (and the research they base it on) of the activists who want to transition children as early as possible has actually strengthened my conviction that medical transition should be an adults-only decision, if made at all. The only thing I can say I might have shifted my opinion on after endless investigation is this: There may be a very small (it’s always been very small) number of people for whom medical intervention is the only way they can live a happy life. I don’t believe we should prohibit these interventions for such people as adults. I still do not believe, weighing up all the evidence, that we should be tampering with the bodies of young people who may very well grow up to be happy without the expensive, drastic, and irreversible meddling of the gender-soaked medical and psychiatric professions. Instead, as I harp on constantly, let’s celebrate and support gender defiance in young people.

So let’s start with the obvious. [Note to regular readers: The information in the next couple of paragraphs is well known to you, but please stick with me, because I’m going to cover some research I haven’t formerly written about]. If gender identity is “innate” how come so many gender dysphoric youngsters change their minds?

4thWaveNow is chock-a-block with posts and research studies—as well as personal narratives from formerly trans-identified people who changed their minds, as well as others who experienced and resolved severe gender dysphoria in childhood—supporting the fact that many children outgrow their dysphoria and grow up to be adults happy to have bodies and brains that have not been tampered with by the medical and psychiatric professions. A 2008 meta-study by Korte et al sums it up:

Multiple longitudinal studies provide evidence that gender-atypical behavior in childhood often leads to a homosexual orientation in adulthood, but only in 2.5% to 20% of cases to a persistent gender identity disorder. Even among children who manifest a major degree of discomfort with their own sex, including an aversion to their own genitalia (GID in the strict sense), only a minority go on to an irreversible development of transsexualism.

Because so many trans activists claim that intensity of discomfort with one’s body parts is some irrefutable sign of “true transgender,” or that prior researchers didn’t adequately differentiate between “true trans kids” and the merely “gender nonconforming,” I’m going to emphasize this bit of the above quote:

even among children who manifest a major degree of discomfort with their own sex, including an aversion to their own genitalia.

Even WPATH—World Professional Association for Transgender Health—whose clinician-activists spend a good deal of time promoting younger and younger ages for “transition,” acknowledges on page 12 of its Standards of Care that most trans-identified kids grow out of it:

In most children, gender dysphoria will disappear before, or early in, puberty.

An earlier online version of  the WPATH SOC-7 cited specific numbers—greater than 80%–and included research citations, but this more specific information, oddly enough, has disappeared. But this 2014 study remembers:

…as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood.

Ok. So most kids grow out of gender dysphoria. But that fact doesn’t by itself dispense with biological evidence for gender dysphoria, whether or not it persists.

Traditionally, feminists have staked their claim on the “nurture” side of the “gender identity is innate” argument, with little acknowledgement of the findings in biology and neuroscience that hint at any real difference between male and female brain physiology.  And there is plenty of hard science bolstering this nurture-based stance: recent MRI studies have mostly corroborated the view that male/female brains are more alike than different, which leads to the conclusion that sex-role stereotyped behaviors are primarily the result of socialization, as Cordelia Fine laid out in her “Delusions of Gender.”

Nature_versus_Nurture

Trans activists and the clinicians who (let’s face it) follow their lead obviously point to other studies of adult transgender people which support the idea that their brains are hard-wired to be closer to the sex they “identify” with. Some of these studies do offer some evidence for sex differentiation in the brain. But imaging studies of adult brains are pretty much impossible to control, because all adults have had life experiences and social influences (not to mention possible cross-sex hormone treatments in some cases) which, owing to neuroplasticity, will of course have an impact on brain structure.

But even in the (primarily MRI) studies of adult brains that are better executed and controlled, it turns out the fundamental difference in these studied brains is not so much a matter of the subjects’ gender identity but of their sexual preference, as sexologist James Cantor draws attention to in a blog post surveying research studies frequently cited to prove a transsexual brain:

 In Scientific American Mind, journalist Francine Russo takes on a fascinating research question: “Is there something unique about the transgender brain?” she reviews some of the relevant brain research on transsexuals and concludes that transgenderism is indeed a phenomenon of the brain.  Although I agree with Russo that transgenderism is a phenomenon of the brain, I believe Russo over-focused on gender identity, which led her away from the better explanation of the data:

These brain scans don’t reflect gender identity, they reflect sexual orientation.

Cantor’s post, Russo’s Scientific American piece, and the cited research studies are all well worth reading.

There is some other research I find compelling: studies of prenatal hormone levels—specifically, testosterone—and their influence on sex-stereotyped behaviors and other characteristics in children.

A couple of years ago, Brynn Tannehill, a trans activist-journalist, posted a list of what Tannehill obviously considered to be airtight studies,  many of them revolving around prenatal hormones,  in support of innate gender identity . But are they airtight?

First, Tannehill conveniently neglects to mention that many of the cited studies (surprise, surprise) also show a link between prenatal testosterone levels and rate of homosexuality—in other words, hormone levels may have some impact on same-sex attraction.

But, more importantly, it turns out that several of the researchers linked by Tannehill have shown that the impact of hormones on both sexual identity and gender identity, while existing, is small. For example, Melissa Hines, in a 2006 paper, “Prenatal testosterone and gender-related behaviour, looked at several studies and concluded that

 Levels of prenatal testosterone predict levels of sex-typed postnatal childhood play behavior.

 Like what kinds of play behavior?

Research on girls and women with CAH has provided some support for the hypothesized influence of testosterone on human behavioural development. Girls with CAH show increased male-typical play behaviour, including increased preferences for toys that are usually chosen by boys, such as vehicles and weapons, increased preferences for boys as playmates and increased interest in rough-and-tumble play.

 Does this preference for rough-and-tumble, stereotypical “boy” play mean these kids are transgender?

Although there are fewer studies relating prenatal testosterone levels to postnatal sexual orientation and core gender identity, there is also some evidence, particularly from women with CAH or CAIS, that testosterone influences these psychosexual outcomes as well. However, these influences are substantially smaller than those on childhood play behaviour.

 

 

 

 

Prenatal testosterone levels are only a small factor in later sexual orientation and gender identity. What they are more predictive of is –wait for it—preference for non-sex-stereotyped activities! In other words: gender nonconformity (or my preferred term: gender defiance).

So some children play with stereotypically opposite-sex toys, prefer the hairstyles and activities of the opposite sex, and prefer the company of children of the opposite sex. Is it possible these preferences are at least partially “hard-wired” due to the effect of androgens on their brains? Sure. Does it follow that this means they are the opposite sex? Of course not. Nor does it necessarily mean they will grow up to be same-sex attracted, either (as I’m sure many heterosexual women who were tomboys can attest).

Let’s put a finer point on it: while some studies show that prenatal hormone levels could contribute to sex-stereotyped differences in human behaviors and, yes, sense of self, acknowledging these differences doesn’t lead to the conclusion that trans activists reach: If a child is born with a set of proclivities and tendencies more typical of the opposite sex, this means they ARE the opposite sex and medical and chemical alteration of the body is fully justified and should be pursued as soon as possible. 

What else does biological or genetic research show? In an earlier post, I argued that the only way to even begin to prove an innate male or female brain would be to scan a huge number of identical-twin newborns (before they had a chance to have any “nurture” influence—i.e., no social experiences), separate the twins at birth, then compare those brains later when the children grew up, some of whom would no doubt decide to undergo transition to the opposite sex.

For ethical reasons, this sort of research would be pretty much impossible (you can’t forcibly separate twins at birth and raise them separately, and you can’t control how kids are raised by dictating to parents how to raise them, even if you could). But an international team of researchers has looked at twins and the prevalence of gender dysphoria/transsexualism in a meta-analysis published in 2012, “Gender Identity Disorder in Twins: A Review of the Case Report Literature.”  (The full study is behind a paywall.)

Using a combination of their own clinic records and an exhaustive search of the literature, they examined a total or 44 twins of which at least one twin had gender identity disorder (GID)—the diagnostic term at the time, since replaced with “gender dysphoria” (GD). Of these, 23 were identical (monozygotic/MZ). The remainder were fraternal (dizygotic/DZ).

What were their findings?

 Nine (39.1%) of the 23 MZ [identical] female and male twins were found to be concordant for GID. In contrast, none of the 21 DZ [fraternal] twin pairs were concordant for GID.

This was a statistically significant difference, leading to the conclusion that “there is a role for genetic factors in the development of GID.” That difference in rate of gender dysphoria in identical twins matters. But let’s not lose sight of the fact that it was still a minority (39.1%) of identical twins who were both gender dysphoric.

Twin studies
In their discussion of their findings, the authors (like all truth-seeking scientists who submit their work to peer review) acknowledge that reality is nuanced:

The higher concordance for GID in MZ than in DZ twins is consistent with a genetic influence on its genesis although shared and nonshared environmental factors cannot be ruled out. Indeed, from these case reports, very little is known about the “equal environments assumption,” that is, the assumption that MZ twins are not treated more similarly than DZ twins in ways that might affect their gender identity.

In other words—“nature” appears to be a factor, but we can’t rule out nurture. ”Influence” is not causality.

And of even greater interest: In the penultimate paragraph of the discussion, we find this gem:

In the studies on genetics and sexual orientation, a higher concordance for homosexuality has been found in MZ versus vs. DZ twins. Using family methodology, there is also evidence for genetic influences [38]. In the reviewed case studies of twins with GID, from those whose sexual orientation is known, all, with the exception of Green [25], were attracted to their biological sex and nearly 50% of the non-GID twins were also homosexual, reflecting a higher percentage than found in the general population [39]. In all the cases reported to be concordant for GID, there was also concordance for sexual orientation.

Here we have it again. As Cantor noted, as I have noted, as the Dutch pioneers of pediatric transition have noted, this study finds—as nearly every study over decades has found: Whatever the precise contributions of nature v. nurture that leads to gender dysphoria or opposite-sex identification, a huge majority (if not 100%) of the studied individuals exhibit same-sex attraction by adolescence or adulthood.

I’ll hammer it home again: The constantly repeated refrain by trans activists that gender identity has “nothing to do with sexual orientation” is directly refuted in every study, as well as many of the personal accounts by trans-identified people splattered all over the media.


 So, what have we learned from looking at a few studies aiming to tease apart the nature-nurture question about gender dysphoria/opposite-sex identification?

  • there is sparse evidence of an innate male or female brain, and what differences there may be are mitigated and influenced by later life experiences. If anything, brain differences seem to indicate variations in sexual preference, not intrinsic gender identity; and
  • prenatal hormones—specifically, testosterone—have an effect, on….gender nonconforming behaviors in childhood. They have a contributing, but minor, effect on later homosexuality and gender identity; and
  • in general, there is evidence for both biological and non-biological (environmental-social) contributions to the development of gender dysphoria.

For me, it all boils down to this: Nature v. nurture is a false dichotomy. We are all the result of our genetic inheritance, hormonal influences, and how we were brought up and continue to live—which also includes both post-natal physiological influences (e.g., the various chemicals we imbibe in our hyper-industrialized world in addition to drugs and hormones we deliberately take in), as well as what we learn and experience over the course of our lifetimes.

In the end, the squabbling over nature v. nurture is a non-issue. What matters is protecting kids from the—however well intentioned—meddling of adults in children’s bodily and psychological integrity.  Whatever the relative contributions of nature and nurture to a child’s sense of self and ultimate decisions, adults should protect children from undergoing interventions that close off future possibilities.

Proponents of medical transition for children are not champions of gender nonconformity. If they were, as I’ve said many times, they would be celebrating it in children and instead of agreeing with the magical thinking of a child that this means they are “born in the wrong body,” they’d be helping these kids realize they are wonderful and unique examples of their natal sex. A healthy, fully functioning body attached to a brain is an integrated whole with that brain. It is an existential reality, no more “wrong” than the body of a person who demonstrates more sex-stereotyped typicality. By promoting the view that research evidence pointing to certain sex-stereotyped behaviors as having a biological component (however small) means kids’ bodies can be “wrong,” they are using science to limit the possibilities for children.

Puberty blockers, cross sex hormones, and surgeries for children and young people permanently limit their options. Options like: sexual experiences in an unaltered, non-surgically-tinkered-with body. Options like: Figuring out your sexual orientation, especially if you’re gay or lesbian and won’t, on average, come to terms with that fully until early adulthood. Options like: Being a role model for other kids that boys and girls can be and do or be anything, regardless of whether they fit into sex-stereotyped-typical behaviors and appearances.

Yes, a person who later decides to “transition,” who undergoes hormone treatments or surgeries after puberty may not “pass” as well as a someone who had natural puberty curtailed (and was incidentally permanently sterilized in the process). But the Cult of Passing as the opposite sex should be challenged—especially since those same trans activists who worry so much about “passing” (in perhaps their most obvious self-undermining argument) want us to also believe (for instance) that a “penis can be female.” To play Devil’s Advocate with the trans activists, if a boy’s penis can be female, you have no business promoting medical transition for anyone’s child.

Puberty blocking is not a benign intervention. While I’ll grant that, if stopped in time, GnRh agonists are “reversible” (as in, they will not prevent natural puberty), the psychological and neurological effects of delaying natural puberty cannot be seen by any thinking person as “fully reversible.” Neither is social transition “fully reversible,” for that matter. You can’t “reverse” a childhood spent cementing the idea that biological sex can be changed by a society bent on denying the existential reality of sexual dimorphism. You can’t “reverse” a message, repeated over and over to a child by trusted adults that there is something fundamentally wrong with his or her body that must be corrected.

Regarding nature-v-nurture?  Here’s what I’d say to my fellow kid transition critics:  Don’t dismiss the stuff from the “nature” side because you’ve pre-decided that any science supporting an innate contribution to gender dysphoria is a priori bunk and it’s all nurture/socialization.

In my opinion, taking seriously the dogma of the other side, examining it closely, and then coming to well-thought-out, nuanced conclusions is a much stronger place to operate from than dismissing out of hand any kernel of truth “they” might be obsessing over. That’s not truth seeking; that’s just being close-minded in service of an impenetrable ideology.

Nature-nurture—it’s both. Just like our thought-generating brains are indivisible from the bodies they’re a part of.

Your thoughts?

The trans-kid honeymoon is sweet—while it lasts

I recently received comments from two readers (here and here) regarding a 2014 Dutch survey study of 55 young transgender adults (average age 20). The study, which reported overall positive psychological outcomes after medical transition, surveyed youth who had been diagnosed with gender dysphoria, after which they had received puberty blockers, then cross-sex hormone treatments, and finally SRS surgery. The average length of time from first pre-treatment assessment to post-surgery was 6 years.

RESULTS:
After gender reassignment, in young adulthood, the GD was
alleviated and psychological functioning had steadily improved. Well-
being was similar to or better than same-age young adults from
the general population. Improvements in psychological functioning

were positively correlated with postsurgical subjective well-being.

These findings would likely reassure parents and others who have ushered children down the medical transition road. And frankly, anyone who has watched even a few YouTube teen transition vlogs would not find these results particularly surprising. For these kids, it must be an exhilarating experience, to feel they can escape their dissatisfaction with sex-role stereotypes and/or physical characteristics, and embark upon the long-awaited transformation into the opposite sex.  The speed with which the metamorphosis happens—with many young people “passing” as the opposite sex after only a few months of hormone treatment–is  downright magical.

No doubt, at least some of these people will go on to live happy, long lives with no regrets. But it’s likely some will begin to question (at what age? 30? 40? 50? 60?) whether giving up their fertility; permanently altering their bodies; and facing a lifelong regimen of injections and medical monitoring were ultimately worth the price.

Here is one young woman who has begun to raise a few questions. In a recent video entitled “Gender Troubles” (uploaded 6 years after she first decided to “transition,” and after 4 years of videos on her channel that mostly celebrated that choice), she acknowledges what she values about her “transition,” while sharing her realization that things are not quite as simple as they originally seemed to her younger self:

 When I decided to go on hormones…it seemed like the most logical choice for me. I was in a very bad place emotionally…I hated myself a lot. I hated my body. I didn’t identify with it….and I felt very separate from my body. And finding YouTube videos of other people who were transitioning and finding out it was an option to do so kind of deeply affected me. It was very difficult to resist those changes….to resist taking hormones, to see those changes in myself, especially because feeling so disconnected from myself it seemed like the best idea….and you don’t often see other narratives out there, on YouTube, about gender…

…. I struggled with the changes, how I felt about them, how it made me feel and why. At first I accepted them. It was exciting. It was euphoric. It was certainly a ride. And I really liked seeing myself with more muscle, I liked my voice deepening, the hair that was growing…

… My parents were really cool with it. They were not cool with me being a lesbian at all…. [now] they didn’t have to say “I have a lesbian daughter. I have a son who’s straight”….My family was supportive of my transition, so we became a lot closer because of that…

…As time went on, I really felt like…I didn’t identify with the changes I was seeing…I didn’t like the fact that these changes weren’t natural. Part of it felt like I was burying a piece of myself…

…The other night, I cried, because I realized I really want to be able to get pregnant. And I really want to be able to breastfeed. … Maybe it’s me getting older, the internal clock…ultimately I don’t regret getting top surgery…but there are elements where I miss having them….only about 15% of the time. But I can’t deny that this happens…

…There’s a lot more that happens besides achieving a male body or a more masculine body….a lot of things change and you don’t realize it. I don’t think I realized it as much until  …  a year or two off hormones. Things started kind of affecting me…

…When I was transitioning I was really caught up in the thrill of it, the excitement of it, the endorphins that went along with it…[but now]  I’ve been thinking about things I wasn’t before.

Transition regret videos aside, even if we restrict our focus to the 55 subjects in the Dutch research study cited above–young people who (so far) are reporting largely positive benefits from their transition–there is more nuance to this study than first meets the eye. 4thWaveNow contributor fightingunreality delves into some of the study’s unexamined implications in the post below.

As you read fightingunreality’s analysis, consider whether survey studies like this one might be subject to the  “interpersonal expectancy ” of researchers and “supportive” parents. The interpersonal expectancy effect is also known as self-fulfilling prophecy, or the Pygmalian effect, extensively studied by preeminent psychological researcher Robert Rosenthal:

 …the tendency for experimenters to obtain results they expect, not simply because they have correctly anticipated nature’s response, but rather because they have helped to shape that response through their expectations. When behavioral researchers expect certain results from their human or animal subjects, they appear unwittingly to treat them in such a way as to increase the probability that they will respond as expected

In more recent years….research has been extended from experiments, to teachers, employers, and therapists whose expectations for their…patients might also come to serve as interpersonal self-fulfilling prophecies.


Analysis of the 2014 Dutch study (available in full at the link, and introduced above),

by fightingunreality

Any discussion of the “outcomes” for those children chosen for the experimental use of puberty-blocking drugs would be remiss without first addressing the ethics of what has been done.

First, this study is about young people, many of whom initially presented to the clinic as prepubescent children. Children’s understanding of gender is primarily comprised of the simplistic social stereotypes through which they have learned to perceive the meaning of biological sex, and which they lack the certainty of identity to resist. Developmentally unable to fully comprehend abstract concepts, they have little understanding of the social forces which inform and compel both them and the adults to behave in certain manners deemed to be “appropriate” on the basis of sex. The vast majority of these children were socially transitioned by their parents prior to their arrival at the clinic, thereby disrupting the chance that they may have had to experience a typical childhood.

hormone graph 2

Because 85% of the fathers and 95% of the mothers were supportive of their children’s desire to live as the other gender, and since virtually all of the children were living for all intents and purposes as socially transitioned, we can assume, with little doubt, that these parents subscribed to the idea of sex-based gender roles for their children akin to those we have seen in the plethora of news stories of (mostly) moms citing wrong toys and early color preferences as indications that their children were different.

Since none of these child-transition studies (this Dutch study being no exception) report the extent to which parents enforce traditional gender roles, we have no real sense of the degree of their influence on these children or how much they might affect the kids’ willingness to defy them in order to express their non-traditional likes and dislikes– without the expressed belief that they are in fact, a different sex. Is it only a coincidence that 94% of the males in this study were either same-sex attracted or bisexual (87.9% SSA, 6.1% BI) or that 100% of the females (89.2 SSA, 10.8% BI) had same sex attractions? Are we really expected to believe that social and parental attitudes in regards to homosexuality play no part in either the formation of the children’s understandings of what constitutes “feeling like the other sex,” or, more importantly, the acceptability to parents of what, in effect, becomes medicalized gay conversion therapy?

Since the stated protocol by these researchers is to provide a six-months to a year “diagnostic phase,” this means that prior to the first assessment for this particular study, they had already been living as cross-gendered for at least that amount of time, plus the previously acknowledged but unspecified duration of social transition. During the actual diagnostic phase, all of them “officially transitioned” –including name changes. Since the youngest, at the time just prior to the administration of hormone blockers, was 11.1 years old, that means this child had been living cross-gendered since a minimum age of 10.6 years old –in addition to the time prior to arriving at the clinic. What can such a child actually know about what it means to live as his or her own natal sex?

Given the willingness, as noted in the study, of peers and parents to promote and solidify by reinforcement these children’s sense of being wrong-bodied, it is hard to see how such children could establish a basis by which they could reasonably fully comprehend–let alone reevaluate–their child-based understanding of gender and gender roles. As has been noted in previous posts on this blog, identity formation throughout childhood and adolescence is both malleable and fluid. It is impossible to believe that the interventions by both the parents and the clinicians did not directly interfere with these children’s identity development. How does a child who has basically reordered their family’s lives by their insistence that they are actually the other sex back down from such claims? How do they tell their friends? We are not talking about adults, here, after all. By the time these children reached the point of choosing to delay their puberty, they had been living as the other gender for years –in some instances possibly half of their young lives. By the time it came to choose whether or not to imbibe cross-sex hormones, it is no surprise that none of these children chose to revert to living as their own sex: they had been socialized trans.

It’s interesting to note from the information in this paper that during the time between starting hormone blockers and their choice to be put on cross-sex hormones, these kids –especially the girls –actually experienced greater levels of “gender dysphoria.” I think it’s important to ask ourselves why that is. These kids were not facing the risk of further development of secondary sexual characteristics. They were living as their chosen gender. Why wouldn’t they be at least somewhat relieved of their dysphoria? Since levels of such dysphoria consist of self-assessment, this worsening could merely reflect the child’s desire to fully transition along with the knowledge that admitting a decreasing level of dysphoria might threaten the willingness of the clinicians to advance their transitions. That is one possibility. The other more likely possibility is that living as fully socially transitioned children, their awareness of not physically “matching” their chosen gender while assuming that role actually worsens the sense of being wrong-bodied. In other words, telling someone that you are actually a boy or a girl when you clearly are not increases self-awareness of and discomfort with your actual sex.

As was articulated in a BBC documentary by a gay Iranian who was pressured into transition, prior to transitioning he often heard, “He’s so girly. He’s so feminine.” After the surgery, whenever [he] wanted to feel like a woman or behave like a woman, everybody would say “look, she’s like a man. She’s manly.” This phenomenon can readily be applied to children who may have been considered like the other sex prior to living akin to that sex, but become seemingly less like the other sex when attempting to assume that role. The very fact that they are attempting to live as the other gender may very well increase the dysphoria that assuming such a role is meant to lessen. Is it a wonder that 100% of the children that comprised this cohort chose to go on to cross-sex hormones?

The gender specialists promoting these studies want us to believe that the use of hormone blockers provides extra time without the stressful development of secondary sexual characteristics. They’d like us to believe that the children are being given a sort of “time-out” to consider their choices and become more mature before committing to irreversible changes, but is that really the case? The hormones required for adolescent brain reorganization and development are not released when a child has received GnRh agonists. Physical development typical for teenagers is prevented, setting the children even farther apart from their peers, and sexual and romantic involvements –a key factor in desistance –are avoided.

Ultimately, 100% of the children who chose to utilize hormone blockers in this study went on to fully transition. In fact, virtually all children inducted for such therapy demonstrate 100% persistence rates despite that fact that even today, major proponents of this therapy (such as Johanna Olson-Kennedy and Robert Garofalo, in their 2016 paper detailing research priorities on gender identity development and biopsychosocial outcomes) acknowledge that “Clinically useful information for predicting individual psychosexual development pathways is lacking.” They do not have reliable information on who will or will not desist. Are we really expected to believe that these hormone blocker advocates are exceptionally lucky in their selection process when they themselves profess such uncertainty and bemoan the lack of adequate research? Or should such absolute rates of persistence be setting off alarm bells to those of us concerned with the practice of funneling children into a pipeline that flows in only one direction: towards lifelong medicalization with unknown long-term consequences?

Because of the extraordinary persistence rates of children infused with hormone blockers, it’s obvious that hormone blockers do not allow these children extra time. The choice to participate in this protocol becomes the decision to transition, because it prevents the aspects of maturation necessary for desistance from ever occurring. The one thing it does do, however, is to make it seem safer to interfere with the children’s natural course of development. Parents are assured that the effects of blockers are reversible, and the moral burden of placing young children in the position of making adult decisions is put aside.   As a result, even more children are being swept up by this 21st century version of reparative therapy. Altogether, we will never know the number of children who would have desisted had they been allowed to develop without social and medical intervention. This is a travesty.

As far as the “positive outcomes” this study purports, there are numerous problems. First, in order to understand this study, we must consider the selection process detailed in a previous paper by the same authors.  The 70 children chosen for this study were selected from an original cohort of 111 (out of 196 children arriving at the UV hospital seeking treatment for GD) eligible for hormone blockers, after having been “thoroughly screened after a comprehensive psychological evaluation with many sessions over a longer period of time” and found “eligible for puberty suppression and cross-sex hormones.” It was a group chosen on the basis of their likelihood of coping with the transition process. They had “no psychosocial problems interfering with assessment or treatment,” and “adequate” (in the case of this cohort, very high) “family or other support,” and what the researchers described as “good comprehension of the impact of medical interventions.” (We can only guess what that could mean, given the fact that pre-adolescents and adolescents do not have the frontal lobe development to fully project themselves into the future.) Altogether, they seem very unlike the average children and adolescents who are currently being inducted into this process of life-long medicalization either in regard to screening or support and ongoing therapy, which the study notes was provided to them for an average of 6 years “after first presenting at the clinic.”

Fifteen of the cohort of 55 had “some missing data” which we are assured resulted in “no significant differences” on the pre-treatment tests.   I think, too, that when considering the outcomes of these children, it would be remiss to ignore the 15 members of the original cohort of 70 who did not participate in follow up: six had not met the one year gender reassignment surgery anniversary for this study and were, therefore, excluded. Two refused to complete the assessment, and two did not return their questionnaires. (Why?) Three had health problems which prevented them from undergoing gender reassignment surgery, one “dropped out of care” (no clarification) and 1 died from complications from surgery. (How does one weigh such a loss against “positive outcomes?”)

Given the fact that all of these children had what is in essence a “gender obsession” since childhood and had been socially transitioned for years, it comes as no surprise that they experienced relief at finally accomplishing their goals. The kids as a whole did overall demonstrate better functioning than at their initial assessment –possibly from the counselling and special attention they were getting –but “it cannot be ruled out that it relates instead or as well to the benefits that accrue from being validated and accepted for treatment.” They were getting what they wanted, after all. Research has shown that gender non-conforming children and adolescents are at higher risk for PTSD due to abuse and bullying because of being different, and the prospect of “fitting in” provided by merely initiating action towards this goal certainly provides a degree of psychological relief- regardless of the actual physical changes that have yet to take place. This is evidenced by the “significant quadratic effect” that commences immediately upon initiation of cross-sex hormones, well before significant physiological effects of the hormones could possibly have occurred.

Would body image and psychological well-being have improved in these children had they been allowed to experience a natural childhood and identity formation without medical intervention? It is well known in the field of child development that children go through a period of significant peer gender enforcement which corresponds with their concrete thinking and familial socialization which certainly affects the self-image of those who fail to conform. This rigidity begins to relax at around 8 to 10 years –after some of the children in this study have already been socially transitioned due to the discomfort this rigidity has created. Would they have come to a more nuanced understanding of gender roles had they made it past this stage? We –and they –will never know. Logically, children have been shown to be more accepted by members of the sex with which they share interests, rather than those whose similarities are based solely on sex, and gender enforcement prior to adolescence tends to be enacted by members of the same sex. Is it any wonder that children tend to “identify” with those who seemingly accept them and share common interests? Would a more mature understanding of abstract concepts assist them in accepting their own bodies without conforming to artificial gender roles as it did for many of us who matured without the alluring possibility of appearing to actually change sex?

As adolescence progresses, criticism is most likely directed by male peers who are not known for impulse control or empathy. Certainly those of us who have been on the receiving end of such mockery can attest to the resulting social stigma and humiliations we suffered in light of it due to our vulnerability at that age and the fact that we were insecure in our own identities and lacking the self-assurance that maturity brings. It has been demonstrated that peer and social disapproval for gender non-conformity peaks in the adolescent years and gradually decreases throughout young adulthood and adulthood. Not only do we mature, but the peers responsible for the harassment mature, as well. The insults decrease. As gay rights activists in the past often said, in an attempt to help bullied gay and lesbian children, “it really does get better.”

Unfortunately, none of the children in this study will ever know whether this would have been the case for them, because they left behind in childhood the bodies which they very well may have come to accept in the absence of such criticism. In a study in which there is no viable way to create a control group with which to compare these children, there’s no way of knowing how well they would have fared with just the extensive psychotherapy alone, nor of desistance which may have taken place without these prolonged social and medical interventions which prevented the maturation and social and sexual experience that would have occurred otherwise.

As a gender non-conforming adult, I am occasionally harassed by what are typically groups of two or three teen boys out to impress their friends. Because I am an adult with a fully-formed sense of self, my identity is not threatened as are those of the children who have not yet discovered, through experience and physical development, who they really are or can be. Sadly, the ultimate result of medicalized disruption of identity formation –which would have included their whole selves, bodies included –creates an identity which is dependent upon exogenous substances, conscious gendered performance, and the willingness of others to deny their own perception in order to validate it. As such, the identity is not sustainable without significant degrees of external support, and remains more highly vulnerable to what are perceived as being threats to self when it is not validated.   As a result, they may be “at increased risk for the development of narcissistic disorders…as a consequence of the inevitable difficulties they face in having their cross-gender feelings and identities affirmed by others.” (Note: While the linked study is not specifically of children, it seems to me children subjected to early medical transition would also be at some risk of narcissism, given the confluence of factors brought to bear upon them.)

Perhaps the greatest hindrance to accurately critiquing this study is related to the ages and the timing of this so-called “long-term” study: it was completed after only a minimum of one year after gender reassignment surgery. These now young adults had barely any life-experience living as fully transitioned persons. They were still in the honeymoon phase of what had become a fully supported childhood desire. A significant portion of them were still living at home with their supportive parents and attending school. Their lives as fully transitioned adults were just beginning, and the difficulties of navigating sexual relationships and the hardships that entails for those not of their natal sex were in their infancy. They were many years away from the rise in suicidality noted in a Swedish long-term study of adult transgendered persons, which began to rise around 8-10 years after transition.

Because of the failure of the Dutch authors to denote significant variables among these youths (as I’ve outlined in this post), their study inspires more questions than it provides answers.   Have these children been harmed by the parental and medical reification of childhood fantasy and desire? We have primarily their own self-reports to rely on –the reports of young adults who never were given the opportunity to experience childhood or adolescence as one would experience their own actual sex. They have nothing with which they can compare their current experienced “gender.” They will not know what it’s like to have sex in their natural bodies, nor be loved as such. Certainly, as partially formed adults (remember- maturation takes place concurrently with hormonal action and resulting brain development and theirs was delayed), they had not reached fully adult status at the time of their self-assessment. We do not know how the difficulties of living as transgendered people will affect them. We do not know if the long-term effects of injecting artificial cross-sex hormones will damage them physically (or mentally). We will never know whether they might have resolved their gender dysphoria, as others have, and pressed on through life, because they were never given the chance to find out.

Their childhood fantasies were to become a different sex. What they have been given, instead, is the means of promoting that illusion—and the reality of becoming a life-long medical patient.

 

Groundbreaking study: Kids mean what they say

The clinic advised that Rudy should start to make his own choices and, specifically, recommended that he was allowed to pick an item of clothing. ‘He chose a Disney princess nightie and skipped around the house in it, laughing,’ recalls Kathryn. Towards the end of Year 1 at school, Rudy started wearing girls’ clothes at home. ‘Of course, he chose to dress as a girl. I watched him at the disco, chatting to girls, wearing a pink glittery dress. That was a turning point.’ Back home, Rudy chose a girl’s school uniform for the new term and asked to be called Ruby.

–Parenting a transgender child: The day my four-year-old son told me he was a girl

 


When Ana was five years old, her mother Cathy organised a birthday party with one rather unusual condition: No girly presents, please. ‘I felt awful doing it, but I knew Ana would be devastated if anything pink or fluffy turned up.’

‘I knew when I was growing up,’ says Alfie now, ‘that I didn’t want to do the things that girls did. I was the sort of kid who ran around and got dirty. … People thought me being a tomboy was a phase, but I knew I wouldn’t change. I didn’t want to wear girl clothes. I hated the way they fitted to me. … I was told I would change and get interested in make-up, but I could never see it happening.’ The paediatrician then brought up the topic of gender transition. So in the car on the way home, I said to mum: ‘I think I’m transgender.’

–My child had a boy’s brain in a girl’s body


Trans activists and gender specialists don’t have much in the way of well controlled, peer-reviewed research to support their core assumption that “gender identity” is innate and immutable. The latest brain science shows very little difference between male and female brains. If this is the case, what is the scientific basis for believing there is an innate “gender identity,” baked in at birth, that would be worth turning young people into sterilized, permanent medical patients as adults?

Recently,  in the activist blogosphere, the transgender press, and on the WPATH Facebook page, there have been excited proclamations that data to prove “true identity” has emerged in the form of a paper published a few months ago in the journal Psychological Science. The study of 32 “transgender” children and the same number of non-trans controls, entitled “Gender Cognition in Transgender Children,” [abstract; full study here] was conducted by University of Washington assistant professor of psychology and director of its TransYouth Project  Kristina Olson (not to be confused with LA Children’s Hospital gender specialist Johanna Olson), along with transgender activist Aidan Key and Stony Brook University assistant professor of psychology Nicholas Eaton.

I’m going to start with the punch line and work backwards from there: The study demonstrates only that 32 socially transitioned children (that is, kids who are being “supported” by their families and “gender specialists” in being referred to by an opposite sex name, pronouns, and assumedly, though the authors don’t tell us, sporting opposite-sex-stereotyped clothing and hairstyles), really, truly do prefer the playmates, hairstyles, and clothing more typical of the opposite sex. Further, these “transgender” children really and truly do prefer and “identify with” the same playmates and physical attributes as the control group of “cisgender” children (yes, the study authors use that term) of the opposite sex.

Who were the “transgender children” recruited for the study?

To be included in the current study, children had to be 5 to 12 years old and live in all contexts as the gender expression “opposite” of their natal sex. These requirements resulted in the exclusion of 4 additional gender-nonconforming participants

And the control group?

Thirty-two control participants (20 female, 12 male; mean age = 9 years) … matched to the transgender participants were recruited through the first author’s research lab from a database of families interested in participating in developmental psychology research studies. They were required to have no significant history of gender nonconformity.

[Note: A group of “cisgender” siblings of the “transgender” children were also part of the study, but time and space in this blog do not allow a full analysis of their responses, which were similar to but not the same as the non-familial “cisgender” control group.]

What do the authors mean by “gender nonconforming” or “no significant history of gender nonconformity”? This is never defined, although we can guess that the “transgender” children dress, play, and appear differently from generally recognized gender stereotypes. But the control group? Do the authors mean these children entirely conformed to stereotypes—i.e., the girls all wore dresses, played with dolls, and had long hair, while the boys played with trucks, had short hair and wore rough-and-tumble   trousers?

Olson et al don’t tell us. And what about the four excluded “gender nonconforming” subjects, who apparently did not “live in all contexts” as “opposite” to their natal sex? Did these children occasionally indulge in sex-stereotyped play and behaviors, so they weren’t “trans” enough?

The study stimuli consisted of questions coupled with pictures of boys and girls, “matched for approximate age and attractiveness.” (And what does “attractiveness” mean? There is an even bigger question vis-à-vis these pictures, which I will get to in a few moments).

Olson and colleagues tested the children in 3 areas:

  • Gender preference (for play/friendship)
  • Object preference (associating a nonsense word with a picture of a boy or girl,  saying this was the name of a toy or food that the pictured child was using)
  • Gender identity (whether the child feels they are a boy or girl)

Each of these three variables were addressed via explicit (i.e., responses to direct questions)  and implicit measures.

What’s the difference between explicit and implicit measures? In psychology research, it has been posited that “implicit” measures

 may resist self-presentational forces that can mask personally or socially undesirable evaluative associations

In other words, “implicit” measures are meant to get at how someone really thinks and feels, whereas a reliance strictly on explicit “self reporting” might be tainted by what a subject thinks someone wants to hear (or other motives).

So, for the “gender preference” part of the Olson et al study, the explicit measure was to ask the child, “who would you rather be friends with?” when shown a pair of pictures of a boy and girl. The implicit measure was to show the children pictures of a boy and girl and ask to label them “good” or “bad.”  (The underlying premise here is that most pre-pubescent kids prefer their own “gender” as playmates).

For gender identity, the implicit measure consisted of asking the research subjects to label pictures of boys and girls as “me” or “not me.” The explicit corollary was

telling them that people have outsides (their physical body) and insides (their feelings, thoughts, and mind). They were told that some people feel like they are boys on the outside, and some feel like they are girls  on the outside, and that those people might feel the same way or different on the inside. They were told some people feel, for example, like a boy on the outside and inside, and that others feel like a boy on the outside but a girl on the inside. Further, they were told that some people feel like both or neither, or that their feelings change over time.

Children were asked whether, on the inside, they felt like a boy, a girl, neither, or both; whether their gender identity changed over time; or whether they did not know.

For “object preferences” the authors didn’t assess preference for actual objects, but only whether the research subjects chose the same preferences as pictured  boys or girls. They were

shown pairs of photographs of children and told that each one had a preferred toy or food. The names of these items were in fact novel words (e.g., “This is Amanda and she likes to play flerp. This is Andrew and he likes to play babber.”). Our interest here was whether children would use the gender of the person endorsing the item to inform their own preferences.

It’s difficult to see how this adds any more information than asking kids what sex playmates they prefer. If a child who “identifies” as a boy sees a picture of a boy playing “babber,” that child would likely prefer to do what the pictured boy is doing.

Be that as it may, what exactly did Olson et al set out to prove with these probes?

… if these children are not confused, delayed, or pretending, and in fact their expressed gender represents their true identity, we would expect them to respond   similarly to gender-matched control participants not only on self-report measures, but also on implicit ones.

We reasoned that if children are confused by the particular questions posed to them….[or] if they are merely self-reporting the “wrong” gender identity… or even if they are just oppositionally reacting to the question of their gender identity— …these children should show one of two patterns of confusion. First, they could be truly confused, as indicated by random responding and no systematic  response across measures and participants. Alternatively, they could implicitly identify as their natal sex (because they actually understand gender and are merely self reporting this “incorrect” gender).

And the results of the study? Surprise—the socially transitioned “transgender” children did indeed respond similarly to the “cisgender” control group.

But what does this actually demonstrate?

First, let’s consider the stimuli, consisting of pictures of age-matched boys and girls. What would distinguish a picture of a prepubescent boy from a picture of a prepubescent girl,  apart from clothing and hair styles? Not much.

Prior to puberty and the influence of estrogen or testosterone, school-aged kids look much the same. So unless the pictured boys and girls had identical haircuts and clothing, the 32 “transgender” children labeling a boy or girl picture as “me” or “not me” would have been identifying with a boy or girl based on stereotyped dress and appearance—haircuts, clothing, and the like. How could it be otherwise?

Put another way, if the pictures of the boys and girls did all have the same haircut and clothes, irrespective of biological sex, would the research subjects have been able to identify the sex of the child they identified with? Likely not.

Now, to the question of whether these kids were confused, delayed, or pretending, the authors did show that these kids are not likely to be knowingly pretending to be the opposite sex, nor are they “confused” i.e., they just don’t know what they think or feel. But why is this of much significance?  What would be the motivation for these children to “merely” self report the “incorrect” gender, or to “oppositionally react”? The fact that these kids are sincere in their convictions is reported by Olson et al as an important finding, but does anyone, including critics of pediatric transition like me, doubt that dysphoric or trans-identified kids really mean their gender nonconformity?

Further,  deliberately “pretending” in order to deceive is not the same as conflating fantasy or desire with objective reality–an aspect of normal childhood development which activists, gender specialists, and researchers like these seem never to have heard of. Just because a child  sincerely sees him or herself as the opposite sex does not make it true.  Child psychologists have known for decades that children’s firmly held beliefs do not always comport with reality.

 Research indicates that children begin to learn the difference between fantasy and reality between the ages of 3 and 5 (University of Texas, 2006).  However, in various contexts, situations, or individual circumstances, children may still have difficulty discerning the difference between fantasy and reality as old as age 8 or 9, and even through age 11 or 12. For some children this tendency may be stronger than with others.

The authors seem not to have thought of the most obvious conclusion: That these kids DO believe they are the opposite sex but that doesn’t make it so—especially since even the implicit measures the authors seem to think are so meaningful are nothing more than identification with gender-stereotyped activities and appearances which they happen to prefer.

By demonstrating that the “transgender” children aren’t just being obstinate or dishonest, Olson et al seem to believe that their study indicates (in their words) “true identity” in the children they have labeled “transgender.”

But what is “true identity?” Is it the elusive Holy Grail of inborn, unchangeable gender, something no one has come remotely close to proving, yet is the unquestioned assumption from which all the current medical and psychological and legal decisions about “transgender children” have flowed in the last few years?

That the authors even use the term “true identity,” which they themselves admit is unproven, is all we need to show the study is fatally tainted by confirmation bias.

 Confirmation bias, as the term is typically used in the psychological literature, connotes the seeking or interpreting of evidence in ways that are partial to existing beliefs, expectations, or a hypothesis in hand.

–Confirmation Bias: A Ubiquitous Phenomenon in Many Guises, by Raymond S. Nickerson,  Tufts University

It’s quite clear that the authors’ “hypothesis in hand” is that there is such a thing as “true identity.” Further, they interpret the evidence that “transgender” children feel as strongly about their identity and gender nonconformity as “cisgender” children do as somehow confirming this hypothesis. Even though they themselves in their Notes section  of the study assert:

  1. We avoid using common colloquial phrases such as “born as a boy” because they suggest that transgender identities are not innate (an unresolved scientific question) and are thus offensive to some individuals.

 On the one hand, because they don’t want to be “offensive” to “some individuals” (and I think we can guess who they are), Olson et al don’t want to “suggest” that gender isn’t innate (and in fact present their study as evidence that their “transgender” research subjects have a “true identity,”). But at the same time, the authors explicitly acknowledge that the question of “innate” gender identity is an “unresolved scientific question.”

But while being careful not to offend “some” people, they don’t have any trouble splattering the term “cisgender” throughout this article,  despite the fact that some other individuals find “cis,” well—offensive. Certainly Olson et al aren’t living in such a bubble that they are unaware that the label “cisgender” is repugnant to many of us who the transgender community apply it to.

And in point 2 in the Notes, we have a further indication that the authors’ work is riddled with confirmation bias:

2. We use the term “opposite” for clarity but acknowledge that gender is not binary.

They “acknowledge” that gender is not binary. But as with “innate  gender identity,” who has proven that “gender is not binary?”  No one. This jargon comes straight from the trans activist lexicon.

In peer-reviewed research, investigators always indicate the limitations and possible flaws in their study.  The weaknesses I’ve pointed out in this post are not even marginally addressed by the authors. What limitations do Olson et al concede?

 All of the participants tested here identified and lived life as one gender at the time of assessment, choosing names consistent with that gender and preferring those pronouns as well. Future studies along the spectrum of childhood transgender experiences will be needed to clarify how generalizable these findings are to children who have different degrees of identified gender expression or to those with different life experiences.

Apparently what’s next is seeing whether their study measures can also be used to prove the “true” identities of “gender fluid,” “genderqueer,” and “nonbinary” children. I wonder what exclusion criteria they’ll have in future studies? Hopefully they will be more precise in their definitions of what constitutes  gender (non)conformity in their next paper.

In their summary, Olson et al reiterate their key finding that these kids really mean it when they say they prefer the lifestyle of the opposite sex:

In summary, our findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. Instead, transgender children show responses that look largely indistinguishable from those of cisgender children, who match transgender children’s gender expression on both more- and less-controllable measures. Further, and addressing the broader concern about transgender individuals’ mere existence raised at the outset of this article,the data reported here should serve as evidence that transgender children do indeed exist and that their identity is a deeply held one.

“Do indeed exist.” Of course children who believe they are, or want to be, the opposite sex “exist.” And of course such children are going to exhibit preferences for the appearances and activities of the opposite sex, in a “deeply held” way. But it doesn’t follow that those children are somehow innately the opposite sex.

All Olson and colleagues have demonstrated is that some children really, really, really want to be the opposite sex; even to the point of saying they are the opposite sex. They want to look and dress like the opposite sex—a girl, for instance, might want a short haircut and to wear comfortable boys’ clothes. They like playing with children of the opposite sex. And they like doing things that the opposite sex likes to do. In other words, these kids are don’t conform to the stereotypes of their birth gender. But does it then follow that they should be groomed and conditioned to believe they are the opposite sex, leading them in the near future to puberty blockers and on to sterilization and surgeries?

If the stakes were not so incredibly high, a study like this could simply be filed away under “strongly held beliefs and desires of gender nonconforming children.” But given the fact that so many activists and gender specialists are in the business of promoting medical transition, this study should instead be filed under “confirmation bias rationalizes non-evidence-based medical experimentation on vulnerable children.” What Olson et al have not proven is innate gender identity. All they have shown is that these kids really mean it when they say they are or want to be the opposite sex.

This study, instead of being promoted as a rationale for pediatric transition, should carry no more weight than any of the thousands of media articles trumpeting the unsubstantiated yet continuously promoted idea that children who refuse to conform to gender stereotypes—yes, who really mean it when they say they want to look and play and dress like the opposite sex—are “transgender.” Like the ones quoted at the beginning of this article. Or the thousands of others that have been published in the last few years. Like this one:

Tom charges about in a Batman costume, brandishing a sword. …Tom loves dressing up. “Normally as a superhero,” Cassie [his mom] says.

“Batman and Superman,” Tom adds. “And Wolverine!” He also likes to play cowboys or policemen with his best friend, Charlie. “Sometimes we arrest people. Remember when we did it yesterday to the dog?” He grins. “He wasn’t putting the ball down.” He shows me his bedroom. There’s his treasured Playmobil pirate ship, his Marvel poster featuring Ironman, Captain America and the Hulk, and his pencil case shaped like a football boot.

When Cassie took three-year-old Tom to the barber for the first time, she wept. “That was the final thing. If I let him get his hair cut short, that was me accepting he is a boy.” The hairdresser was bemused. “I was crying and I had this little boy with me who had hair down to his arse. She asked him: ‘Has your mummy never let you get your hair cut?’ And he loved it, because she thought he was a boy with long hair.” After that, Tom never got mistaken for a girl, and became much happier.

Transgender children: ‘This is who he is – I have to respect that’

 

Skeptical gender therapist: “A medical doctor is not a candy seller”

candy seller

In yesterday’s post, I focused on the situation in the United Kingdom, where the school system is deeply enmeshed with a trans activist organization which peddles its message to kids as young as 4 years old. And the majority of posts on this blog document the seemingly unstoppable trend to diagnose and treat children as “transgender.” With this overwhelming level of societal and medical support, the issue must be pretty much settled—right?

Not according to the gender specialists themselves, it isn’t.

Hot off the presses, in the October 2015 issue of the Journal of Adolescent Health, a team of Dutch researcher-clinicians report findings from a survey of gender clinics which serve dysphoric children around the world.

Although you’d never know it, judging by the accelerating trend to socially “transition” kids as young as 3, freeze adolescents’ natural puberty with GnRh agonists, and then move on to chemical sterilization via cross-sex hormones thereafter, there is no  consensus amongst gender specialists that this current treatment protocol is the way to go.

The qualitative survey, entitled “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study” was conducted by a group of well-known Dutch researchers/gender specialists who are themselves actively involved in administering puberty blockers and other treatments to “transgender” children. The authors surveyed 17 treatment teams (endocrinologists, psychologists, MDs, psychiatrists, ethicists) regarding their views and experiences.

Many of the parents who contribute to and read this blog agonize about their difficulty finding therapists and doctors critical of the I’m-trans-if-I-say-I-am paradigm. I hope this post gives some measure of hope to those parents. While the skeptical specialists (nearly all of them psychologists or psychiatrists, with most endocrinologists and pediatricians apparently submitting pro-transition comments) are quoted anonymously, at least we know they’re out there. And enough of them exist to tell us that the runaway pediatric transition train may not have completely lost its brake pads—yet.

The journal article can be read in its entirety here, and the abstract summarizes the key findings:

The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions…

Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived…

CONCLUSIONS:

As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.

Because my aim here is to show that gender specialists are not unanimously aboard the child transition bandwagon, this post will mostly highlight the comments from the more skeptical gender specialists surveyed. Amazingly (to me), the doubters seem to hit nearly all the same points I do in my blog posts.  [Note: Use of boldface to emphasize certain passages is my own, not that of the authors.]

So what is gender dysphoria?

Is GD a normal variation of gender expression, a social construct, a medical disease, or a mental illness? In the DSM-5 and the to-be-released ICD-11, the main challenge in classifying GD has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to health care, payment by insurance companies, and the communication between diverse professions.

I spend a fair amount of time reading articles and social media posts authored by gender specialists. It’s quite evident that there is currently pressure to completely de-stigmatize the transgender diagnosis…yet still find a way to get the “treatment” paid for by private insurance companies (or the taxpayer via public insurance such as Medicare or Medicaid). This thread from the WPATH public Facebook page [commenter names redacted] is illustrative of the dilemma the survey authors point to in the passage above.

wpath gender incongruence

So, this thread seems to indicate that providers are moving away from gender dysphoria as a disorder; even as an experience which causes distress. But why then would there be a need for medical treatment? This conundrum is addressed by the 17-clinic survey authors:

The interviews and questionnaires show that most informants find it difficult to articulate their thoughts about this aspect. Most see GD as neither a disease nor a social construct, but as a normal, but less frequent variation of gender expression. However, some note that you would not need medical procedures to make the lives of people with GD more satisfying if it were merely a normal variation.

Another thread from the WPATH public Facebook page seems to justify transition services for someone who just wants a “joyful and loving life.”

wpath joyful life

But when it comes to young people, at least one psychiatrist in the survey study gives us a less sanguine view of such quality-of-life justifications for medical transition:

“I find it extremely dangerous to let an adolescent undergo a medical treatment without the existence of a pathophysiology and I consider it just a medical experimentation that does not justify the risk to which adolescents are exposed. Gender dysphoria is the only situation in which medical intervention does not cure a sick body, but healthy organs are mutilated in the process of adapting physical and congruent psychological identity.” –Psychiatrist

I feel certain at least a few of the parents who frequent this blog wish they had the office phone number for this reasonable clinician. Amirite?

On the wisdom of puberty blockers

How many of us have asked, “but what if puberty blockers also inhibit the psychological/neurological maturation that comes with puberty–and beyond?” And, because many kids actually outgrow their gender dysphoria, interrupting puberty would deny them the opportunity to become comfortable in their bodies and avoid a life as a permanent medical patient.

It’s a pleasant surprise to see an acknowledgement of some of these concerns here:

In the literature, the concern is raised that interrupting the development of secondary sex characteristics may disrupt the development of a gender identity during puberty that is congruent with the assigned gender. The interviews and questionnaires show that some treatment teams share this view.

One clinician even talks about lesbian women who would have been misdiagnosed as “trans” children in an earlier time.

I have met gay women who identify as women who would certainly have been diagnosed gender dysphoric as children but who, throughout adolescence, came to accept themselves. This might not have happened on puberty blockers.”–Psychologist

So at least one psychologist who works on a pediatric transition team acknowledges what many, formerly gender dysphoric women, say: that if there had been “gender clinics” for kids in the 1950s, 60s, 70s, or 80s, they would not be happy lesbian adults today, but sterilized “trans men.”

Speaking more broadly, another therapist has this to say:

“I believe that, in adolescence, hypothalamic inhibitors should never be given, because they interfere not only with emotional development, but [also] with the integration process among the various internal and external aspects characterizing the transition to adulthood.” –Psychiatrist

On co-occurring psychological/psychiatric issues

If you read through the part of this blog where most parents congregate and introduce themselves for the first time, some common themes emerge. One is the observation by many parents that their kids have other mental health issues, nearly always predating the (sometimes sudden) announcement that they are transgender.  While most activists insist that transition is the cure for what ails a dysphoric child or teen, the clinicians working in the trenches aren’t so sure.

The risk of co-occurring psychiatric problems in children and adolescents with GD is high. The percentage of children referred for GD who fulfilled DSM criteria of at least one diagnosis other than GD is 52%. The psychiatric comorbidity in adolescents with GD is 32%. Another study shows that 43% of the children and adolescents seen in a gender identity clinic suffer from major psychopathology. To date, the precise mechanisms that link GD and coexisting psychopathology are unknown.

Miscellaneous physical and psychological risks of medical transition

The surveyed clinicians acknowledge many of the concerns discussed regularly on this blog.

The possible consequences of suppressing puberty for cognitive and brain development are unclear and debated at this moment. The normal pubertal increase in bone mineral density may be attenuated by puberty suppression, and it is uncertain if there is complete catch-up after treatment with cross-sex hormones.

While it only merits one sentence (and no direct quotes), the surveyed clinicians appear to view sterilization as an important concern:

In the interviews and questionnaires, the loss of fertility was often mentioned as a major consequence of treatment.

And here’s an additional worry I haven’t seen in writing before: the potential negative impact of puberty blockers on future SRS surgery.

In addition, various informants stressed the importance of the fact that the penis and scrotum should be developed enough to be able to use this tissue to create a vagina later in life. Very early use of puberty suppression impairs penile growth and consequently makes certain surgical techniques impossible.

Will we see this rather thorny issue discussed on an episode of the Jazz Jennings reality show? Will the Tumblr trans activists screaming “now or never” take heed?

On whether kids are mature enough to make these decisions

One informant stated that the decision whether to start with hormones should only be made during adulthood: “We should facilitate his or her process of integration in the society and if he or she would undergo hormone- and surgical treatments he or she could decide [on this] during adulthood.” —Psychiatrist

Influence of the Internet and social media

You know how trans activists scoff at our observations that our kids only started talking about “transition” after binging on YouTube and Reddit?

They speculated that television shows and information on the Internet may have a negative effect and, for example, lead to medicalization of gender-variant behavior.

They [adolescents] are living in their rooms, on the Internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist

Hello? The Advocate? The Boston Globe? The Washington Post? Anybody?

Furthermore, interviews and questionnaires show that treatment teams feel pressure from parents and adolescents to start with treatment at earlier ages.

Puberty suppression has been adopted as part of the treatment protocol by increasing numbers of originally reluctant treatment teams. More and more treatment teams embrace the Dutch protocol but with a feeling of unease…these professionals also have doubts because of the lack of long-term physical and psychological outcomes.

Hey, journalists. Obscure blogger over here quoting actual gender specialists, so you can’t say it’s just a bunch of nervous Nellie-moms making shit up. Need the link again? Oh, that’s just the abstract, here’s the pre-publication full-text, right here.

Self-harm/suicidal ideation

For several informants, a reason to use puberty suppression was the fear of increased suicidality in untreated adolescents with GD. Research shows that transgender youth are at higher risk of suicidal ideation and suicidal attempts. Nevertheless, caution is needed when interpreting these data because they do not show causality or directionality.

The meaning of that last sentence is crystal clear, and entirely in accord with what I, and other critics of the harmful “transition or suicide” meme that adult trans activists continually propagate, have tried to point out. While no one disputes that there is a higher self-harm and suicidality rate amongst trans-identified young people, there is no evidence that such self-harming behaviors and thoughts are ultimately alleviated by “transition.” Further, as this sentence implies, the “directionality” could be the reverse of what trans activists promote. Having a trans identity and/or facing the monumental prospect of medical transition could be a cause of self harming (in addition to the preexisting or comorbid mental health issues so many of these young people seem to have).

This is not the moment for another flippant call for journalists to take heed. This is deadly serious business: the terrible toll of self harm and suicide among trans-identified youth.  I have not seen a single news treatment of suicide or suicide risk that has even hinted at what these clinicians are stating baldly. Isn’t it time for a more nuanced discussion?


And finally: Leave it to a medical ethicist to point out the huge logical fallacy in the “informed consent” model of treatment now running rampant:

“The fact that somebody wants something badly, does not mean that a health care provider should do it for that reason; a medical doctor is not a candy seller.”— Professor of health care ethics and health law

Imminently sensible. So how is it that “informed consent” and the demonization of “gatekeepers” is more and more the norm? How is it that self identification as trans, even for young children, is fast becoming the only requirement for obtaining treatment? There is something strange going on here. If even some experienced gender specialists  are expressing doubts, why does the media behave as if the issue has been settled?

The positive attitude of many health care providers in giving hypothalamic blockers…is based on the need to conform to international standards, even if they are conscious of a lack of information about medium and long term side effects.” –Psychiatrist

But how can there be “standards” (they are talking about WPATH here) that these providers feel pressure to conform to, if the standards are not based on solid information about risks and benefits? Exactly which cart is pulling this runaway horse?

As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (worldwide) multicenter research and debate.


Reason for hope?

The article concludes in a way that makes me feel a whisper of hope for the future.

Several professionals mentioned that participation in the study made them think more explicitly about the various themes, and it encouraged them to discuss the issues in their teams. In the Dutch teams, we therefore introduced moral deliberation sessions to talk about these ethical topics. The first reactions of the professionals were positive; the sessions made them rethink essential aspects of the protocol.

Will this “moral deliberation” and “rethinking” result in more caution, or even a desire to put a halt to the pediatric transition train? Time will tell, but it is encouraging that at least the Dutch researchers may be losing some sleep in pondering the incredible power they wield over the lives of children and their families.

At least we know there is controversy. At least we know they are not all marching in lockstep.

And that is something.