Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents

What is best practice, when a 7-year-old boy announces that he is really a girl? We do have longitudinal cohort studies which provide useful evidence. Wallien and Cohen-Kettenis (2008) reported on 45 boys and 14 girls who presented with gender dysphoria with a mean age of 8.4 years. Ten years later, 28 of those boys, and 5 of the girls, were no longer gender dysphoric. In other words, of 45 boys followed over ten years, 28 boys, or 62%, did not persist in gender dysphoria. In another study (Singh 2012), 139 boys with gender dysphoria were enrolled at an average age of 7.5 years; at follow-up, averaging 13 years later, only 17 boys out of 139 (12.7%) were still gender-dysphoric. These studies, and others like them (see Zucker 2008 for review), suggest that the majority of boys who identify as gender-dysphoric prior to the onset of puberty will not persist in gender dysphoria after the onset of puberty.

Suppose parents consult a physician regarding their 7-year-old son who has said that he is really a girl. Suppose the physician, mindful of Wallien & Cohen-Kettenis (2008), Singh (2012), and Zucker et al. (2012), advises a cautious wait-and-see approach. The 7-year-old wants to study ballet? Excellent. But he will study ballet as a boy, not a girl, at least for the next year.

Rafferty & Committee (2018) savagely denounce such an approach as “outdated.” Even worse: that physician is trying “to prevent children and adolescents from identifying as transgender”. Such an approach they label “reparative therapy.” They then assert that reparative therapies have been shown to be unsuccessful. In support of that assertion they provide one citation, citation #38, a 1994 report of the lack of success of strategies intended to change the sexual orientation of homosexual men and women. Outdated, indeed. A report documenting the failure of efforts to change the sexual orientation of adults is of doubtful relevance to the question of whether a 5-year-old boy who says that he is a girl should be encouraged to transition.

Rafferty & Committee assert that “more robust and current research” has proven that the old strategy of “watchful waiting” is harmful, and that gender-affirmative strategies should be deployed in prepubertal children. They set no lower age limit for the age at which a child can decide that the child should be reassigned to a different gender. They provide no longitudinal cohort study documenting any outcomes significantly different from those cited above. However, if a clinician were to conclude from studies such as Wallien & Cohen-Kettenis (2008) that watchful waiting is a reasonable approach, Rafferty & Committee harshly reject such an approach, without providing any more recent longitudinal cohort study documenting different outcomes.

Common sense suggests that a 3-year-old boy who says that he is a girl should be subject to some degree of watchful waiting before the boy is put in a dress and has his name legally changed. But such common sense is notably lacking from Rafferty & Committee.

Leonard Sax MD PhD

References:

Singh D. A follow-up study of boys with gender identity disorder. Ph.D. Dissertation, University of Toronto, 2012. Online at http://images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf.
Wallien MS, & Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1413–1423

Zucker KJ. On the ‘natural history’ of gender identity disorder in children. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1361-1363.

Zucker KJ. A developmental, biopsychosocial model for the treatment of children with gender identity disorder. J Homosexuality 2012:59(3):369-397.