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International Journal of Transgenderism
ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: http://www.tandfonline.com/loi/wijt20
A critical commentary on follow-up studies and
“desistance” theories about transgender and
gender-nonconforming children
Julia Temple Newhook, Jake Pyne, Kelley Winters, Stephen Feder, Cindy
Holmes, Jemma Tosh, Mari-Lynne Sinnott, Ally Jamieson & Sarah Pickett
To cite this article: Julia Temple Newhook, Jake Pyne, Kelley Winters, Stephen Feder,
Cindy Holmes, Jemma Tosh, Mari-Lynne Sinnott, Ally Jamieson & Sarah Pickett (2018):
A critical commentary on follow-up studies and “desistance” theories about transgender
and gender-nonconforming children, International Journal of Transgenderism, DOI:
10.1080/15532739.2018.1456390
To link to this article: https://doi.org/10.1080/15532739.2018.1456390
Published online: 26 Apr 2018.
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A critical commentary on follow-up studies and “desistance”theories about
transgender and gender-nonconforming children
Julia Temple Newhook
a
, Jake Pyne
b
, Kelley Winters
c
, Stephen Feder
d
, Cindy Holmes
e
, Jemma Tosh
f
,
Mari-Lynne Sinnott
g
, Ally Jamieson
h
, and Sarah Pickett
i
a
Faculty of Medicine, Janeway Pediatric Research Unit, Memorial University, St. Johns, Newfoundland and Labrador, Canada;
b
School of Social
Work, McMaster University, Social Work, Hamilton, Ontario, Canada;
c
GID Reform Advocates, San Diego, California, USA;
d
Department of
Pediatrics, University of Ottawa, Ottawa, Canada;
e
School of Social Work, University of Victoria, Victoria, British Columbia, Canada;
f
The Psygentra
Institute, White Rock, British Columbia, Canada;
g
Department of Family Medicine, Faculty of Medicine, Memorial University, St. Johns,
Newfoundland and Labrador, Canada;
h
Choices for Youth, St. John’s, Newfoundland & Labrador, Canada;
i
Faculty of Education, Memorial
University, St. Johns, Newfoundland and Labrador, Canada
ABSTRACT
Background: It has been widely suggested that over 80% of transgender children will come to
identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans
identity was a temporary “phase.”This statistic is used as the scientific rationale for discouraging
social transition for pre-pubertal children. This article is a critical commentary on the limitations of
this research and a caution against using these studies to develop care recommendations for
gender-nonconforming children.
Methods: A critical review methodology is employed to systematically interpret four frequently-
cited studies that sought to document identity outcomes for gender-nonconforming children (often
referred to as “desistance”research).
Results: Methodological, theoretical, ethical, and interpretive concerns regarding four
“desistance”studies are presented. The authors clarify the historical and clinical contexts within
which these studies were conducted to deconstruct assumptions in interpretations of the results.
The discussion makes distinctions between the specific evidence provided by these studies versus
the assumptions that have shaped recommendations for care. The affirmative model is presented as
a way to move away from the question of, “How should children’s gender identities develop over
time?”toward a more useful question: “How should children best be supported as their gender
identity develops?”
Conclusion: The tethering of childhood gender diversity to the framework of “desistance”or
“persistence”has stifled advancements in our understanding of children’s gender in all its
complexity. These follow-up studies fall short in helping us understand what children need. As work
begins on the 8th version of the Standards of Care by the World Professional Association for
Transgender Health, we call for a more inclusive conceptual framework that takes children’s voices
seriously. Listening to children’s experiences will enable a more comprehensive understanding of
the needs of gender-nonconforming children and provide guidance to scientific and lay
communities.
KEYWORDS
Adolescents; children;
desistance; dysphoria; follow-
up; gender; longitudinal;
research; trans; transgender;
youth
In the media, among the lay public, and in medical
and scientific journals, it has been widely suggested
that over 80% of transgender
1
children will come to
identify as cisgender
2
once they reach adolescence or
early adulthood. This statement largely draws on esti-
mates from four follow-up studies conducted with
samples of gender-nonconforming children in one
of two clinics in Canada or the Netherlands
(Drummond, Bradley, Peterson-Badali, & Zucker,
2008; Steensma, Biemond, de Boer, & Cohen-Kettenis,
2011; Steensma, McGuire, Kreukels, Beekman, &
Cohen-Kettenis, 2013; Wallien & Cohen-Kettenis,
2008). This article outlines methodological, theoreti-
cal, ethical, and interpretive concerns regarding these
studies. We clarify the cultural, historical, and clinical
contexts within which these studies were conducted to
understand and to deconstruct the embedded founda-
tional assumptions of the research as well as the
widespread interpretations of the results. Some of
these critiques have been offered elsewhere in
CONTACT Julia Temple Newhook jtemple@mun.ca Janeway Pediatric Research Unit, Faculty of Medicine, Memorial University, 300 Prince Philip Drive,
St. John’s, NL A1B 3V6, Canada.
© 2018 Taylor & Francis Group, LLC
INTERNATIONAL JOURNAL OF TRANSGENDERISM
https://doi.org/10.1080/15532739.2018.1456390
commentaries, books, and on-line forums (see Ehren-
saft, 2016; Olson & Durwood, 2016; Pyne, 2012,2014;
Serano, 2016; Winters, 2014; Olson, 2016). This analy-
sis seeks to further this discussion by systematically
engaging scholarly literature. This team of co-authors
encompasses a range of theoretical and disciplinary
perspectives which include: clinical care providers in
pediatrics, family medicine, and psychology; research-
ers in the fields of sociology, psychology, neurobiol-
ogy, and social work; and lived experience as trans
and gender diverse people as well as parents and part-
ners of trans and gender diverse people. Our theoreti-
cal approach echoes that of the World Professional
Association for Transgender Health (Coleman et al.,
2012), that transgender identity is “a matter of diver-
sity, not pathology”(p. 4).
We recognize that numerous follow-up studies of
gender-nonconforming children have been reported
since the mid-20th century (e.g., Green, 1987; Money
& Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984).
In that era, most research in the domain focused on
feminine expression among children assigned male at
birth, with the implicit or explicit objective of prevent-
ing homosexuality or transsexualism. However, we
focus here on the four most recent follow-up studies,
published since 2008, which are most often cited as
evidence for desistance theories.
Concerns and contributions: What can
and cannot be learned from follow-up studies
with gender-nonconforming children
Between 2008 and 2013, four follow-up studies of gen-
der-nonconforming children were published in peer-
reviewed journals, with samples of children referred to
one of two gender clinics in Toronto, Canada or in the
Netherlands (Drummond et al., 2008; Steensma et al.,
2011,2013; Wallien & Cohen-Kettenis, 2008). An oft-
accepted interpretation of these findings is that approx-
imately 80% of gender-nonconforming children in
these studies, by adolescence, identified with their sex
assigned at birth. They are often said to have “desisted
3
”
”from a prior transgender identity. This presumption
links directly to questions about whether to support the
self-identities of pre-pubescent gender-nonconforming
children. This article reviews these studies and their
interpretations by noting a number of positive contri-
butions of this research before systematically exploring
the limitations and overgeneralizations that render
these studies less reliable than is often assumed.
In Table 1, we summarize the findings and compare
several of the main measures and concepts explored in
four key peer-reviewed publications between 2008 and
2013, frequently cited to support the 80% “desistance”
estimation. These studies included gender-nonconform-
ing children who were referred for clinical care at early
ages, and atfollow-up in adolescence or early adulthood,
categorized them as either “persisters”or “desisters.”
In the following commentary, we explore these stud-
ies in more depth by focusing on methodological, theo-
retical, ethical, and interpretive concerns, while noting
the extrapolation that may have given rise to problem-
atic treatment recommendations. First, some contribu-
tions from the original research are highlighted.
Contributions of follow-up studies with gender-
nonconforming children
While this commentary offers critiques of desistance
research and its clinical and popular interpretations,
these studies have also made contributions to the liter-
ature worthy of recognition:
1. qualitative data on trans and gender diverse
adolescents in clinical care, and
2. factors in anticipating medical transition for
gender-nonconforming children accessing clini-
cal care.
Steensma et al. (2011) offer some unique and valu-
able qualitative data to this body of literature. In the
perspectives of the trans and gender diverse adoles-
cents that are shared in this study, we are able to learn
that for these youth, the ages of 10–13 were important
for determining which direction their gender would
take, and especially significant at this time were their
feelings about their bodies and emerging sexualities.
The qualitative nature of this research allows us to
hear from two youths who had changed their minds
about their gender after socially transitioning and who
found the process of informing others very stressful.
Although this difficulty is not the only possible out-
come for youth who make more than one transition
(see section on Interpretive Concerns), this research
adds to our understanding of the pressures some
young people may face when exploring gender in a
transphobic society (Steensma et al., 2011).
A second contribution is that the four studies exam-
ined offer evidence that statements of transgender
2 J. T. NEWHOOK ET AL.
identity in childhood may help to anticipate transgen-
der identity in adolescence or adulthood, and similarly,
that the reported intensity of feelings of gender dyspho-
ria in childhood may help to anticipate feelings of gen-
der dysphoria in adulthood. Drummond et al. (2008)
found that the two participants classified as gender dys-
phoric at follow-up “recalled significantly more cross-
gender identity and role behavior in childhood than
participants classified as having no gender dysphoria”
(p. 41). Wallien and Cohen-Kettenis (2008) reported
that “all participants in the persistence group were
given a complete GID diagnosis in childhood, whereas
half of the group of desisting children was subthreshold
for the diagnosis”(pp. 1420–1421). Finally, Steensma
et al. (2013) reported that “explicitly asking children
with GD with which sex they identify seems to be of
great value in predicting a future outcome for [children
diagnosed with gender dysphoria].”(p. 588). Both
media and scientific discussion of this research have
tended to downplay what is suggested here—the value
of asking a child about their gender identity. Gender
identity can indeed shift and evolve over time, and thus
a young person who did not express trans identity in
childhood should not be dismissed in their teen years
on this basis, yet the persistence of this stated identity
for some youth may be instructive. Regardless of
predictive value, however, current approaches to care
recommend that care providers prioritize young peo-
ple’s stated identities, perceptions, and needs in the
present moment, as opposed to attempting to estimate
the likelihood of future identity and needs (Hidalgo
et al., 2013; Temple-Newhook et al., in press 2018). As
clinicians Schreier and Ehrensaft (2016) suggest: “Want
to know a child’s gender? Ask.”We now turn to outlin-
ing a series of critiques and concerns regarding these
studies, including: methodological, theoretical, ethical,
and interpretive concerns.
Methodological concerns
We have identified the following methodological con-
cerns in these four studies:
1. the potential misclassification of child research
participants
2. the lack of acknowledgement of social context
for research participants
3. the age of participants at follow-up, and
4. the potential misclassification of adolescent and
young adult participants lost to follow-up.
The first two methodological concerns address the
broad inclusion criteria for those studied in childhood.
Rather than a representative group of transgender
Table 1. Summary of relevant findings across four follow-up studies with gender-nonconforming children (2008–2013).
Reference Drummond et al. (2008) Wallien et al. (2008) Steensma et al. (2011) Steensma et al. (2013)
1. N, number of subjects at T0 37 (AFAB) 77 53 127
2. T0-age 3–12 yrs 5–12 yrs !12 yrs !12 yrs
3. Selection by GIDC criteria DSM-III DSM-IV DSM-IV DSM-IV
DSM-III-R DSM-IV-TR DSM-IV-TR DSM-IV-TR
DSM-IV
4. T0-GIDC/N60% 75% 100% 63%
5. T0-GIDC-subthreshold/N40% 25% 0% 37%
6. T1-age "17 yrs "16 yrs "14 yrs "15 yrs
7. T1-desistant/N59% 30% 19% 36%
8. T1-desistant-reported-by-3rd-parties/Nn/a 13% n/a 5%
9. T1-persistent/N8% 27% 55% 37%
10. T1-nonbinary n/a n/a 2% n/a
11. T1-nonparticipant/N32% 30% 25% 22%
12. Reporting of nonparticipants Deleted from cohort Assumed to be desistant Assumed to be desistant Assumed to be desistant
13. Reported desistance rate 88% 73% 45% 63%
Notes: All four studies selected subjects at T0 using the diagnostic criteria for Gender Identity Disorder of Childhood in the DSM-III through the DSM-IV, which did
not explicitly require evidence of distress or of gender dysphoria (Row 3). In the Drummond et al. (2008) and Steensma et al. (2013) studies, nearly 40% of sub-
jects were “subthreshold”for GIDC diagnosis, and therefore did not meet those criteria (Row 4). In Row 9, rates are shown for persistent GIDC diagnosis or dis-
tress of gender dysphoria confirmed by re-assessment at T1 in adolescence or young adulthood. Far fewer subjects were confirmed with desisted GIDC
diagnosis or with desisted gender dysphoria distress by re-assessment at T1 (Row 7), than were reported as desisters in these papers (Row 13). Five percent of
Steensma et al. (2013) subjects were judged desistant based only on parental or other 3rd party information at T1, with no reported examination of possible bias
among those parties (Row 8). One subject in Steensma et al. (2011) identified as nonbinary at T1 but was categorized as desistant (Row 10). Between 1/5th and
1/3rd of the samples did not participate in follow-up evaluation at T1 (Row 11). In Steensma (2013), 22% of subjects were termed “nonresponders”at T1, includ-
ing 19% whose status was altogether unknown and 3% who were reported as “indicated”desistant, though not confirmed by actual participation at T1 re-
assessment (p. 584). Despite their outcome status being unknown or unconfirmed, they were categorized as desisters in all three Dutch studies, Steensma et al.
(2011) and Steensma et al. (2013), Wallien and Cohen-Kettenis (2008) (Row 12). Desistance rates in the four papers were reported by the authors as follows: T1-
desistant/T1-participant for Drummond et al. (2008), where T1 nonparticipants were deleted from the cohort denominator; (T1-desistant CT1-nonparticipant)/N
for Wallien and Cohen-Kettenis (2008); (T2-desistant CT2-nonbinary CT2-nonparticipant)/Nfor Steensma et al. (2011); and (T2-desistant CT2-desistant-
reported-by-3rd-parties CT2-nonparticipant)/Nfor Steensma et al. (2013).
INTERNATIONAL JOURNAL OF TRANSGENDERISM 3
children, which is assumed in many interpretations,
this literature focused on small groups of gender-non-
conforming children in two clinics. In Table 1, some
but not all of these children were diagnosed in child-
hood with gender identity disorder in children
(GIDC), in prior editions of the Diagnostic and Statis-
tical Manual of Mental Disorders (DSM) published by
the American Psychiatric Association (1980,1987,
1994,2000). The GIDC category was replaced by gen-
der dysphoria in children (GDC) in the DSM-5
(American Psychiatric Association, 2013). Gender
dysphoria was not defined as a diagnostic category
until release of the DSM-5 in 2013, and therefore, no
subjects were formally diagnosed with gender dyspho-
ria in childhood or at follow-up in any of these studies.
However, the plain-language meaning of gender dys-
phoria, as distress regarding incongruent physical sex
characteristics or ascribed social gender roles, has
been established since the 1970s (Fisk, 1973). When
these four studies refer to gender dysphoria, they are
referring to this plain-language context of distress,
and not the newer DSM-5 diagnostic category.
Due to such shifting diagnostic categories and
inclusion criteria over time, these studies included
children who, by current DSM-5 standards, would not
likely have been categorized as transgender (i.e., they
would not meet the criteria for gender dysphoria) and
therefore, it is not surprising that they would not iden-
tify as transgender at follow-up. Current criteria
require identification with a gender other than what
was assigned at birth, which was not a necessity in
prior versions of the diagnosis. For example, in
Drummond et al. (2008) study (Table 1), the sample
consisted of many children diagnosed with GIDC, as
defined in the DSM editions III, III-R, and IV
(American Psychiatric Association, 1980,1987,1994).
Yet the early GIDC category included a broad range
of gender-nonconforming behaviors that children
might display for a variety of reasons, and not neces-
sarily because they identified as another gender. Evi-
dence of the actual distress of gender dysphoria,
defined as distress with physical sex characteristics
or associated social gender roles (Fisk, 1973), was
dropped as a requirement for GIDC diagnosis in the
DSM-IV (American Psychiatric Association, 1994;
Bradley et al., 1991). Moreover, it is often overlooked
that 40% of the child participants did not even meet
the then-current DSM-IV diagnostic criteria. The
authors conceded: “…it is conceivable that the
childhood criteria for GID may ‘scoop in’girls who
are at relatively low risk for adolescent/adult gender-
dysphoria”and that “40% of the girls were not judged
to have met the complete DSM criteria for GID at the
time of childhood assessment…it could be argued
that if some of the girls were subthreshold for GID in
childhood, then one might assume that they would
not be at risk for GID in adolescence or adulthood”
(p. 42). By not distinguishing between gender-non-
conforming and transgender subjects, there emerges a
significant risk of inflation when reporting that a large
proportion of “transgender”children had desisted. As
noted by Ehrensaft (2016) and Winters (2014), those
young people who did not show indications of identi-
fying as transgender as children would consequently
not be expected to identify as transgender later, and
hence in much public use of this data there has been a
troubling overestimation of desistance.
The second concern brings attention to the scope of
the four studies discussed. Inferences from clinical
research are always bound to specific locations and
timeframes. Generalizing from research on gender
identity is particularly problematic because notions of
gender are highly dependent on social and historic con-
text. For example, the meaning of gender-conformity
and nonconformity varies greatly, and in some non-
Western and indigenous cultures, gender diversity is
either celebrated or considered nonproblematic (Dris-
kell, Finley, Gilley, & Morgensen, 2011; Hunt, 2016).
Furthermore, even within Toronto and the Nether-
lands, this research was limited to children whose
parents chose to bring them to a clinic for diagnosis
and treatment and thus may have believed the child’s
difference was a problem, and one that required psy-
chological treatment. Children whose parents affirmed
their gender (or who did not wish to or who were
unable to access clinical treatment for any reason) were
likely not included in these studies. This is significant
because more recent work has shown that children
raised by parents who validate their gender identity
(Durwood, McLaughlin, & Olson, 2017; Olson & Dur-
wood, 2016) are likely to demonstrate a different (and
in some respects healthier) life course than children
with parents who are reluctant or unwilling to affirm
gender-nonconformity. The outcomes in the one
group, therefore, may not generalize to the other.
The third methodological concern centers on the age
at which follow-up was conducted. As noted in Table 1,
only a minority of the young people who consented to
4 J. T. NEWHOOK ET AL.
be re-studied were diagnosed in adolescence with gen-
der identity disorder in adolescents or adults (GIDAA)
and/or chose to undergo certain trans-affirming sur-
geries in early adulthood. Yet in these four studies
(Table 1), the mean age at follow-up ranged from 16.04
(Steensma et al., 2013) to 23.2 years (Drummond et al.,
2008) and included adolescents as young as 14 years
(Steensma et al., 2011). It is important to acknowledge
that this represents a very early follow-up point in an
individual’s life, and that a trans person might assert or
reassert their identity at any point in their life. An
assumption has been made that young people not diag-
nosed with GID (or Gender Dysphoria in the current
DSM-5) by late adolescence and/or not pursuing medi-
cal transition by a relatively early age, can then by
default be “correctly”categorized as cisgender for their
lifetime. However, this conclusion is contradicted
when an unknown number of those counted as “desist-
ers”may transition later, after the point of follow-up.
Research has found that many trans-identified individ-
uals come out or transition later in adulthood (Reed,
Rhodes, Schofield, & Wylie, 2009).
Afourthmethodologicalconcernfocusesonthemis-
classification of participants who did not participate in
follow-up. A significant challenge to any longitudinal
study is that a number of original participants will not be
able to be located or will not provide research consent
even if located, and so will be lost to follow-up (attrition).
One can only continue to study those participants who
can be located and contacted, and who also then consent
to re-enrol. High levels of attrition limit the generalizabil-
ity of longitudinal research findings, particularly when
attrition might be non-random and related to the out-
come. In the Drummond et al. (2008)study,thedata
from participants who were lost to follow-up (32% of
participants) were removed from the study and analyses
were conducted only with participants who returned.
This list deletion method of handling attrition can be
risky and can introduce bias, as Deng, Hillygus, Reiter, Si,
and Zheng (2013)note,becausethereismuchscholar-
ship suggesting that certain individuals are more likely to
be lost to follow-up than others.
The three other studies analyzed in this review (Steen-
sma et al., 2011,2013;Wallien&Cohen-
Kettenis, 2008)tookwhatmightbeunderstoodasan
even riskier approach to handling attrition, by imputing
all outcomes to missing participants as “desisters,”in
effect, venturing to guess about data that was unavailable.
In these studies, 30% of Wallien and Cohen-Kettenis’
(2008), 25% of Steensma, et al.’s(2011), and 22% of
Steensma et al.’s(2013)participantswhodidnotrespond
or did not participate at adolescent follow-up were
counted as desisters (Table 1). In explanation, Steensma
et al. (2011)write:“As the Amsterdam Gender Identity
Clinic for children and adolescents is the only one in the
country, we assumed that their gender dysphoric feelings
had desisted, and that they no longer had a desire for sex
reassignment.”(p. 501). In other words, desistance was
assessed based on whether or not participants re-engaged
with this specificclinicbyaspeci
fictime.Thismethodo-
logical choice neglects a number of important considera-
tions: (1) the fact that not all transgender people wish to
medically transition, yet still identify as trans; (2) the
socio-economic or cultural factors that may influence
whether an adolescent seeks psychological or medical
treatment; (3) the possibility of a negative perception of
the initial clinic experience, which might discourage a
youth’sreturn;(4)thepossibilityofayouthmovingout
of the country, being institutionalized in a mental health
facility or even the possibility of death (including suicide),
none of which negate a trans identity; and, (5) the possi-
bility that some young people might repress their gender
identity for a period of time, due to societal transphobia,
family rejection, safety, employment and housing secu-
rity, or pressure from therapies designed to discourage
trans identity (Kennedy & Hellen, 2010). The phenome-
non of realizing one’sgenderidentitylongbeforeexpress-
ing it to others has been illustrated in the Trans PULSE
study conducted in Ontario, Canada. While 59% of par-
ticipants had socially transitioned within the four years
prior to study, the majority of participants first realized
that they were trans before the age of 10 years (Scheim &
Bauer, 2015). The classification (and potential misclassifi-
cation) of participants lost to follow-up as desisters could
result in a significant overestimation of the number of
young adults assumed to be cisgender.
Theoretical concerns
We have identified the following theoretical concerns
in the four studies:
1. assumptions inherent in “desistance”terminology
2. binary gender framework, and
3. presumption of gender stability as a positive
outcome.
The first theoretical concern pertains to the unnec-
essary conceptualizing of shifts in gender identity as
either “persistence”or “desistance.”The etymology of
INTERNATIONAL JOURNAL OF TRANSGENDERISM 5
the word desistance (from the Latin desistere, mean-
ing to stop or cease) reveals that the dominant frame-
work for understanding variations of childhood
gender is rooted in the field of criminology (e.g.,
Farrall, Bottoms, & Shapland, 2010; Sampson & Laub,
2003; Stouthamer-Loeber, Wei, Lober, & Masten,
2004), where desistance is defined as “the cessation of
offending or other antisocial behavior”(Kazemian,
2011, p. 656). This choice of terminology positions
gender identity development as a pathway of either
“normal”or “deviant”identity. In addition, the use of
the term desistance in all four studies positions cisgen-
der and transgender as immutable discrete categories
(Serano, 2016). In this framework, cisgender identity
tends to be seen as the healthy opposite of a problem-
atic transgender identity. Assertion of a cisgender
identity at any point in the life cycle is often assumed
to be valid and invalidates any previous assertion of
transgender identity; yet a transgender identity is only
viewed as valid if it is static and unwavering through-
out the life course and if it emerges in a particular
time period (the period of study). In our research and
practice experience, a rigid categorization of gender
does not reflect the lived experiences of transgender
and gender-nonconforming children. A child who has
identified as transgender may indeed at some point in
their life assert their birth-assigned gender, but this is
not necessarily the end of their gender journey.
A second theoretical concern is that the terminology
of “desistance”depends on a binary understanding of
gender. Each of the four studies used binary language
to refer to children as “boys and girls,”prioritizing the
sex they were assigned at birth, as opposed to their own
identity. Furthermore, this language makes nonbinary
and intersex identities invisible. For example, Steensma
et al. (2011) define the following individual as a desister
and thus cisgender, in spite of the young person’s own
self-identification: “At the time of the interview,
Desister 1 (18 years of age), still desired to be a woman,
with breasts and the possibility of giving birth. How-
ever, he considered himself 50% male and 50% female”
(p. 512). The authors acknowledge that not every per-
son who experiences gender dysphoria will seek medi-
cal transition or assert a binary gender identity. They
add that “[i]t would be worthwhile to follow [this non-
binary-identifying young person’s] development much
longer, to see whether [their] ambiguous gender feel-
ings were just part of a passing phase (either into desis-
tence or persistence) or whether they remained a stable
characteristic of this person”(p. 513). We question
here the characterization of a self-described “50% male
and 50% female”research participant as “ambiguous,”
instead of a term supplied by the participant, and hope
that if this study were conducted today, there would be
greater recognition of nonbinary gender identities.
A third theoretical concern is the embedded
assumption in these studies that “stability”of gender
identity is a positive health outcome that should be
prioritized for all children. A desistance framework
reinforces a static understanding of gender that hin-
ders us from understanding the experience of a child
whose gender identity is more fluid, or changeable
over time. While the current understanding of the
developmental trajectories of gender state that most
children are aware of their gender identity by the
age of 4 years (American Association of Pediatrics,
Human Rights Commission, & American College of
Osteopathic Pediatricians, 2016), this does not suggest
that those children for whom gender identity is more
fluid or slower to develop are not also following a
healthy developmental trajectory. While many indi-
viduals experience their gender identity as stable
throughout their lifetimes, others find that a gender
that “fits”at age four may be different from what fits
at age seven, age 18, or age 65. None of these identities
are “wrong”; instead they may have been perfectly and
precisely the right fit for that person at that moment.
Further, for some individuals the most consistent
aspect of their gender is that it is fluid or ever-chang-
ing. Many individuals move through a process of
exploration and/or “[renegotiation] of one’s gender
throughout childhood or adulthood with no observ-
able detriment to their mental health”(Ehrensaft,
2016, p. 59). An alternative framework would concep-
tualize changes and developments in gender identity
not as errors in the development of a “true”gender,
but as necessary paths of exploration along a journey
of self-discovery that might be lifelong. Finally, as Bry-
ant (cited in Schwartzapfel, 2013) points out, it is
likely that the future identities of today’s children can-
not be known for certain, given that the language to
describe or acknowledge these identities may not yet
exist. There is no evidence that caring for a child in
the present requires knowing their future adult gender
identity. A longitudinal research design that records
identity at two relatively early intervals is therefore
arguably not the most appropriate tool for under-
standing either children’s or adult’s health needs.
6 J. T. NEWHOOK ET AL.
The dominance of binary language in interpreta-
tions of desistance research is implied in statements
such as “the majority of those who desist by or during
adolescence grow up to be gay, not transgender”
(Drescher & Pula, 2014, p. S18). Such statements con-
flate gender identity and sexual orientation, with an
underlying assumption that the options are between
identifying as gay and cisgender, or as transgender.
Framing research on childhood gender diversity in
terms of desistance and persistence tends to reproduce
and reinforce this limited binary perspective on gen-
der and sexuality. The conception of gender reflected
in these studies represents a historical and cultural
moment that differs from both traditional and current
understandings of gender and sexuality. As scholars of
human sciences, we are reminded that clinical and
research disciplines are human-made frameworks to
understand complex identities and actions. In scien-
tific and medical research, it is important to acknowl-
edge that the categories used to study people (e.g.,
desisters) often reflect the assumptions and beliefs of
the researchers themselves. We suggest that if we find
that people do not fit our categories, then it is the cate-
gories that must change.
Ethical concerns
We have also identified ethical concerns in these four
studies:
1. intensive treatment and testing of child
participants,
2. questionable goals of treatment, and
3. lack of consideration of children’s autonomy.
From an ethical perspective, it is important to con-
sider that research itself is an intervention. These stud-
ies took place in the context of gender clinics in which
children were put through a substantial degree of test-
ing over periods of months or years. For example,
Drummond et al. (2008) report that in their study,
children and their parents were administered: the
Draw a Person test; a free-play task; the Playmate and
Playstyle Preferences Structured Interview; sex-typed
responses on the Rorschach test; the Gender Identity
Questionnaire for Children; a measure of activity
level/extraversion; and the Games Inventory. Critiques
of the practice of diagnosing gender-nonconforming
children (with the GIDC diagnosis from DSM-III,
DSM III-R, DSM IV) began to be published in the late
1990s and argued that healthy children might have
their self-esteem damaged and their trust in therapy
eroded by being brought into stigmatizing diagnostic
and treatment settings (Isay, 1997; Langer &
Martin, 2004; Menvielle, 1998; Pickstone-Taylor,
2003; Vanderburgh, 2009). This concern continues
and highlights the need for research into possible
adverse effects and ethical complications related to
extensive and ongoing psychological testing for chil-
dren in clinical settings.
A second ethical concern is that many of the chil-
dren in the Toronto studies (Drummond et al., 2008;
Zucker & Bradley, 1995) were enrolled in a treatment
program that sought to “lower the odds”that they
would grow up to be transgender (Drescher & Pula,
2014; Zucker, Wood, Singh, & Bradley, 2012;
Paterson, 2015). Zucker et al. (2012) wrote: “…in our
clinic, treatment is recommended to reduce the likeli-
hood of GID persistence”(p. 393). In a Hastings
Centre Report on LGBT Bioethics, Drescher and Pula
(2014) explain the Toronto clinic’s approach: “The
clinic claims its approach decreases the likelihood that
GD will persist into adolescence, leading to adult
transsexualism, which, for various reasons, such as
social stigma and a lifetime of medical treatment,
is an outcome the clinic considers undesirable”
(pp. S17–18). Drescher and Pula (2014) make an ethi-
cal inquiry about this approach: “Since no clinician
can accurately predict the future gender identity of
any particular child, shouldn’t we assume that efforts
to discourage cross-gender play and identifications
may be experienced as hurtful and possibly even trau-
matic, since, for some children, gender dysphoria will
persist into adolescence and adulthood?”(p. S19).
Drescher and Pula elaborate: “Are the harms so
unknown or so great that it is unethical to offer such
treatment at all?”(p. S19). The Toronto clinic was
closed in 2015 (Schreier & Ehrensaft, 2016), but ques-
tions regarding the interpretation of research con-
ducted in this setting are ongoing.
Drummond et al. (2008) report that their follow-up
study provides information on the “natural histories”
of “girls with gender identity disorder”(p. 34), yet the
clinical pursuit of an a priori goal for a child’s gender
is already inconsistent with the meaning of the term
“natural history,”which refers to the natural progres-
sion of a condition in the absence of treatment (Center
for Disease Control, 2012). While the Netherlands
clinic did not discourage children from exploring their
gender expression, it did discourage children from
INTERNATIONAL JOURNAL OF TRANSGENDERISM 7
socially transitioning prior to puberty (Drescher &
Pula, 2014; Steensma et al., 2013). It is important to
acknowledge that discouraging social transition is
itself an intervention with the potential to impact
research findings, as discussed below in reference to
interpretive concerns.
A lack of consideration of children’s autonomy in
desistance literature is a third ethical concern. Chil-
dren have their own rights to autonomy and self-
determination (Powell, Fitzgerald, Taylor, & Graham,
2012).
4
However, children’s own assertions of identity
and their own perspectives on their gender are subor-
dinate in this literature to the diagnostic measures cre-
ated by clinicians and researchers. In one case,
Steensma et al. (2013) write that, “because the role of
parental report on gender-variant behaviors and sur-
face behaviors such as gender role transitioning are of
less value in predicting a future persistence of gender
dysphoria in [children assigned female at birth], it
seems important to provide extra focus on [assigned-
female children’s] own experiences of cross-gender
identification and wishes”(p. 588). We agree with this
statement of concern for children’s own identification
and wishes and would extend it to children of all
genders.
This consideration of children’s own wishes should
also extend to their right to decline participation in
research. In the four studies, there is an absence of
information about whether research participation was
optional and if steps were taken to ensure that chil-
dren could decline research consent while continuing
to receive needed services. The need to decouple
research participation from access to medical and
mental health care is consistent with emerging pro-
posals for ethical research with transgender subjects
(Adams et al., 2017; Devor, Bauer, Pyne, Heinz, &
Marshall, 2016)
These ethical concerns raise questions about the
validity of research with children whose parents
believe they have a medical problem, who are sub-
jected to a high level of testing and treatment, who are
disallowed or discouraged from asserting their own
gender identity, and who are being raised in a broader
society that often punishes perceived transgressions of
male and female boundaries. Interpretations of desis-
tance research have assumed that the difference
recorded between measures of gender dysphoria and/
or identity at childhood and at early adulthood mean
that “the majority of [trans children] will become
comfortable with their natal gender over time”(Byne
et al., 2012). However, the larger social context shap-
ing young people’s identities is essential to consider.
Wallien and Cohen-Kettenis (2008) point out that
there are challenges in research based on self-report of
sexual orientation, given that “social desirability is a
key validity issue in the assessment of sexual orienta-
tion during the adolescent years”(p. 1421). It would
be fair to assume that the same concern would hold
for self-report of gender identity. Drummond et al.
(2008) attempt to account for the possible effect of
social desirability by assessing participant responses to
questions about a range of socially undesirable issues,
yet it is unclear if this can account for the way trans-
gender identity might be uniquely undesirable in a
clinic that explicitly seeks to discourage it (see Zucker
et al., 2012). In interpreting the results of these studies,
it is important to ask questions about limitations in
the validity of self-report when the research is con-
ducted under conditions that might compromise
authentic responses, for example, within a clinic where
transgender identity is defined as less desirable than
cisgender identity.
Interpretive concerns
We also have concerns with the authors’interpreta-
tion in these four studies, including:
1. the assumption that unknown future adult
needs should supersede known childhood needs,
and
2. the underestimation of harm when attempting
to delay or defer transition.
Desistance studies are often drawn on to suggest
that delaying a young person’s social transition is jus-
tified because it may prevent them from having to
transition back in the future. There is an assumption
that a second transition would be distressing.
Steensma et al. (2013) write: “the percentage of transi-
tioned children is increasing …which could result in a
larger proportion of children who have to change
back to their original gender role, because of
desisting GD, accompanied with a possible struggle”
(pp. 588–589). Yet we note that this projected struggle
is acknowledged only as “possible”rather than certain
(p. 589). Similarly, in a letter to the editor entitled
“Gender Transitioning before Puberty?”, Steensma
and Cohen-Kettenis (2011) write: “It is conceivable
that the drawbacks of having to wait until early
8 J. T. NEWHOOK ET AL.
adolescence (but with support in coping with the gen-
der variance until that phase) may be less serious than
having to make a social transition twice”(p. 649). Yet
again, this statement itself acknowledges that future
distress is merely “conceivable”and again, not certain.
As Ehrensaft, Giammattei, Storck, Tishelman, and
Keo-Meier (2018) note, the evidence that a second
transition would be traumatic is very thin, drawn
from a case study of two children who found a rever-
sion back to their original gender challenging in
Steensma and Cohen-Kettenis’s(2011) clinic. Yet in
another clinic (Edwards-Leeper & Spack, 2012), a
de-transitioning girl and her mother expressed grati-
tude for her opportunity to live as a boy for a time,
and they felt that if she had been forced to live as a girl
for her entire childhood, that her mental health would
have suffered. Thus, with many possible outcomes for
the future, young people’s needs in the present must
be prioritized.
A further related interpretive concern is the pre-
sumption that childhood needs, adolescent needs, and
adult needs should “match”in a simplistic sense. Yet a
child may need to use “she”pronouns in childhood,
“he”pronouns in adolescence, and “they”pronouns in
adulthood. Nothing about this is inherently problem-
atic. What is needed in childhood may differ from
what is needed in adolescence or adulthood, but this
does not negate childhood needs. What is problematic
is the assumption that a potential future shift in a
child’s gender identity is a justification for suppressing
or redirecting their assertion of identity in childhood.
The underestimation of harm in suppressing or
redirecting children’s gender expression is the most
serious concern in interpretations of desistance litera-
ture. That gender identity or expression may change
among children (or adults) does not support the
hypothesis that it is preferable or possible to externally
“coax”gender in a particular direction, or that this
could be done without harm. In contrast, the position-
ing of this goal as benign ignores the potential harms
to young people who have undergone such treatments
(Bryant, 2006). A 2013 attachment-based theoretical
comparison of gender therapies for children con-
cluded that there is a risk that children who are dis-
couraged from expressing their gender identity may
integrate shame into their fundamental sense of self
(Wallace & Russell, 2013). Drescher and Pula (2014)
offer: “It could be construed …that clinical attempts
to prevent transsexualism, no matter how well
meaning, are unethical because they demean the dig-
nity of gender-variant children”(p. S19). Although
the term “conversion therapy”originally referred to
religious-based therapies purported to change an indi-
vidual’s sexual orientation, as noted by the American
Academy of Child and Adolescent Psychiatry
(AACAP), the meaning of the term has expanded in
recent years to encompass efforts to change an indi-
vidual’s core gender identity or promote a preferred
outcome for their gender identity, therapies that
according to the AACAP “lack scientific credibility”
(AACAP, 2018). In our experience, disallowing child-
ren’s assertions of gender identity is far from a “neu-
tral”option. From a developmental perspective, a
child who is repeatedly discouraged when she ear-
nestly insists on being called “she,”is learning, on a
fundamental level, that (1) she cannot trust her own
knowledge of herself and, (2) the adults she depends
on may not value her for who she knows herself to be.
Lastly, while many clinicians would not propose
attempting to alter gender expression, many still interpret
desistance research as support for delaying transition, lest
atransidentitybecomesmorelikely.Steensmaetal.
(2013)write:“…with a link between social transitioning
and the cognitive representation of the self [social transi-
tion may] influence the future rates of persistence”(pp.
588–589). Yet we would ask why an increase in the num-
ber of transgender people (“persistence”)wouldbeinter-
preted in a negative light, and how this sentiment could
be consistent with the WPATH position that transgender
identity is a matter of diversity not pathology (Coleman
et al., 2012). Drescher and Pula (2014)aswellas
Ehrensaft et al. (2018)notethatattimesthereappearsto
be a willingness to expose transgender children to the
stress of living in a gender they do not identify with, in
order to protect cisgender children from the possibility of
“mistakenly”transitioning. Yet we would contend that
the quality of life of transgender children is no less impor-
tant and no less valuable than that of cisgender children.
Discussion: What is the future of care for trans
and gender diverse children?
It is essential to distinguish between the evidence pro-
vided by these studies and the flawed interpretations
of these studies that may be used to shape care for
trans and gender-nonconforming children. These con-
cerns address the differences between the questions:
(1) how should children’s gender identities develop over
INTERNATIONAL JOURNAL OF TRANSGENDERISM 9
time? and, (2) how should children best be supported as
their gender identity develops?
In the first question, desistance studies give us some
information about how some gender-nonconforming
children’s identities have been recorded in certain cul-
tural and clinical circumstances. However, the World
Professional Association for Transgender Health
Standards of Care now recognizes gender-nonconfor-
mity as a matter of diversity not pathology (Coleman
et al., 2012, pp. 1, 3, 4, 6); thus, no path need be con-
sidered the correct or healthy trajectory. While trans-
gender identity has certainly been pathologized in
Western medicine, present-day best practice promotes
the recognition of a plurality of healthy developmental
trajectories for gender.
In the second question, the affirmative care model,
which is now practiced by the majority of North
American gender clinics (Ehrensaft, 2016), promotes
support for children as their gender identity develops,
with no expectations for any particular direction of
the gender journey. In the affirmative care model, chil-
dren are provided with the space to explore and try
out different self-expressions to discover a place that
is comfortable for them (Ehrensaft, 2016; Hidalgo
et al., 2013). This means that instead of attempting to
direct a child toward a particular identity, parents and
caregivers accept a child’s own individual journey.
Within this model of care, adult scrutiny and invest-
ment in any particular current or future gender iden-
tity are removed. Children are not prevented from
exploring aspects of gender as they develop a sense of
what fits for them through the language available to
them at that time. Within this model of care, it is
understood that the gender that is the “right fit”may
differ at different ages and stages of life. Emergent
research on the health and well-being of trans children
who are affirmed in their gender identity, indicates
mental health outcomes equivalent with cisgender
peers (Durwood et al., 2017; Olson, Durwood,
DeMeules, & McLaughlin, 2016). As Sherer (2016)
and Turban (2017) note, this is in stark contrast to the
high levels of psychological distress and behavioral
problems documented among children who were dis-
couraged from asserting their identities in childhood
(Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker,
2003).
From a research perspective, noting the gap
between the questions of (1) gender trajectories and
(2) the health of gender-nonconforming children, we
suggest that longitudinal studies about identity “desis-
tance”or “persistence”are not the best tools for
understanding the needs of gender-nonconforming
children. As work begins on the 8th version of the
Standards of Care by the World Professional Associa-
tion for Transgender Health, we call for a refocus of
research and clinical practice with transgender and
gender-nonconforming children and youth, to priori-
tize listening to how young people articulate their
wishes and needs. The potential harm inherent in
approaches that lack support for children’s own asser-
tions must be acknowledged as we create a more
nuanced framework for understanding and caring for
gender-nonconforming children. Such a framework
would integrate an understanding of intersectionality
(Cole, 2009; Collins, 1990; Crenshaw, 1991; Singh,
2013), which involves taking into account the multiple
systems of oppression that simultaneously shape trans
and gender-nonconforming children’s lives.
Conclusion
In this critical review of four primary follow-up stud-
ies with gender-nonconforming children in Toronto,
Canada and the Netherlands (Table 1), we identify a
total of 12 methodological, theoretical, ethical, and
interpretive concerns as well as two often-overlooked
contributions of this literature. We conclude that,
while our understanding of gender diversity in adults
has progressed, the tethering of childhood gender
identity to the idea of “desistance”has stifled similar
advancements in our understanding of children’s gen-
der diversity. As we progress towards a fuller under-
standing of children’s gender in all its complexity, it
will be important to move beyond longitudinal studies
of identity that seek to predict children’s futures, and
instead prioritize respect for children’s autonomy in
the present. For all the resources devoted to studying
these children, we have much more to learn by listen-
ing to them.
Notes
1. We use the term trans or transgender when an individu-
al’s gender differs from the one assigned to them at birth
and/or differs from what others expect of their physical
presentation. This is not a universal definition, rather it is
a description of our use of the term in this article.
2. We use the term cis or cisgender when an individual’s
gender aligns with the one assigned to them at birth and
matches what others expect of their physical presentation.
10 J. T. NEWHOOK ET AL.
3. We consider the term “desistance”to be flawed (see Theo-
retical Concerns section) but we use the term in this com-
mentary because it is widely understood in the field of
transgender health.
4. The authors acknowledge that beliefs about children’s
autonomy vary cross-culturally.
Declaration of conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human partici-
pants performed by any of the authors.
Acknowledgments
The authors would like to thank Ayden Scheim and Greta
Bauer as well as the anonymous reviewers and editors of this
special issue for their helpful comments on earlier drafts.
Funding
No funding was provided for the writing of this article.
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