EDITORIAL
Transgender Youth: The Building Evidence Base
for Early Social Transition
Jack L. Turban,
T ransgender youth are individuals who experience an
incongruence between their gender assigned at birth
and their experienced gender identity.1 Such patients
are increasingly coming to the attention of mental health
providers,2-4 because they are subject to significant rates of
depression, anxiety, and suicidality.5-9
In the past few decades, the medical community has
made large strides to support these youth. After a compre-
hensive evaluation, clinicians can now, in conjunction with
psychosocial support, offer a range of hormonal
interventions to patients that help their bodies match their
identities. Transgender adolescents who receive puberty
blockers and cross-sex hormones, as outlined in the World
Professional Association of Transgender Health Standards of
Care10 and the 2009 Endocrine Society guidelines,11 have
been shown to have less internalizing psychopathology after
treatment.12
Despite clear protocols for the endocrine treatment of
transgender adolescents who have reached puberty,10,11 the
approach to treating prepubertal children has remained
controversial. The most recent American Academy of Child
and Adolescent Psychiatry Practice Parameter on Gay,
Lesbian, or Bisexual Orientation, Gender Nonconformity,
and Gender Discordance in Children and Adolescents pub-
lished in 2012 highlighted that the evidence base for treating
prepubertal transgender children at that time was nearly
nonexistent, leaving practitioners with little more than their
own clinical judgment.13 However, clinical judgment in this
area varies significantly.14 Judgments fall primarily into 3
approaches. The first approach suggests that psychothera-
peutic techniques should be instituted to help transgender
children identify with their gender assigned at birth. This
approach rests on the assumption that gender identity in
prepubertal youth may be malleable and that psychothera-
peutic interventions may promote identification with one’s
gender assigned at birth, preventing the need for future
medical intervention. The second approach recommends
exploring gender identity with the patient, with no
interventions to lessen cross-gender identification. However,
this approach simultaneously advises against “social tran-
sition,” citing potential high rates of desistence in cross-
gender identification from childhood to adolescence,15,16
and anecdotal evidence that some transgender youth who
ultimately transition back to living as their birth genders
suffer distress, mostly owing to fear of peer judgment.17 The
third approach recommends an open exploration of the
child’s gender identity with no goal in sight (transgender or
not) and supports social transition for those children who
express a desire. This approach rests on the belief that
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prohibiting social transition can lead to patient shame and
damaged alliances among the patient, family, and provider,
ultimately leading to poor mental health outcomes.
In this issue of the Journal, Durwood et al.18 add to the
evidence base for this third approach, which is unique in
allowing transgender youth, including prepubertal children,
to socially transition (i.e., live full time as their experienced
gender identity including, in this study, using the pronoun
“opposite” one’s gender assigned at birth).
The first article to suggest that early social transition
might have desirable outcomes came from Olson et al.19 in
the journal Pediatrics in 2016. The study examined 73 pre-
pubertal transgender youth who were allowed to socially
transition. The study found that parent report of these chil-
dren’s anxiety and depression metrics were similar to those
of age-matched non-transgender controls, a stark contrast to
past reports of clinic-referred children who were not allowed
to socially transition.19,20 Transgender youth in this study
showed only mildly increased levels of anxiety (below the
subclinical range).
This report came under criticism with suggestions that
parents who allowed their transgender children to socially
transition might be biased to underreport their children’s
mental health difficulties.21 Durwood et al.’s article in this
issue of the Journal addresses this criticism by measuring
child self-report data in combination with parent report. In
this study, Durwood et al. found that parents, in fact, over-
estimated their children’s levels of anxiety and reported
similar levels of depression. Child-report measurements
showed once again that transgender youth who are allowed
to socially transition have anxiety and depression metrics on
par with matched non-transgender controls. Furthermore,
child-report levels of self-worth were similar to those of
matched non-transgender controls.
Importantly, the article included diverse representation of
geographic locations within the United States, although it
was underpowered to examine differences between loca-
tions. It also showed developmentally normative levels of
anxiety and depression for prepubertal children and for
those who had begun puberty (Table 4 of Durwood et al.18).
This is important because prepubertal social transition has
been the primary topic of contention, with postpubertal
social transition being generally accepted as beneficial given
the low rates of desistence in cross-gender identification after
puberty.12
Nonetheless, it is important to note that these measure-
ments were collected at 1 unspecified time point after social
transition. It is possible that as these children progress into
adolescence and adulthood, their mental health metrics
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TURBAN
change as they potentially face new bullying and peer
ostracism.22 Future work is needed to follow these
individuals longitudinally. It also is important to note that
these children were not referred to a clinic and thus could
represent a healthier cohort at baseline compared with past
reports that showed high rates of mental health difficulties in
clinic-referred transgender youth.20 Some also will wonder
whether early transition increases the likelihood of persis-
tence in cross-gender identification from childhood into
adolescence. Although 1 study has suggested an association
between childhood social transition and persistence in cross-
gender identification from childhood into adolescence,16 this
question requires additional research. One also must ask
whether desistence of cross-gender identification is an ethi-
cally sound goal.
In addition, this article examined children who clearly
identify as the gender opposite their gender assigned at
birth. Not all gender-nonconforming youth fall into this
binary category. Children have a range of identities along a
spectrum that might not fall neatly into male or female
categories. More data are needed to better understand the
benefits of social transition in these gender–non-binary
children.
As Durwood et al. point out in this article, it would likely
be unethical to conduct a randomized controlled trial of
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102 www.jaacap.com
transgender children who are and are not permitted to
socially transition. Thus, clinicians are faced with imperfect
data. Nonetheless, all existing data at this time suggest that
transgender youth who are binary in their gender identity,
when allowed to socially transition, have developmentally
normative mental health scores, at least in the short term.
Although the literature is limited as described earlier,
the building evidence base suggests that these socially
transitioned youth have superior mental health compared
with past cohorts of clinic-referred transgender youth who
were not permitted to socially transition.20 &
Accepted November 22, 2016.
Mr. Turban is with the Child Study Center, Yale School of Medicine, New
Haven, CT.
Mr. Turban thanks Annelou de Vries, MD, PhD, of VU University Medical
Center, and Christy Olezeski, PhD, of Yale University, for their thoughtful
comments on this editorial.
Disclosure: Mr. Turban reports no biomedical financial interests or potential
conflicts of interest.
Correspondence to Jack L. Turban, BA, 333 Cedar Street, New Haven, CT
06510; e-mail: jack.turban@yale.edu
0890-8567/$36.00/ª2016 American Academy of Child and Adolescent
Psychiatry
http://dx.doi.org/10.1016/j.jaac.2016.11.008
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(AACAP) Committee on Quality Issues (CQI). Practice parameter on gay,
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gender discordance in children and adolescents. J Am Acad Child Ado-
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http://dx.doi.org/10.1542/peds.2016-1203B.
22. McGuire JK, Anderson CR, Toomey RB, Russell ST. School climate for
transgender youth: a mixed method investigation of student experiences
and school responses. J Youth Adolesc. 2010;39:1175-1188.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 56 NUMBER 2 FEBRUARY 2017