Developmental evolution of gender identity in
youth and disarming “De-Transition” narratives

 

Written by Dr. Kade Goepferd

The risks of increased visibility of transgender and gender diverse youth

As our society gains more understanding and language around gender identity and gender expression, the young people who identity as transgender or gender diverse have become increasingly visible in our communities and schools. While change is happening slowly to embrace and support the 1-3% of youth who identify as transgender (Herman, 2022), too many transgender and gender diverse young people still face lack of support, including outright discrimination, when it comes to their gender identities. Negative views and unsupportive actions toward transgender youth often stems from a lack of understanding about gender identity, including how and when it develops over a young person’s childhood, adolescence and young adulthood. Far too often misunderstanding and misinformation leads to rejection of a young person by their community, their peers, and even their own family. This stigma and discrimination results in significant health disparities for transgender and gender diverse youth, including higher rates of harassment, discrimination, homelessness and suicidality (Johns, 2019). Often because of this type of gender discrimination and bias, transgender and gender diverse youth are more likely to experience anxiety, depressed mood and suicidal ideation and attempts (Hisle-Gorman E, 2021). Transgender youth are also chronically medically underserved as patients and families often don’t know where to go to access medical or mental health care or have to wait several months to access care from those trained to meet their pediatric and adolescent health needs (Goetz, 2023).

Expanding language and generational differences

Language plays a pivotal role in shaping our understanding of gender identity. New terms and concepts have emerged to describe experiences that were previously unrecognized. For instance, words like “non-binary” and “genderqueer” have become part of the common lexicon, allowing individuals to articulate their identities more accurately. This expansion of language reflects a broader cultural shift towards inclusivity and recognition of diverse gender experiences.

It’s important to note that transgender and gender diverse identities have always existed, however, the language to accurately describe those identities has varied significantly across cultures and communities. As language around gender identity evolves, so do young people’s understanding of themselves and their gendered experiences. Our world is only as big as the language we have to describe it; someone’s gendered experience and how they describe it as they get older may shift as they learn new terms to describe who they are and how they experience their identity.

According to recent statistics, approximately one in six members of Generation Z identify as LGBTQ (Pew Research Center, 2023). This demographic shift highlights the growing visibility and acceptance of diverse sexual orientations and gender identities with newer generations. This can often lead to confusion and misunderstanding between our pediatric and adolescent patients and their parents. A recent survey by the Pew Research Center found that more than one-third of Americans in their teens and early twenties know someone who uses gender-neutral pronouns like “they/them” (Pew Research Center, 2023). This is double the number of those in their forties and triple the number of those in their fifties and sixties. These generational differences underscore the rapid pace at which language and cultural norms are evolving. In addition to generational differences, relational proximity to transgender identities and community impacts cultural norms and understanding. A 2019 study on beliefs about gender identity revealed that while 55% of Americans believe that gender is binary, this percentage is significantly higher (61%) among those who do not have a relationship with a transgender person. Conversely, 54% of Americans with a close friend or family member who is transgender believe in a range of gender identities (PRRI survey, 2019). This indicates that in addition to differences in generational understanding of gender identities, personal relationships with transgender individuals can influence beliefs about gender identity and expression.

Due in part to generational differences and community proximity, parents often have questions about why their children or teenagers are transgender or gender diverse. Common concerns include whether these identities are “real” or influenced by peers, and whether they will last or are “just a phase.” These fears are often fueled by media and anti-transgender groups that highlight stories of regret, despite such cases representing far less than one percent of all transgender people. To support transgender youth effectively, it is essential to reframe the “detransition” narrative and understand the developmental aspects of gender identity.

This article will equip you with the information you need to support transgender and gender diverse youth in their families and communities and explain evolution of gender identities into young adulthood. Now more than ever, transgender and gender diverse youth need those in healthcare to help advocate for the support, care and culture change that they need and deserve.

Starting with the basics: Concepts of sex, gender identity and gender expression

As we approach understanding how gender identity develops over time, it’s first important to recognize that no two children are alike. Each has their own unique identity, developmental progress and family and social environment that will shape how and when they come to understand their gender identity. That being said, we do have a good understanding of how and when children and adolescents will come to learn and relate to concepts around gender and gender identity, which will be outlined below.

Before we approach a developmental framework for gender identity, let’s go over some basic concepts and terms that relate to gender. First, the concept of “biological sex”, or to frame it more simply “bodies”. By medical and societal convention, when humans are born, we look for recognizable anatomic patterns to decide if we are going to categorize them as “male” or “female”. When we say that someone is “biologically male” or “assigned male at birth”, what we mean is that their genital anatomy and/or their chromosomal pattern fits that which we associate with the categorization of “male” (or conversely, with “female”). Nearly all infants will have a recognizable anatomic pattern of their genitals and/or chromosomes that fit with our categories of “male” and “female”, though it’s important to note that a small percentage of the time (up to 2%), infants won’t fit a recognizable pattern in either their genitalia, chromosomes or both, and those infants are referred to as “intersex”. Next is the concept of “gender identity” or “gender”. This is a concept that is fundamentally about our brains, or rather, how we internally understand our identity as male, female or something else, regardless of our bodies or our sex assigned at birth. Again, for most children and adolescents, their “gender” or “gender identity” will match with the assignment they were given at birth (a term we refer to as “cisgender”) and for a smaller percentage of children and adolescents, they will not (which we refer to as “transgender” or any other related term such as “gender diverse”, “gender expansive”, etc). No one can tell someone else what their gender identity is, it is internally developed over time by each person for themselves. Lastly, the concept of “gender expression”, or external cues and clues that we give to others about our gender identity and how we see ourselves and want to be perceived by others. Gender expression consists of name, pronouns, haircuts, clothing, activities, mannerisms, etc. that we choose to reflect our sense of self. Again, often gender expression (which society tends to categorize as “masculine” or “feminine” according to cultural norms) aligns with gender identity, but in many cases, it may not. Gender expression can also be fluid over time, as we reflect different degrees of cultural femininity or masculinity dependent on place, setting, time and age.

Developmental stages of gender identity development

Now that we have the basics down, let’s dive into child development. From the age of about 2-years-old, children understand basic concepts of gender. Children at this young age are very binary in their thinking and often place things into one of two opposing and concrete categories, and may not hold much nuance for the in-between or degrees of being fast or slow, or male or female. Once children develop a basic framework for what “boys” are and what “girls” are they begin to place themselves into one of these categories around ages 3-4 years old, and you might hear a child declare for the first time that they are a boy or they are a girl. And yes, some transgender children will declare their gender identities this young as well, noting to the adults in their lives that the category being used to refer to them doesn’t line up with who they are on the inside, or how they see and experience themselves. For transgender and gender diverse children, whether they are able to identify their exact gender identity at this young age is dependent on many factors. They have to have the language to understand how to explain this to adults, the safety to initiate this conversation in their family, and the agency to translate what they feel inside to those around them. Often, transgender young people who express their gender identity around these young ages also have a very binary gender identity, as opposed to a non-binary type of identity, as the nuance to hold and understand those more expansive identities has not yet developed.

As children move into elementary school at ages 5-6 years old, they begin to associate their newly understood gender identity as a boy or girl (or something else) with social norms and expectations that we have for those genders. They learn by watching and absorbing the cultural messages that are all around them, constantly reading the “gender scripts” being played out in their schools, families, communities, books, TV shows and other forms of media. Sometimes they get very explicit messages from both adults and peers about what is expected of them (“boys don’t wear dresses!” or “girls look prettier with long hair”), but even without these spoken directions, between ages 4-6 years old, young kids are figuring out gender roles and rules. Often kids will move into a very binary gender expression during these ages, with girls (both cisgender and transgender girls) leaning into hyperfeminine expression (think princess dresses) and boys (both cisgender and transgender boys) avoiding anything feminine for fear of being punished in big or small ways for not being masculine. This can be a hard time for both cisgender and transgender kids alike, as they have to decide if the clothing and activities and friends that they prefer are worth sticking with even if they violate expected gender expectations.

Beyond age 6 or so, children develop first a sense of “gender permanence”, an understanding that boys grow up to become men or girls grow up to become women, and that the body and anatomy that they have will be theirs indefinitely. For cisgender kids, this often results in a change in fantasy play to more gender specific roles (boys no longer playing “mommy” for example) and for transgender kids, this may be the first time they experience true gender dysphoria or distress about their body and gender identity.

As they realize that there is a permanence to the body they are in, which doesn’t align with who they are and experience themselves to be on the inside, there can be an anxiety, sadness or fear that develops about what this means for them and their future. This can be particularly true for transgender kids who have been very socially supported and not yet experienced any distress during their early pursuit of gender expressions and social presentations that align with their identity. Facing an understanding of what may or may not be possible to align how others see them with how they see themselves can be a time when transgender youth first seek professional support for their identities.

As older elementary school students mature into their “tween” years, a few things are happening for them developmentally. First, their concepts of “boy” and “girl” are becoming less rigid and binary. Girls often become less intensely feminine in their presentation, trading their dresses for different clothes, and learning more about their abilities to be smart, strong and independent that may or may not line up with restrictive cultural gender expectations. Boys, unfortunately, experience less of this loosening of gender roles and expectations, but they do similarly develop a more nuanced understanding of gender. Categories of gender often expand around these ages, including a more sophisticated understanding that gender exists on a spectrum of male and female. They can understand that beyond boys and girls, there are people who are non-binary and gender expansive. Kids may explore using they/them pronouns or a combination of the binary pronouns of he/him and she/her with they/them as they seek to find where they exactly fit within more expansive ideas of gender. Fortunately, this is also a time when cisgender kids can hold more understanding and care and kindness for their transgender peers and often easily adapt to their friends’ new pronouns and/or names.

And then……our patients hit adolescence. First and foremost, the fundamental developmental task of becoming a teenager is finding your identity. Who am I? What is important to me? Who are my people? What defines who I am? How do others see me? Am I like my parents, friends, and family or am I different and differentiated from them? Even though all teenagers are wrestling with these questions, it’s important to ground us in the reality that a relatively small percentage of teenagers will end up exploring their gender identity or identifying as transgender or gender diverse. For most adolescents, their gender identity has been fixed and stable for quite some time, and among the many identity questions they will wrestle with, including sexual and dating identities, their gender identity will not come into question. The other important thing that happens during adolescence is that at the very time they are figuring out who they are, their bodies are changing, inside and out, right before their eyes. Puberty, for all teenagers, is an intense time emotionally and physically.

For transgender and gender diverse teenagers, the onset of puberty may bring to the forefront thoughts or feelings that they might have had about their gender identity for several years or may intensify thoughts and feelings they didn’t know were so important to them. They are also experiencing an independence in peer group development and media and internet information that they may not have had previously. As their exposure to people and ideas expands, they may discover that they now have words to describe or understand themselves that they didn’t have previously. All of these factors combined sometimes culminate in a teenager sharing their gender identity with a parent for the first time as an adolescent, and it may come as a surprise or seem incongruent to a parent or caregiver. As with most things relating to teenagers, they need our patience, they need us to see and try to understand them, and they need us to love and support them, even as we might seek additional information or have curious and questioning conversations with them.

Adolescents and young adults may continue to refine and define who they are, how they describe their gender identity and which name or pronouns feel best to them over a period of several months or even years. As this is a time that may overlap with questions about pursuing medical interventions to alleviate gender related distress or dysphoria and a desire for teenagers to experience a pubertal experience and physical changes that align with their identity, it is a time to be thoughtful and careful in our approach to help discern what steps might be best during these years. Working with mental health professionals who have an evidence-based and developmental approach to supporting gender diverse adolescents that is informed by WPATH guidelines, is typically recommended (Coleman, 2022). It’s important to note that while parts of teenagers and young adults’ brains will continue to develop into young adulthood (most notably, their pre-frontal cortex, or impulse control center of their brain), the parts of their brain that govern both their identity formation as well as their ability to make informed decisions are fully developed and functional.

Essential healthcare for transgender and gender diverse youth

One trend among those who push “de-transition” narratives is to frame the essential healthcare that we provide to transgender and gender diverse youth as dangerous, experimental and scary. These disinformation messages serve the purpose of creating an “overstory” that makes the outcome they are sharing about a single young person’s unfortunate journey seem inevitable and common, which is the farthest thing from the truth. A key role that we can play as healthcare professionals, is to lend our voices to dispelling these disinformation myths and by reinforcing accurate messages about what gender affirming care actually entails for young people. We should emphasize that satisfaction with care is high, that care should involve mental health and medical professionals and that decisions are slow, methodical, developmentally appropriate and involve parents and guardians every step of they way. It’s important to keep our discussions of essential healthcare for transgender and gender diverse simple, factual and grounded in evidence and science. Some key components of gender affirming care for youth are outlined below, with messages that we can reinforce to our colleagues, our patients and our communities.

Gender-affirming care for youth includes developmentally appropriate medical, mental health, and social services. This care supports the spectrum of gender affirmation, including social, legal, medical, and surgical affirmation. Key interventions include:

● Social transition in childhood and beyond

● Fully reversible interventions like puberty suppression, menstrual suppression and voice therapy for adolescents

● Partially reversible interventions like hormone therapy for older adolescents after thorough mental health and medical assessment

● Surgical interventions are not a key component of essential healthcare for trans youth, and these procedures if pursued, are usually undertaken as a part of adult transgender care for those over age 18. o It is also important to note that while “de-transition” narratives often focus on surgical stories, less than 0.5% of transgender youth will have any surgical procedures (which will be almost exclusively gender affirming chest surgeries). Also, surgical care isn’t always a desired part of transgender healthcare even for transgender adults, as many transgender adults do not decide to pursue surgical procedures as a part of their medical affirmation. (Dannie Dai, 2024)

It is important to underscore these messages and key components of essential healthcare for transgender and gender diverse youth:

• Developmentally and age appropriate

• Focused on support of kids and families in community

• Supports the process of gender development and exploration, not tied to a particular path or outcome, which will be unique for each patient

• Includes many non-medical interventions

• Medical interventions (medications) are reserved for kids who have reached puberty or older

• Treatment always involves parental/guardian consent

Studies have shown that gender-affirming care reduces harm, with decreased rates of depression, anxiety, and other adverse mental health outcomes (Chen, 2023; DeVries, 2014; Lee, 2023). Every major medical organization in the United States, including the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, Endocrine Society, American Medical Association, American Psychological Association, and American Psychiatric Association, supports gender-affirming care for youth. Decades of research on more than 30,000 transgender and gender diverse young people have shown better mental health outcomes, including reduced depression and suicidality (Hembree, 2017).

Reframing harmful narratives of “de-transition”

When it comes to the hard work of not only undoing the disinformation that is rampant in the media and online but also countering and providing context for harmful narratives around “de-transition”, the conversations can become challenging. First and foremost, our work in medicine is to constantly seek to improve the care we are providing and improve the outcomes of our patients. For this reason, we cannot ignore or try to minimize negative experiences that small numbers of transgender and gender diverse young people have had with healthcare. These patients and young adults, and indeed all transgender patients, deserve our understanding and support. While their stories are not to be conflated and given the over-importance that they have been in media stories and legislative chambers across the country, we can still look into the details of their care and seek to improve patient experience as we would with any area of healthcare. We can focus our conversations on the overwhelming majority of young people and families who have benefitted from care, dispel misinformation and lean into evidence-based care and outcomes, while still leaving the door open to have compassionate conversations about the small numbers of patients who have not had optimal care or outcomes.

With that in mind, it is absolutely necessary that conversations and stories about “de-transition” are taken in an appropriate developmental, cultural and clinical context. First, these stories should take up proportional space as compared to the stories of lives saved, families grateful for care and young people thriving. To reflect the data that we have, for every one story of regret, there should be 200 stories sitting beside it that accurately represent the outcomes and the stories of our young transgender patients. A simple internet search will quickly reveal that this is not the case. As clinicians, we should continue to advocate for stories of the benefits of care, stories of the positive outcomes we see in our research and stories we see and hear every day of our patients thriving into adulthood. We can also develop tools to help us have factual conversations and provide clinical and developmental context for harmful “de-transition” narratives, so let’s dig in.

One myth that fuels fears about de-transition or regret is the myth of “social contagion”. This is the concept that young people truly are not transgender, but merely influenced by the culture, the media or their peers. Parents are encouraged to ignore and not support their teenager’s gender identity or exploration as it is viewed as a “phase”. This myth often focuses on narratives that include young transgender people connecting with transgender information or peers online and the young person’s identity seems to have “come out of nowhere”. The myth of “social contagion” is tied very tightly with the falsely constructed concept of “rapid onset gender dysphoria”. The concept of “rapid onset gender dysphoria” (ROGD) was invented by a researcher using information from anti-transgender websites. Multiple studies have shown that ROGD does not exist, and over 60 health professional associations, led by the American Psychological Association, have stated that the theory is baseless (Turban, 2023). The journal that published the original study that proposed the theory of ROGD has issued a correction, acknowledging that ROGD is not a real mental health diagnosis.

A second myth that feeds disinformation about essential healthcare for transgender youth and is often paired with stories of “de-transition” is the myth that regret is common for those who receive gender affirming care and that many transgender young people will change their minds or identities as they get older and should not be affirmed or supported when they are expressing and exploring their gender identity as children or adolescents. The truth is that studies show that regret is extremely rare for any treatment associated with gender dysphoria, with more than 98% of youth treated according to standards of care identifying as transgender into adulthood (Wiepies, 2018; Olson, 2022; van der Loos, 2022). Stories of “de-transition” often focus on patients who have received surgical treatment at some point (usually as young adults over 18), despite the fact that regret associated with gender affirming surgical procedures is less than 1% (Bruce, 2023; Narayan, 2021). This is far lower than many other surgical procedures, including those like gastric bypass, which carries a regret rate around 20% (Bustos, 2021).

By focusing on false theories of “social contagion”, “rapid onset gender dysphoria” and presenting false data and information about regret, those who push narratives of “de-transition” to fuel anti-transgender legislation seeking to ban access to essential healthcare for transgender youth have successfully moved the conversation away from science and evidence-based medicine and how we typically measure successful outcomes in healthcare. When measuring successful outcomes for all other areas of medicine we focus on improvement in health and well-being, whether that is physical health or psychological health, to determine if our treatment or interventions have positive benefit. All healthcare interventions are designed to improve health, and reduce harm with as much benefit and as little risk as possible. In no other area of healthcare do we focus this intensely on rates of “regret”, nor do we ask an entire country, including legislators and the public, to regulate and account for healthcare that has proven benefit in countless research studies and is overwhelmingly supported by the medical and mental health communities as well as by individual patients who have received care.

As a healthcare community, we should be centering our decisions around essential healthcare for transgender youth on the benefits and outcomes associated with that care to decide whether our approach is successful. When we do this, we see that satisfaction rates with gender affirming care for youth are extraordinarily high and continuation rates for care into adulthood are greater than 97%. (Olson, 2024). We also see that there is measurable benefit for intervening in an affirming way for transgender youth, with reduction in suicidality rates and improvement in mental health. Gender affirming care is associated with decreased rates of long- term adverse outcomes, including decreased rates of depression, anxiety and other adverse mental health outcomes. Transgender youth with access to puberty suppression and gender affirming hormones were 60 percent less likely to have depression and 73 percent less likely to consider suicide. (Tordoff, 2022). With this kind of evidence linked to outcomes, it is clear that doing nothing would cause more harm than providing access to the life-saving care, resources and supports that transgender and gender diverse families need and deserve.

Moving forward with a new framework

As a medical community, we can push back against harmful narratives of “de-transition” while still remaining compassionate and curious about each young person’s experience of their gender identity and any treatment they receive as part of their healthcare. We must move forward with a focus on accurate data and information about the benefits of access to essential healthcare for transgender and gender diverse youth as well as the harm that ensues when this care is blocked or banned. The surge in negative impacts on youth mental health in the wake of anti-transgender legislation is undeniable (Trevor Project, 2024) and we must do everything we can to continue to provide access to evidence-based, life-saving healthcare for transgender youth, as well as continued access to community supports, including sports, school resources, teachers, peers and family members.

Parents often struggle to know how to best support their kids on top of dealing with their own feelings of grief, anger, disappointment or fear. Parents often need just as much, if not more, room to ask questions and seek support as they learn more about their child’s identity. Parental rejection is a significant risk factor for poor physical and mental health outcomes for transgender youth (Campbell, 2023), including a significantly increased risk of suicide. We should always courage parents and caregivers to consistently reassure their children that they love them, even when they are struggling to understand their expressed identities or to determine what, if any, social or medical changes they might ultimately make with regard to their child or teenager’s gender identity. Unconditional parental love is the single biggest protective factor to keep transgender and gender-diverse kids healthy and safe.

As healthcare professionals, we can bring to our conversations with parents and others a developmental framework for gender identity evolution, acknowledging the stages at which gender identity develops, and the understanding that adolescents and young adults may continue to explore the nuances of their identities, including labels and gender expression into their adulthood. Indeed, some adolescents who are completely satisfied with their care may at some point choose to stop taking or reduce doses of certain medications, and that should not be seen as a negative outcome. Even though 97% or more of young people will continue gender affirming medical treatments into adulthood, that does not mean that the up to 3 percent of young people who stop taking medications experience regret. In fact, most of them do not. Some young people stop taking medications because they have achieved the end result they were looking for and do not have a need for ongoing hormonal intervention. Some need to stop certain medications because they experience a medical side effect or have a different medical condition that prevents them from taking the medications that they would have otherwise wished to continue. And in today’s healthcare environment, the harsh reality is that sometimes healthcare and medications become unaffordable, as more transgender adults experience higher rates of being uninsured than their cisgender counterparts. When asked, the majority of patients who stopped treatment and “re-transitioned” did so because of societal or familial pressure, not because their gender identity changed. Top reasons cited by patients for changing their gender identity and stopping medical treatment included pressure from a parent (36%), harassment and discrimination (31%), and couldn’t find work (29%) (Narayan, 2021). Of those who stopped treatment AND experienced true regret, they represent only 2-4% of those who “de-transition”, who overall represent less than 3% of patients who access gender affirming medical care. When we consider this, only 0.1% of patients who access gender affirming medical care as adolescents experience true regret and “de-transition”. These stories should not be allowed to dominate news media reports about transgender youth or legislative arguments that seek to ban access to care. Our healthcare community has an obligation to protect access to care that we know improves outcomes for youth, is driven by evidence-based guidelines and allows transgender youth to thrive.

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