Even as transgender issues reach the mainstream, there is still a lot of confusion about even the most basic facts about trans people, gender identity, and gender expression.

Recently, trans journalist and writer Julia Serano, author of Whipping Girl and Excluded, wrote a piece on Medium debunking some of the myths surrounding trans children in particular. The post tackles many of the misconceptions about trans kids today — what it means to be transgender (someone who doesn’t identify with the gender assigned to them at birth) versus transsexual (someone who transitions), how rare it is for someone to “detransition” back to the gender assigned at birth, and why medicine is increasingly adopting “gender-affirming care” instead of the old “gender-reparative therapy.”

Serano focuses on the debate between gender-affirming care, which allows kids to transition if they meet certain criteria (consistence, insistence, and persistence), and gender-reparative therapy, which effectively treats trans and gender nonconforming children as needing to be fixed by pushing them to their birth-assigned gender.

One of the core arguments for gender-reparative therapy is that it prevents kids who will eventually decide not to transition from starting the process. But Serano questions why this barrier is necessary at all — and argues that fears about “detransitioning” are really rooted in systemic transphobia:

I can’t help but notice that these op-eds and think-pieces [in favor of gender-reparative therapy] are invariably written by cisgender authors who (as outsiders to all this) look upon this situation and reflexively come to the conclusion: “Oh no, some cisgender people are choosing or being misled into a transgender lifestyle!” But I would as ask: Why is this even a problem? I mean, so long as these supposed “cisgender-people-turned-transgender” are happy with their life choices and their post-transition lives, why should anyone even care? Frankly, I believe that this concern stems directly from the transphobic assumption that cisgender bodies are valid and valuable, whereas trans people’s are invalid and defective. It is this assumption that leads these authors to view these supposed “cisgender-people-turned-transgender” as an inherently undesirable outcome, even if these individuals wind up being happy in the end. After all, they have taken their precious and perfect cisgender bodies, and transformed them into defective transsexual ones. This helps to explain why the implicit premise of these pieces (i.e., that gender transition should be restricted in order to protect cis people) resonates with so many readers: Denying trans people access to healthcare and living happy lives seems like a small price to pay if it saves even a few cisgender people from making such a horrible mistake with their bodies.

As Serano notes, gender-reparative therapy is so obstructive that it hurts trans kids — since they can’t socially or medically transition at all or without jumping through several hoops, they’d frequently suffer with untreated gender dysphoria (a state of emotional distress caused by how someone's body or the gender they were assigned at birth conflicts with their gender identity). As the American Medical Association and American Psychiatric Association now acknowledge, that’s very dangerous: Untreated dysphoria can lead to anxiety, depression, and self-harm or suicide.

Gender-affirming care takes steps to avoid these negative outcomes. It won’t always turn out perfectly for everyone, as some of the doctors who practice it acknowledge. But by taking children’s signals more seriously and trying to affirm — rather than forcefully change — their gender identity, it can make sure that children end up where they really want and need to be for their own mental health.

For more on all of this, you should really check out Serano’s full post on Medium, which goes into a lot more detail about this debate.

But in the meantime, I chatted with Serano by email over the weekend to discuss her piece. What follows is our full conversation, edited for length and clarity.

The biggest myths about transgender children

German Lopez: What do you think is the biggest misconception in current discussions about transgender children?

Julia Serano: I think that there are two misconceptions that make discussions about transgender children particularly difficult. One is the notion that these kids are simply “confused” about their genders, and that they simply need to have their birth-assigned genders more stringently enforced. This denies the fact that there is natural variation in gender, and that by the ages of three and four, children have often developed a strong sense of gender identity and preferences that are not readily susceptible to change.

Another misconception is the idea that the phrase “transgender children” automatically refers to children who should or will gender transition. In actuality, transgender is an umbrella term that refers to all people who defy expectations associated with their birth-assigned gender. So “transgender” includes trans people who transition and are happy doing so, but it also includes people who don't transition and/or who identify or express their genders outside of a strict gender binary. So when we talk about these children, there needs to be an acknowledgment that each individual child may have a different life path or trajectory.

The differences between “gender-affirming” and “gender-reparative” treatments

GL: The public debate right now over health care for trans kids seems to be between gender-affirming care and gender-reparative therapy. What are the key differences between these two?

JS: Gender-reparative approaches presume that children’s genders are still malleable at these earlier stages, and they use a combination of positive and negative reinforcement strategies (such as restricting certain types of toys or play or play partners) in the hopes that the child will become more gender-conforming over time.

In the gender-affirming approach, rather than enforcing strict gender norms onto these children (which may cause them to feel shame or stigma regarding their gender nonconformity), the child is instead given the space and support to explore their own genders and make their own decisions about who they feel they are. A subset of these children who “consistently, insistently, and persistently” identify as the gender other than the one they were assigned at birth may be allowed to socially transition (i.e., live as members of that gender) and perhaps even access physical interventions (e.g., puberty blockers or hormones) as they become older if that identity remains strong.

How the conversation about trans children is changing

GL: Based on your decades of reporting on these topics, how have you seen the debate around trans children change?

JS: When I first became involved in transgender communities in the mid-1990s, gender-reparative therapies were the predominant approach. While this issue received little to no mainstream attention back then, there were concerns within feminist and LGBTQ circles that many of the children who were brought into this system were simply gender nonconforming, rather than experiencing actual gender dysphoria — see, for example, Phyllis Burke’s 1996 book Gender Shock: Exploding the Myths of Male & Female, which has a whole section on this.

At the same time, many adult trans people who had been subjected to gender-reparative therapies [and] found them stigmatizing or traumatic were raising awareness among trans health providers about their experiences.

During the ’00s, there was a noticeable shift within the field of trans health care away from gender-reparative therapies and toward gender-affirming ones. WPATH [the World Professional Association for Transgender Health], the world’s largest and longstanding transgender health professional organization, has since denounced reparative therapies as ineffective and unethical.

One of the frustrating things about recent media coverage of these “transgender children debates” is that they make it seem like there are two equivalent sides at work here (gender-reparative versus gender-affirming), both of which have their scientific supporters. In reality, there has been a huge shift within the last 30 years from the former position to the latter. Sure, there still remain some researchers who support gender-reparative approaches, but they are most certainly in the minority these days.

How gender-affirming care works

GL: Your last answer there backs what I’ve seen: Based on the doctors I’ve talked to and the most up-to-date research, the medical field is generally landing on gender-affirming care. So what exactly does this type of care entail? How does a doctor make sure a child is insistent, persistent, and consistent, what kind of steps are taken after that, and are these steps reversible?

JS: Everyone on the “gender-affirming” side of the debate seems to agree that transgender and gender nonconforming children should be given support to explore their gender identities and expressions without feeling forced to adhere to the expectations of their birth-assigned gender. But beyond that, differences in opinion may emerge with regards to when (or for whom) gender transition may be warranted. Rather than some hard-and-fast rule, this is generally an individualized determination made based on the child in question, their parents, and their health care provider.

The criteria of “insistent, persistent, and consistent” is meant to separate out children who are simply exploring or imagining themselves being the other gender from those who strongly and steadfastly identify that way. Only children in the latter category would be considered eligible candidates for gender transition.

For those children who progress toward gender transition, there are three potential “steps,” which should each be considered somewhat separately (as they have different consequences): There is social transition, which simply means that the child lives as a member of their identified gender without any physical interventions; this step is completely reversible. When transgender children reach puberty, they may be placed on puberty blockers, which simply delays the physical changes associated with puberty; this step is also reversible. The third potential step is hormone therapy, which typically doesn’t occur until the age of 16; it is only at this stage that irreversible bodily changes may occur.

There is a growing consensus that, for adolescents whose gender identities are insistent, persistent, and consistent, gender transition is usually quite successful. There is far less consensus when it comes to children who socially transition at much younger ages. Some people will point to previous research suggesting that 80 percent of these younger children will eventually “desist” — that is, no longer experience gender dysphoria as they grow older. In my article, I argue that this statistic and its popular interpretation (that gender dysphoria simply “resolves” in these children) ought not be taken at face value. Others may point to recent studies showing that children who socially transition at young ages are indistinguishable from their cisgender counterparts with regards to both mental health and their sense of gender identity.

Fears about detransitioning are largely overblown

GL: I see a lot of fears in conservative media about detransitioning. How common is detransitioning, really? And why do you think people are so worried about it?

JS: Detransitioning is a rare occurrence, but it does happen. There are no good statistics for it, but if you use “transition regret” as a proxy, that occurs less than 4 percent of the time, perhaps even lower, according to most reports. When detransition does occur, many times it is partially or primarily driven by societal transphobia — the person has problems finding a job or housing, or [is] harassed for being a visibly trans person — rather than (or in addition to) any dissatisfaction with the physical changes associated with gender transition.

Every medical procedure will have some level of regret associated with it. We should work to both reduce it (where we can) and to provide adequate health care and support for those who experience it. And anyone who is concerned with transgender detransition in particular should also be concerned with reducing or eliminating societal transphobia, as that is clearly an exacerbating factor here.

Unfortunately, many people outside of transgender communities merely want to use people who detransition as political pawns: either as evidence that transitioning doesn’t work at all (which is contrary to all the available evidence) or to suggest that some cisgender people are unnecessarily getting caught up in the system and being “turned transgender.” In my article, I debunk this “cisgender people turned transgender” trope, which seems to be driving much of these debates. For one thing, these are not “cisgender people” per se — they are people who fall somewhere along the transgender spectrum, but for whom transitioning was not the right answer.

More importantly, many people outside of trans communities seem disproportionately concerned with the relatively small percentage of people who may someday detransition, without considering the negative effects that limiting or ending this practice would have on the far larger numbers of transgender people who would be happier having transitioned.

I am not a health care professional myself, nor do I work with transgender children personally. But knowing the diversity of life paths and trajectories that occur among adult trans people, I don’t think that we’ll ever find a one-size-fits-all protocol that will work for each and every transgender and gender nonconforming child. I favor the gender-affirming approach because it allows for each child to follow their own paths, and to ultimately decide for themselves who they are. I believe that we can strive for reducing transition regret (working at the individual level) without having to withhold trans-related health care from other children and adults.

Systemic transphobia could be driving support for gender-reparative therapy

GL: Something we haven’t touched much on is the systemic transphobia behind these issues. How much do you think transphobia is driving fears over transitioning?

JS: I definitely believe that transphobia is playing a role in these debates. Transphobia isn’t always an explicit “fear” or “hatred” of trans people. It can be a more subtle or unconscious belief that transgender identities and bodies are inherently illegitimate, inauthentic, and defective in comparison to cisgender ones. I think this explains why people are so suspicious of trans people’s experiences with gender identity and gender dysphoria, and why some people view children who grow up to become happy and healthy transgender adults as a “bad outcome” by default.

At the end of my article, I argue that the current debates we are having aren’t so much about gender-affirming versus gender-reparative approaches. Rather, this is largely a debate about what constitutes a good outcome. I believe that a good outcome is a happy child, regardless of whether they decide to transition or not transition, or how they identify in the end. Others seem to think that the only worthy outcome is a cisgender adult, and they seem willing to sacrifice the potential happiness of many transgender children in order to maximize that result.

GL: Do you worry about the other side of the spectrum, where some parents may be too enthusiastic about helping their children and may inadvertently push them into transitioning when the kid doesn’t really want or need to? Or do you not see that as a big problem?

JS: From the parents whom I’ve personally spoken with, I’ve gotten the impression that they are trying hard not to tip the balance in either direction, and to let their child come to their own self-understanding. But I can’t rule out the possibility that there might be some parents or clinicians who are a little too enthusiastic about suggesting transition as an option. Just as there are most certainly some parents and clinicians who will be strongly opposed to transition as a potential option.

While I am open to having sincere discussions about over-enthusiastically pro-transition parents, I find that most people who bring up this possibility refuse to discuss the opposing (and more systemic) pressure of transphobia, which is likely to dissuade these children not only from transitioning, but from expressing their gender variance or gender nonconformity more generally.