Over the past decade, I have often come across Facebook posts from distant friends or acquaintances announcing the arrival of a recently “born” daughter or son. These updates are paired with photos of an exuberant girl with gap-toothed grin in a sparkly dress; short curls falling just over the top of her ears; a boy in a Gap polo, mugging for the camera, his arms crossed with newfound confidence. We are introduced to Hailey or Carsten and told how a previously withdrawn child has found their spark.
Parents confess they should have seen it sooner. The comment sections fill with congratulations, hugs and likes. “What a lovely smile.” “What a beautiful daughter.” “What a handsome boy.” How lucky, readers agree, that a child can be their true self at such a young age.
I have a soft spot for coming-out stories like Hailey’s and Carsten’s. I am a trans woman who transitioned in my 20s, and I remember the pain of a childhood and young adulthood marked by persistent gender dysphoria, particularly the distress of seeing my body masculinize during puberty. Once I decided to transition, the effects of having gone through that puberty required hundreds of hours of electrolysis and multiple facial surgeries to allow me to consistently read as female and for me to be comfortable with seeing my own reflection.
I was fortunate not to develop the kind of masculine features that would have been impossible to reverse, and I was financially able to access high-quality medical, cosmetic and surgical care. Still, I often wonder how my life would have unspooled if I had the opportunity to have transitioned earlier in my childhood, and to have avoided all those hardships and wasted years.
And while I acknowledge that I was able to pass and assimilate well even though I transitioned as a young adult, many trans people cannot access comparable care, or have pubertal changes that no amount of hormones or surgery can fully address, leaving them to manage the stigma of being visibly trans. That, together with the psychological burden of longstanding dysphoria, may contribute to the elevated rates of mental illness, substance use, economic hardship and suicide risk seen in trans adults. It brings me comfort to believe that Hailey and Carsten may be on a path to avoiding this tumult and are getting an early start on the rest of their lives.
Most current guidance on the care of gender-variant or cross-sex-identifying youth supports a child-led social transition with strong family backing while recognizing the challenges of navigating an often treacherous social landscape. This approach rests on the assumption that cross-gender identification is innate and largely fixed, and thus delaying transition is just delaying the inevitable; and on the belief that social transition can be easily discontinued in the minority of cases where a child no longer strongly identifies as or wishes to live in the role of the opposite sex. The evidence supporting this recommendation is based on data from small clinic-based cohorts and interviews of parents of transitioned children, but the long-term outcomes of children who socially transitioned prior to puberty has not been previously well described.
A new report published this past September by University of Washington researchers and colleagues provides a clearer view. The Trans Youth Project, led by Kristina Olson, is the largest longitudinal study of gender variant children who were socially transitioned prior to age 12 with the support of their parents. It has now tracked outcomes in more than 300 children for an average of seven years, with most subjects now well into their adolescence.
Nearly 90 per cent of those children remain in their chosen gender role, with similar persistence among those living as boys and those living as girls. Among the small number who desisted, about two-thirds identified as non-binary and about one-third returned to their birth sex. In simple terms, social transition in childhood appears to be highly stable, at least through mid-adolescence.
In simple terms, social transition in childhood appears to be highly stable, at least through mid-adolescence.
However, even in the best-case scenario, in a society where transphobia has always been present and is currently ascendant, a mentally well-adjusted and physically healthy trans adult who is consistently read as their affirmed sex can face stigmatization and discrimination should their status become known. For those who pursue gonadal surgical interventions, there will be a long-term need for exogenous hormone therapies, and fertility options are limited for those who wish to start families.
Also importantly, with the United Kingdom and many parts of the U.S. instituting broad bans of minors accessing puberty blockers and cross sex hormones, children who are socially transitioned may find themselves with a more profound and unshakable attachment to their preferred gender role with no mechanism to halt the onset and progression of their natural puberty. Though these treatments are still widely available in Canada, public support for minors to be able to access these therapies is waning, and Alberta has already proposed legislation to curtail the ability of clinicians to offer these interventions to those under 16. Older studies – from periods when pre-pubertal social transition was discouraged – reported that 61-93 per cent of gender incongruent pre-pubescent children who presented for assessment desisted from their cross-gender identity prior to puberty. Furthermore, considering the majority did not subsequently pursue gender transition in adolescence or early adulthood, it begs the questions of whether social transition might be nudging some children who would have otherwise desisted and grown up to be cisgender into a more persistent trans identity, and with it, all the challenges that living a trans life entails.
However, restrictions on early social transition foreclose a path to a more typical and less arduous life for some gender-variant children. While most would presume a cisgender outcome is always superior to a trans outcome, we do not have robust data on how gender-variant children who did not transition in childhood fare in the long term. While prior studies have suggested most previously gender-variant children who do not transition will be opposite-sex attracted as adults, there is no reporting on their mental and physical health, relationship outcomes, life satisfaction or ongoing dysphoria.
Also, for the subset of gender-variant children with severe persistent dysphoria, its continuance into and throughout adolescence and adulthood is likely the rule, and they will have to decide between living with unrelenting dysphoria or transitioning later in life, when assimilation is harder and the risks of stigma and victimization are greater. Persistent, untreated mental health problems in childhood also predict poorer adult outcomes, including higher rates of disability and financial dependence, and there is no reason to believe this would be different for those with unaddressed dysphoria.
Given the consequentiality of embarking on a social transition, it would seem wise in most cases to pursue this path only if the child’s suffering from dysphoria is so persistent and severe as to make untenable the prospect of living with that suffering, and to adopt a more watchful waiting strategy for children who lack significant and persistent dysphoria. And parents, as the closest and most constant observers of their child, should in most cases be granted the autonomy and discretion to determine what they believe in their child’s best interests, guided by unbiased clinicians who are focused on the relief of dysphoria and not by whether the child transitions or not, and free from governmental interference in that decision making process.
While the Trans Youth Project has and will continue to provide useful information on how socially transitioned children manage through their adolescence and into adulthood (the study is designed to follow its subjects for up to 20 years), it will never be able to answer whether social transition will be the best choice for Hailey, Carsten or for any gender-variant child, just as I will never know whether the life I have now, while definitely fulfilling, was my best possible one.
One thing we do know is that a child with loving and supportive parents and a stable home has the best chance of growing up to become a flourishing and healthy adult, regardless of their gender identity. This definitely was the case for me, and probably explains more of my current success than the timing of my transition.
And judging Hailey’s and Carsten’s smiles and their parents’ obvious love and support, I have a feeling those kids will be all right.
