The Ethical Quandary of Social Transition

Novel psychological interventions now being implemented in schools create a pipeline to lifelong medicalization of people who would otherwise have become gay

Today’s guest post by Lisa Selin Davis looks at how the media framed a recently published study of the effects of socially transitioning gender nonconforming youths (“a process that typically involves changing a child’s pronouns, first name, hairstyle, and clothing,”) to support a favored conclusion (that cross-gender identity is stable over time in trans kids) when the findings might better be seen as providing evidence for a very different conclusion (that social transition primes many gender nonconforming and dysphoric young people for a lifetime of intensive medical interventions with a broad range of known and unknown risks and harms that they would not otherwise have undertaken in the absence of such interventions.) This tendentious massaging of the findings of social science that are themselves often hijacked by activists and laundered into a pseudo-consensus is one of the key mechanisms of ideological succession.

By Lisa Selin Davis

Trans kids know themselves and emerge at a very young age. If they are not affirmed in their gender identity and facilitated to live as the opposite sex—or a gender identity outside of sex­—they are at tremendous risk for suicide. Social transition eases depression and anxiety, and helps trans children live as their authentic selves.

If you already believed this, then a study that came out last week likely confirmed your biases—and those of many in the media whose uncritical coverage reflected such beliefs. The study, “Gender Identity 5 Years After Social Transition,” followed 317 young people who had socially transitioned, “a process that typically involves changing a child’s pronouns, first name, hairstyle, and clothing,” per the authors, Kristina R. Olson, et al. Some 208 biological males and 109 biological females, ranging in ages from three to 12 at the start of the study, had socially transitioned to live “in line with their gender identity” for five years. Would that gender identity stick?

At the end of the study, 94% “identified as binary transgender youth” and 3.5% identified as nonbinary. Just 2.5% of identified as cisgender. And a mere 7.3% had socially “retransitioned at least once.” Thus, media outlets like Insider reported, “Trans kids rarely change their minds.”

But there’s another way to view the same research. “Socially Transitioning Children Increases Likelihood of Lifelong Medicalization,” is one possible alternate headline. Or even: “Study Shows Transgender Children Can Be Created Via Psychological Interventions.”

In 11 previous studies of young children with cross-sex identities, gender identity disorder or gender dysphoria (as the diagnosis is now called), the majority of children who were not socially transitioned reversed course by the end of puberty. In a recent study, for instance, almost 88% of boys referred to a clinic for gender dysphoria (not all of them met the criteria for it) desisted. Nearly 64% were later same-sex attracted. Just 12% went on to identify as transgender.

Compare that to the new study, in which not only did almost all the kids persist, but 60% of them went on to medicalize with puberty blockers and/or hormones. (We don’t know how many had surgeries.) In fact, there was an expectation that they would medicalize. “[B]ecause these youth had socially transitioned at such early ages, most participants were followed by an endocrinologist well-before puberty began,” Olson writes. These hormone specialists “helped families identify the onset of Tanner 2 (the first stage of puberty) and prescribed puberty blockers within a few months of this time.” The children seem to have been put into a pipeline directed at medicalization from the get-go.

Taken together, the whole body of literature suggests that if you don’t socially transition a child, you’ll decrease the likelihood of medicating and increase the possibility of having a gay kid; and if you do socially transition a child, you may increase the likelihood of a persistent trans identity with lifelong medical interventions. Social transition seems to make permanent what might have been temporary. This is known as iatrogenesis: the treatment creates the condition.

But stories about the Olson study, like the one in The New York Times, only mention the desistance literature to dissuade readers from considering it. The objections to it include that some kids might have desisted in their trans identification in the past because it was less socially acceptable when those studies were done. Activists and proponents of gender-affirming care often argue that we should abandon the desistance literature because it’s “built upon bad statistics, bad science, homophobia and transphobia.” The problem, they believe, is that there might have an assumption among the attending clinicians and researchers that it was worse to be trans. “For those reasons, it doesn’t make sense to compare the new study with older research,” a Times reporter wrote.

I disagree. It makes perfect sense to discuss the results of one approach versus another and to consider what’s safe, effective, ethical, and what is the least invasive and does the least amount of harm. The issue is not identification, or a way of understanding oneself. The issue concerns medical interventions that can shorten lives, as well as negatively affect fertility, brain development, heart and sexual function, bone density and many other potential facets of developments still yet unknown. How can we know without good studies? (For even more detail about these physical effects, and a scientific review of Olson’s paper, check out the Society for Evidence-Based Gender Medicine’s response.)

The desistance literature is also sometimes criticized because some participants didn’t meet all the criteria for the gender identity disorder diagnosis, and because that diagnosis became gender dysphoria later, with slightly different criteria. Why, it is argued, should kids diagnosed with one condition be used to figure out how to treat kids diagnosed with a different version of it? After all, maybe some kids desisted because they were just gender nonconforming and not really trans.

But the children in the Olson study which received such favorable coverage didn’t even have to be officially diagnosed with gender dysphoria—a marked incongruence between one’s sexed body and sense of themselves as boy, girl or neither—to participate. They just had to have been socially transitioned by their parents. Likewise, “Many parents in this study did not believe that such diagnoses were either ethical or useful and some children did not experience the required distress criterion,” the authors reported. They were transitioned with “significant ‘cross-sex’ identification and preferences,” meaning they liked the toys or clothes stereotypically associated with the opposite sex, or felt like they were a member of that category. They were transitioned whether they had “clinically significant distress,” which is a criterion for dysphoria, or not.

The kids in the Dutch study we wrote about earlier, on which the model of gender-affirming care is based, were also diagnosed with the older version of gender identity disorder, but critics of the desistance literature never mention that. These medical interventions, known as the Dutch protocol, were shown to improve gender dysphoria, but that entire methodology has now been questioned; the fact is that we actually know very little about the physical or psychological safety and efficacy of these drugs and surgeries.

The Olson study runs on the assumption that social transition is the best path for a child with a cross-sex identification. But it’s a very new, mostly untested, and poorly understood psychological intervention. Social transition was “Relatively unheard-of 10 years ago,” per a 2019 paper, which admits that “early-childhood social transitions are a contentious issue within the clinical, scientific, and broader public communities.” Another paper notes, “Research provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis.” That study, by the way, finds social support is more important than social transition for kids with GD.

According to the Cass Interim review, a report in the UK which was conducted to improve services for gender dysphoric youth, social transition should be considered “an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning… it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes.” 

Not only is social transition not neutral, but it rests itself on the foundation of harmful gender stereotypes. Per Olson, it is “a process that typically involves changing a child’s pronouns, first name, hairstyle, and clothing.” But names, hairstyles, clothing—none of those things are sexed, and even their stereotypical associations aren’t fixed. In the 1970s, it was common for both boys and girls to have bowl haircuts, and unisex clothes were readily available along with pink frilly dresses. The names Evelyn, Carol, Ashley, Beverly—all boys’ names until parents started giving girls those names. In the name of liberation, social transition winds up reinforcing gender stereotypes, instead of exploding them.

Olson et al write that their study aims to address concerns that socially transitioned children will later identify as their birth sex, which they call “retransitioning.” This is a sneaky way of disassociating with the ever-growing number of detransitioners, who identified as trans and medically altered their bodies before later regretting it. I know of only one person who uses “retransition” to describe his experience. He’s an adult.

The concern is not that socially transitioned kids will detransition. It’s that we’re encouraging young people to dissociate from reality, to believe that sex is mutable and gender identity isn’t, and to feel a need to radically alter their bodies to align with that gender identity, in ways they might regret, or which might physically hurt them. The concern is that kids who might have been gay without social transition are undergoing the same medical interventions once used to punish gay adults—relying on a version of the very same chemical castration drugs that were used on the pioneering British computer scientist Alan Turing. The concern is that social transition is a serious psychological intervention that eases the way to medical interventions with real consequences. And this study inadvertently gives ample evidence that these concerns are well-founded.