Researching Hidden Populations: The Littman Study and Rapid Onset Gender Dysphoria

In academia, a very hot topic now is Brown University’s response to criticism of Lisa Littman’s PLOS One paper on rapid onset gender dysphoria (see here and here). Brown initially promoted Littman’s paper which reported on her survey of 256 parents of children with late onset gender dysphoria. However, when transgender activists raised criticisms, the school pulled their press release about the study from distribution.

One of the key criticisms is that Littman posted her call for respondents on three websites which are frequented by parents who describe rapid onset gender dysphoria in their children. Critic Julia Serano called this “begging the question.” Diane Ehrensaft was quoted in the Economist as saying Littman’s recruitment “would be like recruiting from Klan or alt-right sites to demonstrate that blacks really are an inferior race.”

If Littman was trying to generally study gender dysphoria in adolescent or make a claim that the onset of all gender dysphoria in adolescence was rapid, then these criticisms might be more on point. However, Littman’s interest was more specific. She wanted to understand the relatively recent experience of rapid onset gender dysphoria in social groups where the prevalence is much greater than expected. Thus, she went where the subjects were.

The analogy offered by Ehrensaft is off because Littman wasn’t studying gender dysphoric teens in a general sense. She was trying to get a look at a subset of teens who reported gender dysphoria in the context of social groups where many such teens were reporting it. The analogy also fails because the websites Littman used for recruitment do not have negative attitudes toward transgender people in general. They do seem defensive in the face unrelenting attacks by transgender activists, but I can’t blame them for that.

Hidden Populations Are Hard to Reach

The history of research in sexuality is filled with studies of activist groups and websites. Early GLBT studies were populated by appeals to secret groups and it is still common to reach out to activist groups. In thinking about this study, I thought of the one by Ariel Shidlo and Michael Shroeder on harm done by conversion therapy. When they first recruited for subjects, they went to GLB activist groups with the following message:

Homophobic Therapies: Documenting the Damage

The National Lesbian & Gay Health Association is sponsoring an investigation of the outcomes of so-called treatments of the so-called disorder of homosexuality.

In the press release was this call for subjects:

You can be of help in the long process of getting the message out that these “conversion” therapies don’t work and do the opposite of healing *by informing your lesbian/gay/bi communities of our search for participants to be interviewed.* Please announce our project in any upcoming lesbian and gay community meetings and spread the word.

This study was a pilot study but helped to shine some light on the reactions of clients to sexual orientation change efforts. The study was widely criticized but it never claimed to be a representative sampling of all people who had tried change therapy. Therefore, the most careful interpretation of the work was focused on people who felt harmed. By analogy, that is what can be said about Littman’s study. One cannot generalize to all trans teens, nor does Littman do that. Anything that can be said can only be said about the parent reports and that is a valuable contribution at this stage of research.

Opponents Should Talk Less and Research More

Parents who see their children changing suddenly often feel struck by lightning and need empathy and support. They get some of that from talking to other parents via these websites. Critics do not help their cause by disregarding the experience of parents who know their children well and feel adrift.

For the record, I understand that the trans regret rate is less than one percent and I am not anti-trans. At the same time, I am pro-academic freedom and challenge critics to research more and criticize less. The answer to research you don’t like or disagree with is more research and academic inquiry.

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Former Dean of Harvard Medical School Criticizes Brown University’s Actions Regarding Gender Dysphoria Study

At Quillette, former Dean of Harvard’s Medical School Jeffrey Flier provides a scathing review of Brown University’s lack of support for Assistant Professor Lisa Littman and her study of rapid onset gender dysphoria (see my summary of this issue). Setting the stage for his review, Flier makes it clear that this issue is relevant to academic freedom for all:

This week’s controversy surrounding an academic paper on gender dysphoria published by Brown University assistant professor Lisa Littman—brought on by the post-publication questioning of Dr Littman’s scholarship by both the journal that published it, PLOS One, and Brown’s own School of Public Health—raises serious concerns about the ability of all academics to conduct research on controversial topics.

Flier spends the bulk of his article taking apart Brown University’s rationale for removing their press release about Littman’s PLOS One paper.  He then concludes with this stinging call for a defense of academic freedom:

At a time such as this, when a university’s academic mandate is under threat from diverse ideological actors, there is simply no substitute for a strong leader who supports academic freedom and discourse. The dean’s letter raises serious questions about whether the dean of Brown’s School of Public Health is willing to be such a leader.

For centuries, universities struggled to protect the ability of their faculties to conduct research seen as offensive—whether by the church, the state, or other powerful influences. Their success in this regard represents one of the great intellectual triumphs of modern times, one that sits at the foundation of liberal societies. This is why the stakes are high at Brown University. Its leaders must not allow any single politically charged issue—including gender dysphoria—from becoming the thin edge of a wedge that gradually undermines our precious, hard-won academic freedoms.

I certainly agree. There is a process for bringing research to the community of scholars and Littman followed it. Brown’s administrators should stand for the principle of academic freedom by leaving up the press release. The study can easily be criticized but at the same time it is similar to many pilot studies of hidden populations. Unless some kind of academic misconduct is found, Brown University should defend the work of this professor.

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Academic Freedom Under Review at Brown University

On August 16, peer reviewed journal PLOS One published “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports” by Lisa Littman, an Assistant Professor at Brown University. In essence, Littman surveyed over 250 parents of children who expressed gender dysphoria with an onset in adolescence or later. She also found that the onset of gender dysphoria took place in the context of peer groups where others in the group became gender dysphoric. On August 22, Brown University published a press release (archived) regarding the study. Then on August 27, Brown removed the news item from the school website, stating:

Brown University Statement — Monday, Aug. 27, 2018

In light of questions raised about research design and data collection related to Lisa Littman’s study on “rapid-onset gender dysphoria,” Brown determined that removing the article from news distribution is the most responsible course of action.

As a general practice, university news offices often make determinations about publishing faculty research based on its publication in established, peer-reviewed journals considered to be in good standing. The journal PLOS ONE on the morning of Aug. 27 published a comment on the research study by Lisa Littman, who holds the position of assistant professor of the practice of behavioral and social sciences at Brown, indicating that the journal “will seek further expert assessment on the study’s methodology and analyses.” Below is the comment posted on the study in the journal PLOS ONE:

“PLOS ONE is aware of the reader concerns raised on the study’s content and methodology. We take all concerns raised about publications in the journal very seriously, and are following up on these per our policy and COPE guidelines. As part of our follow up we will seek further expert assessment on the study’s methodology and analyses. We will provide a further update once we have completed our assessment and discussions.” — PLOS ONE August 27, 2018

Then today, Brown’s Dean of the School of Public Health Bess H. Marcus issued a statement explaining the decision to remove the news item. After repeating the above statement, Dr. Marcus added the following:

Independent of the University’s removal of the article because of concerns about research methodology, the School of Public Health has heard from Brown community members expressing concerns that the conclusions of the study could be used to discredit efforts to support transgender youth and invalidate the perspectives of members of the transgender community.

The University and School have always affirmed the importance of academic freedom and the value of rigorous debate informed by research. The merits of all research should be debated vigorously, because that is the process by which knowledge ultimately advances, often through tentative findings that are often overridden or corrected in subsequent higher quality research. The spirit of free inquiry and scholarly debate is central to academic excellence. At the same time, we believe firmly that it is also incumbent on public health researchers to listen to multiple perspectives and to recognize and articulate the limitations of their work. This process includes acknowledging and considering the perspectives of those who criticize our research methods and conclusions and working to improve future research to address these limitations and better serve public health. There is an added obligation for vigilance in research design and analysis any time there are implications for the health of the communities at the center of research and study.

The School’s commitment to studying and supporting the health and well-being of sexual and gender minority populations is unwavering. Our faculty and students are on the cutting edge of research on transgender populations domestically and globally. The commitment of the School to diversity and inclusion is central to our mission, and we pride ourselves on building a community that fully recognizes and affirms the full diversity of gender and sexual identity in its members. These commitments are an unshakable part of our core values as a community.

In an effort to support robust research and constructive dialogue on gender identity in adolescents and youth, the School will be organizing a panel of experts to present the latest research in this area and to define directions for future work to optimize health in transgender communities. We believe that more and better research is needed to help guide advances in the health of the LGBTQ community. We welcome input from faculty, staff and students about the composition of this panel and scope of the discussion.

Researchers Come to Littman’s Defense

In response to Brown’s actions, a group of sexuality researchers signed a letter in support of Littman. Written by J. Michael Bailey, professor of psychology at Northwestern University, the letter cautions Brown to consider the source of criticism:

We are aware of the very loud opposition to Dr. Littman’s article from some transgender activists. This was predictable to anyone who has followed transgender issues during the past few years. However, you should not overreact to this criticism, for several reasons. First, these activists do not represent all transgender persons. There is no one transgender community that speaks as one. Second, those who are protesting the loudest are trying to silence Dr. Littman by intimidation and false or irrelevant accusations. They are not engaging in good faith scientific criticism. Some of us know this strategy all too well, having been targets of it. Third, and most importantly, ROGD is a very serious public health concern. You should be proud that Brown University has opened the door to its study, and hopefully someday, to its successful treatment.

The study has been criticized on several methodological points summarized in an article by transgender activist Julia Serano. These critiques have been answered by Roberto D’Angelo and Lisa Marchiano of the Pediatric and Adolescent Gender Dysphoria Working Group.

From my perspective, the study is a preliminary examination of a syndrome which was once rare but is now increasingly seen by clinicians. I have heard about these cases more frequently over the past decade and seen several such situations. As such, the study is worthwhile and true to the stated purpose (“A study of parent reports”).

It should go without saying that more data are needed and interviews with the teens who are in the groups identifying as transgender need to follow this study. Even so, that is no reason to walk back on this preliminary effort to examine what parents are seeing in their children.

 

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Regret in Medical Transition: Research from the Amsterdam Gender Dysphoria Study

One of the significant issues in treating gender dysphoria is an examination of regret, if any, experienced by patients who engage in surgical interventions. In a remarkable paper published recently in The Journal of Sexual Medicine, a report of cases seen from 1972-2015 in the largest gender identity clinic in Amsterdam is presented. The sample was large and as a group showed very little regret.

6,793 people (4,432 birth-assigned male, 2,361 birth-assigned female) visited our gender identity clinic from 1972 through 2015. The number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015. The estimated prevalence in the Netherlands in 2015 was 1:3,800 for men (transwomen) and 1:5,200 for women (transmen)*. The percentage of people who started HT within 5 years after the 1st visit decreased over time, with almost 90% in 1980 to 65% in 2010. The percentage of people who underwent gonadectomy within 5 years after starting HT remained stable over time (74.7% of transwomen and 83.8% of transmen). Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.

The idea that regret is common is promoted by Christians who disapprove of gender transition.*** One such website “Sex Change Regret” (sexchangeregret.com) carries articles by Ryan Anderson, Walt Heyer, and Michelle Cretella.** Whether one agrees with transition or not, one should not promote a tendentious reading of research to promote one’s views. While a very small number of people have expressed regret, most don’t. In this study, some experienced social losses after transition, while others did not experience relief from their dysphoria.
If anything, the appropriate stance for a Christian is love and curiosity. Let’s keep our minds and hearts open.
**UPDATE:
After I published this post, Ryan Anderson took exception with my characterization of his position. See his tweet below:


Although Anderson quoted Walt Heyer’s article Regret Isn’t Rare in his new book When Harry Became Sally, I removed this phrase in the post:

all of whom promote the idea that regret is may be widespread

Anderson denies that he believes anything about regret. I also asked him to characterize his position which I will include in a separate post. There was no intent to misrepresent him. Given the section in his book on the subject of regret, his approving citation of Walt Heyer, and an essay in the Daily Signal, I felt I fairly and non-controversially represented his position.
 
*In the study, the authors defined “transwomen as having a male birth assignment and transmen as having a female birth assignment who might receive medical treatment to adapt their physical characteristics to their experienced gender.”
***edited to change “disapprove of transgender people” to “disapprove of gender transition.” To transgender people, there is little difference, but to be as fair as possible to those who have moral misgivings about transitioning, I made the change.

A Real Life Reason to Reject the Nashville Statement

Nashville logoLast week I wrote some reactions to the Nashville Statement on sexual orientation and gender identity.  The statement was written by the Council on Biblical Manhood and Womanhood and has been the focus of much controversy since it was released a week ago.  I thought the statement missed the mark in several ways, but the one I want to highlight with this follow up post is the Nashville Statement’s claim about disorders of sex development.
After my post on the Nashville Statement came out, I received the following email from Lianne Simon. Lianne is an intersex individual who tells her story on her website and also accompanies Dr. Megan DeFranza (PhD, theology, Marquette University) on speaking engagements regarding intersex conditions and theology. They manage the website intersexandfaith.org. Simon gave me permission to use her email:

In your Patheos post you said, “Practically, the Nashville signers don’t give us a clue how people Jesus referred to here can “embrace their biological sex.”
I think their intention is fairly clear. Sex is strictly binary to the signatories. Gender identity is entirely ‘adopted’ rather than rooted in biology. Therefore, intersex people must have a biological sex (i.e. male or female) that is confused or obscured by their disorder. So. the statement
“…and should embrace their biological sex insofar as it may be known.”
means that intersex people should embrace the sex assigned them by doctors and accept the medical treatment involved.
This is the way I, as a Christian intersex person, understand their position. As do my intersex friends.
We are castrated by doctors, undergo cosmetic sex assignment surgeries without our consent, are given hormones, lied to, have secrets kept from us, and made to live in shame–all in the name of their bloody binary view of sex.
That’s what their statement means to us.
They not only approve, they’re demanding that we embrace the evil that’s being done to us.
And if we object to the binary sex forced upon us, then we’re rejecting God’s plan and departing from the faith.
Kind regards,
Lianne Simon
www.intersexandfaith.org
www.liannesimon.com

Simon’s story is fascinating and well worth reading. She wrote a detailed response to the Nashville Statement at her website. She provides a human face to the topics covered in the Nashville Statement. I hope the signers will reconsider their pronouncements about disorders of sex development in light of Lianne’s life.
The part of the Nashville Statement Lianne referred to is below:

WE AFFIRM that those born with a physical disorder of sex development are created in the image of God and have dignity and worth equal to all other image-bearers. They are acknowledged by our Lord Jesus in his words about “eunuchs who were born that way from their mother’s womb.” With all others they are welcome as faithful followers of Jesus Christ and should embrace their biological sex insofar as it may be known.
WE DENY that ambiguities related to a person’s biological sex render one incapable of living a fruitful life in joyful obedience to Christ.

Lianne’s story provides a real life foundation for my criticism that the guidance offered by the Nashville Statement is uninformed and inadequate. She concludes her blog post with this:

I’m grateful that the Nashville Statement says that we who are intersex are “created in the image of God and have dignity and worth equal to all other image-bearers.” But I’m troubled that this affirmation appears to require us to give up our bodily integrity and embrace some doctor’s guess at what sex God meant us to be.
Understand this—your Nashville Statement drives intersex people away from the Gospel.

The real world of sexuality is not as neat and clean as portrayed by the signers of the Nashville Statement. I hope Lianne’s story provides a caution to those who marginalize those who have been dealt a hand they didn’t ask for.

The New Atlantis Study on Sexual Orientation and Gender Identity That's Not a Study

UPDATE: In a post out on 8/27/16, Adam Keiper, editor at The New Atlantis magazine responds to this post with a rebuttal to my points below. I urge you to go read it. I in turn respond to him. I also make a correction in my original post below based on his communication to me.
————————————————- (original post below)
Over the past year, hot discussions of sexual orientation have been pushed aside by controversies over gender identity and bathrooms. A new article from The New Atlantis shows that both topics have plenty of life. Yesterday, social media was buzzing about a new “study” of sexual orientation and gender identity by Lawrence Mayer and Paul McHugh. Actually, the article was not a study but a review and summary of empirical studies. As far as I can tell, it is being touted most by conservative leaning and anti-gay organizations.
The New Atlantis describes itself as a “Journal of Technology and Society.” However, the article did not receive peer review and it shows. Lawrence Mayer, the first author, is not well known in sexuality research circles but the second author is. Paul McHugh is retired from Johns Hopkins and was responsible for discontinuing the sex reassignment program there. He also was an advisor to the Repressed Memory Foundation in the 1990s.
Quickly, the National Organization for Marriage touted the paper as “Groundbreaking New Research.” Even calling the paper a new study isn’t accurate, there are no new studies in the paper. A bunch of old ones are missing as well.
In this post, I want to include some initial reactions and then some notes from Michael Bailey, professor at Northwestern, who was cited several times in TNA paper. I am going to focus on their points about sexual orientation and leave the gender identity points for a future post.
Here is their summary of research regarding sexual orientation:

● The understanding of sexual orientation as an innate, biologically fixed property of human beings — the idea that people are “born that way” — is not supported by scientific evidence.
● While there is evidence that biological factors such as genes and hormones are associated with sexual behaviors and attractions, there are no compelling causal biological explanations for human sexual orientation. While minor differences in the brain structures and brain activity between homosexual and heterosexual individuals have been identified by researchers, such neurobiological findings do not demonstrate whether these differences are innate or are the result of environmental and psychological factors.
● Longitudinal studies of adolescents suggest that sexual orientation may be quite fluid over the life course for some people, with one study estimating that as many as 80% of male adolescents who report same-sex attractions no longer do so as adults (although the extent to which this figure reflects actual changes in same-sex attractions and not just artifacts of the survey process has been contested by some researchers).
● Compared to heterosexuals, non-heterosexuals are about two to three times as likely to have experienced childhood sexual abuse.
● Compared to the general population, non-heterosexual subpopulations are at an elevated risk for a variety of adverse health and mental health outcomes.
● Members of the non-heterosexual population are estimated to have about 1.5 times higher risk of experiencing anxiety disorders than members of the heterosexual population, as well as roughly double the risk of depression, 1.5 times the risk of substance abuse, and nearly 2.5 times the risk of suicide.
● Members of the transgender population are also at higher risk of a variety of mental health problems compared to members of the non-transgender population. Especially alarmingly, the rate of lifetime suicide attempts across all ages of transgender individuals is estimated at 41%, compared to under 5% in the overall U.S. population.
● There is evidence, albeit limited, that social stressors such as discrimination and stigma contribute to the elevated risk of poor mental health outcomes for non-heterosexual and transgender populations. More high-quality longitudinal studies are necessary for the “social stress model” to be a useful tool for understanding public health concerns.

First, here is Michael Bailey’s quick reaction:

1. Their review of sexual orientation is not up to date (A major omission is that it neglects to cite our recent magnum opus on this topic: http://psi.sagepub.com/content/17/2/45.full.pdf+htmlf). The idea that sexual orientation is fluid has some plausibility for women, but not for men.
2. I agree with the authors that discrimination alone is unlikely to completely explain differences between heterosexual and homosexual people in mental health profiles, although it may contribute.
3. They are right on that the idea of innate, fixed gender identity is not consistent with empirical evidence. I differ from them, however, in believing that sex reassignment is still the best option for some individuals.
4. Most importantly, I agree that all of these issues should be openly discussed and researched. There is little government support for open-minded investigation for these controversial issues. That is unfortunate and exactly backwards. Support should be directed to resolve the most contentious issues.

As I reviewed the sexual orientations sections, I agree with Bailey. I especially agree that readers should read this major review of research on sexual orientation published earlier this year. Mayer and McHugh’s paper is missing any serious discussion of epigenetics, they overlook the new genetic linkage paper involving gay brothers, (they do address it, see the follow up post) as well as work on “gay rams.” The TNA authors minimize the neural differences between gays and straights, calling them “minor differences in brain structures.” How do these authors know what differences are minor and which are not? In fact, the differences in symmetry and brain activity are quite provocative and have not been accounted for by any environmental theory. Of course, we need more research with larger sample sizes but Mayer and McHugh just shrug these studies off as inconsequential.
Regarding sexual abuse, the authors review several studies which demonstrate higher rates of sexual abuse among GLB people as opposed to heterosexuals. For the most part, they report the relevant details but they failed to catch the mistakes in the Tomeo study and report it incorrectly (see this post for the problems with using Tomeo). Even though some who are touting the study miss this, the authors provide caution for those wanting to see homosexuality as the result of sexual abuse:

In short, while this study suggests that sexual abuse may sometimes be a causal contributor to having a non-heterosexual orientation, more research is needed to elucidate the biological or psychological mechanisms. Without such research, the idea that sexual abuse may be a causal factor in sexual orientation remains speculative.

They say “sometimes.” I would say infrequently or rarely and would add that we really don’t know. What we do know is that most people who are GLB were not abused. The TNA paper affirms that observation.
On the “born that way” claim, I find it contradictory that the authors express uncertainty about the causes of orientation but then say with great certainty that the “born that way” theory isn’t supported by scientific evidence. This line is apparently meant to hook the social conservatives which indeed it has. I mentioned the misleading “Groundbreaking New Research” headline from NOM, and then I just saw Liberty Counsel’s email which leads: “Scientific Research Debunks LGBT Propaganda.”
For readers wanting a more thorough review of the literature, please see the paper from Bailey and colleagues linked here.
 

Iowa Civil Rights Commission Releases Revised Sexual Orientation and Gender Identity Public Accommodations Brochure

This just in from the Iowa Civil Rights Commission:

Iowa Civil Rights Commission Releases Revised Sexual Orientation & Gender Identity Public Accommodations Brochure
The Iowa Civil Rights Commission announced today the publication of its Revised Sexual Orientation & Gender Identity Public Accommodations Brochure.  The revision replaces the previous version which had not been updated since 2008 and clarifies that religious activities by a church are exempt from the Iowa Civil Rights Act.
“The Iowa Civil Rights Commission has never considered a complaint against a church or other place of worship on this issue,” said director Kristin H. Johnson. “This statute was amended to add these protected classes (sexual orientation and gender identity) in 2007 and has been in effect since then. The Iowa Civil Rights Commission has not done anything to suggest it would be enforcing these laws against ministers in the pulpit, and there has been no new publication or statement from the ICRC raising the issue. The Commission regrets the confusion caused by the previous publication.”
The revised brochure may be found at this link: https://icrc.iowa.gov/sites/default/files/publications/2016/2016.sogi_.pa1_.pdf

This new language is more clear:

P L A C E S O F W O R S H I P
Places of worship (e.g. churches, synagogues, mosques, etc.) are generally exempt from the Iowa law’s prohibition of discrimination, unless the place of worship engages in non-religious activities which are open to the public. For example, the law may apply to an independent day care or polling place located on the premises of the place of worship.

By independent day care, the Commission means a day care renting or leasing a place of worship and not being conducted by the church as a part of the church’s ministry. Ms. Johnson clarified that to me earlier in the week.
For background on this issue see these posts: Link, link

Information and Misinformation on Gender Dysphoria from Wallbuilders and the American College of Pediatricians, Part One

Tuesday on Wallbuilders Live, Dr. Michelle Cretella represented tiny pediatric breakaway group the American College of Pediatricians. She briefly discussed the organization’s position paper on responding to gender identity issues. In doing so, she said something which caught my irony sensor. It also occurred to me, as it repeatedly has in the discussion of gender dysphoria, how difficult it is to avoid taking extreme positions.
Listen to her response to a question from host Rick Green about how much harm gender dysphoria is causing.

I want to address two claims that came up in this segment. In this post, I address the claim that 80% of gender dysphoric children will accept their biological sex with therapy. In a future post, I will write about the claim about suicide rates.
Cretella says:

They’re [advocates for transgender children] cooperating with, at least, mental confusion.  You know, initially, we know that there is psychiatric literature that shows if you work with these children one on one and with their families, the vast majority, over 80% will come to accept their biological sex after puberty before adulthood. So yes, to put these children to reaffirm their confused thinking, to put them on puberty blockers, and then cross-sex hormones to make them quote unquote the other gender, you are permanently sterilizing children. It’s insanity.

Cretella is correct that persistence rates are low (gender dysphoria continuing into adulthood) among gender dysphoric children, but this is not the case with adolescents who remain gender dysphoric or those who experience it with an adolescent onset. In their paper, ACP uses the American Psychiatric Association’s DSM-V as an authority. The section of the DSM-V cited by ACP supports the claim about persistence but does not fully support Cretella’s claim about the role of therapy.

Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistence has ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. In one sample of natal males, lower socioeconomic background was also modestly correlated with persistence. It is unclear if particular therapeutic approaches to gender dysphoria in children are related to rates of long-term persistence. Extant follow-up samples consisted of children receiving no formal therapeutic intervention or receiving therapeutic interventions of various types, ranging from active efforts to reduce gender dysphoria to a more neutral, “watchful waiting” approach. It is unclear if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence, since such children have not yet been followed longitudinally in a systematic manner. For both natal male and female children showing persistence, almost all are sexually attracted to individuals of their natal sex. For natal male children whose gender dysphoria does not persist, the majority are androphilic (sexually attracted to males) and often self-identify as gay or homosexual (ranging from 63% to 100%). In natal female children whose gender dysphoria does not persist, the percentage who are gynephilic (sexually attracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%). (APA, DSM-V, p. 455)

To the DSM-V, I can add the description of persistence developed by the World Professional Association for Transgender Health (WPATH) in their standards of care.

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.V Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty-suppressing hormones, all continued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010).
Another difference between gender dysphoric children and adolescents is in the sex ratios for each age group. In clinically referred, gender dysphoric children under age 12, the male/female ratio ranges from 6:1 to 3:1 (Zucker, 2004). In clinically referred, gender dysphoric adolescents older than age 12, the male/female ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin, 2003). (WPATH, p. 11).

The irony of Cretella’s confidence in psychiatric intervention relates to the expulsion from ACP membership of George Rekers who was infamous for his own personal decline and his discredited treatment approach to what was then called gender identity disorder. In fact, we don’t know the role, if any, therapy plays in influencing the current persistence rates. While there is reason to think parental permission to transition in childhood might increase the persistence rates, there isn’t sufficient research to say for sure.
After listening to Cretella and reading the ACP paper, I wonder what the ACP recommends for the 10-20% of people with gender dysphoria persisting into the late teens. Do they favor reassignment for those persons? They focus on the data which make their point but don’t seem to have an answer for the rest of the people involved.
Another problem with ACP’s confidence in psychiatric interventions for gender dysphoria is that they also oppose a frequent end point in the trajectory of many gender dysphoric children: homosexuality (see image at the end of the post). One of the reasons George Rekers tried to re-orient gender dysphoria was to prevent homosexuality. Furthermore, one of the prime objectives of reparative therapists like Joseph Nicolosi is to prevent homosexuality via the alteration of parenting behaviors toward gender nonconforming children. ACP should stop pretending to sympathize with gender dysphoric children when they also write letters to school personnel promoting reparative change therapy for gay people.
Summary
Cretella is right that studies of gender dysphoric children (mostly with boys) find low rates of persistence of gender dysphoria into adulthood. However, she should have distinguished between prepubescent children and teens. The outcomes for these two groups do not appear to be the same. No doubt her listeners will not make that distinction.
Cretella was wrong to invoke psychiatric treatment as the reason for low persistence rates. If anything, some treatments have been shown to be harmful in some cases while others may not be harmful but may not cause a reduction in gender dysphoria. From her presentation, one could get the impression that advocates for gender dysphoric children know these treatments work but are motivated to undermine the natural family and therefore withhold appropriate medical care. While there is strong disagreement among experts and some advocates might oppose traditional families, it is simply not true that gender dysphoria could be easily treated if only activists would get out of the way.
Another important factor is that the treatment advocated by Cretella and the ACP is an outdated, discredited, psychoanalytically based approach which has not shown success. Even among those in the mainstream who are skeptical of puberty blocking drugs, the treatments advocated by ACP are rejected.
Gender Dysphoria After Childhood
The following image comes from a 2012 study by Devita Singh on gender dysphoric boys. Note the columns titled “sexual orientation in fantasy” and “sexual orientation in behavior.” By far, the most common end point for gender dysphoric children across studies is some level of same sex attraction. Gay advocates have in the past confided to me that they are ambivalent about supporting interruption of puberty because such interventions may interfere with a natural homosexual outcome. Please see this common sense article by Michael Bailey and Eric Vilain on the dilemma many parents of gender dysphoric children face.
Singh table

Ted Cruz and Bobby Jindal Headline David Barton's ProFamily Legislative Conference

Ted Cruz and Bobby Jindal will headline David Barton’s ProFamily Legislative Conference in early November. Cruz and Jindal are both running for the GOP’s presidential nomination.
In all seriousness, how can this be a good thing when the person sponsoring the conference can’t get his facts straight? Just in the last two days, Barton has made false claims about gender identity in the military and the Obama administration’s record on prosecution of child porn.
Watch this video to see if your state senator or representative endorses the conference.
[vimeo]https://vimeo.com/134212588[/vimeo]
 
 

David Barton Doubles Down on His Gender Identity Nonsense

Before you exclaim, “Not another David Barton post!” I want you to remember that at least two men running for the GOP presidential nomination (Ted Cruz and Mike Huckabee) take Mr. Barton seriously and encourage others to do the same.
Recently, David Barton said on a Mission Radio podcast that churches had to hire pedophiles to run their nurseries because you can’t discriminate on the basis of sexual orientation. Nearly everything he said about that topic was incorrect.
Now, Right Wing Watch discovered that Barton is telling evangelicals (click the link for the audio) that the military can’t discharge soldiers for bestiality and/or pedophilia.

“There’s 82 official gender identities now and they all have equal status and protection here,” Barton said, “so we’re talking pedophiles. If you’re a military member and you have an inclination for young children, you can’t be kicked out of the military for that anymore because that is your gender identity. If you are into having sex with animals, bestiality, that is one of the 82 gender identities, you cannot be kicked out for your lack of judgment and your very perverse taste on that.”

If Barton protests that he is only talking about inclinations, then he is making things up just to generate unfocused outrage. You never could be kicked out of somewhere for thinking something unknown to anyone but yourself.
The Uniform Code of Military Justice addresses these matters.
Media covering Cruz and Huckabee: When you have some down time and you are not talking about weighty matters like Iran and abortion, ask the candidates about their praise for a pundit who didn’t know that ENDA hasn’t passed yet and thinks that, by law, churches have to hire pedophiles. Oh, and ask them if the Constitution quotes the Bible verbatim. Ask if violent crime in the nation is going up or down. And how about asking if HIV/AIDS research is a pointless effort since God won’t allow an HIV vaccine.