The Washington PostDemocracy Dies in Darkness

Opinion Who should we listen to on gender dysphoric children? Everyone.

Hundreds protest a Trump administration announcement that rescinded an Obama-era order allowing transgender students to use school bathrooms matching their gender identities.
Hundreds protest a Trump administration announcement that rescinded an Obama-era order allowing transgender students to use school bathrooms matching their gender identities. (Spencer Platt/Getty Images)

When it comes to transgender adults, it’s obvious what they’re entitled to: the pronouns they prefer, the treatment they want and the respect that all humans deserve. When it comes to children, however, the matter becomes more fraught, as Jesse Singal outlines in a new feature for the Atlantic.

Singal’s article touches on many of the challenges faced by kids with gender dysphoria — and by parents and society in helping them to grow up. One of the most vexing issues is that in at least some cases the children’s gender dysphoria seems to resolve without their transitioning.

It is hard to know exactly what percentage of gender-dysphoric children will end up “desisting.” Some studies suggest that it’s a large majority, but those studies tend to be small, and there is some argument over whether all those kids were truly gender-dysphoric. But the number is also made elusive by social stigma against trans people; there’s no way to know how much that might have deterred people in the studies from transitioning. Or for that matter, how much it still deters transition, for the world remains a bigoted place.

This means that the rate of desistance is what statisticians call a “dark figure” — the correct answer exists, but we can’t see it. Such numbers easily become political footballs. In the case of trans children, public discussions often devolve into a vicious scrimmage between cultural conservatives, who want kids to remain true to their anatomy at birth, and trans activists, who say desistance is rare and the focus should be on suffering trans kids.

To whom should we listen? In the past few years, we seem to have decided that the obvious answer is trans adults. After all, they can speak from experience.

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But there’s a problem: When people are faced with dark figures, they tend to use whatever data they do have as proxies for the data they don’t. And worse, those proxies are often confused with the information actually being sought. The question we’re trying to answer is “What’s the greatest good for the greatest number of children with gender dysphoria?” But when we ask it, that dark figure creates a substantial asymmetry in the answers that come back.

Desisters probably don’t form activist groups or even necessarily talk much about their experience. Trans adults, still struggling against discrimination, have a community and a voice, so they’re the ones most likely to speak up. We’re so happy to have an answer that we tend to forget that they’re actually answering a related but different question: “What would have been best for trans adults when they were young?”

I’m 6-foot-2, tall enough that distracted store clerks often call me “sir,” a fact that caused me great distress as a young woman. But that’s a tiny fraction of the anguish that trans women endure because of the mismatch between their bodies and their self-images. I believe trans people when they say that puberty blockers, followed by hormone therapy to make their adult bodies match their identities, would have been best for them. And yet, if desisters from childhood gender dysphoria are as common as some research suggests, that wouldn’t necessarily be the best protocol for these young people as a group.

Unfortunately, the breadth and irreversibility of the physical changes wrought by puberty force us toward hard decisions despite having imperfect information. Without medical intervention before puberty, trans adults will have to live with changes to their bodies that make them greatly unhappy. But if doctors do intervene, desisters face, at the very least, the consequences of having failed to go through a normal puberty at the normal time.

This dilemma can of course be mitigated if high-quality gender clinics can help children sort out whether their dysphoria is persistent. But such intensive expert services are not available to everyone, in part because there is a shortage of expert clinicians in this fast-evolving area, and in part because in rural areas the treatment of relatively rare conditions can be inconsistent. If there aren’t enough cases for clinicians to practice on, they don’t develop the necessary expertise, and it’s hard to persuade the ones who are already trained to relocate to remote areas.

Realistically, many gender-dysphoric children will probably be treated by ordinary practitioners relying on broad guidelines. That is why it’s so important to think about who’s speaking for those patients when those guidelines are drawn up.

To whom should we listen? The answer is “everyone,” and trans adults very closely. But let’s remember the limits of current knowledge and the voices that are absent from the debate, rather than simply following a natural impulse to give the loudest, most anguished voice the final say.

Twitter: @asymmetricinfo

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