A Follow-Up Study of Boys With Gender Identity Disorder

cohort studytransition outcomesdetransitiongender dysphoriagender identity disordersexual orientationchildhooddesistancepersistence

Authors: Devita Singh, Susan J. Bradley, Kenneth J. Zucker
Year: 2021
Journal: Frontiers in Psychiatry
Source: www.frontiersin.org/articles/10.3389/fpsyt.2021.632784/full

Methodological Limitations

The study conflates gender identity and sexual orientation, classifying participants based on a combination of 'persistence' of gender dysphoria and sexual orientation, which are distinct constructs. This conflation is methodologically problematic and potentially misleading.
The study used different metrics to assess gender identity/dysphoria at follow-up (GIDYQ-AA for 64 participants, GDIQ for 42 participants, and interview/chart/parent report for 33 participants), creating method variance that could affect classification reliability, despite authors' claims to the contrary.
Only 110 of 139 participants (79.1%) completed face-to-face assessments; 29 participants were assessed via telephone, parent report, or chart review, potentially compromising data quality and validity of classifications.
The follow-up represents a single 'moment in time' at mean age 20.58 years, with no longitudinal tracking beyond this point. The authors acknowledge that gender identity may fluctuate over time and some 'desisters' may later re-identify as transgender.
32 participants (23%) entered the study after re-contacting the clinic for clinical reasons, introducing potential selection bias. These participants showed more childhood cross-gender behavior and higher internalizing problems than research-recruited participants, and had a higher persistence rate (22% vs. 9%) that approached significance.
162 eligible participants were not contacted due to 'lack of study resources and time constraints,' and 19 participants could not be traced. The authors acknowledge participants had higher IQ than non-participants, and those from two-parent households were more likely to be traced, suggesting demographic bias.
The childhood assessments spanned 1975-2009 using different DSM criteria (DSM-III, III-R, and IV), creating diagnostic inconsistency across the sample. 36.7% of participants were subthreshold for GID diagnosis.
The study's therapeutic context is historically specific and not generalizable to contemporary practice. The authors note that most participants were seen during a period when 'therapeutic approach of recommending or supporting a gender social transition prior to puberty was not made,' with only one patient having socially transitioned. This makes the desistance findings largely inapplicable to current clinical populations where social transition is more common.
The classification of 'persisters' vs. 'desisters' relies on a cutoff score on the GIDYQ-AA (≤3.00) that was developed with different populations, and two participants were reclassified based on 'clinical judgment' despite scoring above the cutoff, introducing subjective decision-making.
The study's framing of 'desistance' has been widely criticized in the literature (citations 60-63) for potentially misclassifying children who were never truly gender dysphoric or who were responding to social pressure, yet the authors' rebuttal (citation 64) is primarily self-cited.
The term 'biphilic' is acknowledged by the authors as a 'dubious neologism, combining Latin and Greek derivatives,' with 'diphilic' being more accurate, yet they retained the imprecise term for reader familiarity.
The study assumes a binary classification of gender identity outcomes (persisters vs. desisters) that may not capture the complexity and fluidity of gender identity development, particularly given contemporary understanding of non-binary and gender-fluid identities.
Reviewer Ray Blanchard declared a past co-authorship with author Kenneth J. Zucker, raising potential conflict of interest in the peer review process, though the handling editor was informed.

Key Findings

Of 139 boys clinic-referred for gender dysphoria in childhood, only 12.2% (17) persisted with gender dysphoria into adolescence/adulthood, while 87.8% (122) desisted.
A large majority of boys in the study developed a biphilic/androphilic (same-sex attracted) sexual orientation: 63.6% in fantasy and 47.2% in behavior, with an additional quarter reporting no sexual behaviors.
Boys who persisted with gender dysphoria tended to be older at childhood assessment, from lower social class backgrounds, and showed more severe gender-variant behavior in childhood compared to desisters.
The study found no significant difference in persistence rates between boys who met full diagnostic criteria for gender identity disorder in childhood (13.6%) versus those who were subthreshold (9.8%).
The authors note this is the largest follow-up study of its kind and discuss implications for contemporary treatment approaches, particularly the increasing practice of early social gender transition which was rare in their sample.

Abstract

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07- 39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender- variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

Summary

This study followed 139 boys who were clinic-referred for gender dysphoria in childhood, assessing them again in adolescence or adulthood at a mean age of 20.6 years. The researchers found that 87.8% of participants no longer experienced gender dysphoria (desisters), while 12.2% continued to identify as transgender (persisters). Most participants developed a biphilic/androphilic sexual orientation, and childhood predictors of persistence included more severe gender-variant behavior, older age at initial assessment, and lower social class background.

Conclusion

This study provided follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139). Three key findings emerged: (1) The persistence of gender dysphoria was relatively low at 12.2% (17 persisters), while desistance was 87.8% (122 desisters); (2) A high percentage had a biphilic/androphilic sexual orientation—in fantasy, 63.6% (82 of 129 participants), and in behavior, 47.2% (51 of 108 participants); (3) Predictors of outcome included childhood age at assessment, social class, and degree of childhood gender-variant behavior. Specifically, biphilic/androphilic persisters tended to be older at childhood assessment, from lower social class backgrounds, and more gender-variant in childhood. Biphilic/androphilic desisters were more gender-variant than gynephilic desisters. The threshold vs. subthreshold GID diagnostic status in childhood did not significantly predict persistence. The authors note that these data were collected during a period when gender social transition prior to puberty was not commonly recommended, contrasting with more recent clinical approaches. The findings support prior research showing that desistance from gender dysphoria is the more common outcome in childhood-referred boys, and that dimensional measures of childhood sex-typed behavior provide added nuance in predicting long-term trajectories. The implications of these data for current models of care for treating gender dysphoria in children are discussed, particularly in light of contemporary approaches that may include earlier social transition and puberty-blocking interventions.