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.

14 thoughts on “Early or Late Onset?

  1. Totally agree. Two distinct populations.
    The lockstep opposition only intensifies the desire to seek treatment. Like all prohibitions, they increase our desire for that thing whatever it is.
    The young trans kids are a very different group.

    Liked by 1 person

  2. Thankyou. You’ve said everything I’ve been thinking for quite a while. It’s tragic that what I agree is part teen angst/rebellion (in part, people, only in part!) is now mixed in with lifelong gender dysphoria. I don’t see a way out. It’s torturous.


  3. Well, I am from Oklahoma and the situation is also bleak an dire here. Thank you for your courage to speak out and help.


  4. It seems to me that it shouldn’t be controversial in any regard. I understand you to be saying that this is something in need of more attention and that responsible, attentive therapy should be be the norm for dealing with it. I started transition in my early 50’s and therapy is what helped me understand and accept myself. She let me talk thru my confusion and find my own acceptance after decades of repression. I can’t know what it would have been like for me had those resources been available in my youth, but I can’t imagine therapy wouldn’t have been the best path toward finding me even then.


  5. Excellent medical and psychological care is critical. In my experience our child did not come out until age 13, but I always watched for it because of signs I saw in early childhood. Our child told us they did not understand what was going on in them (and didn’t talk about it with us) until they met others on the LGBTQ spectrum. Puberty blockers are the best medications ever, and gave our child time to think, go to therapy and work out what their mind and heart really said. We have an alive, happy young adult who transitioned smoothly, and we are thankful. We wish that for all parents.


  6. Hi, Paula! Thank you for articulating what I’ve been observing for some time now. I’m one of those people who has healthfully relaxed into identifying as genderqueer after decades of good old evangelical repression, thanks mostly to excellent and healthy therapy, but it was something I always knew about myself. I belonged for a while to a non-binary group but it was overrun with late onset AFAB individuals who were rarely glad to be free in their self-expression, and mostly focused on being angry at their oppression.

    It reminds me of the early days of Celiac diagnosis, a couple decades ago. My sister and I were significantly ill; I very nearly died from malnourishment before a specialist brought up an esoteric disease nobody knew about. Research suggests my father did actually die from undiagnosed Celiac sprue. And within 10 years everyone was gluten sensitive, or wheat allergic, or unnecessarily choosing a gluten free diet, when those of us with the actual disease were just glad to be alive and healthy. As others have dropped the gf restrictions over time, we who are truly diagnosed are still living as we must to be healthy and happy.

    Maybe it’s not the best analogy, but it does address the herd mentality. I absolutely believe it’s a fact that sometimes a person is assigned the wrong gender at birth and they need to transition to whatever degree necessary to make them whole. But if my teen self was in the current climate I’d be confused as hell about the difference between non-binary and transgender. I remember the terror of developing a post-puberty masculine body, but it was because of the role I was expected to imprison myself in. Really good therapy was needed. Young people, children, need freedom to explore and express without judgement or recrimination, and without conclusions made by anyone else. Then the herd sorts itself out to find their own truth. If they were just allowed to live and let live.

    Liked by 2 people

  7. I can’t get past the thought that these kids go through so much outcasting in their communities and politicians trying to eradicate them and you’re casting doubt on them. No one would choose to be treated this way. It would be so much easier to not be non-binary and/or trans.

    Much of the narrative and representation about trans people have been MTF. If girls are getting to an age where they learn that feeling like a boy is also “a thing” because they’re seeing it more, then I’m not surprised that girls are transitioning to boys more than we’ve seen in the past. I wouldn’t expect that 0.58% to stay put forever with all the same factors, let alone that increased language and representation and community have made people feel braver to come out or even realize there is a word to explain how they’re feeling.

    If you trust doctors and families to make decisions for “early onset” trans kids, then there is no reason to not put that same trust and use the same methods with “late onset” kids.

    Overall, your take on this feels very patriarchal.


  8. This is actually getting at the core of a lot of the current “controversy” surrounding transgender people right now. There’s a tsunami of the younger generation identifying as transgender. And it is something that needs to be understood.

    Conservatives have proposed “reasons” for this rise that are incorrect, dangerous and hateful. And I won’t even list them here. But, part of countering that is understanding the truth.

    I don’t think we can really expect the 0.58% value to hold though. It might have been that in Western civilization of late, but how about other cultures or times in the past? Another example of a rate that increased dramatically was left handedness. When left handedness was suppressed it was around 2%, but now has settled at about 10%. So there was a steep rise when left handedness started to not being suppressed. We really should expect something similar for transgender people who have been suppressed similar to left handed people. Where it will even off at is a good question…

    The other question with the rise of transgender people is — has the regret rate for interventions increased of late? And my understanding is that has not been seen in current research. For example here’s a very recent study that shows low levels of detransition


    If there currently is a “bubble” of young transgender people that aren’t really trans, we would expect that a lot of those will detransition and have high rates of regret. So far it’s not looking that way…

    To give full credit. Here’s the article I took some of what I say above from…



    • Thank you for all of this, Erik. So much of the US current info on de-transition is from the right, and not very reliable. In Europe we are seeing higher numbers than in the past, and mostly among teens. I think it’ll be about 10 years before we have a handle on whether the percentages significantly change or not. I know my perspective that they are not likely to change is a minority position within the queer community.


  9. I can respond to this from a position of knowledge as a parent of a non-binary kid who met their non-binary life partner when they were 16. They are 34 now. I have watched them both grow up in their transition together.

    My child was always gender non-conforming but fluid. One day they loved a frilly dress, the next they were mortified at the thought. I was a smart enough parent to pick my battles, and forcing her into gender conformity as a child wasn’t going to be one of them. Their pronouns are fluid to this day, so there was never anything to really pin on puberty, though the dysphoria showed up much worse at that time. Long story short, they always had counseling support, and it was never brought to our attention as something to look into, but it was no big surprise either. Even so, they didn’t come out to me until after college. They have chosen not to have hormone therapy, but do want top surgery.

    Their partner, on the other hand, does take hormone therapy and uses both masculine and non-binary pronouns. My point is, that these two children both had parents who would have listened and learned whenever they were ready to share. Together, they decided to wait. Would we have taken them to whichever doctors we needed to when they were teens to keep them safe? You betcha. But would we also have done our research and taken our role as parents dead seriously? Absolutely.

    At this point in our society, I can see nothing wrong with medical intervention at any point, because the alternative is more dead kids. Sure, require extensive therapy and psychiatric evaluation before any irreversible treatments happen, but that is likely a good idea regardless of how long the child has been exhibiting telltale behaviors. But to make it illegal to use puberty blockers, or wait for appropriate hormone replacement until that child is 18 is dangerous and stupid.

    Time will tell if the rise in kids identifying as transgender will actually rise as young people become more informed, or if it will level out as society finds something else to freak out about. In the meantime, all kids who identify as trans, for whatever reason, are in danger.

    I just can’t see the value in gatekeeping that right now. I’m too scared.

    Liked by 1 person

  10. Hi Paula, Our child came out to us as a transgender woman at age 28. According to your definition, she is “late onset,” and you wonder if she’ll still identify as transgender 10 years from now. She’s told us definitively that she’s comfortable with her current identity and that there are no circumstances that would motivate her to detransition. According to her (she’s done research, I haven’t) most people who detransition do so due to family and societal pressure and are deeply unhappy afterwards to the point of depression or suicide.

    She apparently felt dysphoric as early as puberty but she tells us that she didn’t have the language to describe how she felt until she was in her mid-20s. She said she thought about coming out during college but if she had, she’d have called herself non-binary. She also told us that if she’d had a sister all of this would have come out a lot earlier.

    She found your book immensely useful and called your stories of early life “very relatable.” It gave us a platform for discussing dysphoria and how it had impacted her life growing up. As a mother, I which I had known that something was up so I could have gotten her help earlier. I didn’t know the word “transgender” until she came out to us.

    So I’d agree that more study and more gender-informed therapy is needed.

    Thanks as always for your thoughts.

    Liked by 1 person

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