The following is a discussion of a recent paper by Turban and Keuroghlian entitled “Dynamic Gender Presentations: Understanding Transition and “De-Transition” Among Transgender Youth”. The paper can be downloaded at https://jaacap.org/article/S0890-8567(18)30219-3/fulltext
We welcome your thoughts and comments and invite you to join the discussion.
This paper touches on a number of key issues in the current discourse around gender dysphoria (GD) in young people and highlights the many unanswered questions in this debate. Importantly, the title acknowledges that gender identity can be “dynamic” rather than a fixed an immutable quality. The author states that some cases of GD in young people may be “dynamic”, ie open to change, but implies that these are the exception. The degree to which gender identity is open to change is one of the central controversies in the debate, as evidenced by the ongoing disagreements about the desistence data. How we view the malleability of gender identity in many ways determines how we approach young people presenting with GD. Assuming that young people can be certain about their gender identity and that this is unlikely to change leads to the current gender-affirming clinical approach. It also means that there has been very little research examining psychological therapies for Gender Dysphoria, one of the notable exceptions being the work of Ken Zucker and his team. Almost all of the ongoing research into how to manage GD looks at biological and surgical treatments.
If we view gender identity as a dynamic state determined by multiple influences, including social, family, developmental and biological factors – it is possible then that it could be open to change as a response to a change in one or more of these influences. This would lead to a different clinical approach in which we would try to keep things open to the possibility of development and change. Gender-affirming interventions are in themselves powerful influences affecting how the child experiences him or herself and potentially affect how their gender identity will evolve over time. This would seem to be supported by the 2011 study by Steensma et al, which found that social transition was a predictor of persistence of GD. The recently documented phenomenon of “Rapid Onset Gender Dysphoria” is also considered to be a consequence of social factors including social contagion, and suggests that gender identity is perhaps more malleable than we may have considered so far.
The paper raises the important issue of de-transition, which rarely gets more than a passing mention in publications in the area of gender dysphoria. The author suggests, in line with the published data, that de-transition is exceedingly rare. He also argues that any irreversible changes resulting from hormonal intervention are likely to be of little consequence for the de-transitioned individual. We know very little about people who have detransitioned and how they feel about the consequences of their gender-affirming treatments. It is also possible that there are many more detransitioners than we are currently aware of. The incidence data on de-transition, or regret, is based on individuals who have changed that gender back to their natal gender by notifying a government registry. There may be many more people who have detransitioned, or regret their gender re-assignment, yet do not change their gender back officially, and who drop out of contact with health services because of shame or psychological morbidity and some detransitioners have indicated that they feel there is no place for them in current gender health services.
A critical aspect of this paper is the reference to suicide. The author states that the 40% lifetime suicide attempt risk in transgender people means that withholding gender-affirming treatment presents a greater risk than does providing gender-affirming treatment, as regret is apparently very rare. It is actually not clear whether gender-affirming care actually reduces the risk of suicide as it is commonly claimed to do. In fact, one of the most rigorous studies by Dhejne et al in 2011 suggested that the suicide rate remains extremely high after gender-affirming treatment. Gender-affirming treatment is often promoted in terms of its potential to save lives (by preventing suicide), however this is an inference and is not supported by reliable data.
The two cases the author uses to illustrate his position both refer to a past history of Major Depressive Disorder and this seems almost incidental. There is no detail about the social and family situation in which the young person became depressed, and how the depression related to their GD. Were they depressed because they experienced GD, or was their desire to change their gender a way to try to address other issues that were making them depressed? Is Gender Dysphoria a “stand alone” condition or is it the consequence of complicated social, psychological, family and biological issues that we do not yet fully understand? If it is the latter, perhaps this explains why post-operative trans individuals may continue to be highly suicidal, as the sources of the young person’s unhappiness have not been addressed by gender-focussed treatments.