How Do You Know He Won't Change His Mind?

I have a tremendous backlog of writing notes--at the moment, I have notes in three different notebooks, which is simply unacceptable to me. I'm going to try to write a post every day during the month of August; I did it in May of 2012 and enjoyed it very much. I hope to be able to retire two notebooks. So here we go, in Notebook #1, all the way back to June, when I was at the TransHealth conference and had the opportunity to attend a talk by Dr. Johanna Olson, who works with transgender youth at the Children's Hospital of Los Angeles.

Whenever I am involved in a conversation about young gender variant kids, somebody asks, "But how do you know he won't change his mind?" I've been asked this about the Tiny Tornado, and I've heard it asked at conferences and in on-line forums. The asker is generally concerned that such a young child is being allowed to make what seems like such a momentous decision. In addition, they imagine complications if a child chooses to live as their chosen gender for some number of years, and then remits.

I think these people would be interested to know that people who work extensively with trans and gender variant kids wonder about this, too: how can you tell, at age 6 or 7 or 8, which kids will revert and which kids will maintain their gender identity into adulthood? How do you choose an effective and appropriate treatment plan when you can't know a child's future gender with absolute certainty? Most kids, according to Dr. Jo, do grow through their gender variant behavior, and though many grow up to be lesbian, gay, or bisexual, only a minority of gender variant kids are trans. How do you know which are which?

Well, according to Dr. Jo, trans kids tend to have a constellation of characteristics that gender variant kids will not share. They will tend to have most of the following characteristics:

• There is an early onset of gender variant behavior; age 2 or 3 is common (and in parent support groups, many of us had stories of kids asserting their gender preferences before age 2).
• The child experiences body dysphoria, which is to say, their body seems wrong to them. The Tiny Tornado, for instance, was never willing to call his genitals anything but a penis, and he still has anxiety about the possibility of someday growing breasts.
• The child has a consistent self-articulation around gender; their assertion of their chosen gender is, to quote Dr. Jo's PowerPoint slide, "tenaciously clung to, unremitting, pervasive, insistent, clear, and acute."
• The child engages in cross-gender play extensively or exclusively. A child identified as male will play only with dolls and his big sister's kitchen set; a child identified as female seeks out trucks and building toys.
• The child cross-dresses, either in daily life if allowed, or in pretend play.
• The child chooses playmates who share their preferred gender.
• The child either does or does not tend to engage in rough-and-tumble play.

I can hear you saying, "But some of those things fit me, and I'm not trans!" Me, too. I went through a stage in late elementary school when I preferred to wear my older brother's hand-me-downs over wearing my own girl clothes, and I was pleased if I was mistaken for a boy. This lasted a year or so. This list is explicitly making a distinction between a kid like me, who engages in gender variant behavior for some period of time, or in some circumstances, and a child whose gender identity is lasting and engages multiple areas of their life.

You may also be uncomfortable with the stereotypical elements of those last four items on the list. So is Dr. Jo. Nobody wants gender identity to depend on stereotypical behaviors. We all want kids to feel that they can engage in any kind of play, and with any playmates they choose, regardless of their gender. But anyone who has been a parent knows that it's not as easy as you think to create a generation of freewheelers, and, for now at least, it seems to be true that consistently crossing lines on gender stereotypical behavior is meaningful if it occurs in a context where other items on that list are also present.

Given the difficulty of predicting a child's future preference, Dr. Olson said that the tendency is to intervene cautiously, avoiding engaging in irreversible treatments prematurely. Social transition, which is what the Tiny Tornado has done by living full-time as a boy, is both the most effective treatment for young kids, and completely reversible. I had a friend once express her concern that we were making such an "irreversible" decision at such a young age--TT was not quite five. My response was that all we'd done was buy him boys' underwear and start calling him "he," and that these things could be reversed with a trip to Meijer and the letter "s."

Puberty suppression is also a completely reversible treatment. The use of hormone blockers delays puberty; it doesn't cause a child to enter puberty as the "other" sex. Discontinuing puberty blockers without engaging in cross-sex hormone replacement therapy simply allows the child to enter puberty as their biological sex later than they would otherwise have done.

Even the use of HRT is partially reversible, depending on how long a person has been using hormones and at what doses. Only sex-reassignment surgery (also called sex-confirmation surgery) is irreversible in all cases. So you can see that practitioners, children, and families have lots of time to develop an understanding and make good choices.

I have pages and pages of notes from Dr. Jo's presentation, but I think I've hit the highlights, and given myself something to point people to when they ask me this classic question. We can't know for sure he won't change his mind, but we can make a pretty good guess based on what we know about him, and about other trans kids.

I'm going to close with a semi-random collection of bits and pieces that didn't make it into the body of the post.

• By age 6 or 7, kids generally have internal gender constancy.
• Dr. Jo says, "You can't make a kid trans." This is also an answer to a question--or is it an accusation?--I've heard from time to time. So there.
• Gender Dysphoria is not, in and of itself, a psychiatric diagnosis. Well-adjusted trans kids do not necessarily need psychotherapy.
• It is hard to know how many kids are remitters--revert to their assigned gender--in part because, in most research, those who can't be followed up on are classified as remitters. Dr. Jo commented, for instance, that one Dutch clinic reports all clients they lose track of as remitters, because they assume that any trans youth who does not remit is still in treatment with them. For this and other reasons, she suspects that the reversion rate is overstated in the available research.
• Among adult trans people, about 1% express regret. Dr Jo says that this is often due to the difficulty of reconciling a new life when older, and she hopes that as this first cohort of effectively-treated trans youth grow up the rate will be lower.
• Social transition is a pretty strong predictor of persistence; kids who undergo social transition are about five times more likely to maintain their gender identity into adulthood.

 

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