Social Transition: Supporting Our Youngest Transgender Children

Those of us who work with transgender children frequently face decisions based on evidence that is conflicted or lacking and encounter opponents who are rightfully wary about what they see as experimental treatments without well-examined outcomes. However, in a transgender population where nearly one half experience suicidal ideation, the risk of nonintervention is quite high.¹ In this issue of Pediatrics, Olson and colleagues² provide evidence in support of social transition, a completely reversible intervention associated with lower rates of depression and anxiety in transgender prepubescent children. Socially transitioned children, or those who have adopted the name, hairstyle, clothing, and pronoun associated with their affirmed, rather than birth gender, have become more visible in the media over the last several years. Although to date there has been no published evidence to support providers in suggesting social transition as a beneficial intervention, many families, often guided by mental health professionals, make that decision based on observational evidence in response to seeing how suffering can be alleviated by allowing the child to express their own sense of gender.

Much of the research that is available on transgender youth and adults points to the dismal psychosocial outcomes faced by this population. Homelessness, substance abuse, HIV infection, depression, anxiety, self-harm, and suicidality are much higher than in the general population, and are thought to result from family and community rejection.^3,4 In the last decade, we have learned that medical interventions, including hormone blockers and later phenotypic transition with feminizing or masculinizing hormones, can improve these outcomes in youth.^4,5 We have also learned the key role that family acceptance plays in improving outcomes.⁶

Olson and colleagues report on the mental health outcomes of prepubescent, socially transitioned transgender children, comparing their depression and anxiety scores with those of age-matched controls. They interpret these scores in light of the findings of previous studies of children with the diagnosis of gender identity disorder (GID; a diagnosis that has now been replaced by gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) who had not socially transitioned. Children in the Olson sample who had socially transitioned had depression scores equal to their cis-gender peers and anxiety scores dramatically lower than the GID study sample (although anxiety scores were higher than age-matched peers and siblings). The authors use social transition as a proxy for family acceptance. Although families can be accepting without allowing a social transition, social transition can be an incredibly affirming process for the child, showing the child that their identity is supported.

The rationale cited by those who oppose social transition are that children cannot possibly know their gender at such an early age and that social transition could encourage children to later seek out treatment of medical transition.⁷ A 2013 study by Steensma and colleagues⁸ looked at factors associated with “persistence”, that is eventual pursuance of medical treatment, and “desistance” of gender dysphoria. Among the factors associated with persistence was early social transition. This set up a “chicken or egg” question: is it early social transition that leads to later transgender identification or are the children most likely to identify as transgender later on also more likely to socially transition? Those most likely to seek out later transition are also those with the strongest sense of dysphoria, an older age at the time of the study, and those most likely to describe their identity in declarative, rather than affective form (ie, “I am a boy,” as opposed to “I feel like a boy.” Thus, the “persisters” may be a qualitatively different group than the “desisters,” and further research may be able to distinguish them at earlier ages.

Proponents have argued that social transition is useful both in improving function in those children who are intensely gender dysphoric and in helping to test the waters so to speak; that is, giving the child a completely reversible way to explore life in the other gender before committing to any medical interventions.⁹ Observational evidence has shown that once they have socially transitioned, children with intense gender dysphoria often settle down and show marked improvement in behavior and mood. If the child or family later realizes the need to transition back to the birth gender, that can also happen, with the appropriate social supports and without any irreversible changes.⁹

Olson and colleagues give supporters of social transition evidence that shows what we have suspected all along: that socially transitioned children are doing fine, or at least as well as their age-matched peers and siblings. This finding is truly stunning in light of the numerous studies that show depression and anxiety internalizing psychopathology scores up to 3 times higher for non–socially transitioned children; although, as pointed out by the authors, there are some differences in the patient population of those studies and in the methods used to rate internalizing psychopathology. Although it does not establish a causal relationship, this finding is crucially important to professionals who work with these children, as well as their families, in showing us that they are not likely to suffer any additional harm and may benefit from early social transition. While there is obviously more research needed to determine if providers should recommend social transition as a beneficial intervention, for families who have already chosen this avenue for their children, professionals should have no concern over supporting the family’s (or mental health team’s) decision, and reassuring the parents that social transition should have little negative impact on their child’s mental health.

• Copyright © 2016 by the American Academy of Pediatrics