Last week, the New York Times reported on a “first of its kind” study purporting to show that a “vast majority” of “transgender children” continue to identify as transgender five years after they begin their “social transition.” According to the study’s lead investigator, Princeton University psychologist Kristina Olson, only 2.5 percent of the children tracked over that period reverted to the sex they were “assigned at birth.” An additional 3.5 percent identified as “nonbinary,” leaving 94 percent who persisted in their cross-sex identification.
But far from supporting the narrative that there are “transgender kids” out there who need to be “affirmed” to enjoy basic “mental health,” the Olson study actually lends support to those who criticize the practice of disfiguring and sexually incapacitating children as a means of offering them temporary relief from puberty-related distress—a practice known euphemistically as “gender-affirming health care.”
To its credit, the Times emphasized a key limitation of the new study as it relates to battles over pediatric gender transition: the cohort in Olson’s study was made up mainly of boys who began showing signs of gender-related distress prior to puberty—in other words, the same patient population for whom medical transition was originally intended. In contrast, the bulk of referrals to gender clinics nowadays are teenage girls with no history of gender-related distress and with high rates of mental-health comorbidities including autism, anxiety, and depression. The Times even quotes Laura Edwards-Leeper, a leading proponent of gender-affirming therapy who recently raised concerns about its use in the pediatric setting, who says that the new study “tells us nothing” about the bulk of teenagers showing up at the approximately 300 gender clinics throughout the country. Because state bans on pediatric transition are designed primarily with this new patient cohort in mind, it is safe to say that the Olson study is at best irrelevant to the debate over these laws.
What the Times does not tell its readers is that the high rates of mental-health comorbidities among teenage referrals creates a potential for “diagnostic overshadowing.” This happens when practitioners mistakenly interpret one of several co-occurring symptoms as the cause of the others. In simple terms, a teenage girl may express her distress in gendered ways—for instance, by insisting that she is really a boy. But if the cross-gender “identification” is not the cause of her distress, then using her proclamations to justify hormonal intervention and surgeries will not solve her problems and will likely make them worse.
It is not even clear whether the two patient cohorts—natal boys with early-onset symptoms and teenage girls with late-onset symptoms—belong under the same diagnostic category of “gender dysphoria.” Though both present with similar symptoms, these might reflect different etiologies, have different development pathways and prognoses, and respond to different treatment protocols.
The deeper problem here is that psychiatry since the 1980s has steadily moved from etiology-based to symptom-based classification and diagnosis. In branches of medicine dealing with the body, we would think it absurd and dangerous if doctors diagnosed and treated patients based purely on their symptoms. Doctors would prescribe chemotherapy for patients presenting with fatigue, stomach cramps, and constant vomiting (symptoms of colon cancer), even if the true cause of their symptoms was, say, chronic work-related anxiety.
The inherent difficulty of understanding the causes of mental disorder and the diverging theoretical approaches to this question that emerged within psychiatry over the twentieth century prompted leaders in the field to broker a compromise. “By providing clear, explicit descriptions of diagnostic criteria,” writes Harvard professor of psychology Richard McNally, the symptom-based approach “allowed clinicians and researchers of diverse theoretical persuasions—psychodynamic, cognitive, behavioral, and biological—to agree, at least in principle, whether someone qualified for a certain diagnosis, even if they could not agree about its causes.” In short, symptom-based psychiatry represents a pragmatic effort to achieve uniformity across the field, but it does so, experts have argued, at great expense. “The concept of mental disorder,” McNally reports, “implies that something internal to the person’s psychobiology is not functioning properly.” But psychiatry’s current emphasis on symptoms at the expenses of causes increases “the risk of classifying people as disordered whose suffering does not arise from mental illness at all.”
Pediatric gender transition illustrates the agonizing downsides of symptoms-based psychiatry. Medical practitioners are now giving puberty blockers, cross-sex hormones, and surgeries to teenage girls with no history of gender-related distress simply because they present with symptoms similar to the ones observed in the preteen boys in the original Dutch studies of the 1990s. The fact that the girls begin presenting around puberty (whereas most of the boys desist around then), and that they arrive at gender clinics often after prolonged social isolation and exposure to social media, are crucial contextual points. They might suggest that “gender dysphoria” in the case of girls is a result of social contagion—and thus a temporary phase. Clinicians focusing on symptoms alone tend to be oblivious to these confounding factors.
The patient population Olson and her colleagues followed was made up of children who began “social transition” on average between ages six and seven, who were supported in that transition, and who were still “identifying” as the opposite sex around the onset of puberty five years later. The study’s major flaw is that it fails to consider that “social transition” may itself contribute to the persistence of gender dysphoria—something that the Dutch pioneers of pediatric gender transition, as well as the recently published Cass Review study of the U.K.’s Tavistock Clinic, have both emphasized. In other words, the Olson study treats the practice of giving children a new name, using pronouns and words like “son” and “daughter” in accordance with the opposite sex, dressing them as that sex, and encouraging them to engage in activities conventionally associated with that sex, as mere background supports rather than as an active form of intervention in a child’s psychosocial development.
Considering how impressionable children are, how susceptible to messaging from the adults in their lives, and how invested they and those adults often become in maintaining the transgender identity, is it any wonder that the vast majority of the children in Olson’s study continued perceiving themselves as “trans” five years on? Indeed, the more striking finding is that 2.5 percent of these children managed to revert back to “identifying” as their biological sex. Imagine the courage it takes for an 11-year-old boy to say to his parents, teachers, and psychologist: “I guess I was wrong. I guess you were all wrong.”
Olson and her coauthors could have designed their study with controls—for instance, by comparing a group of kids who had undergone early social transition with a group with similar psychological profiles that did not undergo social transition. If it turned out that the first group was much more likely to proceed to puberty blockers and cross-sex hormone injections, then this would suggest that social transition is not a treatment for but rather a cause of persisting gender dysphoria. “Affirming” these kids would therefore be locking in an “identity” that might otherwise have proved temporary.
The Olson study will likely become ground zero in a war of narratives. Progressives, in particular those in the mental-health professions, will refer to it as evidence that clinicians are remarkably good at picking out transgender kids from those whose gender nonconformity is merely a passing phase. Progressive policymakers will cite it as confirmation that gender-affirming policies are beneficial and necessary in K-12 schools.
Critics of medicalizing the innocent confusions and playfulness of youth should not, however, shy away from the Olson study simply because progressives believe it supports their position. On the contrary: they should tout the study at every opportunity, explaining how it provides further evidence that “gender-affirming” therapy creates or prolongs the very problem it purports to solve.
Later this month, the Biden administration’s Department of Education plans to release its proposed Title IX regulations, which will likely reintroduce Obama-era guidelines for how schools should handle students who reject their bodies and wish to be identified as the opposite sex. These regulations are technically framed as “civil rights” measures, which means that they are fundamentally about getting schools not to draw arbitrary distinctions between students. But neither the Obama administration nor the federal courts ever made a real effort to explain why distinguishing biological boys from biological girls who self-identify as boys is arbitrary. Instead, the argument was that such distinctions harm the self-esteem, and hence “mental health,” of boy-identified girls.
Federal and state regulations designed to change how schools classify students use the rhetoric of civil rights but are really about pressuring school personnel to facilitate and even play an active role in students’ social transitions. Critics of pediatric transition should continue to make the case that social transition is a form of direct intervention, not neutral support. And they can use the Olson study to bolster their case.