The World Professional Association for Transgender Health's guidelines for clinicians, called the Standards of Care, states that “treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth” is “no longer considered ethical.”

Zucker was the psychologist-in-chief and head of the gender identity clinic at a Toronto mental health hospital before administrators shut down the clinic in 2015, after a review of his practices. That was also controversial, and Zucker is suing his former employer for defamation. (Zucker declined to comment for this article. For a defense of his work, you can read Jesse Singal’s reporting from 2016.)

Watchful Waiting

Zucker’s approach aside, there is another alternative to gender affirmative therapy. It’s the approach taken by the Center of Expertise on Gender Dysphoria in Amsterdam, and gender specialists commonly refer to it as the “Dutch Model.”

This treatment sometimes involves the social transition of young children, according to Thomas Steensma, a researcher and clinician at the center. But for the most part, its counseling incorporates the idea that the vast majority of gender dysphoric children will eventually stop identifying as transgender.

The research literature calls these individuals “desistant.” The kids who retain their transgender identity as they grow up are dubbed “persistent.”

The Desistance Controversy

Nothing roils the world of transgender research like the topic of desistance. Brynn Tannehill, a transgender activist who follows the research closely, said the concept is often used by anti-LGBT groups to make the case that rejecting children’s transgender identity is in their best interests.

'[Desistance research] is used primarily as an attack on the validity of transgender identities, which usually quickly disintegrates into a debate on whether we should exist.' Brynn Tannehill, transgender activist .

“It is used primarily as an attack on the validity of transgender identities, which usually quickly disintegrates into a debate on whether we should exist,” Tannehill said.

And yet, the fact is that just about every published study on the topic to date has found that a majority of children who once reported various degrees of gender dysphoria ended up eventually giving up their transgender identity.

To grasp the implications of this, remember Molly’s anxious questioning of the gender therapist: What if we go through all this, and it turns out to be just a phase? Shouldn’t we wait?

The gender affirmative camp says no. That’s because it doesn’t believe that the body of research on desistance, some of it conducted by Zucker and his associates, is valid.

Many gender researchers maintain that the current criteria for diagnosing gender dysphoria are much more stringent than in the past. Therefore, many of the studies that found so many kids had "grown out" of their transgender identity were actually measuring children who were never really transgender in the first place.

“Some of those studies are decades old,” said gender researcher Kristina Olson. “So if you had a son in the early 1980s who liked playing with dolls and wanted to occasionally wear a dress, even today maybe you would think to bring that child to talk to a doctor about it. But that child wouldn't necessarily be transgender, because that kid doesn't necessarily think of himself as a girl."

Ehrensaft said that her San Francisco clinic sees “a tiny, tiny proportion” of clients who stop identifying as transgender after transitioning.

Even the Amsterdam clinic’s Thomas Steensma, who firmly believes most gender dysphoric kids will not grow up to be transgender, acknowledged the earlier studies probably included “milder cases” that are “hard to compare with the clinical samples we see now in our clinics.”

Nevertheless, he said, “The only evidence I have from studies and reports in the literature ... is that children who struggle with gender incongruence … will not all persist into adolescence."

Talking to Steensma over Skype, he seemed bemused by the fact that the “Dutch model” is now considered conservative compared to what has taken hold in America. After all, his Amsterdam clinic had been a pioneer in the medical treatment of transgender youth, especially in the use of puberty blockers, which delay the onset of secondary sex characteristics.

But what about the social transitioning of young kids?

"It's not a 'yes' or a 'no' in our opinion, but a 'maybe,' Steensma told me.

I wondered if there was any real argument between him and Ehrensaft, after all. So I described to him the case of persistent, insistent, consistent Gracie.

A slam dunk for social transition?

Steensma said no.

“We would counsel them ... that it's okay to express your feelings, your interests, to show your behaviors. But with certain steps like a name change, or a pronoun change, with a result that maybe others will only perceive you as a girl — that's somewhere where we say, ‘Okay, maybe you should explore things without taking steps that are hard to reverse.’”

There are mental health professionals in the U.S. who agree. Dr. Jack Drescher is a clinical professor of psychiatry at Columbia University; he served on the American Psychiatric Association's committee that revised the diagnosis of gender identity disorder in 2013. He said gender affirmative therapists have never proven they can successfully identify those kids who will stick with transgender identity.

'There are some people that think folks like myself, and the people at our clinic, have fallen off the deep end.” Diane Ehrensaft, UCSF

He also says there’s no evidence to back a corollary belief, that kids who might later need to “detransition” back to their original gender will not suffer any long-lasting psychological effects.

“This is what they believe, but it's not based on research,” he said of gender affirmative clinicians. “This is a meme, not really a piece of scientific finding.”

Steensma concurred: “If a child transitions, it is not just, ‘Oh, we do the transition and we go on with our life.’ It has a huge impact on the child, on the family and their environment.’”

The current Standards of Care, issued by the World Professional Association of Transgender Health in 2011, are more or less in accordance with this view, as even Ehrensaft acknowledges. The guidelines describe “relatively low persistence rates” as “relevant” to helping parents weigh the decision to socially transition. The standards also state that “a change back to the original gender role can be highly distressing.”

The one thing everyone in the field agrees on is more research is needed. Almost every gender specialist I spoke with cited Kristina Olson’s longitudinal study at the University of Washington as critical to answering some of these hotly debated unknowns. Olson recently received a $1 million grant from the National Science Foundation, which she's using to expand the study.

Preliminary research coming out of the project has already provided good news for the families of transgender kids. In a pair of studies published over the last several years, Olson and her colleagues found that socially transitioned children and adolescents between the ages of 3 and 14 did not experience any more depression than separate control groups of peers and siblings, as well as the general population.

The transgender health association is now gearing up to revise the Standards of Care. Both Steensma, known for “watchful waiting,” and Ehrensaft, of the gender affirmative school, are on the committee in charge of the section about children. The jockeying to influence the direction of the committee has already begun, as evidenced by the critical commentaries now appearing in academic journals.

“My prediction is that there will be more endorsement of social transitions at earlier ages, without the cautionary tales,” Ehrensaft said of the upcoming revision.

Not Just Numbers

When it comes down to it, when we talk about the controversy over socially transitioning young kids, we are talking about risk analysis. Which is more disruptive and potentially harmful: to deny children their genuinely felt gender identity in the present moment, until the adults are absolutely sure it will stick? Or to validate a child’s persistent, consistent and insistent protestations that ‘Hey, someone has made a terrible mistake here,’ even if they eventually decide they no longer feel that way?

Ehrensaft, at least, is clear on the answer:

“Why would we deny for the vast majority of kids something that is basically suicide prevention?”

As a parent, I wonder: If my daughter became incandescently happy when allowed to change her name and take on other aspects of being transgender — as happy as Molly describes Gracie becoming when recognized as a girl — what would I do? If some statistics indicated my child might one day switch back, but my deepest parental instincts told me to trust her joyfulness, could I ignore the latter?

At Rainbow Day Camp, I spoke to James, a 9-year-old transgender boy who’d transitioned during second grade. He told me matter-of-factly that he’d been bullied by older kids, who’d called him an “It.”

After he transitioned, his mother said, “There was just this comfort that came about him, and comfort's something that you can't really fake. He’s [just] a happier kid.”

Similarly, before Gracie’s transition, family life was “lackluster,” Molly recalled. The constant tension drained the joy out of childhood for everybody.

“You never got to see that sort of sparkle, or that sort of magic of, like, a Christmas morning, or a Halloween, or just regular day-to-day happiness,” Molly said.