gender-atypical preferences among contemporary parents, which I discuss in chapter 1.
The Transgender Child
Children’s normative gender identity development has consumed decades of research and theorizing in the fields of psychology and social psychology.63 Sociologists, too, have studied the ways in which young children actively incorporate, and sometimes challenge, normative gender expectations.64 The governing questions of much of this research are, what are the processes through which children become normatively differentiated boys and girls, in accordance with the expectations of their assigned birth sex, and how are aberrations from those norms addressed or regulated among otherwise culturally compliant children? In these ways, perhaps refreshingly so, much of the traditional research on children’s gender development aimed to explain gender-conforming outcomes, not the nonnormative ones.
Gender-nonconforming children, however, have consumed a different vein of psychological research, namely that of “gender identity disorders” in the Diagnostic and Statistical Manual of Mental Disorders (DSM).65 As sociologist Karl Bryant has documented, longitudinal studies of gender-nonconforming children, or of “feminine boys,” as they were often called at the time, took hold in the 1960s, following the development of adult transsexual medicine in the United States.66 Though these children were originally surveilled for insights into the potential origins of adult transsexuality, the resulting data suggested a strong statistical correlation between childhood gender nonconformity and adult homosexuality. That is, most of these children allegedly did not grow up to identify as transgender, but as gay.67
Of course, these outcomes (“gay” and “trans”) are not necessarily mutually exclusive or divergent—one can go on to identify as both gay and trans, for example—but they have figured as such in parents’ and practitioners’ deliberations, which I examine more extensively in chapter 2. These statistical outcomes raised red flags about the “gender identity disorder in childhood” diagnosis that came out of this body of research, which was hotly contested by clinicians, academics, and gay rights activists. Many scholars argued, for example, that the diagnosis served as a “backdoor” preventative tool against homosexuality,68 especially since some of the early studies on children entailed reparative interventions.69 The childhood diagnosis was also formalized around the same time that adult homosexuality was removed from the DSM because it was no longer considered a disorder. In the eyes of the critics, if childhood gender conformity is correlated with adult homosexuality, what is the motivation behind its diagnostic category? Why is it up for scrutiny? Notwithstanding, the statistical relationship between childhood gender nonconformity and adult homosexuality continued through the latter half of the twentieth century, albeit with decreasing majorities.70 This includes studies on children assigned female as well, in both the United States and Europe.71
Eventually, parents and practitioners moved to depathologize childhood gender nonconformity, often explicitly in terms of pro-gay advocacy. Leigh, one of the founders of a major support group for families of gender-nonconforming children in the 1990s, was a key informant for my project. She explained to me that her group’s purpose was to normalize gender nonconformity, and ultimately “gay” outcomes, for parents, especially for children assigned male, but that the group was largely oblivious to transgender possibilities. For Leigh, as for many parents and therapists at the time, childhood gender nonconformity was almost always a matter of “proto-homosexuality” or not, dialectics I review in chapter 2.
Decades since, a particularly trans-aware, trans-affirmative paradigm has gained traction among mental health professionals.72 Under this approach, parents are encouraged to embrace their children’s gender-nonconforming expressions as natural and healthy, not to repress or pathologize them.73 As part of this, practitioners promote serious consideration for early childhood social transitions, if and when a child expresses a desire for this. They are also skeptical of the “just gay” narrative from prior longitudinal studies, as the statistics from other studies have increasingly swayed toward more transgender outcomes.74 In addition, new research in cognitive psychology has used traditional cognitive assessments on trans-identified children, and the results indicate that their responses mirror their cisgender counterparts.75 This effectively “proves” to psychologists that these children are not “confused” or “faking” their gender identities, that their identities are no less cognitively rooted than other children’s, and that they are no more anxious or depressed when living as affirmed, transitioned children. These research efforts continue, and represent a widening trend across the psych sciences to be more inclusive of transgender and gender-nonconforming children.
Related to these developments, the latest edition of the DSM has changed the terminology from “gender identity disorder” (GID) to “gender dysphoria” (GD), in part to remove the stigma of “mental disorder” from transgender identity.76 Reparative or “conversion” therapies for LGBT youth are opposed by the American Psychiatric Association (APA) and have been banned in nineteen states and counting. In addition, one of the leading researchers on childhood gender nonconformity, Dr. Kenneth Zucker, was required to shut down his clinic in Toronto, Canada, due to allegations of conducting conversion therapy.77
On the biomedical side, several major gender clinics have been established across the United States, including in Boston, Los Angeles, San Francisco, and Chicago. Beyond providing pediatric and endocrinologic expertise, including hormone therapy for kids, these clinics often connect parents to affiliated specialists in mental health, the law, and education and advocacy. The use of hormones and puberty blockers on children has been another source of debate, including when to administer them and what health risks they may pose. Originally, many researchers, particularly in the Netherlands, advised waiting until at least age twelve to consider social transition, including using puberty blockers, and until age sixteen for cross-sex hormones. These protocols were known as the “Dutch Model.”78 But, as I learned, these recommendations were unpopular stateside, and have faded as the use of blockers has become normalized among clinicians.
Today, many advocates believe in transitioning a child whenever they assert the desire for this (well before twelve years old in some cases), especially since using blockers alone does not cause any known medically permanent changes for the child. Practitioners may also endorse the start of cross-sex hormones at a time that achieves “peer concordance” with the rest of the child’s cohort (sometimes sooner than sixteen years of age). Fundamentally, the reigning medical approach is to treat each child on a case-by-case basis. As one of the physicians I interviewed explained, who is considered an expert in the medical management of transgender children in the United States: each child is so unique, both physiologically and psychosocially—and gender is such a “highly subjective” experience—that every case is carefully assessed on an individual basis.79
Despite these affirmative trends, some clinicians are more reserved about early childhood transitions, in part because of the longitudinal statistics I have described: most childhood gender nonconformity does not “persist” into adult transsexuality, as it is often put, but allegedly “desists,” resulting most commonly in “just” homosexuality, if anything nonnormative at all.80 In 2012, for example, two leading mental health practitioners issued the following precautions in a special issue of the Journal of Homosexuality: “There are no reliable screening instruments that differentiate between young children in whom [gender dysphoria] will desist and those in whom it will persist,” and “Some clinicians believe that facilitating childhood gender transition may increase the probability of persistence into adolescence and adulthood.”81 As another psychiatrist wrote in a 2015 New York Times op-ed, “If
