Is it a Myth that the Vast Majority of Gender Dysphoric Children Desist?

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Challenging the Unequivocal Results

Recently there has been an increasing number of articles claiming that the high desistence rates of gender dysphoric children is a myth. Brynn Tannehill, Zack Ford and Zinnia Jones are a few of the authors1)Olson, 2015 is a scholarly article that covers some of the same ground. https://www.jaacap.com/article/S0890-8567(15)00794-7/fulltext that take on one of the most robust findings of the literature concerning gender dysphoria,2)I survey all the studies done on the subject in this 30 minute video: https://www.youtube.com/watch?v=2N2kbfNyXw8 namely that in the vast majority of children the dysphoria will go away in adolescence.3)Steensma, 2011: “Although the persistence rates differed between the various studies (2% to 27%), the results unequivocally showed that the gender dysphoria remitted after puberty in the vast majority of children.”http://journals.sagepub.com/doi/abs/10.1177/1359104510378303

Their arguments are many, and some are easily dismissed, but they center on the idea that the criteria for a diagnosis of Gender Dysphoria (GD) in the DSM-5 has changed from that of Gender Identity Disorder (GID) in the DSM-IV, and has become more stringent. On account of this greater strictness, they argue, the previous studies which showed majority desistence are not comparable to the present-day situation. Rather, they only demonstrate that those who were merely gender non-conforming desisted at a high rate, not those who were truly dysphoric.

First, let me clarify where these authors are correct and where we have no quarrel. The older studies sometimes incorporated children that did not meet the full criteria of the DSM-IV diagnosis for GID. The children with stronger dysphoria did not desist at the same levels as those with weaker dysphoria in most of the studies.4)Singh, 2012 (all males) was an exception And the DSM-5 criteria is stricter than that of the DSM-IV.

There are, however, insuperable difficulties to the claims that the child-transition advocates make regarding the significance of these facts. Moreover, I don’t think these authors have fully worked through the ramifications of their arguments. In this article I will argue that, firstly, the changes in the DSM are not nearly as significant as some are making them out to be, and in fact are being portrayed in substantially erroneous ways. Secondly, the social changes in experience and understanding of “gender” in children over the last few years dwarf these DSM changes, rendering them moot in comparison. Lastly, and most importantly, if these child-transition advocates are correct in their desistence-myth theory, the result is that their larger narratives and theories concerning child-transition are destroyed at their foundations.

Misrepresentation of the Significance of DSM Changes

The major change made from the DSM-IV to the DSM-5 is that the one required criterion has changed from “discomfort with gender role of assigned sex” to “desire or insistence to be ‘the other sex'”. Previously this latter criterion was one of five, of which four needed to be met for the GID diagnosis. Again, let me reiterate that this is, so far as the diagnosis itself is concerned, a restriction. As DeCuypere states, “This will appropriately prevent children with a gender variant expression without an incongruence between gender identity and sex assigned at birth to receive the diagnosis, which was a common point of critique for DSM IV.”5)http://www.tandfonline.com/doi/full/10.1080/15532739.2010.509214 Both Singh, 2012 (p22-24),6)http://images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf and Wallien, 2008,7)http://www.jaacap.com/article/S0890-8567(08)60142-2/abstract make similar mention of the changes.

However, authors commenting on this have grossly misrepresented the change. Zack Ford, in particular, states that “children must meet that first criterion of desiring or insisting that they are ‘the other sex.'” He then follows this by saying “If a kid is adamant that they are a gender different from what they were assigned at birth, that feeling doesn’t go away, and it plays out across their entire life, it distinguishes what that child is experiencing from other kids who are gender nonconforming but not transgender.” Zinnia Jones’ article is more carefully worded, but still gives largely the same impression, which is that under the DMS-5  only those who claim to actually be the opposite sex fulfill the criteria. Jones references Steensma, 2011, a qualitative study that reports that persisters were more likely to identify as the opposite sex, while desisters were more likely to only wish they were the other sex.

However, criterion 1 under the DSM-5 is fulfilled not only with an insistence in being the other sex, but also a desire to be other sex! This means that if a female 8-year old prefers overalls to dresses (criterion 2), playing the “dad” role during make-believe (criterion 3), enjoys looking for critters in the backyard and playing with boys rather than with girls (criteria 4 and  5), pouts and complains about going to girl guides (criterion 6), and desires to be a boy (criterion 1), they could theoretically be diagnosed with gender dysphoria under the DSM-5. While I don’t necessarily think a child such as this is normally going to be diagnosed with GD under the DSM-5, the point is that a child’s insistence that they are the opposite gender is not necessary, contrary to the impression one gets from reading these authors critiquing the “vast-majority desist” finding.

Thus while the DSM-V is certainly more restrictive than the DSM-IV for a clinical diagnosis, it seems to me highly unlikely that the degree of change is such that it would disqualify enough children in the past desistence studies to significantly alter the outcome of majority desistence. Later in this article I will explore some of the math behind this question.

Context is Everything

The second major issue with the “desistence-myth” theory is that the DSM changes are not occurring in a vacuum but in a context in which there are substantial ideological and culture changes in understanding sex and gender. Thirty years ago a boy who said he was a girl was considered not only to be pyschopathological, but strongly so. In our current climate, however, this is not the case. Indeed, some gender specialists have argued that this ought not to be considered pathological at all, although the element of distress and the issue of medical insurance for treatment have complicated the matter for them.8)For an excellent rebuttal to the depathologizing trend see Spitzer, 2005 http://www.tandfonline.com/doi/abs/10.1300/J056v17n03_06

Trans advocates and their allies have been working hard for some time now “educating” the public that sex is different than gender, that cis-normativity is evil, and that for a child to identify as a gender different from their sex is normal and good. The incredible irony, then, is that these advocates are holding to the normalization of cross-gender identification while at the same time arguing that the need to fulfill the criterion of the “desire or insistence to be ‘the other sex'” is a highly significant restriction. You can’t have it both ways.

Let me give you an illustration from the latest public school educational resources on gender from the province of BC, here in Canada. In one of the training videos a young primary-school class is introduced to the idea of sex/gender stereotypes and that gender and sexuality are different in some people. After the teaching session, the children are asked to put their own names on a poster board where there are three lines/spectrums. The first is “Gender Biology” with the female symbol on the left and the male on the right. From what we can see, the children have placed their names at the poles of this biological spectrum. The second is “Gender Expression” with stick-figures of a woman and man at either end of the spectrum. Children’s names fill the spaces in between the two figures, with few at the poles. The last is “Gender Identity”, with the words “I am female” and “I am male” at the pole points. Here the name distributions largely parallel that for “Gender Expression” with most of the children placing themselves on the spectrum between “female” and “male” with a significant amount in the middle.

To say that I find this video troubling would be a gross understatement, however my purpose in referencing it is merely observational at this point. Children are increasingly “educated” such that it is neither rare nor pathological to identify as the opposite sex/gender. After a single class on gender identity, the vast majority of these kids no longer see themselves as fully male or female. And keep in mind that a child doesn’t even have to identify as the opposite sex/gender to receive the DSM-V diagnosis–merely that they want to be such. To sum up, the enormity of the contextual changes over the last decade dwarf the changes made in the DSM.

The Math Doesn’t Work

The final problem for the authors of these articles is a quantitative problem, and especially in light of their assumptions. Let us suppose for the sake of argument that the DSM changes were not being misconstrued or inflated, and that there were no significant contextual changes in which these diagnoses were being made. What amount of children in the prior DSM-IV studies would have to have eliminated by the new DSM-5 criteria to make desistence a “myth” which is what is claimed by Ford and Tannehill?

Let’s run some numbers using the three desistence/persistence studies that use the DSM-IV criteria (Wallien, Drummond,9)http://psycnet.apa.org/fulltext/2007-19851-005.html Singh). We have to leave one out (Steensma, 2013) due to the fact that social transition was an enormous factor in predicting persistence and we don’t have diagnosis vs no diagnosis numbers for non-socially transitioned children. This study was also significantly shorter than the others at almost half the length of Singh, 2012.

The total amount of children in these three studies who had the full diagnosis was 161. Of these 125 desisted in their dysphoria for a total desistence rate of 77.6%. The sub-threshold children numbered 80 and of these 71 desisted for a desistence rate of 88.8%. While these rates are different, both exhibit vast-majority desistence. The question is, how many of these full-DSM-IV-diagnosis children would have fail to meet the DSM-5 criteria to significantly change the findings? Let’s run some mathematical scenarios in which the 161 are theoretically re-assessed under the DSM-5, with “sub-threshold” now meaning they would meet the old DSM-IV diagnosis but not that of the DSM-5.

Scenario 1 

Of the 161 DSM-diagnosed children, let us imagine half (81) wouldn’t meet DSM-5 criteria. Of the 80 who do only 10 desist (12.5% desistence) and let us give the 81 sub-threshold children the desistence rate of the prior sub-threshold amount, 88%, which is extremely generous to our opponents, for a total of 71. The total desistence of the group would be 50%, far short of the actual 77.6% we need to hit. The numbers don’t work.

Scenario 2

Of the 161 DSM-diagnosed children, let us now imagine three-quarters (121) wouldn’t meet DSM-5 criteria. Of the 40 who do, let us say only 3 desist (8% desistence) and let us again give the 121 sub-threshold children the desistence rate of the prior sub-threshold amount, 88%, for a total of 106. The total desistence of the group would be closer to our target at 68%, but still significantly short.

Scenario 3

Of the 161 DSM-diagnosed children, let us finally imagine that fully seven-eighths (141) of them wouldn’t meet DSM-5 criteria. Only 20 do, and of them let us imagine that there is no desistence whatsoever. Of the 141 sub-threshold children, using the generous 88% amount we would arrive at 124 desisters and nearly reach our target with 77% total desistence.

You can monkey with the math a little bit, but it is very unforgiving to the theory of a desistence “myth”. To make the math even remotely work you need the “actual” group of gender dysphoric children to be incredibly small and the desistence rate of the vastly larger sub-threshold group to be as high or higher than that seen even in those who didn’t meet the threshold for the DSM-IV. The math can work, just barely, but notice what happens when it does.

Firstly, it would mean that those like Zucker who didn’t use an affirmative model were doing it right- the great majority of even their full-GID diagnosis patients would desist. In fact, you would be forced to argue that stricter gate-keeping was needed in the past in order to separate this theoretically very-small but incredibly-persistent group from the much-larger but incredibly-desistent group. Thus a “desistence-myth” theorizer like Zack Ford is in the embarrassing position of recognizing that Zucker probably wasn’t strict enough.

Secondly, if the “desistence-myth” theorizers need the very-persistent DSM-V diagnosed group to be very small (and they do), and if they continue to uphold the affirmative model currently (which they do), notice what this does to the rise in gender dysphoria. The NHS in the UK has reported a twenty-fold increase in referrals to their gender clinics for adolescents and children over the last 8 years. Similar rises are seen in most other places that are reporting. However, if seven-eighths of the previous groups were not truly gender dysphoric, this turns a twenty-fold rise, already beyond alarming, into a 160-fold rise!!10)Take note that my point here does not rely on a conflation of fully GD diagnosed with gender clinic referrals, merely that the incredible increase seen in the referrals more or less points to a similar magnitude increase in the “truly” dysphoric Imagine a pathology or pathway that involved sterilization, lifelong medicalization, and surgical removal of functioning, healthy body parts of young adults increasing from 10 patients a year to 1600, or from 40 patients a year to 6400. I would argue that even the current rise (20x) virtually demands a social-contagion explanation, let alone a 160-fold one. A social contagion explanation is the result of an adherence to the “desistence-myth” theory without arguing for extreme gate-keeping.

So Zack Ford, Brynne Tannehill, Zinnia Jones- you can have your “desistence-myth” if you want it, although it is almost mathematically untenable. What you can’t have is an affirmative model along with it, and to continue to beat up on those who were cautious gate-keepers in years past, and now. A balanced conclusion would recognize that the slightly stricter new criteria under the DSM-5 is overwhelmed by unprecedented cultural changes in gender identification of children, and that the vast-majority desistence found in every single study ever done on the subject ought to be carefully minded. Currently it is not, and the result will be a generation of children who were unnecessarily “treated” and the multi-million dollar medical malpractice suits that will go along with it.

 

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References   [ + ]

1. Olson, 2015 is a scholarly article that covers some of the same ground. https://www.jaacap.com/article/S0890-8567(15)00794-7/fulltext
2. I survey all the studies done on the subject in this 30 minute video: https://www.youtube.com/watch?v=2N2kbfNyXw8
3. Steensma, 2011: “Although the persistence rates differed between the various studies (2% to 27%), the results unequivocally showed that the gender dysphoria remitted after puberty in the vast majority of children.”http://journals.sagepub.com/doi/abs/10.1177/1359104510378303
4. Singh, 2012 (all males) was an exception
5. http://www.tandfonline.com/doi/full/10.1080/15532739.2010.509214
6. http://images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf
7. http://www.jaacap.com/article/S0890-8567(08)60142-2/abstract
8. For an excellent rebuttal to the depathologizing trend see Spitzer, 2005 http://www.tandfonline.com/doi/abs/10.1300/J056v17n03_06
9. http://psycnet.apa.org/fulltext/2007-19851-005.html
10. Take note that my point here does not rely on a conflation of fully GD diagnosed with gender clinic referrals, merely that the incredible increase seen in the referrals more or less points to a similar magnitude increase in the “truly” dysphoric