A presentation to the 23rd World Professional Association for Transgender Health Biennial Symposium, Feb. 16, 2014, Bangkok, Thailand, by Kelley Winters, Ph.D., of GID Reform Advocates. It is frequently repeated in mental health literature and popular media that the vast majority of children whose gender identity differs from their assigned birth-sex, or who are severely distressed by their birth-sex, will "desist" in their gender identities and gender dysphoria by adolescence. As a consequence, gender dysphoric children are pressed to remain in their birth-assigned roles throughout the world. But are gender dysphoria and diverse gender identities just a phase? This presentation reexamines research in Canada and The Netherlands that underlies the "desistence" axiom, with respect to methodological rigor and validity of claims. Conclusions: (1) Evidence from these studies suggests that the majority of gender nonconforming children are not gender dysphoric adolescents or adults. (2) It does not support the stereotype that most children who are actually gender dysphoric will "desist" in their gender identities before adolescence. (3) These studies do acknowledge that intense anatomic dysphoria in childhood may be associated with persistent gender dysphoria and persistent gender identity through adolescence. (4) Speculation that allowing childhood social transition traps cisgender youth in roles that are incongruent with their identities is not supported by evidence. (5) These studies fail to examine the diagnostic value of Real Life Experience in congruent gender roles for gender dysphoric children.

1. Methodological Questions in
Childhood Gender Identity
‘Desistence’ Research
Kelley Winters, Ph.D.
GID Reform Advocates
The 23rd WPATH Biennial Symposium
Feb. 16, 2013
from Loveland, Colorado, USA
(Ver. E, expanded)
©2014 Kelley Winters, www.gidreform.org
Photo by Kelley Winters Images Photography

2. How pervasive is this axiom about
childhood gender dysphoria?
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2

3. “Desistence” in the WPATH Standards of
Care, Version 7
“[Gender] dysphoria persisted into
adulthood for only 6­23% of children.
...Newer studies, also including girls,
showed a 12­ 27% persistence rate of
gender dysphoria into adulthood”
(p. 11, 2011)
Logo ©2014 WPATH
3

4. “Desistence” in the WPATH Standards of
Care, Version 7
“In most children, gender dysphoria
will disappear before or early in
puberty.”
(p. 12, 2011)
Logo ©2014 WPATH
4

5. “Desistence” in the DSM-5
5

6. “Desistence” in the APA Task Force
Report on Treatment of GID.
“the majority [of children with GID]
will become comfortable with their
natal gender over time (a phenomenon
termed desistence)”
(Byne, et al., 2012)
Logo ©2014 WPATH
6

7. “Desistence” in the Press
“Actually, no one knows whether Coy
[Mathis] will continue to feel that she
is a girl when her body develops
further, since most children like her
grow up to be gay, not transgender.”
(Drescher,
New York Times,
2013)
7

8. Consequent Defamation of “Confusion”
“What to do if your child is
gender­confused. Next, on Dr. Phil"
(McGraw, CBS TV, 2008)
8

9. “Confusion” in Religious Extremism
“very few children who demonstrate
gender confused behavior continue to
do so in their later teen years or early
adulthood”
(Stanton, focusonthefamily.com,2009)
9

10. “Confusion” in Political Extremism
“[California] AB 1266 aims to require
all public schools to allow gender
confused youth to use facilities,...
based solely on their perceived
'gender identity' and not their
biological sex.”
(Pacific Justice Institute, 2013)
10

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i l
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Dogma?
Given the stakes,
11

12. A Point of Science:
“the burden of proof in science rests
invariably on the individuals making a
claim, not on the critic.”
Lilienfeld, Lynn and Lorh, Science and
Pseudoscience in Clinical Psychology, 2004
12

13. Three Key Cited Studies from
Toronto and the Netherlands:
Drummond, K. D.; Bradley, S. J.;
Peterson-Badali, M.; Zucker, K. J. (2008)
Wallien, M.S.C. & Cohen-Kettenis, P.T.
(2008)
Steensma, T.D.; Biemond, R.; de Boer, F.
& Cohen-Kettenis, P.T. (2011)
13

14. Concern 1: Fallacy of Conflated Subsets
Are Socially Transitioned Kids, Gender
Dysphoric Kids, Kids Dx with “GID,”
and Nonconforming Kids
synonymous?
14

15. Conflated Subsets
(Wallien,
et al. 2008)
“Children diagnosed with
gender identity disorder
(GID) have a strong cross­
gender identification and
a persistent discomfort
with their biological sex
or gender role associated
with that sex (gender
dysphoria)”
15

16. Conflated Subsets
In truth,
Socially Transitioned Kids
are a tiny subset of-Gender Dysphoric Kids
are a subset of-Kids Dx with GIDC/GDC
are a small subset of-Gender Nonconforming Kids
16

17. Concern 2: Sample Bias in DSM Intake
Criteria
17
“it is conceivable that the childhood
criteria for GID may “scoop in” girls
who are at relatively low risk for
adolescent/adult gender­dysphoria
that revolves so much around
somatic indicators...”
(Drummond, et al., 2008)

18. Concern 3: Results Skewed by Treatment
“It is beyond the scope of this report
to describe the types of therapies ...
received between the assessment in
childhood and follow­up...
13 of the 25 girls had
at least some contact
with our clinic ...”
(Drummond, et al., 2008)
18

19. Concern 4: Omitted Long Term
Followup
19
“the median age at which trans
people first visited their GP to discuss
their gender dysphoria has been
rising and is currently 42.”
(Reed, et al., 2009)

20. Concern 5: Dismissed Retrospective
Evidence
“Age of epiphany... clear spike at age
5 years, representing the modal
average, with a mean average of 7.9
years. ”
(Kennedy, et al., 2012)
20

21. Concern 6: Unfounded Assumptions
“...(45.3%) did not
reapply for
treatment at the
Gender Identity
Clinic during
adolescence... we
assumed that their
gender dysphoric
feelings had
(Steensma, et al., 2011)
desisted...”
21

22. Concern 7: Magic Sticky Flypaper Theory
“[Parents/Caregivers]
may help the child to
handle their gender
variance in a supportive
way, but without taking
social steps long before
puberty, which are hard
to reverse. ”
(Steensma, et al., 2011)
22

23. The Magic Sticky Flypaper Theory
The Steensma paper
speculatively disparaged
childhood social transition,
without studying gender
dysphoric children who
actually transitioned
socially.
23

24. Concern 8: The 800 lb. Taboo Question
Does Real Life
Experience in
congruent roles
(including nonbinary
roles) have similar
diagnostic value for
children as in adults
and adolescents?
24

25. A Closer Look at Drummond, et al., 2008
The Claim-- 88% “desistence” of 25
“girls” with full or sub-threshold
childhood GID after age 17.
A Clarification-- 59% of a cohort of 37
nonconforming birth-assigned girls
reported female identity after age 17;
8% transitioned medically; 32%
unknown; none were followed long term.
25

26. A Closer Look at Wallien, et al., 2008
The Claim-- “27% of our total group of
gender-dysphoric children was still
gender dysphoric in adolescence.”
A Clarification-- 27% of 77 gender
nonconforming children transitioned
medically after age 16; less than half,
43%, identified with birth-assignment;
30% unknown; none followed long term.
26

27. A Closer Look at Steensma, et al., 2011
The Claim-- 55% of 53 children meeting
GIC criteria sought medical transition in
adolescence; nonrespondents, 45%,
“desisted” in gender dysphoria.
A Clarification—More than half, 55%, of
77 children meeting GID criteria sought
medical transition in adolescence; 45%
were unknown.
27

28. Speaking of Steensma, et al., 2011
The Claim-- “These accounts imply that
the presence of body discomfort may
contribute significantly to persistence or
desistence of childhood gender
dysphoria .”
-- This key finding, persistence of early
anatomic dysphoria, has been ignored in
much of the literature and press. 28

29. Summary
(1) Evidence from these studies suggests
that the majority of gender
nonconforming children are not gender
dysphoric adolescents or adults.
(2) It does not support the stereotype
that most children who are actually
gender dysphoric will "desist" in their
gender identities before adolescence.
29

30. Summary
(3) These studies do acknowledge that
intense anatomic dysphoria in childhood
may be associated with persistent gender
dysphoria and persistent gender identity
through adolescence.
30

31. Summary
(4) Speculation that allowing childhood
social transition traps cisgender youth in
roles that are incongruent with their
identities is not supported by evidence.
(5) These studies fail to examine the
diagnostic value of Real Life Experience
in congruent gender roles for gender
dysphoric children.
31

32. References
American Psychiatric Association (2014). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Byne, W., Bradley, S.J., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., Meyer-Bahlburg, H.F.L., Pleak, R.R. & Tompkins, D.A.
(2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of
Sexual Behavior, 41(4):759-796.
Drescher, J. (2013) "Sunday Dialogue: Our Notions of Gender," New York Times, June 29,
http://www.nytimes.com/2013/06/30/opinion/sunday/sunday-dialogue-our-notions-of-gender.html
Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), "A follow-up study of girls with
gender identity disorder," Developmental Psychology. Vol 44(1), Jan 2008, 34-45.
Kennedy, N. (2012) "Transgender children: more than a theoretical challenge," Goldsmiths College, University of London,
http://academia.edu/2760086/
Reed, B., Rhodes, S., Schofield, P., Wylie, K., (2009) "Gender variance in the UK. Prevalence, incidence, growth and geographic
distribution," GIRES – the Gender Identity Research and Education Society, http://www.gires.org.uk/assets/MedproAssets/GenderVarianceUK-report.pdf
Steensma, T.D., Biemond, R., de Boer, F. & Cohen-Kettenis, P.T. (2011). Desisting and persisting gender dysphoria after
childhood: A qualitative follow-up study. Clinical Child Psychology & Psychiatry, 16(4):499-516.
Wallien, M.S.C. & Cohen-Kettenis, P.T. (2008). Psychosexual outcome of gender-dysphoric children. J American Academy Child &
Adolescent Psychiatry, 47:1413-1423.
Winters, K. (2013) Response to Dr. Jack Drescher and the NY Times About Childhood Transition, GID Reform Weblog, July 5,
http://gidreform.wordpress.com/category/childhood-social-transition/
World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender,
and Gender Nonconforming People: Author.
32

33. Methodological Questions in
Childhood Gender Identity
‘Desistence’ Research
Kelley Winters, Ph.D.
GID Reform Advocates
The 23rd WPATH Biennial Symposium
Feb. 16, 2013
from Loveland, Colorado, USA
(Ver. E, expanded)
©2014 Kelley Winters, www.gidreform.org
Photo by Kelley Winters Images Photography