LETTER TO THE EDITOR
Gender Transitioning before Puberty?
Thomas D. Steensma •Peggy T. Cohen-Kettenis
Published online: 4 March 2011
ÓSpringer Science+Business Media, LLC 2011
In the last decade, delaying puberty by means of GnRH analogs
in gender dysphoric adolescents has become an increasingly
accepted treatment (Hembree et al., 2009). The induced puber-
tal delay is meant to give gender dysphoric adolescents time to
reﬂect on their wish for gender reassignment, quietly and with-
out the alarming physical puberty development. During puberty
suppression, a complete social transition (change in clothing
and hair style, ﬁrst name, and use of pronouns) is not required.
However, most youth who are on puberty delaying hormones
appear not to wait with transitioning until they can start cross-
sex hormone treatment.
A similar trend can be observed in gender variant prepu-
bertal children. For quite some time, gender variant children who
came to clinical attention were treated by psychotherapy with the
purpose of decreasing cross-gender behavior and identiﬁcation
(Zucker, 2008). More recently, a more gender afﬁrmative
approach has been proposed (e.g., Saeger, 2006). This approach
may involve complete social transitioning (including a change of
ﬁrst name and pronouns) of children as young as 4 or 5 years of
age. Even without contacting clinicians, an increasing number of
parents also support young children in their wish to live in the
desired gender role on a daily basis. Before the year 2000, 2
(1.7%) prepubertal boys out of 112 referred children to the
Amsterdam gender identity clinic were living completely in the
female role. Between 2000 and 2004, 3.3% (4 out of 121 chil-
dren; 3 boys and 1 girl) had completely transitioned (clothing,
hairstyle, change of name, and use of pronouns) when they were
referred, and 19% (23 out of 121 children; 9 boys and 14 girls)
were living in the preferred gender role in clothing style and hair-
style, but did not announce that they wanted a name and pronoun
change.Between 2005 and 2009, these percentages increased to
8.9% (16 out of 180 children; 10 boys and 6 girls) and 33.3% (60
out of 180, 17 boys and 43 girls) respectively.
Such an approach assumes a high persistence of gender dys-
phoria or gender identity disorder (GID) after puberty. How-
ever, follow-up studies show that the persistence rate of GID is
about 15.8% (39 out of the 246 children who were reported on
in the literature) (for an overview, see Steensma, Biemond, de
Boer, & Cohen-Kettenis, 2011), and that a more likely psy-
chosexual outcome in adulthood is a homosexual sexual ori-
entation without gender dysphoria (Wallien & Cohen-Kettenis,
We wondered what would happen to children who transi-
tioned in childhood, but discover at an older age that they pre-
ferred to live in the gender role of their natal sex again. Recently,
we conducted a qualitative study among older adolescents who
had been gender dysphoric in childhood (Steensma et al., 2011).
Some of these children appeared to be persisters and theyapplied
for gender reassignment when entering puberty. Others appeared
to be desisters and were only interviewed for the follow-up study.
In the desisting group, two girls, who had transitioned when they
were in elementary school, reported that they had been struggling
with the desire to return to their original gender role, once they
realized that they no longer wanted to live in the‘‘other’’gender
role. Fear of teasing and shame to admit that they had been
‘‘wrong’’resulted in a prolonged period of distress. Only when
they started high school did they dare to make thechange back.
Although gender afﬁrmative treatment, including a com-
plete social transition, may be beneﬁcial for children who will
turn out to be persisters, clinicians and caregivers should real-
ize that prediction of an individual child’s psychosexual out-
come is very difﬁcult in young children. It is conceivable that
the drawbacks of having to wait until early adolescence (but
with support in coping with the gender variance until that phase)
may be less serious than having to make a social transition twice.
T. D. Steensma (&)P. T. Cohen-Kettenis
Department of Medical Psychology, VU University Medical
Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
Arch Sex Behav (2011) 40:649–650
Because the chances are high that the gender dysphoria will
disappear by early adolescence, it seems advisable to be very
careful when taking steps that are difﬁcult to reverse.
Hembree, W. C., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A.,
Gooren, L. J., Meyer, W. J., Spack, N. P., et al. (2009). Endocrine
treatment of transsexual persons: An Endocrine Society practice
guideline. Journal of Clinical Endocrinology and Metabolism, 94,
Saeger, K. (2006). Finding our way: Guiding a young transgender child.
Journal of GLBT Family Studies, 2, 207–245.
Steensma, T. D., Biemond, R., de Boer, F., & Cohen-Kettenis, P. T.
(2011). Desisting and persisting gender dysphoria after childhood:
A qualitative follow-up study. Clinical Child Psychology and Psy-
Wallien, M. S., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome
of gender-dysphoric children. Journal of the American Academy of
Child and Adolescent Psychiatry, 47, 1413–1423.
Zucker, K. J. (2008). Children with gender identity disorder: Is there a
best practice? Neuropsychiatrie de l’Enafance et de l’Adolescence,
650 Arch Sex Behav (2011) 40:649–650