Of the four levels of so-called gender transitioning for gender dysphoria or incongruence in minors—social, puberty blocking, cross-sex (wrong-sex) hormones and surgery—social transition is by far the easiest to engage: namely, as soon as one chooses to do so. It’s no more complicated than changing choices of presentation (clothing, makeup and so forth) and/or name. In certain states, such as mine of California, it is enforced by the power of the law with repercussions for parents and schools that fail to comply. It is said to be protective, helpful and even lifesaving. However, it is not, and lawsuits are being filed to oppose this harm to children, families and communities.

 

The natural course of gender dysphoria is desistance by adulthood, conservatively in 85 percent, unless it is affirmed.[1][2][3][4][5]  However, social transitioning itself leads to persistence of gender dysphoria. The pro-transition Endocrine Society guidelines state, “Social transition is associated with the persistence of [gender dysphoria] as a child progresses into adolescence.”[6] Psychologist Ken Zucker found, “Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence,” and that it “might be characterized as iatrogenic.”[7] The 2014 APA Handbook on Sexuality and Psychology warns, “Premature labeling of gender identity should be avoided. Early social transition (i.e., change of gender role,…) should be approached with caution to avoid foreclosing this stage of (trans)gender identity development.”[8] As for premature affirmation, it further asserts: “This approach runs the risk of neglecting individual problems the child might be experiencing and may involve an early gender role transition that might be challenging to reverse if cross-gender feelings do not persist…”[9] Challenging indeed, and with profoundly few physicians, surgeons and mental health professionals willing to dare help them for fear of being accused of “conversion therapy.” As I have informed legislatures and parliaments, I can think of nothing more “conversionary” than the chemical sterilization and surgical mutilation of healthy young bodies for a mental health issue expected to desist by adulthood. It is social transition that takes them on that path.

 

In April 2022, Hall, et al, published a systematic review and narrative summary of the literature on social transitioning for children and adolescents as part of Cass Review Final.[10] They found that the 10 studies that qualified for inclusion were generally “of low quality,” mostly from the U.S., and using community samples and cross-sectional analyses (thus, poor). They concluded, “Importantly, there are no prospective longitudinal studies with appropriate comparator groups assessing the impact of social transition on mental health or gender-related outcomes for children/adolescents.” Hall’s results summarized this, “Overall studies consistently reported no difference in mental health outcomes for children who socially transitioned across all comparators. Studies found mixed evidence for adolescents who socially transitioned.”  Hall specifically alerted that professionals working in the field “should be aware of the absence of robust evidence of the benefits or harms of social transition for children and adolescents.” So, there is no proof of the sales pitch of the benefits of social transitioning, let alone that it mitigates suicidality and save lives.

 

The Cass Review Final section on social transition (p.31)[11] from April 2024 asserted “73. One key difference between children and adolescents is that parental attitudes and beliefs will have an impact on whether the child socially transitions. For adolescents, exploration is a normal process, and rigid binary gender stereotypes can be unhelpful.” Thus, pro-transition parents, be that of their own accord or due to professional insistence, contribute to minors transitioning. As for gender stereotypes, there are so many ways to be a boy and still be a boy, and so many ways to be a girl and still be a girl. Gender non-conforming behavior is simply and only that: different, not disqualifying.

 

Cass Review Final paragraph 76 noted, “The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence. However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.” Also, “78. …and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence” (p.32).  Put another way, affirmation derails natural desistance. The Cass Review Interim Report (2022)[12] said this about social transition: “it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning” (p.62); and that “it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes” (p.63).

 

A 2021 study from the Hamburg Gender Identity Service carried the title, “Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with gender dysphoria.” It bluntly declared, “Therefore, claims that gender affirmation through transitioning socially is beneficial for children with [gender dysphoria] could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.”[13]

 

Previously, and contrary to these findings from the United Kingdom and Germany, the claim has been that affirming parents improve the poor mental health stats for gender dysphoria in minors, citing works from Olson, et al. (2016)[14] and Durwood, McLaughlin and Olson (2017).[15]  These studies were reassessed by Schumm and Crawford in 2019[16] who reported, “a reanalysis of their findings suggests otherwise, with slightly higher levels of depression but significantly and substantively meaningful differences in anxiety and self-worth, and with results favoring cisgender children, even when the transgender children had high levels of parental support for their gender transitioning.” Affirming parents don’t improve the stats.

 

In my estimation, the problem of consent in minors looms large here. I have stated in legislative testimonies and elsewhere, “Children have developing and immature brains, their minds change often, they are prone to risk taking and vulnerable to peer-pressure, and they don’t grasp long-term consequences.”[17][18][19][20] This makes informed consent in minors reliably unreliable for a great many options, which is why society protects them from such via age limits.

 

On May 2, 2019, the Swedish Pediatric Society issued a letter in which they cautioned, “Giving children the right to independently make vital decisions whereby at that age they cannot be expected to understand the consequences of their decisions is not scientifically founded and contrary to medical practice.”[21] The UK High Court in Bell vs. Tavistock (December 12, 2020) stated, “There is no age appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years.”[22]

Anthony Latham, chair of the Scottish Council on Human Bioethics, wrote in 2022, “The young brain is biologically and socially immature, tends towards short-term risk taking, does not possess the ability to comprehend long term consequences and is highly influenced by peers…” He concluded, “Children cannot consent, and therefore should not be asked to consent to being treated with puberty blockers for gender dysphoria.”[23] Again, social transition is the gateway to medical transition experimentation.

 

Finally, regarding transition as a whole, Levine, Abbruzzese and Mason observed in 2022, “…the process of obtaining informed consent from patients and their families has no established standard. There is no consensus about the requisite elements of evaluations, nor is there unanimity about how informed consent processes should be conducted (Byne et al., 2012). These two matters are inconsistent from practitioner to practitioner, clinic to clinic, and country to country.”[24] As it stands, the consent standard is no standard.

 

Social transition and its affirmation are not proven to be safe or effective long-term, have not been shown to reduce suicides and do not repair mental health issues and trauma. Informed consent in minors is highly questionable as they lack the requisite faculties to make such consequential decisions. Social transition derails natural desistance and cannot be viewed as benign or neutral. Lawsuits against states imposing mandates on parents/guardians and schools to encourage social transition for gender dysphoric/incongruent minors are being file, and justifiably so. A more honest way is always available to deal with gender confusion than transition, social or otherwise.

 

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[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. P.455.

[2] Bockting, W. (2014). Chapter 24: Transgender Identity Development. In Tolman, D., & Diamond, L., Co-Editors-in-Chief (2014) APA Handbook of Sexuality and Psychology (2 volumes). Washington D.C.: American Psychological Association, 1: 744.)

[3] Singh D, Bradley SJ and Zucker KJ (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784. doi: 10.3389/fpsyt.2021.632784

[4] Hembree, W., Cohen-Kettenis, et al., (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guildeline. J Clin Endocrinol Metab,102:1–35.

[5] Zucker, K. J. (2018). The myth of persistence: response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism, 19(2), 231–245. Published online May 29, 2018. http://doi.org/10.1080/15532739.2018.1468293

[6] Hembree, W., Cohen-Kettenis, et al., (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guildeline. J Clin Endocrinol Metab,102:1–35.

[7] Zucker, K.J. (2020), Debate: Different strokes for different folks. Child Adolesc Ment Health, 25: 36-37. https://doi.org/10.1111/camh.12330

[8] W. Bockting, Ch. 24: Transgender Identity Development, in 1 American Psychological Association Handbook on Sexuality and Psychology, 744 (D. Tolman & L. Diamond eds., 2014).

[9] W. Bockting, Ch. 24: Transgender Identity Development, in 1 American Psychological Association Handbook on Sexuality and Psychology, 750 (D. Tolman & L. Diamond eds., 2014).

[10] Hall R, Taylor J, Hewitt CE, et al, Impact of social transition in relation to gender for children and adolescents: a systematic review. Archives of Disease in Childhood  Published Online First: 09 April 2024. doi: 10.1136/archdischild-2023-326112

[11] https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf

[12] Cass Review, Interim Report (2022) https://cass.independent-review.uk/publications/interim-report/

[13] Sievert ED, Schweizer K, Barkmann C, Fahrenkrug S, Becker-Hebly I. Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with Gender Dysphoria. Clin Child Psychol Psychiatry. 2021 Jan;26(1):79-95. doi: 10.1177/1359104520964530. Epub 2020 Oct 20. PMID: 33081539.

[14] Olson, Kristina R., Lily Durwood, Madeleine DeMeules, and Katie A. McLaughlin. 2016b. “Mental Health of Transgender Children Who Are Supported in Their Identities.” Pediatrics 137:e20153223.

[15] Durwood, Lily, Katie A. McLaughlin, and Kristina R. Olson. 2017. “Mental Health and Self-worth in Socially Transitioned Transgender Youth.” Journal of the American Academy of Child & Adolescent Psychiatry 57:116–23.

[16] Schumm, Walter & Crawford, Duane. (2019). Is Research on Transgender Children What It Seems? Comments on Recent Research on Transgender Children with High Levels of Parental Support. The Linacre Quarterly. 87. 002436391988479. 10.1177/0024363919884799.

 

[17] Andre Van Mol, “Transing California Foster Children & Why Doctors Like Us Opposed It,” PublicDiscourse.com, October 28, 2018.

Cited therein:

National Institute of Mental Health (2001). Teenage Brain: A work in progress. http://www2.isu.edu/irh/projects/better_todays/B2T2VirtualPacket/BrainFunction/NIMH-Teenage%20Brain%20-%20A%20Work%20in%20Progress.pdf.

Pustilnik AC, and Henry LM. Adolescent Medical Decision Making and the Law of the Horse. Journal of Health Care Law and Policy 2012; 15:1-14.  (U of Maryland Legal Studies Research Paper 2013-14).

[18] Steinberg L. A Social Neuroscience Perspective on Adolescent Risk-Taking. Dev Rev. 2008 Mar;28(1):78-106. doi: 10.1016/j.dr.2007.08.002. PMID: 18509515; PMCID: PMC2396566.

[19] Antony Latham (2022) Puberty Blockers for Children: Can They Consent?, The New Bioethics, 28:3, 268-291, DOI: 10.1080/20502877.2022.2088048

[20] Arain M, Haque M, Johal L, Mathur P, Nel W, Rais A, Sandhu R, Sharma S. Maturation of the adolescent brain. Neuropsychiatr Dis Treat. 2013;9:449-461
https://doi.org/10.2147/NDT.S39776

[21] http://www.barnlakarforeningen.se/2019/05/02/blf-staller-sig-bakom-smers-skrivelse-angaende-konsdysfori/

[22] https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf

[23] Antony Latham (2022) Puberty Blockers for Children: Can They Consent?, The New Bioethics, 28:3, 268-291, DOI: 10.1080/20502877.2022.2088048

[24] Stephen B. Levine, E. Abbruzzese & Julia W. Mason (2022): Reconsidering

Informed Consent for Trans-Identified Children, Adolescents, and Young Adults, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2022.2046221