Singh et al, 2021

A Follow-Up Study of Boys With Gender Identity Disorder

Frontiers in Psychology

Open Access

Summary

The study follows 139 boys presenting to the Gender Identity Service in Toronto 1975 - 2009. The authors investigate whether gender identity disorder (GID), the prior term for gender dysphoria (GD), persisted in adulthood. The authors collect information on the sexual orientation of subjects.

Participants

The clinic had 307 eligible patients during the intake period. 162 of the patients were not contacted for follow-up due to time and resource constraints. This left 145 patients where an attempt was made to follow-up. 6 declined to participate giving a participation rate of of 96%.

Results

The researchers find that a majority of subjects grew up to be gay adults without GID/GD in agreement with prior studies. Table 1. presents the outcomes for boys from cited earlier studies alongside Singh et al.

Table. 1

Study	Year	n	Bi/Homo-philic	Age at Followup	Persistence
Green	1987	44	75%	19	2%
Wallien and Cohen-Kettenis	2008	59	~68%	19.4	20.3%
Steensma et al.	2013	79	64-87%	16.1	29.1%
Singh et al.	2021	139	47-64%	20.6	12%

Lower social class was significantly associated with the persistence of GID/GD in biphilic and homophilic subjects.

Discussion

Temple Newhook et al. (2018) has criticised “desistance studies”. Zucker (2018) has responded to these criticisms. Key point of debate are:

Are the subjects in these studies representative of children and young people presenting to gender clinics more recently?
The implications for the more recent cohort. Are GD children also likely to grow out of GD and ‘grow into’ a realisation of a homosexual or bisexual status?

There are notable differences between the pre-2010 and post-2010 eras in the treatment of children and young people with gender dysphoria that make comparison inexact.

First, the majority of the recent cohort are female (e.g. Delahunt et al. (2018) ). Second, the diagnostic criteria for ‘gender dysphoria’ has tightened versus the prior term ‘gender identity disorder’, and not all subjects met the diagnostic threshold at assessment. Zucker (2018) (who was directly involved in formalising the diagnostic criteria for GD) argues the differences are not substantial. Singh et al. are aware of these criticisms and point out that case notes from the 51 subthreshold subjects indicate they would have met the complete criteria at some point in their lives. The authors analyse outcomes between complete and subthreshold subjects and find no differences. Third, since 2009 many clinics have de-emphasised ‘gate-keeping’ and instead promote the ‘autonomy’ of children and young people to choose pharmaceutical and surgical modifications (euphemistically known as a ‘gender journey’) ( Griffin et al. 2020 ; Oliphant et al. 2018 ; Schwartz, 2021 ). None of the subjects in Singh et al. received puberty suppression in early (Tanner 2) puberty, though an unknown number may have had their puberty suppressed at later stages. It is also notable that while the formal diagnostic criteria may have changed, it is doubtful that clinical practice has become stricter. For example, the Oliphant et al. (2018) guidelines are ambiguous about the requirement for a formal diagnosis before beginning treatment with puberty blockers. Instead the authors emphasise how formal diagnosis can be “pathologising”.

Fourth, for the recent cohort, many more clinicians, parents, and school staff practice “social transition” i.e. the enculturation of a child in an gender role, prior to puberty. In contrast, only one of the subjects in the Singh et al. was socially transitioned prior to puberty.

Taking a step back and assuming that these differences mean that the results of Singh et al. cannot apply more broadly and recently it seems odd that a clinic specifically set up to address childhood distress around gender identity would not attract those with a more fixed innate gender identity over the 34 year intake period. Assuming a stable 1-2% of the Toronto population is ‘truly’ transgender (including many from an early age), why did they not present to the clinic, and why did the clinic instead attract mostly gay boys?

The more likely explanation is that early childhood GD/GID is largely a feature of homosexuality and bisexuality in the same way that gender atypical behaviour is ( Alanko et al., 2010 ). It is also possible that the early medical intervention and social transition have lead to greater persistence, in opposition to stated aims. Steensma et al. (2013) found that early social transition was associated with increased persistence of gender identity disorder. Commenting on this finding Zucker (2018) states:

“I would hypothesize that when more follow-up data of children who socially transition prior to puberty become available, the persistence rate will be extremely high…I would argue that parents who support, implement, or encourage a gender social transition (and clinicians who recommend one) are implementing a psychosocial treatment that will increase the odds of long-term persistence.”

Treatment with puberty blockers and consequent suppression of sexuality could delay the child’s realisation of their minority sexuality status and conceivably lead to a persistence of gender identity confusion.

Conclusion