Transgender Kids: No Harm, Possible Benefit, From Early Social Changeover

Liam Davenport

February 29, 2016

Prepubescent transgender children who socially transition to the opposite sex have good mental health outcomes, with only slightly elevated rates of anxiety, results of a nationally representative study indicate.

An analysis of more than 70 transgender children that included their nontransitioned siblings and matched control children showed that social transitioning, which involves, for example, changing names, clothing, pronoun use, and hairstyles, did not increase rates of depression or anxiety above clinical and preclinical levels.

Previous studies have shown that children with gender identity disorder, or gender dysphoria, can have high rates of internalizing disorders, including anxiety and depression.

"These data suggest at least the possibility that being transgender is not synonymous with, nor the direct result of, psychopathology in childhood," the researchers, led by Kristina R. Olson, PhD, assistant professor of psychology at the University of Washington, in Seattle, write.

"Instead, these results provide clear evidence that transgender children have levels of anxiety and depression no different from their nontransgender siblings and peers."

The research was published online February 26 in Pediatrics.

Stigma Still an Issue

The investigators examined data from a community-based national sample of 73 transgender children, including 22 natal girls and 51 natal boys, aged 3 to 12 years, who were recruited via support groups, a website advertized via media stories, and word of mouth. They also recruited 73 age- and sex-matched community control children and 49 siblings of the transgender participants.

Participants are part of the TransYouth Project, a longitudinal study of American and Canadian transgender children. All parents were informed that the current analysis was part of a larger study about the development of gender-nonconforming children.

Symptoms of depression and anxiety were assessed using the National Institutes of Health Patient Reported Outcomes Measurement Information System parental proxy short forms for anxiety and depression. Parents also completed demographic questionnaires.

The results showed that compared with a general population derived from previous studies, transgender children did not have significantly different rates of depression symptoms (P = .883).

Although transgender children had significantly increased rates of anxiety compared with the population average (P < .001), the mean anxiety symptoms were not in the clinical or preclinical range.

Compared with the control and sibling groups, there were no significant differences in rates of depressive symptoms (P = .320). In contrast, there was a trend for differences in rates of anxiety symptoms (P = .057).

There was no relationship between natal sex and rates of anxiety or depression (P = .498, P = .979, respectively)

Although the findings are reassuring in terms of the impact of social transitioning, Dr Olsen does not believe that they will, of themselves, dispel some of the prejudice and misunderstandings around transitioning.

"I think to reduce stigma surrounding transgender people of any age, we need a lot more education and visibility, not just research studies," she said. "I'd say I'm cautiously optimistic that this work and future work from my lab and other labs will help us to better understand when and for whom social transitioning in early development is helpful."

One Size Does Not Fit All

Dr Olsen stressed that as a researcher, her role is not to be "an advocate of any kind of intervention as a blanket policy.

"Sometimes I worry that people will infer that I'm advocating that all gender nonconforming children socially transition," she said. "To my knowledge, no one believes that.

"There are lots of children who have preferences and behaviors that we associate with the other gender but who are perfectly content with their gender identity. They would often be much happier if society simply accepted a broader range of gender identities or presentations," she said.

"A much smaller subset of children are the ones in this study who truly identify themselves, for a long period of time, as the other gender. These are the children for whom there's more discussion about social transitions and for whom social transitions seem to be associated with good mental health," Dr Olsen added.

Nevertheless, she emphasized that social transitioning may not benefit all of these children. For example, there are communities in the United States "where it not safe for a child to transition.

"So if a family does not have the resources to move, I suspect many therapists would not recommend this child transition. Therefore, we need continued research to really understand when and for whom social transitions are recommended."

The investigators will continue to examine long-term outcomes of early transitioners and the impact of early support on mental health in the teen and adult years.

"Ultimately, we want to be able to provide information that would help a family of a young transgender or gender-nonconforming child make the best decisions possible, increasing the odds that that child will have a happy, healthy life, just like any other child," she said.

"Stunning" Finding

In an accompanying commentary, Ilana Sherer, MD, Palo Alto Medical Foundation, Dublin, California, notes that opponents of social transitioning in prepubescent children argue that such children "cannot possibly know their gender at such an early age and that social transition could encourage children to later seek out treatment of medical transition."

Proponents of social transitioning, on the other hand, suggest that it both improves function in children who are "intensely gender dysphoric" and helps to "test the waters so to speak; that is, giving the child a completely reversible way to explore life in the other gender before committing to any medical intervention."

Dr Sherer notes that the study provides supporters of social transition evidence that "socially transitioned children are doing fine, or at least as well as their age-matched peers and siblings.

"This finding is truly stunning in light of the numerous studies that show depression and anxiety internalizing psychopathology scores up to 3 times higher for non-socially transitioned children."

Dr Sherer notes that more research is needed to assess whether social transitioning should be recommended as a beneficial intervention.

"For families who have already chosen this avenue for their children, professionals should have no concern over supporting the family's (or mental health team's) decision, and reassuring the parents that social transition should have little negative impact on their child's mental health," Dr Sherer concludes.

The study was supported by an internal grant from the Royalty Research Fund at the University of Washington and by a grant from the National Institute of Mental Health and the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online February 26, 2016. Full text, Editorial

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