Early or Late Onset?

I am concerned for trans kids. My greatest concern is for those who need medical care and are being prohibited from receiving it. In Kentucky, physicians can be indicted for not beginning detransition care. That’s right, they can be arrested for not undoing transitions that have already begun! Altogether this year, there have been 495 laws introduced or signed into law taking away the civil rights of transgender people.

This post is not about those laws, and the damage they are doing to transgender people. I’ve written about that before, and will write about it again. But not today. This blog is about something else.

I have a second concern, one that does not curry favor with everyone in the transgender community. The percentage of the transgender population has remained steady for a long time at about .58 percent of all people. Roughly one in every two-hundred people is transgender. Recently, however, that number has tripled, and almost all of the growth has been among adolescents, specifically adolescents who were identified female at birth.

The vast majority of mental health providers believe that exploring gender identity, particularly during one’s adolescent years, is good and appropriate for individuation and differentiation. In both the United States and Europe, the biggest controversy among medical personnel is not such exploration, but about the medical treatment of adolescents who say they are transgender or nonbinary.

A study in the January 19, 2023 New England Journal of Medicine followed 315 transgender adolescents through two years of hormone therapy. A total of 60.3 percent were transmasculine and the remainder transfeminine. The study found that the majority of young people who received treatment had a remarkably better quality of life after those two years than they had before. The truth is that for a certain subset of the trans population, we have known that to be true for a long time. But the study failed to answer an important question. Were these study participants individuals whose gender dysphoria was later onset or earlier onset?

Most clinicians with concerns about treatment, including those who are generally supportive of medical treatment for trans youth, are concerned about the increasing numbers of young people whose dysphoria is later onset, after the age of 12. It is still true that any child five or six years of age who consistently and persistently says he or she is not the gender listed on their birth certificate, will continue to feel that way throughout life. Providing gender affirming care to these young people is still supported by the vast majority of clinicians in the United States and Europe. I am not talking about that segment of the population. My question about medical care is reserved for adolescents who do not present as transgender until 12 or later.

In the United States, providing medical care to any transgender young people, regardless of age of onset, has become a political lightning rod. To gain a more balanced perspective on the circumstances, I want to turn to Europe, where the subject is less political.

There is significant rethinking of medical treatment for transgender adolescents in Europe, including the United Kingdom. Why? One study in the UK of 221 adolescents receiving treatment at the Tavistock Clinic, found no detectible improvement in overall mental health after three years of medical treatment. While that study is an outlier, it does raise yellow flags.

No European nation has legally prohibited medical care for transgender adolescents, but there is growing concern about the demographic shift. One clinic in Ghent, Belgium has seen a 42-fold increase in those presenting for treatment. The increase in Sweden has been 17-fold. Finland has seen a marked increase of those presenting for treatment as having been identified female at birth, 75 percent of whom have a separate and severe mental health diagnosis, as opposed to fewer than 33 percent comorbidity in other studies. There is even concern being expressed in Netherlands, the birthplace of transgender adolescent care with what became known as the Dutch protocol.

Amsterdam’s first transgender care center was opened in 1972, and they have been the most progressive nation in terms of transgender care since that time. The Dutch protocol for children was developed in the 1990s. Over the last ten years the number of children seeking care has grown from 60 to 1600, with the vast majority being adolescents who were assigned female at birth.

What is increasingly clear is that for children who present as transgender at a very early age, providing puberty blockers during adolescence is appropriate. For those whose presentation with gender dysphoria is later onset, more study needs to be done. Are these children truly transgender, or are other maturational issues at work?

I have a lot of observations, but have reached no firm conclusions. It appears that a lot of young people who might have presented as goth in a previous generation are now identifying as transgender or nonbinary. Is what we are seeing typical differentiation or individuation, albeit with a new presentation, chosen for its ability to shock and trouble a new generation of confused parents or right-wing politicians? I believe it is possible.

How many of the adolescents who present as transgender today will identify as transgender ten years from now? The truth is that we do not know. My suspicion is that it will be about .58 percent, the same percentage that has always identified as transgender.

What about those who are nonbinary? The 2017 US Transgender Survey found that 62 percent of those who identified as nonbinary were between 16 and 26 years of age. Is that because older people were not free to identify as nonbinary until now? It is possible. There are several nonbinary individuals in my church, none of whom fall into the age category above. But it is also possible that the majority of adolescents who identify as nonbinary today will not do so in ten years.

Having anti-transgender zealots attacking all medical care for trans adolescents is tragic. And let’s be clear. It is evangelical Christians who are behind these laws. In 2017, 84 percent of evangelicals believed gender is immutably determined at birth. Sixty-one percent believed we give transgender people too many civil rights, and only 25 percent knew someone who was out as a transgender person.

Six years later, the numbers have gotten worse. Eighty-seven percent of evangelicals now believe gender is immutably determined at birth. Sixty-seven percent believe we give transgender people too many civil rights, and 31 percent know someone who is out as a transgender person. The number of evangelicals who know someone who is transgender has increased, but so has the opposition to trans rights. What accounts for the increase in knowing someone who is trans? It is probably an increase in those who know a transgender adolescent, not those who know a trans adult. That makes a difference in the conclusions one draws about gender dysphoria.

It is not difficult to determine the adolescents who need puberty blockers during adolescence. They are the early-onset individuals who have consistently and persistently identified as transgender since early childhood. They need medical care, or their suicide completion rate will increase dramatically. Being deprived of that medical care could have tragic consequences. No wonder people are moving from Texas to Colorado. Texas has some of the most restrictive transgender laws in the nation. Colorado is a wonderful environment for thoughtful treatment of transgender adolescents. We Coloradans are pleased to see so many families finding refuge in our beautiful state.

As for those who have later onset gender dysphoria, I believe watchful waiting is advised, as well as a good therapist well-versed in gender identity issues. Time will tell if these young people continue to identify as transgender or nonbinary, or if they will later identify as cisgender adults. There is nothing wrong with watchful waiting.

I imagine some of you will have thoughts about this post. I look forward to hearing from you.