I recently received comments from two readers (here and here) regarding a 2014 Dutch survey study of 55 young transgender adults (average age 20). The study, which reported overall positive psychological outcomes after medical transition, surveyed youth who had been diagnosed with gender dysphoria, after which they had received puberty blockers, then cross-sex hormone treatments, and finally SRS surgery. The average length of time from first pre-treatment assessment to post-surgery was 6 years.

RESULTS: After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well- being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

These findings would likely reassure parents and others who have ushered children down the medical transition road. And frankly, anyone who has watched even a few YouTube teen transition vlogs would not find these results particularly surprising. For these kids, it must be an exhilarating experience, to feel they can escape their dissatisfaction with sex-role stereotypes and/or physical characteristics, and embark upon the long-awaited transformation into the opposite sex. The speed with which the metamorphosis happens—with many young people “passing” as the opposite sex after only a few months of hormone treatment–is downright magical.

No doubt, at least some of these people will go on to live happy, long lives with no regrets. But it’s likely some will begin to question (at what age? 30? 40? 50? 60?) whether giving up their fertility; permanently altering their bodies; and facing a lifelong regimen of injections and medical monitoring were ultimately worth the price.

Here is one young woman who has begun to raise a few questions. In a recent video entitled “Gender Troubles” (uploaded 6 years after she first decided to “transition,” and after 4 years of videos on her channel that mostly celebrated that choice), she acknowledges what she values about her “transition,” while sharing her realization that things are not quite as simple as they originally seemed to her younger self:

When I decided to go on hormones…it seemed like the most logical choice for me. I was in a very bad place emotionally…I hated myself a lot. I hated my body. I didn’t identify with it….and I felt very separate from my body. And finding YouTube videos of other people who were transitioning and finding out it was an option to do so kind of deeply affected me. It was very difficult to resist those changes….to resist taking hormones, to see those changes in myself, especially because feeling so disconnected from myself it seemed like the best idea….and you don’t often see other narratives out there, on YouTube, about gender… …. I struggled with the changes, how I felt about them, how it made me feel and why. At first I accepted them. It was exciting. It was euphoric. It was certainly a ride. And I really liked seeing myself with more muscle, I liked my voice deepening, the hair that was growing… … My parents were really cool with it. They were not cool with me being a lesbian at all…. [now] they didn’t have to say “I have a lesbian daughter. I have a son who’s straight”….My family was supportive of my transition, so we became a lot closer because of that… …As time went on, I really felt like…I didn’t identify with the changes I was seeing…I didn’t like the fact that these changes weren’t natural. Part of it felt like I was burying a piece of myself… …The other night, I cried, because I realized I really want to be able to get pregnant. And I really want to be able to breastfeed. … Maybe it’s me getting older, the internal clock…ultimately I don’t regret getting top surgery…but there are elements where I miss having them….only about 15% of the time. But I can’t deny that this happens… …There’s a lot more that happens besides achieving a male body or a more masculine body….a lot of things change and you don’t realize it. I don’t think I realized it as much until … a year or two off hormones. Things started kind of affecting me… …When I was transitioning I was really caught up in the thrill of it, the excitement of it, the endorphins that went along with it…[but now] I’ve been thinking about things I wasn’t before.

Transition regret videos aside, even if we restrict our focus to the 55 subjects in the Dutch research study cited above–young people who (so far) are reporting largely positive benefits from their transition–there is more nuance to this study than first meets the eye. 4thWaveNow contributor fightingunreality delves into some of the study’s unexamined implications in the post below.

As you read fightingunreality’s analysis, consider whether survey studies like this one might be subject to the “interpersonal expectancy ” of researchers and “supportive” parents. The interpersonal expectancy effect is also known as self-fulfilling prophecy, or the Pygmalian effect, extensively studied by preeminent psychological researcher Robert Rosenthal:

…the tendency for experimenters to obtain results they expect, not simply because they have correctly anticipated nature’s response, but rather because they have helped to shape that response through their expectations. When behavioral researchers expect certain results from their human or animal subjects, they appear unwittingly to treat them in such a way as to increase the probability that they will respond as expected… In more recent years….research has been extended from experiments, to teachers, employers, and therapists whose expectations for their…patients might also come to serve as interpersonal self-fulfilling prophecies.

Analysis of the 2014 Dutch study (available in full at the link, and introduced above),

by fightingunreality

Any discussion of the “outcomes” for those children chosen for the experimental use of puberty-blocking drugs would be remiss without first addressing the ethics of what has been done.

First, this study is about young people, many of whom initially presented to the clinic as prepubescent children. Children’s understanding of gender is primarily comprised of the simplistic social stereotypes through which they have learned to perceive the meaning of biological sex, and which they lack the certainty of identity to resist. Developmentally unable to fully comprehend abstract concepts, they have little understanding of the social forces which inform and compel both them and the adults to behave in certain manners deemed to be “appropriate” on the basis of sex. The vast majority of these children were socially transitioned by their parents prior to their arrival at the clinic, thereby disrupting the chance that they may have had to experience a typical childhood.

Because 85% of the fathers and 95% of the mothers were supportive of their children’s desire to live as the other gender, and since virtually all of the children were living for all intents and purposes as socially transitioned, we can assume, with little doubt, that these parents subscribed to the idea of sex-based gender roles for their children akin to those we have seen in the plethora of news stories of (mostly) moms citing wrong toys and early color preferences as indications that their children were different.

Since none of these child-transition studies (this Dutch study being no exception) report the extent to which parents enforce traditional gender roles, we have no real sense of the degree of their influence on these children or how much they might affect the kids’ willingness to defy them in order to express their non-traditional likes and dislikes– without the expressed belief that they are in fact, a different sex. Is it only a coincidence that 94% of the males in this study were either same-sex attracted or bisexual (87.9% SSA, 6.1% BI) or that 100% of the females (89.2 SSA, 10.8% BI) had same sex attractions? Are we really expected to believe that social and parental attitudes in regards to homosexuality play no part in either the formation of the children’s understandings of what constitutes “feeling like the other sex,” or, more importantly, the acceptability to parents of what, in effect, becomes medicalized gay conversion therapy?

Since the stated protocol by these researchers is to provide a six-months to a year “diagnostic phase,” this means that prior to the first assessment for this particular study, they had already been living as cross-gendered for at least that amount of time, plus the previously acknowledged but unspecified duration of social transition. During the actual diagnostic phase, all of them “officially transitioned” –including name changes. Since the youngest, at the time just prior to the administration of hormone blockers, was 11.1 years old, that means this child had been living cross-gendered since a minimum age of 10.6 years old –in addition to the time prior to arriving at the clinic. What can such a child actually know about what it means to live as his or her own natal sex?

Given the willingness, as noted in the study, of peers and parents to promote and solidify by reinforcement these children’s sense of being wrong-bodied, it is hard to see how such children could establish a basis by which they could reasonably fully comprehend–let alone reevaluate–their child-based understanding of gender and gender roles. As has been noted in previous posts on this blog, identity formation throughout childhood and adolescence is both malleable and fluid. It is impossible to believe that the interventions by both the parents and the clinicians did not directly interfere with these children’s identity development. How does a child who has basically reordered their family’s lives by their insistence that they are actually the other sex back down from such claims? How do they tell their friends? We are not talking about adults, here, after all. By the time these children reached the point of choosing to delay their puberty, they had been living as the other gender for years –in some instances possibly half of their young lives. By the time it came to choose whether or not to imbibe cross-sex hormones, it is no surprise that none of these children chose to revert to living as their own sex: they had been socialized trans.

It’s interesting to note from the information in this paper that during the time between starting hormone blockers and their choice to be put on cross-sex hormones, these kids –especially the girls –actually experienced greater levels of “gender dysphoria.” I think it’s important to ask ourselves why that is. These kids were not facing the risk of further development of secondary sexual characteristics. They were living as their chosen gender. Why wouldn’t they be at least somewhat relieved of their dysphoria? Since levels of such dysphoria consist of self-assessment, this worsening could merely reflect the child’s desire to fully transition along with the knowledge that admitting a decreasing level of dysphoria might threaten the willingness of the clinicians to advance their transitions. That is one possibility. The other more likely possibility is that living as fully socially transitioned children, their awareness of not physically “matching” their chosen gender while assuming that role actually worsens the sense of being wrong-bodied. In other words, telling someone that you are actually a boy or a girl when you clearly are not increases self-awareness of and discomfort with your actual sex.

As was articulated in a BBC documentary by a gay Iranian who was pressured into transition, prior to transitioning he often heard, “He’s so girly. He’s so feminine.” After the surgery, whenever [he] wanted to feel like a woman or behave like a woman, everybody would say “look, she’s like a man. She’s manly.” This phenomenon can readily be applied to children who may have been considered like the other sex prior to living akin to that sex, but become seemingly less like the other sex when attempting to assume that role. The very fact that they are attempting to live as the other gender may very well increase the dysphoria that assuming such a role is meant to lessen. Is it a wonder that 100% of the children that comprised this cohort chose to go on to cross-sex hormones?

The gender specialists promoting these studies want us to believe that the use of hormone blockers provides extra time without the stressful development of secondary sexual characteristics. They’d like us to believe that the children are being given a sort of “time-out” to consider their choices and become more mature before committing to irreversible changes, but is that really the case? The hormones required for adolescent brain reorganization and development are not released when a child has received GnRh agonists. Physical development typical for teenagers is prevented, setting the children even farther apart from their peers, and sexual and romantic involvements –a key factor in desistance –are avoided.

Ultimately, 100% of the children who chose to utilize hormone blockers in this study went on to fully transition. In fact, virtually all children inducted for such therapy demonstrate 100% persistence rates despite that fact that even today, major proponents of this therapy (such as Johanna Olson-Kennedy and Robert Garofalo, in their 2016 paper detailing research priorities on gender identity development and biopsychosocial outcomes) acknowledge that “Clinically useful information for predicting individual psychosexual development pathways is lacking.” They do not have reliable information on who will or will not desist. Are we really expected to believe that these hormone blocker advocates are exceptionally lucky in their selection process when they themselves profess such uncertainty and bemoan the lack of adequate research? Or should such absolute rates of persistence be setting off alarm bells to those of us concerned with the practice of funneling children into a pipeline that flows in only one direction: towards lifelong medicalization with unknown long-term consequences?

Because of the extraordinary persistence rates of children infused with hormone blockers, it’s obvious that hormone blockers do not allow these children extra time. The choice to participate in this protocol becomes the decision to transition, because it prevents the aspects of maturation necessary for desistance from ever occurring. The one thing it does do, however, is to make it seem safer to interfere with the children’s natural course of development. Parents are assured that the effects of blockers are reversible, and the moral burden of placing young children in the position of making adult decisions is put aside. As a result, even more children are being swept up by this 21st century version of reparative therapy. Altogether, we will never know the number of children who would have desisted had they been allowed to develop without social and medical intervention. This is a travesty.

As far as the “positive outcomes” this study purports, there are numerous problems. First, in order to understand this study, we must consider the selection process detailed in a previous paper by the same authors. The 70 children chosen for this study were selected from an original cohort of 111 (out of 196 children arriving at the UV hospital seeking treatment for GD) eligible for hormone blockers, after having been “thoroughly screened after a comprehensive psychological evaluation with many sessions over a longer period of time” and found “eligible for puberty suppression and cross-sex hormones.” It was a group chosen on the basis of their likelihood of coping with the transition process. They had “no psychosocial problems interfering with assessment or treatment,” and “adequate” (in the case of this cohort, very high) “family or other support,” and what the researchers described as “good comprehension of the impact of medical interventions.” (We can only guess what that could mean, given the fact that pre-adolescents and adolescents do not have the frontal lobe development to fully project themselves into the future.) Altogether, they seem very unlike the average children and adolescents who are currently being inducted into this process of life-long medicalization either in regard to screening or support and ongoing therapy, which the study notes was provided to them for an average of 6 years “after first presenting at the clinic.”

Fifteen of the cohort of 55 had “some missing data” which we are assured resulted in “no significant differences” on the pre-treatment tests. I think, too, that when considering the outcomes of these children, it would be remiss to ignore the 15 members of the original cohort of 70 who did not participate in follow up: six had not met the one year gender reassignment surgery anniversary for this study and were, therefore, excluded. Two refused to complete the assessment, and two did not return their questionnaires. (Why?) Three had health problems which prevented them from undergoing gender reassignment surgery, one “dropped out of care” (no clarification) and 1 died from complications from surgery. (How does one weigh such a loss against “positive outcomes?”)

Given the fact that all of these children had what is in essence a “gender obsession” since childhood and had been socially transitioned for years, it comes as no surprise that they experienced relief at finally accomplishing their goals. The kids as a whole did overall demonstrate better functioning than at their initial assessment –possibly from the counselling and special attention they were getting –but “it cannot be ruled out that it relates instead or as well to the benefits that accrue from being validated and accepted for treatment.” They were getting what they wanted, after all. Research has shown that gender non-conforming children and adolescents are at higher risk for PTSD due to abuse and bullying because of being different, and the prospect of “fitting in” provided by merely initiating action towards this goal certainly provides a degree of psychological relief- regardless of the actual physical changes that have yet to take place. This is evidenced by the “significant quadratic effect” that commences immediately upon initiation of cross-sex hormones, well before significant physiological effects of the hormones could possibly have occurred.

Would body image and psychological well-being have improved in these children had they been allowed to experience a natural childhood and identity formation without medical intervention? It is well known in the field of child development that children go through a period of significant peer gender enforcement which corresponds with their concrete thinking and familial socialization which certainly affects the self-image of those who fail to conform. This rigidity begins to relax at around 8 to 10 years –after some of the children in this study have already been socially transitioned due to the discomfort this rigidity has created. Would they have come to a more nuanced understanding of gender roles had they made it past this stage? We –and they –will never know. Logically, children have been shown to be more accepted by members of the sex with which they share interests, rather than those whose similarities are based solely on sex, and gender enforcement prior to adolescence tends to be enacted by members of the same sex. Is it any wonder that children tend to “identify” with those who seemingly accept them and share common interests? Would a more mature understanding of abstract concepts assist them in accepting their own bodies without conforming to artificial gender roles as it did for many of us who matured without the alluring possibility of appearing to actually change sex?

As adolescence progresses, criticism is most likely directed by male peers who are not known for impulse control or empathy. Certainly those of us who have been on the receiving end of such mockery can attest to the resulting social stigma and humiliations we suffered in light of it due to our vulnerability at that age and the fact that we were insecure in our own identities and lacking the self-assurance that maturity brings. It has been demonstrated that peer and social disapproval for gender non-conformity peaks in the adolescent years and gradually decreases throughout young adulthood and adulthood. Not only do we mature, but the peers responsible for the harassment mature, as well. The insults decrease. As gay rights activists in the past often said, in an attempt to help bullied gay and lesbian children, “it really does get better.”

Unfortunately, none of the children in this study will ever know whether this would have been the case for them, because they left behind in childhood the bodies which they very well may have come to accept in the absence of such criticism. In a study in which there is no viable way to create a control group with which to compare these children, there’s no way of knowing how well they would have fared with just the extensive psychotherapy alone, nor of desistance which may have taken place without these prolonged social and medical interventions which prevented the maturation and social and sexual experience that would have occurred otherwise.

As a gender non-conforming adult, I am occasionally harassed by what are typically groups of two or three teen boys out to impress their friends. Because I am an adult with a fully-formed sense of self, my identity is not threatened as are those of the children who have not yet discovered, through experience and physical development, who they really are or can be. Sadly, the ultimate result of medicalized disruption of identity formation –which would have included their whole selves, bodies included –creates an identity which is dependent upon exogenous substances, conscious gendered performance, and the willingness of others to deny their own perception in order to validate it. As such, the identity is not sustainable without significant degrees of external support, and remains more highly vulnerable to what are perceived as being threats to self when it is not validated. As a result, they may be “at increased risk for the development of narcissistic disorders…as a consequence of the inevitable difficulties they face in having their cross-gender feelings and identities affirmed by others.” (Note: While the linked study is not specifically of children, it seems to me children subjected to early medical transition would also be at some risk of narcissism, given the confluence of factors brought to bear upon them.)

Perhaps the greatest hindrance to accurately critiquing this study is related to the ages and the timing of this so-called “long-term” study: it was completed after only a minimum of one year after gender reassignment surgery. These now young adults had barely any life-experience living as fully transitioned persons. They were still in the honeymoon phase of what had become a fully supported childhood desire. A significant portion of them were still living at home with their supportive parents and attending school. Their lives as fully transitioned adults were just beginning, and the difficulties of navigating sexual relationships and the hardships that entails for those not of their natal sex were in their infancy. They were many years away from the rise in suicidality noted in a Swedish long-term study of adult transgendered persons, which began to rise around 8-10 years after transition.

Because of the failure of the Dutch authors to denote significant variables among these youths (as I’ve outlined in this post), their study inspires more questions than it provides answers. Have these children been harmed by the parental and medical reification of childhood fantasy and desire? We have primarily their own self-reports to rely on –the reports of young adults who never were given the opportunity to experience childhood or adolescence as one would experience their own actual sex. They have nothing with which they can compare their current experienced “gender.” They will not know what it’s like to have sex in their natural bodies, nor be loved as such. Certainly, as partially formed adults (remember- maturation takes place concurrently with hormonal action and resulting brain development and theirs was delayed), they had not reached fully adult status at the time of their self-assessment. We do not know how the difficulties of living as transgendered people will affect them. We do not know if the long-term effects of injecting artificial cross-sex hormones will damage them physically (or mentally). We will never know whether they might have resolved their gender dysphoria, as others have, and pressed on through life, because they were never given the chance to find out.

Their childhood fantasies were to become a different sex. What they have been given, instead, is the means of promoting that illusion—and the reality of becoming a life-long medical patient.

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