Wanting to protect my daughter’s health does not make me a bigot

By Susan Nagel

Susan Nagel is the mom of a 17-year-old girl who identifies as transgender. Nagel wrote this essay as a way to educate people who assume she is transphobic because she is unsupportive of her daughter’s desire to medically transition. She hopes others may find this essay helpful if they are trying to educate friends, family members, teachers, doctors, therapists, or journalists. Nagel is using a pseudonym to protect the identity of her daughter, and is available to interact in the comments section of this post.

A PDF version of this article is available here.

About a year ago my then 16-year–old daughter told us she believes she is transgender. Soon after, she began begging to take testosterone, to wear a breast binder, to have others call her by male pronouns, and to legally change her name. Nothing about her childhood prepared us for this; she always had stereotypically feminine interests and tastes. She loved stuffed animals, preferred skirts over pants for school, chose bright pink paint for her room, and experimented with makeup and curling her hair. When she was little. I joked that I had to add a pink load to laundry day in addition to lights and darks. Over the course of a month or two after coming out, she changed from a generally cheerful person to a morose one who spent hours crying and who told me to hide the knives.

Before I go further, I think you should know the lens through which I view things. I am a liberal, and I fully support equal access to housing, employment, education, and healthcare for all marginalized people, including transgender people. I do not think being transgender is immoral or that gender diversity is disturbing. Still after spending many sleepless nights researching the transgender movement, I have come to be very afraid for my daughter. My fears are about the rush to turn physically healthy teenage girls and young women into permanent medical patients and to do so before their brains are fully developed and with almost no oversight by mental health professionals.

bigot circleI encounter many well-meaning people who believe the transgender movement is simply a civil rights movement. They do not understand my concerns and assume I am ignorant or a bigot. I think it is because most people’s knowledge of the transgender movement is limited to mass media accounts focusing on discrimination against transgender people or on an individual’s struggle to be true to his or her self. Below are some things I wish people understood about how the transgender movement is impacting the health of children and young people along with some questions I would like people to ponder.

  1. Few children who experience gender dysphoria grow up to be transgender.

Gender dysphoria, a feeling of discomfort or distress with a person’s own biological sex, is a temporary issue for a sizeable majority of the children who experience it. Studies show that only between 6% and 27% of children who experience gender dysphoria will grow up to be transgender.  These statistics do not come from a conservative source. They are from the World Professional Association for Transgender Health Standards of Care.

  1. The drug regimen used to treat pre-pubescent children with gender dysphoria causes permanent sterility.

Some parents whose young children experience gender dysphoria place their children on drugs called puberty blockers to stop the onset of puberty. The rationale: postponing puberty will give a child time to decide which gender the child is. If the child later decides to transition, the child will more easily pass as a member of the opposite sex because the normal development of secondary sex characteristics was blocked. If the child decides not to transition, the child stops the puberty blockers, and normal puberty occurs.  Those wishing to complete medical transition, must follow puberty blockers with the hormones of the opposite sex. When puberty blockers are followed by cross sex hormones, the child never undergoes puberty for his/her birth sex and will be unable to produce viable ova or sperm as an adult.

Sterility is not the only problem caused by the typical treatment route of puberty blockers plus cross-sex hormones . The drugs being used to block puberty are being used off-label; i.e. they have not been approved for this use by the Food and Drug Administration. According to Eli Coleman, a psychologist who heads the human-sexuality program at the University of Minnesota Medical School quoted in The New Yorker, “We still don’t know the subtle or potential long-term effects (of puberty blockers) on brain function or bone development. Many people recognize it’s not a benign treatment.”

Puberty blockers have been used for a number of years to treat precocious puberty and to allow short kids more time to grow.  The FDA is currently conducting a review of nervous system and psychiatric events as well as deadly seizures among pediatric patients using GnRH agonists including one of the most common puberty blockers, Lupron. Over 10,000 adverse event reports in relation to Lupron usage have been filed with the FDA.  According to Kaiser Health News, “…thousands of women have joined Facebook groups or internet forums in recent years claiming that Lupron ruined their lives or left them crippled.”  Complaints include osteoporosis, degenerative disk disease, and deteriorating joints.

My questions are: How can it possibly be ethical to sterilize children before they are old enough to give informed consent? If your child had a medical condition with a 73 to 94 percent chance of remitting without treatment, would you agree to experimental therapies with known serious side effects? What parent can predict whether his/her child will prefer to be fertile or to pass as the opposite sex as an adult?

3. Not every person who medically transitions stays transitioned.

Although trans activists claim otherwise, it is not uncommon for transgender people who have transitioned, medically and/or socially (social transition includes adopting the dress, hairstyles, names, and pronouns of the opposite sex) to eventually change their minds and detransition. For example, a 2016 survey on detransitioning that was posted online for only 10 days collected over 200 responses from detransitioned women. Blogs and videos of detransitioners are easy to find online.

  1. There is little research on the safety of the long-term use of cross-sex hormones for the purposes of sexual transition.

Using testosterone for the purposes of sexual transition is an off-label use of the drug. One observational study of the immediate impact of testosterone treatment on females transitioning to male showed that testosterone impaired mitochondrial function and created a state of oxidative stress in the subjects’ white blood cells.  Oxidative stress is associated with neurodegenerative diseases, gene mutations, cancers, heart and blood disorders, and inflammatory diseases among other pathologies. Research on the long-term effects of using testosterone for transition is sparse.  Given the effect testosterone has on the white blood cells of women, it seems reckless to me to prescribe this drug without further studies of its long-term effects.

Below are just a few items from a consent form that girls and women wishing to take testosterone must sign:

  • “I understand that it is not known exactly what the effects of testosterone are on fertility…,”
  • “I understand that brain structures are affected by testosterone and estrogen. The long term effects of changing the levels of one’s natal estrogen through the use of testosterone therapy have not been scientifically studied and are impossible to predict. These effects may be beneficial, damaging, or both.”
  • “I have been informed that using testosterone may increase my risk of developing diabetes in the future because of changes in my ovaries.”
  • “I understand that the endometrium (lining of the uterus) is able to turn testosterone into estrogen and may increase the risk of cancer of the endometrium.”
  • “I understand fatty tissue in the breasts and body is able to turn excess testosterone into estrogen, which may increase my risk of breast cancer and decrease or impede the desired effects of testosterone therapy.”
  • “I have been informed that testosterone may lead to liver inflammation and damage. I have been informed that I will be monitored for liver problems before starting testosterone therapy and periodically during therapy.”

My daughter sees nothing scary about this list. She is a teenager, and teenagers believe they are invincible. She reassures me that she would receive the treatments from a doctor, so in her mind, nothing could go wrong. She lacks the life experience that has taught me all medical treatments entail risks and side effects, many drugs are withdrawn from the market when they are later found unsafe, some medical professionals are motivated by profit, and that doctors make mistakes.  In the study of detransitioned women mentioned above, the average age of transition was 17, and the average age of detransition was 22. I suspect the timing of detransition had something to do with young women reaching sufficient maturity to calculate risks versus benefits.

In addition to the health risks, testosterone causes irreversible cosmetic changes. Male pattern baldness, facial hair, and a deepened voice follow transmen who detransition to reclaim womanhood.

I am shocked by how readily some friends accept the idea of using synthetic hormones for the purpose of transitioning teenagers. Some of these people avoid drinking milk from cows treated with bovine growth hormone and avoid eating inorganic vegetables or food tainted by genetically modified organisms. If teenagers ingest risky chemicals for politically correct reasons, is the harm is somehow reduced? 

  1. A thorough evaluation and therapy from a mental health professional are not required before a young adult medically transitions.

Several people have told me not to worry that my daughter might transition unnecessarily because a person must have a thorough evaluation by a therapist to assure he/she is truly transgender before receiving medical treatments. That may have been universally true at one time, but unfortunately it is no longer the case.  In the survey of detransitioned women mentioned above, 117 of the surveyed women had medically transitioned. Only 41 (35%) of those women had received any therapy beforehand. The vast majority (68%) felt they had not received adequate counseling and accurate information about transition before transitioning.

Some trans advocates say evaluation by a therapist should not be required for medical transition because they say being transgender is not a mental illness. Consequently, there has been a move toward informed-consent clinics. Under this scenario, any adult claiming to be transgender is allowed to receive medical transition treatments with a letter from a therapist stating they have been informed of the risks involved in transition and are capable of giving consent.

The website of RECLAIM, a St. Paul, Minnesota mental-health center for transgender youth ages 13 through 25, explains that the informed-consent process may take as little as two sessions to 10 or more. It also explains that the resulting letter to medical providers “…does not involve the evaluation of readiness…” for medical transition by the therapist. Call me old-fashioned, but I think most 18-year-olds could benefit from an evaluation of readiness.

The website of a St. Paul therapist specializing in gender issues, Bystrom Counseling and Consultation, tells potential clients that a number of Minnesota physicians “…are now comfortable prescribing hormones without written documentation of completion of (the) Global Review of risks and benefits from a therapist.” The website goes on to list the medical clinics most often accessed for this purpose.

University of Michigan Professor of Social Work Kathleen Levinstein wrote about her autistic daughter’s medical transition for 4thWaveNow. Her daughter was a special-education student, who as an adult, qualifies for disability payments and is not capable of managing her own finances. She functions at such a level, that her mother had to explain to her that women who take testosterone do not grow penises. The day after her 18th birthday, the daughter‘s gender therapist approved a double mastectomy for the daughter after only two sessions together. The daughter began testosterone treatments several months later. The daughter who also suffers from Crohn’s Disease has been hospitalized three times due to adverse reactions to the hormone.

If transgender people are not ill, doesn’t that make their treatments elective and therefore ineligible for insurance coverage? If transgender people are ill, don’t they deserve a thorough evaluation and a diagnosis before undergoing medical treatments? 

  1. When children and teens experience gender dysphoria, they are often allowed to diagnose themselves as transgender.

Parents who convince a child to seek therapy before pursuing transition should know that many mental-health professionals especially those calling themselves gender therapists use an identity approach to treating gender dysphoria, also called the gender affirmative approach. Lisa Marchiano, a Philadelphia social worker, wrote an essay contrasting the identity model of therapy to the traditional mental-health model. Under the identity model, gender dysphoria can mean only one thing: that someone is transgender. Therapists are not allowed to use their own clinical judgement to analyze whether there might be other reasons people are feeling uncomfortable with their bodies. Marchiano states, “Our role as therapists becomes limited to enthusiastic affirmation only.”

I witnessed the prevalence of this model in my own search for a therapist to help my daughter. I interviewed approximately ten therapists by phone before finding one who understood that teenagers experiment with identities and that teenagers’ beliefs about who they are may change over time, something that used to be common sense and common knowledge.

In contrast to the gender-identity model of therapy, Marchiano says the mental-health model sees gender dysphoria as a symptom. The therapist’s job is to help the client “…explore the symptoms without making assumptions about what the symptoms mean. In fact, while identity therapy knows what gender dysphoria means – i.e. that the client is trans – mental health therapy will start with the assumption that we have no idea what the symptom means. We must be open to the meaning that emerges for patients as we explore their experience with them.”

What besides being transgender could cause gender dysphoria? In a letter to the American Psychological Association, Marchiano says the survey of detransitioned women in addition to the online writings and videos of detransitioners indicate “…that many who underwent transition feel that they were doing so as a maladaptive coping mechanism to deal with trauma, anxiety, social difficulties, or other issues. The majority of detransitioners speaking out online now identify as lesbian, and many of them feel that internalized homophobia played a part in their believing that they were men.”

As a woman, I fully understand the impulse to transition to stay safe and sane in a misogynistic world. But please, let’s not view women attaining better camouflage through transition as progressive. Progress occurs when women no longer feel a need to hide.

Studies show most children no longer feel gender dysphoria as adults. It is easy to find examples of people detransitioning. So why do gender therapists assume that every instance of gender dysphoria indicates that a person is transgender? We used to require people to have advanced degrees and licenses to make mental-health diagnoses. Why are we, in effect, allowing children and teenagers to diagnose themselves?  

  1. There is no persuasive evidence that gender transition reduces suicidality in children with gender dysphoria.

One of the scariest things a parent in my position encounters is the widely reported increased risk of suicide among transgender people. Many people believe transition is the only way to prevent suicides among transgender youth. A common sentiment is, “Would you rather have a dead daughter or a live son?” I encourage anyone with this concern to read a recent essay by Michael Bailey and Ray Blanchard. Their key take-away is, “There is no persuasive evidence that gender transition reduces gender dysphoric children’s likelihood of killing themselves. The idea that mental health problems–including suicidality–are caused by gender dysphoria rather than the other way around (i.e., mental health and personality issues cause a vulnerability to experience gender dysphoria) is currently popular and politically correct. It is, however, unproven and as likely to be false as true.” There are, in fact, some studies that show higher suicide rates for transgender people who have transitioned compared to those who have not.

While there is no proof that transition reduces suicidality, teenagers are coached by others on sites such as reddit and Tumblr about how to use suicide threats as a bargaining chip.  In one of the more chilling reddit exchanges reposted on the website Transgender Reality, an 18-year-old whose father is concerned about the wisdom of hormone therapy is asked by a commenter, “Are you ready to talk to him (the father) about the possibility of suicide? Or do you want to couch it more gently, and say you ‘can’t go on living like this’ etc.?” In another post, a 14-year-old is told, “…communicate to your parents that this is not optional. It is either this or depression, isolation, suicide.” Finally, a 13-year-old is told to tell his parents, “If you don’t help me like you need to as the parents who made me, I’ll wind up bitter, miserable or dead.”

  1. Some psychologists and mental health professionals believe teenage girls and young women are experiencing a new type of gender dysphoria caught from peers and through exposure to the concept online.

aitken-sex-ratio-graphUp until about 7 years ago, more boys than girls presented with gender dysphoria at gender clinics in western countries. Around 2010, the number of girls started to exceed the number of boys and began to increase significantly. Many girls experiencing gender dysphoria in the past decade have a different profile than they did in earlier years. In the past, girls with gender dysphoria began expressing discomfort with feminine clothes, interests and toys during preschool. Most would eventually become comfortable with their biological sex while dysphoria would persist into adulthood for some. Now many girls are first experiencing gender dysphoria suddenly in adolescence. Some researchers are calling this phenomenon rapid onset gender dysphoria (ROGD) and theorize it may be a kind of social contagion spread among friends and through the internet.

A 2016 survey of 164 parents of transgender adolescents and young adults demonstrates the current contagious nature of gender dysphoria among young women. Eighty-five percent of the parents surveyed had transgender youth who were biologically female with an average age of 15. In the general population, less than one percent of young adults would be expected to be transgender, however, many of the parents in this survey said that multiple members of their child’s pre-existing friend group were also declaring themselves transgender. To be exact, 50 percent of a youth’s pre-existing friend group became transgender in close to 40 percent of the friend groups described in the study. The average number of friends becoming transgender was 3.5.

Psychologists Ray Blanchard and Michael Bailey recently reported that young people with ROGD (primarily girls) falsely come to believe that all their problems are due gender dysphoria. Girls with ROGD often become obsessed with the idea of transition, and their mental health and social relationships deteriorate. The subculture surrounding ROGD includes attributes found in cults including an “… expectation of absolute ideological agreement …and encouragement to cut off ties with family and friends…” who do not agree with them.” Since ROGD is “…based on a false belief acquired through social means,” Bailey and Blanchard believe transition will not help youth with this condition. They pull no punches: “If knowledge is power, then lack of knowledge is malpractice. The ignorance of some leading gender clinicians regarding all scientific aspects of gender dysphoria is scandalous.”

My own daughter’s experience of gender dysphoria matches the description of ROGD closely. She first began experiencing gender dysphoria as a teenager. Four member of her pre-existing friend group also began identifying as transgender in their teens. Because I have expressed doubts about her transgender identity and voiced opposition to medical transition, she refuses to talk to me about those subjects much as a cult member refuses to listen to anything that contradicts his/her beliefs. Her mental health and relationships with family have suffered.

  1. Many people stand to gain financially by the boom in children, teens and young adults seeking medical transition.

Quite an industry has built up around the treatment of transgender people. In 2007, there was one transgender clinic that served children in the United States; now there are 40 . Transgender people who medically transition become permanent medical patients. To maintain their transitions, they must take hormones and have regular blood tests for the rest of their lives. Puberty blockers, hormone treatments, blood tests, genital electrolysis, facial electrolysis, laser body hair reduction, breast augmentation, facial feminization surgery, orchiectomies, vaginoplasties, colovaginoplasties, metoidioplasties, phalloplasties, and double mastectomies are some of the expensive treatments that may be pursued by transgender people.

Additional treatments may be needed to address complications resulting from medical transition treatments. The Truth About Transition Tumblr blog has compiled posts by female to male transitioners who have experienced difficulties. One trans man posts a video about multiple doctor visits he made recently to correct his testosterone levels and stop bleeding, leading him to 1) increase his testosterone dosage, 2) start taking progesterone, and 3) to go on Lupron, usually used as a puberty blocker. Another young trans man expresses his weariness anticipating his 20th transition-related surgery. The latest surgery is a third attempt to treat an abscess that developed during his surgical pursuit of a penis.

Revenue from testosterone sales has increased dramatically in recent years. Testosterone sales generated $2.4 billion in revenue in the United States in 2013. The projection for 2018 sales is $3.8 billion, a 58 percent increase.  While testosterone is used for purposes other than sexual transition, the increase in revenue correlates with the proliferation of gender clinics.

In addition to risky medical treatments, many girls and women use binders to compress their breasts and make their chests appear flatter. Binders have side effects such as back pain, shortness of breath, and rib fractures. When I Googled the term, “binder risks,” the first site that popped up was a plastic surgery clinic that does “top surgeries” for girls/women who want to transition to male. Yes, the folks who will profit by cutting off girls’ healthy breasts want to make very sure girls and their families understand the risks of binders.

What other civil rights movement has involved supporting body modifications for minors and young adults?

I have never felt so alone. People who would normally be allies for parents of a troubled child including therapists, doctors, teachers, and friends support this madness. I can only assume it is because they believe some or all of the following:

  • Only transgender people experience gender dysphoria.
  • Being transgender is always an innate and permanent condition.
  • People with gender dysphoria receive careful evaluation and therapy before being allowed to medically modify their bodies.
  • Transgender minors are not being allowed to make permanent changes to their bodies.
  • Transition-related medical treatments are well-tested and proven safe.
  • Children, youth and adults always fully understand why they are feeling dysphoric.
  • Physicians and drug companies would never experiment on children or put profit ahead of patients’ best interests.
  • Research has proven that transition prevents suicide.


None of it is true.

A friend told me recently that I have nothing to gain by resisting my daughter’s desire to transition. I strongly disagree. If resistance means my daughter postpones medical treatments until she can weigh the risks versus the benefits with more maturity, I gain plenty. If I can buy more time for her to discern whether her dysphoria really means she is transgender or whether something else precipitates her discomfort, I gain plenty.

I feel genuine rage toward the therapists and doctors who are complicit in the pursuit of medical transitions for kids, teenagers and young adults. You swore you would first do no harm. You should be ashamed!

If anyone working in the malpractice insurance industry happens to read this story, I have one final question specifically for you. Is it wise to cover the therapists and doctors involved in the transition of children and youth? When the lawsuits begin, I hope the settlements are breathtaking.


Gender dysphoria is not one thing

by J. Michael Bailey, Ph.D  and Ray Blanchard, Ph.D

This is the second in a series of articles authored by Drs. Bailey and Blanchard; see here for their first piece.

Many parents who are part of the 4thWaveNow community have daughters who fit the profile of a sudden onset of gender dysphoria in adolescence. This phenomenon is discussed in detail by the authors after the first two types, in the section “Rapid-onset Gender Dysphoria (Mostly Adolescent and Young Adult Females).” Some 4thWave parents will also find the section “Two Rarer Types of Gender Dysphoria” of particular interest (near the end of the article).

We recognize that regular readers and members of 4thWaveNow will not agree with all of what Bailey and Blanchard have to say, but as always, if you wish to challenge the authors, your comments will be more likely to be published if they are delivered respectfully.

As their time permits, Drs. Bailey and Blanchard will be available to interact in the comments section of this post.

Michael Bailey is Professor of Psychology at Northwestern University. His book The Man Who Would Be Queen provides a readable scientific account of two kinds of gender dysphoria among natal males, and is available as a free download here.

 Ray Blanchard received his A.B. in psychology from the University of Pennsylvania in 1967 and his Ph.D. from the University of Illinois in 1973. He was the psychologist in the Adult Gender Identity Clinic of Toronto’s Centre for Addiction and Mental Health (CAMH) from 1980–1995 and the Head of CAMH’s Clinical Sexology Services from 1995–2010.

One problem with the current mainstream narrative regarding gender dysphoria is that it makes no distinctions among apparently very different kinds of persons. For example, Bruce Jenner appeared to be a very masculine man, an Olympic athlete who was married to three different women and had six children with them, before becoming Caitlyn Jenner. In contrast, Jazz Jennings, a natal male, was so feminine that she earned a diagnosis of gender identity disorder at the age of four. She is attracted to males. Jenner and Jennings are so different in their presentation and history that it is surprising to us that anyone thinks they have the same condition. Jenner and Jennings are examples of two very different kinds of gender dysphoria that have been scientifically well studied, and have fundamentally different motivations, clinical presentations, and likely causes.

The failure of so many therapists and activists to acknowledge this distinction is disturbing for at least two reasons. First, it suggests they are either ignorant of relevant scientific evidence or are purposefully ignoring it. Second, failure to make scientifically valid and fundamental distinctions among different kinds of gender dysphoric persons can only prevent progress toward finding the best approach to helping each. Measles, influenza, and strep throat are all associated with fever. But if we had merely lumped them together as “fever,” we would not have effective treatments for them.

 Types of Gender Dysphoria

Gender dysphoria isn’t common. But there are at least three distinct types of gender dysphoria that, presently, regularly occur in children and adolescents. We summarize these at length here. Two other kinds of gender dysphoria are much less common in these age groups, and so we address them less fully near the end of this essay. The main three types differ in their age of onset (childhood, adolescence, or adulthood), their speed of onset (gradual or sudden), their associated sexual orientations (members of the same sex or the fantasy of belonging to the opposite sex), and their sex ratio (equally or unequally likely in males and females).

The first type—childhood-onset gender dysphoria—definitely occurs in both biological boys and girls. It is highly correlated with homosexuality–the sexual preference for one’s own biological sex–especially in natal males. (Sexual orientation is usually not apparent until a child reaches adolescence or adulthood, however.) This is the type that Jazz Jennings had before her gender transition. The second type—autogynephilic gender dysphoria—occurs only in males. It is associated with a tendency to be sexually aroused by the thought or image of oneself as a female. This type of gender dysphoria sometimes starts during adolescence and sometimes during adulthood, and its onset is typically gradual. (Onset may appear sudden to family members, however.) Although Caitlyn Jenner has not discussed her feelings openly, we strongly suspect she is autogynephilic. The third type—rapid-onset gender dysphoria—mostly occurs in adolescent girls. This type is primarily characterized by the age and speed of onset rather than the associated sexual orientation, and it may not be limited to one sex, as the second type is. Our impression is that rapid-onset gender dysphoria is especially common among daughters of parents who read 4thWaveNow as well as those who post on the support board at gendercriticalresources.com.

The first two types (childhood-onset gender dysphoria and autogynephilic gender dysphoria) have been well studied, although autogynephilic gender dysphoria has primarily been studied in adults. The third (rapid-onset gender dysphoria) has only recently been noticed, and it is possible that it didn’t occur much until recently.

How do you know which type of gender dysphoria your child has? If there were clear signs well before puberty that your child was gender dysphoric, s/he has child-onset gender dysphoria. (You would certainly have noticed signs at the time; at the very least you would have coded your child as extremely gender nonconforming.) If your child showed signs of gender dysphoria for the first time during adolescence, s/he has one of the other types. Remember, autogynephilic gender dysphoria occurs only in natal males, and it starts either during adolescence or adulthood. (And to a parent, it usually seems sudden.) We describe the three types more thoroughly below.

Childhood-onset Gender Dysphoria (Boys and Girls)

The most obvious feature that distinguishes childhood-onset gender dysphoria from the other types is early appearance of gender nonconformity. Gender nonconformity is a persistent tendency to behave like the other sex in a variety of ways, including preferences of dress and appearance, play style, playmate preferences, and interests and goals. A very gender nonconforming boy may dress up as a girl, play with dolls, dislike rough play, show indifference to team sports or contact sports, prefer girl playmates, try to be around adult women rather than adult men, and be known by other children as a “sissy” (a term generally used to ridicule and shame feminine boys). A very gender nonconforming girl shows an opposite pattern, with the less derogatory word “tomboy” replacing sissy.

Onset of gender nonconformity is childhood cases is very early, typically about as early as gendered behavior can be noticed.

It is important to understand that not all gender nonconforming children (even very gender nonconforming children) have gender dysphoria. Probably most don’t, in fact. But we know of no cases of childhood-onset gender dysphoria without gender nonconformity.

Gender dysphoria in the childhood cases requires that children are unhappy with their birth sex. Furthermore, they typically yearn to be–or even assert that they are–the other sex.

What do we know about childhood-onset gender dysphoria?

Childhood-onset gender dysphoria has been systematically studied by two high quality international research centers (one in Toronto, which was led by Kenneth Zucker, and one in the Netherlands, which was led by Peggy Cohen-Kettenis). Both centers have assessed and followed representative samples of gender dysphoric children seen at their clinics. Reassuringly, results are fairly similar across the two sites. Furthermore, their results are similar to less representative samples studied earlier in the United States.

The published literature shows that at least in the past, 60-90% of children whose gender dysphoria began before puberty adjusted to their birth sex without requiring gender transition. That may be changing, however, due to changes in clinical practice that encourage gender transition. (See below.)

It is important to realize that childhood-onset gender dysphoria is the only kind of gender dysphoria that has been well-studied in children and adolescents. This means, for example, that the persistence and desistance figures we have provided apply only to that type. We do not know comparable figures about autogynephilic or rapid-onset gender dysphoria. Furthermore, most people, when they think of “transgender children and adolescents” have childhood-onset gender dysphoria in mind. (And they think of happy Jazz more than they think of Jazz’s serious medical surgeries and hormonal treatment for life.) But this association is misleading for all cases of gender dysphoria that are not childhood-onset. Autogynephilic and rapid-onset gender dysphoria have very different causes and presentations than childhood-onset gender dysphoria.


Children with childhood-onset gender dysphoria have a much higher likelihood of non-heterosexual (i.e., homosexual or bisexual) adult outcomes compared with typical children. Childhood-onset gender dysphoric boys who desist usually become nonheterosexual men. A smaller percentage have reported that they are heterosexual at follow up. Those who transition become transwomen attracted to men.

Although most childhood-onset gender dysphoric girls who have been followed identify as heterosexual, those who desist have a much higher rate of nonheterosexuality compared with the general population. Among those who transition, most are attracted to women.

We repeat: there is no evidence that parents can change their children’s eventual sexual orientation, and we don’t think they should try.

Risk Factors for Persistence of Childhood-onset Gender Dysphoria

Which childhood-onset gender dysphoric children will persist, and which will desist? Evidence suggests that we can’t distinguish these two groups with high confidence, although we can distinguish them better than chance.

There is some evidence that the severity of gender dysphoria distinguishes these two groups, although it is far from a perfect predictor. Children who not only say they want to be the other sex but who assert that they are the other sex may be especially likely to persist. The reasons why a child’s expressed belief that s/he is the other sex predicts persistence remain unclear, and this variable does not allow even near-perfect prediction. The idea that it is the essential test of “true trans” is an overstatement.

Other empirically supported risk factors include being of lower socioeconomic status and having autistic traits, both of which predict persistence. Why should these factors matter? Researchers have speculated that socioeconomically disadvantaged families are more likely to have problems that prevent them from providing the consistent supportive social environment that may be most likely to help the gender dysphoric child desist. Autistic traits include perseverative and obsessional thinking, both of which may make desistance more difficult. Furthermore, parents of children with autistic traits may be so concerned about other problems that they are permissive about things likely to foster gender transition.

One powerful predictor of persistence is social transition, or a child’s living as the other sex. Until recently this was practically unheard of. Increasingly, however, it is not only known but encouraged by many gender therapists. (Watch an episode of “I am Jazz.”) In the Netherlands social transition has been common longer than in the United States. A recent study found that social transition was the most powerful predictor of persistence among natal males. That is, gender dysphoric boys allowed to live as girls strongly tended to want to become adult women. (The same trend occurred for natal females, but it was less robust.) This is not surprising. If a gender dysphoric child is allowed to live as the other sex, what will change his/her mind? No one disputes that gender dysphoric children really, really would like to change sex.

What should you do?

The necessary studies have not been conducted to be certain. But based on the overall picture, we suggest:

If you want your childhood-onset gender dysphoric child to desist, and if your child is still well below the age of puberty (which varies, but let’s say, younger than 11 years), you should firmly (but kindly and patiently) insist that your child is a member of his/her birth sex. You should consider finding a therapist if this is difficult for you and your child. You should not allow your child to engage in behaviors such as cross dressing and fantasy play as the other sex. Above all else, you should not let your child socially transition to the other sex.

At the same time, you should recognize that despite your best efforts, your child may ultimately need to transition to be happy. If your child’s gender dysphoria persists well into adolescence (again, the ages vary by child, but let’s say age 14 or so), s/he is much more likely to transition. At that point, in our opinion, parents should consider supporting transition.

Autogynephilic Gender Dysphoria (Adolescent Boys and Men)

From a parent’s perspective, autogynephilic gender dysphoria (which occurs only in natal males) often seems to come out of the blue. This is likely to be true whether the onset is during adolescence or adulthood. A teenage boy may suddenly announce that he is actually a woman trapped in a man’s body, or that he is transgender, or that he wants gender transition. Typically, this revelation follows his intensive internet research and participation in internet transgender forums. Importantly, the adolescent showed no clear, consistent signs of either gender nonconformity or gender dysphoria during childhood (that is, before puberty).

There is an important distinction between rapid-onset gender dysphoria and autogynephilic gender dysphoria that happens to have an adolescent onset. Rapid-onset gender dysphoria is suddenly acquired, whereas autogynephilic gender dysphoria may be suddenly revealed, after having grown in secret for a number of years. We will talk more about this later.

Where does autogynephilic gender dysphoria come from? We know a lot about the motivation of this kind of gender dysphoria. Most of our knowledge comes from studies of adults born male who transitioned during adulthood. Some of these adults had gender dysphoria during adolescence, but all of them had the root cause of their condition: autogynephilia.

(Warning: Autogynephilia is about sex. We understand that it is awkward and uncomfortable for any parent to consider their children’s sexual fantasies. But you can’t understand your son with this kind of gender dysphoria without doing so.)

Autogynephilia is a male’s sexual arousal by the fantasy of being a woman. That is, autogynephilic males are turned on by thinking about themselves as women, or behaving like women. The typical heterosexual adolescent boy has sexual fantasies about attractive girls or women. The autogynephilic adolescent boy’s may also have such fantasies, but in addition he fantasizes that he is an attractive, sexy woman. The most common behavior associated with autogynephilia during adolescence is fetishistic cross dressing. In this behavior, the adolescent male wears female clothing (typically, lingerie) in private, looks at himself in the mirror, and masturbates. Some autogynephilic males are not only sexually aroused by cross dressing, but also by the idea of having female body parts. These body-related fantasies are especially likely to be associated with gender dysphoria.

It is important to distinguish between autogynephilia and autogynephilic gender dysphoria. Autogynephilia is basically a sexual orientation, and once present does not go away, although its intensity may wax and wane. Autogynephilic gender dysphoria sometimes follows autogynephilia, and is the strong wish to transition from male to female. A male must have autogynephilia to have autogynephilic gender dysphoria, but just because he is autogynephilic doesn’t mean he will be gender dysphoric. Many autogynephilic males live their lives contented to remain male. Furthermore, sometimes autogynephilic gender dysphoria remits so that a male who wanted to change sex no longer does so.

In general, adolescent boys are unlikely to divulge their sexual fantasies to their parents. This is likely especially true of boys with autogynephilia. Furthermore, many boys who engage in cross dressing feel ashamed for doing so. The fact that autogynephilic fantasies and behaviors are largely private is one reason why autogynephilic gender dysphoria usually seems to emerge from nowhere. Another reason is that autogynephilic males are not naturally very feminine. An adolescent boy with autogynephilia does not give off obvious signals of gender nonconformity or gender dysphoria.

It is likely that most autogynephilic males do not pursue gender reassignment, but this is difficult to know. (We would need to conduct a representative survey of all persons born male, asking about both autogynephilia and gender transition. This has not been done and won’t be done anytime soon.) Many males with autogynephilia are content to cross dress occasionally. Some get married to women and many also have children. Family formation is no guarantee against later transition, although that may slow it up somewhat. In past decades, when autogynephilic males have transitioned, they have most often done so during the ages 30-50, after having married women and fathered children. It is possible that autogynephilic males have recently been attempting transition at younger ages, including adolescence.

The relationship between autogynephilia and (autogynephilic-type) gender dysphoria is uncertain. One view is that gender dysphoria may arise as a complication of autogynephilia, depending perhaps on chance events or environmental factors. Another view is that autogynephiles who become progressively gender dysphoric were somewhat different from simple autogynephiles from the beginning (for example, more obsessional). Because we do not actually know the causes of autogynephilia, it is quite difficult to sort out these various interpretations at present.

Autogynephilia—the central motivation of autogynephilic gender dysphoria—can be considered an unusual sexual orientation. As with other kinds of male sexual orientation, we do not know how to change it, and we shouldn’t try. The dilemma is how to live with autogynephilia in a way that allows the most happiness. For some with autogynephilia, this will mean staying male. For others, it will mean transitioning to female.

What do we know about autogynephilic gender dysphoria?

Much of what we know about autogynephilic gender dysphoria comes from research conducted on adults. Most of the early research was conducted by the scientist who developed the theory of autogynephilia, Ray Blanchard. This work was subsequently confirmed and extended by other researchers, especially Anne Lawrence, Michael Bailey, and Bailey’s students.

Blanchard’s research identified two distinct subtypes of gender dysphoria among adult male gender patients. One type, which he called “homosexual gender dysphoria” is identical to childhood onset male gender dysphoria. Males with this condition are homosexual, in the sense that they are attracted to other biological males. Blanchard provided persuasive evidence that the other male gender patients were autogynephilic. We currently favor the theory that there are only two well established kinds of gender dysphoria among males, because no convincing evidence for any other types has been offered. This could change­–we are committed to a scientific open-mindedness. In particular, it is possible that some cases of adolescent-onset gender dysphoria among males are essentially the same as Rapid-onset Gender Dysphoria that occurs among natal females. This will require more research to establish, however.

Autogynephilia is a probably rare, although it is difficult to know for certain. Among males who seek gender transition, however, it is common. In fact, in Western countries in recent years, including the United States, autogynephilia has accounted for at least 75% of cases of male-to-female transsexualism.

Given how important autogynephilia is for understanding gender dysphoria, it may surprise you that you had never heard of it. Autogynephilia remains a largely hidden idea because most people–including journalists, families, and many males with autogynephilia–strongly prefer the standard, though false, narrative: “Transsexualism is about having the mind of one sex in the body of the other sex.” Many people find this narrative both easier to understand and less disturbing than the idea that some males want a sex change because they find that idea strongly erotic.

Although many autogynephilic males find discovery of the idea of autogynephilia to be a positive revelation–autogynephilia has been as puzzling to them as it is to you–some others are enraged at the idea. There are two main reasons why some autogynephilic males are in denial. First, they correctly believe that many people find a sexual explanation of gender dysphoria unappealing–discomfort with sexuality is rampant. Second, they find this explanation of their own feelings less satisfying than the standard “woman trapped in man’s body” explanation. This is because autogynephilia is a male trait, and autogynephilia is about wanting to be female.

It is good to be aware of autogynephilia’s controversial status, because transgender activists are often hostile to the idea. You will not learn more about it from the activists. And if your son has frequented internet discussions, he may also resent the idea. We emphasize that autogynephilia is controversial for social reasons, not for scientific ones. No scientific data have seriously challenged it.


Males with autogynephilia can have a variety of autogynephilic fantasies and interests, from cross dressing to fantasizing about having female bodies to enjoying (for erotic reasons) stereotypical female activities such as knitting to fantasizing about being pregnant or menstruating. One study found that autogynephilic males who fantasize about having female genitalia also tended to be those with the greatest gender dysphoria.

Autogynephilic males sometimes identify as heterosexual (i.e., attracted exclusively to women); sometimes as bisexual (attracted to both men and women), and sometimes as asexual (i.e., attracted to no individuals). Blanchard’s work has shown that autogynephilia can be thought of as a type of male heterosexuality, one that is inwardly directed. Autogynephilia often coexists with outward-directed heterosexuality, and so autogynephilic males usually say they are also attracted to women. Some autogynephilic males enjoy the idea that they are attractive, as women, to other men. They may have sexual fantasies about having sex with men (in the female role); some may even act on these fantasies. This accounts for the bisexual identification among some autogynephilic males. In some others, the intensity of the autogynephilia–which is attraction to an imagined “inner woman”–is so great that there are no erotic feelings left for other people. This accounts for asexual identification. (Asexual autogynephilic males have plenty of sexual fantasies, but these fantasies tend not to involve other people.)

When autogynephilic males receive female hormones as part of their gender transition, they typically experience a noticeable decrease in their sex drive. Some have reported that this has diminished their desire for gender transition as well. Others, however, have reported no change in their desire for transition. (In any case, hormonal therapy is a medical intervention with serious potential side effects, and we do not recommend it as a way to treat gender dysphoria, except in cases in which after very careful consideration, gender transition is pursued.)

Autogynephilia is a paraphilia, meaning an unusual sexual interest nearly exclusively found in males.

We repeat: Autogynephilia is a sexual orientation–to be sure, an unusual orientation that is difficult to understand. There is no evidence that parents can change their children’s sexual orientations. And we don’t think they should try.

What should you do?

Consistent with our values, knowledge, and common sense, we believe that males with autogynephilic gender dysphoria should not pursue gender transition right away, as soon as they first have the idea. Transition ultimately requires serious medical procedures with irreversible consequences. But we are unsure what the right approach to autogynephilic gender dysphoria is. In part, this is because there has been too little outcome research conducted by scientists knowledgeable and open about autogynephilia.

First, we recommend that your son be informed about autogynephilia. The best way to do this is up to you. There is probably no non-awkward way. Consider showing them this blog. People should make important life decisions based upon facts, and for males autogynephilic gender dysphoria, autogynephilia is a fact. The standard “female mind/brain in male body” is a fiction.

Some males become less motivated to pursue gender change when they understand their autogynephilia. However, some do not become less motivated. We know far less about patterns of persistence and desistance of autogynephilic gender dysphoria than we do about childhood onset gender dysphoria.

If an autogynephilic male has become familiar with the scientific evidence, has patiently considered the potential consequences of gender transition over a non-trivial time period, and still wishes to transition, we do not oppose this decision. It is possible that many autogynephilic males are happier after gender transition. But there is no rush for any adolescent to decide.

Rapid-onset Gender Dysphoria (Mostly Adolescent and Young Adult Females)

Rapid-onset gender dysphoria (ROGD) seems to come out of the blue. We think this is because ROGD does come out of the blue. This is not to say that all adolescents with ROGD were happy and mentally healthy before their ROGD began. But importantly, they had no sign of gender dysphoria as young children (before puberty).

The typical case of ROGD involves an adolescent or young adult female whose social world outside the family glorifies transgender phenomena and exaggerates their prevalence. Furthermore, it likely includes a heavy dose of internet involvement. The adolescent female acquires the conviction that she is transgender. (Not uncommonly, others in her peer group acquire the same conviction.) These peer groups encouraged each other to believe that all unhappiness, anxiety, and life problems are likely due to their being transgender, and that gender transition is the only solution. Subsequently, there may be a rush towards gender transition, including hormones. Parental opposition to gender transition often leads to family discord, even estrangement. Suicidal threats are common.*

We believe that ROGD is a socially contagious phenomenon in which a young person–typically a natal female–comes to believe that she has a condition that she does not have. ROGD is not about discovering gender dysphoria that was there all along; rather, it is about falsely coming to believe that one’s problems have been due to gender dysphoria previously hidden (from the self and others). Let us be clear: People with ROGD do have a kind of gender dysphoria, but it is gender dysphoria due to persuasion of those especially vulnerable to a false idea. It is not gender dysphoria due to anything like having the mind/brain of one sex trapped in the body of the other. Those with ROGD do, of course, wish to gender transition, and they often obsess over this prospect.

The subculture that fosters ROGD appears to share aspects with cults. These aspects include expectation of absolute ideological agreement, use of very specific jargon, thinking of the world as “us” versus “them” (even more than typical adolescents do), and encouragement to cut off ties with family and friends who are not “with the program.” It also has uncanny similarities to a very harmful epidemic that occurred a generation ago: the epidemic of false “recovered memories” of childhood sexual abuse and the associated epidemic of multiple personality disorder. We discuss these more below. First, however, we review what little we know about ROGD.

What About Natal Males?

Why do we keep emphasizing natal females versus natal males? There are three reasons. First, the single study that has been conducted on ROGD found substantially higher numbers of females than males (more than 80% female cases). Second, there has been a striking surge in the number of adolescent females identifying as transgender and presenting at gender clinics. Third, there is a different kind of gender dysphoria–Autogynephilic Gender Dysphoria–that likely accounts for most or all of the apparent cases of ROGD in natal males. However, we cannot be completely sure that the smallish number of ROGD cases in natal males are due to autogynephilia. It’s possible, therefore, that what we discuss here applies to some natal males as well.

What Do We Know?

ROGD is such a recent phenomenon that we know little for certain. We have four sources of data. First, an important study of ROGD has been presented by Lisa Littman at the annual meeting of the International Academy of Sex Research. (It has not yet been published, but we suspect it will be soon.) This is the only systematic empirical study to date. Second, we have had numerous conversations with mothers of girls with ROGD. Third, we have read several case studies of the phenomenon. Fourth, we have been in touch with clinicians who work (either as therapists or consultants) with children with ROGD, or their families. Fortunately, the sources have provided convergent findings. We are fairly confident about the following generalizations:

–The large majority of persons with ROGD are female, and the most typical age of onset ranges from high school to college ages.

–Persons with ROGD have a high rate of non-heterosexual identities before the onset of their ROGD.

–Signs of extreme social contagion are typical. For example, this includes multiple peer group members who all began to identify as transgender. Sometimes this occurs after school-sponsored transgender educational programs.

–Persons with ROGD have high rates of certain psychiatric problems, especially aspects related to borderline personality disorder (e.g., non-suicidal self-harm) and mild forms of autism (that used to be called “Asperger Syndrome).

–In general, the mental health and social relationships of children with ROGD get much worse once they adopt transgender identities.

–Parents resisting their children’s ROGD are not “transphobic” or socially intolerant. These are parents who, for example, usually approve of gay marriage and equal rights for transgender persons.

Our Current Take on ROGD

Rapid-onset Gender Dysphoria (ROGD) occurs when a young person (generally an adolescent female) is persuaded that she is transgender, despite strong evidence that the young person had few or no signs associated with established forms of transgender. How and why does this happen?

Despite the very limited available research to date, we have strong intuitions and hunches about what is going on, based on its similarity to similar phenomena in the past: the recovered memories and multiple personality epidemics. We spend considerable effort in this section both explaining these past epidemics and drawing the parallels to the current one that concerns us now: Rapid-onset Gender Dysphoria. We believe that she who forgets (or ignores) the past is doomed to repeat it.

During the 1990s there was an explosion of cases in which women came to believe that they had been sexually molested, usually by their fathers and often repeatedly and brutally. They believed these things even though prior to “recovering” these “memories”–most often during psychotherapy–they did not remember anything like them. They believed in the memories even though the memories were often highly implausible (for example, family members would have noticed). Many women with recovered memories cut off relationships with their families. Some developed symptoms of multiple personality disorder. We know now that the recovered memories were false. And multiple personality disorder doesn’t exist, at least in the way those affected and their therapists believed. We refer to recovered memories and multiple personality disorder, which have similar causes–and also some similar causes to ROGD–as RM/MPD

Here are the main similarities between ROGD and RM/MPD:

  1. Cases consistent with RM/MPD were very rare prior to the 1980s but became an epidemic. The same appears to be happening with ROGD.
  2. Both have primarily affected young females, although RM/MPD began substantially later (on average, age 32) than ROGD (typically during adolescence). (Another destructive epidemic of social contagion–witch accusations in colonial Salem–primarily involved adolescent girls.)
  3. The explanations of both RM/MPD and ROGD by “true believers” are contradicted by past experience, common sense, and science. Memory and personality integration did not work the way that therapists treating RM/MPD believed they did. For example, children and adults who experienced trauma can’t repress them–they remember them despite their best attempts. And gender dysphoria in natal females does not begin after childhood–unless it is the acquired condition that is ROGD.
  4. Both show ample evidence of social contagion of false, harmful beliefs. In RM/MPD, the “infection route” usually went from therapists who strongly believed in RM/MPD to their suggestible patients, who acquired a similar belief, applied it to their own lives, and manufactured false and monstrous accusations against previously loved ones. (A harmful result of therapy or medical treatment is called iatrogenic,) In ROGD, the infection route appears to be primarily directly from youngster to youngster. To be sure, therapists get into the act after the person with ROGD acquires the belief that she is transgender, and then they are complicit in tremendous harm. But it seems rarely to occur (yet) for a youngster to be talked into ROGD by a therapist.
  5. Both are associated with sociopolitical ideologies. (Interestingly, both ideologies still find comfortable homes in Gender Studies programs in many universities.) For RM/MPD, the ideological system was that men’s sexual abuse of children has not only been too common (true), but that it has been rampant, even the rule (false). Couple this ideology with a belief in Freudian theory and methods (like hypnosis), and what could go wrong? Plenty, it turned out. For ROGD, the relevant ideology is less coherent, but includes the seemingly contradictory ideas that gender is “fluid” (here meaning that not everyone fits into a male-female dichotomy); that forcing people into rigid gender categories is a common cause of societal and personal anguish; but that gender transition is an underused way of helping people.
  6. Both RM/MPD and ROGD are associated with mental health issues, generally, and especially a personality profile consistent with borderline personality disorder (BPD). This is not to say that all persons with either RM/MPD or ROGD have BPD; simply that evidence suggests that it is common in these groups. For example, the high rate of non-suicidal self-injury we have noticed from the aforementioned sources is striking. Such behavior is strongly associated with BPD. (For a discussion of BPD among those with RM/MPD, see this article, pages 510ff.)
  7. Adopting the belief that one has either RM/MPD or ROGD has been associated with a marked decline in functioning and mental health.

Some of the factors that seem to be common in ROGD–and some that are similar between ROGD and RM/MPD–likely encourage the adoption of false beliefs and identities. These include a fragile sense of self (BPD), attention seeking (BPD), social difficulties (BPD and autistic traits), social malleability (BPD, and adolescence), social pressure (adolescence), and strongly held (if irrational and poorly supported) beliefs that make embracing false conclusions especially likely (sociopolitical indoctrination). Adolescents with an actual history of gender nonconformity, or whose sexual orientations are non-heterosexual, may be especially vulnerable to believing that these are signs they have always been transgender. Adolescents whose lives have not been going well may be especially looking for an explanation and may be especially receptive to drastic change.

Based on the aforementioned data sources with which we are familiar, and on our informed hunches, we suspect that many persons with ROGD were usually troubled before they decided they were gender dysphoric and many will lead somewhat troubled lives even after their ROGD (hopefully) dissipates. Of course, ROGD can only make things worse, both for the affected person and her family.

What to do

Because ROGD is such a recent phenomenon, there is very little guidance about helping affected persons. Lisa Marchiano has written two excellent essays abounding with good sense, and we recommend starting with those.

Second, set aside, for now, rapid-onset gender dysphoria. Identify your child’s problems that existed before ROGD and that may have contributed to it. Attending to these problems will be useful for everybody, and perhaps your child will even agree.

Third, with respect to ROGD, do what you can to delay any consideration of gender transition. Of the different kinds of gender dysphoria, ROGD is the type for which gender transition is least justifiable and least researched. Remember, ROGD is based on a false belief acquired through social means. None of the aforementioned factors that have caused your child to embrace this false belief will be corrected by allowing her to transition.

Two Rarer Types of Gender Dysphoria

For the sake of completeness, we include two other kinds of gender dysphoria. We suspect that both are rare, even among persons with gender dysphoria. One of us (Blanchard) has seen cases of the first type, autohomoerotic gender dysphoria, which appears to be an erotically motivated gender dysphoria. In this case, sexually mature natal females (i.e., not biologically still children) become sexually preoccupied with the idea of becoming a gay man and interacting with other gay men. Neither of us has seen someone clearly fitting the second type, gender dysphoria resulting from psychosis. (Our inclusion of this type was motivated in large part by the argument of Dr. Anne Lawrence, an important scholar we both respect.) In this type, a person (either male or female by birth) acquires the delusion that s/he is the other sex, because s/he is suffering from gross thinking deficiencies.

Superficially, both of these conditions have some similarities to some other kinds of gender dysphoria. For example, a female with rapid onset gender dysphoria may be sexually attracted to males and thus strive to become a gay man, similar to autohomoerotic gender dysphoria. The important difference is that the female with rapid onset gender dysphoria is not primarily motivated by an erotic desire to be a gay man. Instead, having the prospect of having sex with gay men is a by-product of her condition, not the main point of it. The female with rapid onset gender dysphoria acquires it via social contagion, broadly speaking (i.e., including cultural signals that gender dysphoria is in some crucial ways desirable). With respect to the other rare subtype, we have both known gender dysphoric persons with psychosis. However, in these cases, the psychosis was not the cause of the gender dysphoria. It was simply an additional problem that the gender dysphoric person had. In the case of gender dysphoria resulting from psychosis, the belief that one is transgender (or the other sex) is clearly a delusion resulting from disordered thinking–and not, for example, from social contagion or autogynephilia.

Autohomoerotic Gender Dysphoria

This rare type of gender dysphoria is limited to females. Published cases have consisted of women whose gender dysphoria began in late adolescence or adulthood. (It is conceivable that it might begin earlier in some cases.) It occurs in (heterosexual) females who are sexually attracted to men, but who wish to undergo sex reassignment so that they can have “homosexual” relations with other men. These females appear to be sexually aroused by the thought or image of themselves as gay men. We have created the label autohomoerotic gender dysphoria to denote this sexual orientation. There are little systematic data on this type of gender dysphoria, although clinical mentions of heterosexual women with strong masculine traits, who say that they feel as if they were homosexual men, and who feel strongly attracted to effeminate men go back over 100 years.

It is well documented that at least a few autohomoerotic gender dysphorics have undergone surgical sex reassignment and were satisfied with their decision to do so. There is no compelling reason to question such self-reports of postoperative satisfaction, although current surgical techniques do not produce fully convincing or functional artificial penises, and it is difficult to imagine that autohomoerotics find it easy to attract gay male partners who can overlook this.

This type of gender dysphoria does not appear to be the female counterpart of autogynephilic gender dysphoria, although the differences might appear subtle. Autogynephilic (male) gender dysphorics are attracted to the idea of having a woman’s body; autohomoerotic (female) gender dysphorics are attracted to the idea of participating in gay male sex. For autogynephiles, becoming a lesbian woman is a secondary goal—the logical consequence of being attracted to women and wanting to become a woman. For autohomoerotics, becoming a gay man appears to be the primary goal or very close to it.

The few available case reports suggest that autohomoerotic gender dysphoria may have ideational or behavioral antecedents in childhood. However, these females are not as conspicuously masculine as girls with (pre-homosexual) Childhood Onset Gender Dysphoria. For this reason, and because it is rare to start with, it is unlikely that many parents will detect this syndrome in daughters. It is conceivable, however, that when they occur, cases of autohomoerotic gender dysphoria may be perceived by others as Rapid Onset Gender Dysphoria. This is not because their gender dysphoria arose suddenly, but rather because their early, atypical erotic fantasies were invisible to their parents.

Gender Dysphoria Caused by Psychotic Delusions

The idea that gender dysphoria can sometimes reflect psychotic delusions is certainly plausible. Delusions in schizophrenia, for example, are often bizarre but compelling to the person who has them. Unfortunately, neither of us (Ray Blanchard or Michael Bailey) has had direct contact with a person clearly meeting this profile, and so we have less confidence in this gender dysphoria category than in the others. Our lack of direct familiarity doesn’t necessarily mean that much. Even if gender dysphoria due to psychosis were fairly common (compared with other forms of gender dysphoria), we wouldn’t have expected to come across it. Persons with severe mental illness have generally been treated for their mental illness and not for gender dysphoria. Until recently, clinics treating persons with gender dysphoria would have screened out patients with severe mental illness, because of concerns that their diagnosis and treatment might be compromised. But we are hesitant to embrace this kind of gender dysphoria as “definitely existing,” because we worry that psychiatrists who have claimed to see it may have been insufficiently trained to notice other kinds of gender dysphoria, such as autogynephilia. Thus, they may have concluded that psychosis caused the gender dysphoria, when in fact, psychosis may have simply occurred with autogynephilia within the same person. One of us (Bailey) has recently been in touch with a mother of a young man who appears to have the profile we would expect for gender dysphoria due to psychotic delusions, and there was no evidence that this young man was autogynephilic. Still, we are least sure about the existence–much less the prevalence–of this kind of gender dysphoria.

Not Just One Type of Gender Dysphoria: Some Implications

It should be clear by now that “gender dysphoria” is not a precise enough term. Parents of gender dysphoric children should know which type of gender dysphoria their child has. To do so it is necessary to learn about all three of the most common types. That is, in order to understand why one’s child is Type X, it is necessary to know why s/he is not Type Y or Type Z. This is not simply academic. There are essential differences between the different types of gender dysphoria.

If knowledge is power, then lack of knowledge is malpractice. The ignorance of some leading gender clinicians regarding all scientific aspects of gender dysphoria is scandalous. To do better, they should start here. We recommend against hiring gender clinicians who are hostile to our typology. Ideally, they would agree with it.

Knowing there are very distinct kinds of gender dysphoria also raises questions–and concerns–about transgender persons of one type using their own experiences to make recommendations for children/adolescents of other types. Nothing in Caitlyn Jenner’s experience allows her to understand what it was like to be Jazz Jennings–and vice versa. Yet a number of vocal transgender activists who have histories typical of autogynephilic gender dysphorics do not hesitate to pressure parents, legislators, and clinicians for acquiescence, laws, and therapies that do not distinguish among types of gender dysphoric children. Moreover, they not infrequently claim inside knowledge based on their own experiences. Yet their experiences are irrelevant to the two types of gender dysphoria that they don’t have. And even with respect to autogynephilia, these transgender activists are nearly all in denial. This means that their public recollections of their experiences are either distorted or outright lies. A notable exception is Dr. Anne Lawrence, who has become an important researcher of gender dysphoria, and who has been honest and open about her autogynephilia. Dr. Lawrence has taken the time to learn the scientific literature regarding different types of gender dysphoria and does not insist that her personal experiences apply to non-autogynephilic gender dysphorics. The biggest victims in the attempts by autogynephiles-in-denial to steer the narrative towards sameness are, in fact, other persons with autogynephilia. These include honest autogynephiles, who frequently contact us but are fearful of public attacks by those in denial. Most relevant to this blog as potential victims are autogynephilic youngsters, who are at risk of being swayed toward decisions they would not otherwise make, on the basis of inaccurate fantasies embraced by those who cannot face the truth of their own condition.

To us, the most tragic group, along with their families, includes those who have acquired rapid-onset gender dysphoria. That condition appears to be the tragic interaction of the current transgender zeitgeist (“It’s everywhere, and it’s great!”) and social media with the vulnerability of troubled adolescents, especially adolescent girls. They are at risk for unnecessary, disfiguring, and unhealthy medical interventions.

*Note. Suicide is tragic and awful, and because of this, we recommend taking seriously your child’s suicidal ideas, threats, and gestures. We have written elsewhere about the risk of suicide among gender dysphoric persons, and we think that this risk is elevated compared with non-gender-dysphoric persons, but still unlikely.


Suicide or transition: The only options for gender dysphoric kids?

by J. Michael Bailey, Ph.D  and Ray Blanchard, Ph.D

This is the first in a series of articles authored by Drs. Bailey and Blanchard. As their time permits, they will be available to interact in the comments section of this post. Please note: As always on 4thWaveNow, if you disagree with the content of this article, your comments will be more likely to be published if they are delivered respectfully. Hateful or trollish comments will be deleted.

Michael Bailey is Professor of Psychology at Northwestern University. His book The Man Who Would Be Queen provides a readable scientific account of two kinds of gender dysphoria among natal males, and is available as a free download here.

Ray Blanchard received his A.B. in psychology from the University of Pennsylvania in 1967 and his Ph.D. from the University of Illinois in 1973. He was the psychologist in the Adult Gender Identity Clinic of Toronto’s Centre for Addiction and Mental Health (CAMH) from 1980–1995 and the Head of CAMH’s Clinical Sexology Services from 1995–2010.

It is increasingly common for gender dysphoric adolescents and mental health professionals to claim that transition is necessary to prevent suicide. The tragic case of Leelah Alcorn is often cited as the rallying cry: “transition or else!” Leelah (originally Joshua) was a gender dysphoric natal male who committed suicide at age 17, blaming her parents for failing to support her gender transition and forcing her into Christian reparative therapy. Subsequently, various “Leelah’s Laws” banning “conversion therapy” for gender dysphoria (among other things) have been passed or are being considered across the United States.

The suicide of one’s child is every parent’s nightmare. Given the choice for our child between gender transition and suicide, we would certainly choose transition. But the best scientific evidence suggests that gender transition is not necessary to prevent suicide.

We provide a more detailed essay below, but here’s the bottom line:

  1. Children (most commonly, adolescents) who threaten to commit suicide rarely do so, although they are more likely to kill themselves than children who do not threaten suicide.
  2. Mental health problems, including suicide, are associated with some forms of gender dysphoria. But suicide is rare even among gender dysphoric persons.
  3. There is no persuasive evidence that gender transition reduces gender dysphoric children’s likelihood of killing themselves.
  4. The idea that mental health problems–including suicidality–are caused by gender dysphoria rather than the other way around (i.e., mental health and personality issues cause a vulnerability to experience gender dysphoria) is currently popular and politically correct. It is, however, unproven and as likely to be false as true.

Suicide vs Suicidality vs Non-suicidal Self-injury

Suicide is a rare event. In the United States in 2014, about 13 out of every 100,000 persons committed suicide. Suicide was most common among middle aged white males, who accounted for about 7 out of 10 known suicides.

It is helpful to distinguish at least four different things: Completed suicide means death by suicide. Suicidality means either thinking about committing suicide or attempting suicide. Non-suicidal self-injury means injuring oneself (most often by cutting one’s skin) without intending to die. Finally, mental illness includes a variety of conditions, from depression to conduct disorder to personality disorders (such as borderline personality disorder) to schizophrenia–some of which are especially strongly associated with completed suicide and suicidality, others of which are more strongly associated with non-suicidal self-injury.

Obviously, completed suicide is what we are most worried about. Because it is so rare, however, and because it is often difficult to know about the dead person’s motivations for suicide, it has been especially difficult to study. There are fewer studies focusing on gender dysphoria and completed suicide than on gender dysphoria and either suicidality or non-suicidal self-injury. Studies of suicidality must rely on self-report (for example, someone must report that they are, or have been, thinking about committing suicide), and this complicates interpretations of results. (Maybe some people, some times, are especially likely to say they have been suicidal, even if they haven’t been.) Also there is more than one kind of gender dysphoria–we think there are three (this is a topic for another day)–and we should not expect risks to be identical for all types.

The Scientific Literature

Our aim here is not to review every available study, but to focus on the best evidence. Larger, more representative studies–and most importantly, studies of completed suicide–are most informative.

Studies of Completed Suicides

 Two large systematic studies of completed suicide and gender dysphoria have been published, one from the Netherlands, the other from Sweden. Notably, both countries are socially liberal, and both studies were conducted fairly recently (1997 and 2011). Both studies focused on patients who had been treated medically at national gender clinics. These patients all either began or completed medical gender transition, and we refer to them as “transsexuals.” (We don’t know how many of the patients there were from each of the three types we believe exist.)

The Dutch study’s suicide data were of male-to-female transsexuals (natal males transitioned to females) treated with cross-sex hormones (and many also with surgery). Of 816 male-to-female transsexuals, 13 (1.6%) completed suicide. This was 9 times higher than expected. Still, suicide was rare in the sample. The Swedish study found an even larger increase in the rate of suicide, 19 times higher among the transsexuals than among a non-transsexual control group. Still, only 10 out of 324 transsexuals (i.e., 3.1% of the group) committed suicide. Again, still rare. Note that both studies were of gender dysphoric persons who transitioned. As such, their results hardly support the curative effects of transition.

The Dutch and Swedish studies were of adults whose gender dysphoria may or may not have begun in childhood. No published study has focused only on childhood onset cases. However, psychologist Kenneth Zucker has tracked the outcome of more than 150 childhood onset cases treated at the Centre for Addiction and Mental Health into adolescence and young adulthood. He has generously shared with us (in a personal communication) his outcome data for suicide. Out of those more than 150 cases followed, only one had committed suicide. Furthermore, Dr. Zucker’s understanding (based on parent report) is that this suicide was not due to gender dysphoria, but rather to an unrelated psychiatric illness. On the one hand, one suicide out of 150 cases is more than we’d expect by chance. On the other hand, it is a rare outcome among gender dysphoric children and adults.

Studies of Suicidality and Non-suicidal Self-injury

People who commit suicide were suicidal before they did so. But most people who are suicidal do not commit suicide. “Suicidal” is necessarily a vague word, encompassing “intends to commit suicide” and “thinks about suicide,” both in a wide range of intensity. Furthermore, most studies would include as “suicidal” someone who falsely reports a past or present intention to commit suicide.

Why would anyone falsely report being suicidal? One reason is to influence the behavior of others. Saying that one is suicidal usually gets attention–sympathy, for example. It can be a way of impressing others with the seriousness of one’s feelings or needs. Although this possibility has not been directly studied, reporting suicidality may sometimes be a strategy for advancing a social cause.

According to data from the Centers for Disease Control (CDC), the rates of intentional but non-fatal self-injury peak during adolescence at about 450 per 100,000 girls and a bit fewer than 250 per 100,000 boys. These rates are much higher than the 13 per 100,000 American completed suicides per year (and remember that suicide is more common among adults than adolescents). So it is reasonable to assume that most adolescent self-injury is not intended to end one’s life. We are not suggesting that parents ignore children’s self-injury. We simply mean that self-injury often has motives besides genuinely suicidal intent.

 Not surprisingly, given the increased rates of suicide among gender dysphoric adults, suicidality (i.e., self-reported suicidal thoughts and past “suicide attempts”) is also higher among the transgendered. One recent survey statistically analyzed by the Williams Institute reported that 41% of transgender adults had ever made a suicide attempt, compared with a rate of 4.6% for controls. This survey recruited respondents using convenience sampling, however, and this may have inflated the rate of suicidal reports. Additionally, the authors of the survey included the following (admirable) disclaimer):

Data from the U.S. population at large, however, show clear demographic differences between suicide attempters and those who die by suicide. While almost 80 percent of all suicide deaths occur among males, about 75 percent of suicide attempts are made by females. Adolescents, who overall have a relatively low suicide rate of about 7 per 100,000 people, account for a substantial proportion of suicide attempts, making perhaps 100 or more attempts for every suicide death. By contrast, the elderly have a much higher suicide rate of about 15 per 100,000, but make only four attempts for every completed suicide. Although making a suicide attempt generally increases the risk of subsequent suicidal behavior, six separate studies that have followed suicide attempters for periods of five to 37 years found death by suicide to occur in 7 to 13 percent of the samples (Tidemalm et al., 2008). We do not know whether these general population patterns hold true for transgender people but in the absence of supporting data, we should be especially careful not to extrapolate findings about suicide attempts among transgender adults to imply conclusions about completed suicide in this population.

That is, importantly, the authors realize that suicidality and completed suicide are very different things, and it is suicidality that they have studied. Completed suicides in their group will be much, much lower.

Increased suicidality for gender dysphoric children was also reported by parents in a recent study by Kenneth Zucker’s research group.

A systematic review of non-suicidal self-injurious behavior in “trans people” found a higher rate, especially for trans men (i.e., natal females who have transitioned to males). The most common method mentioned was self-cutting. (Self-cutting is a common symptom of borderline personality disorder, which is also far more common among non-transgender natal females than among natal males.)

Is Transition the Answer, After All?

In a very recent study psychologist Kristina Olson reported that parents who supported their gender dysphoric children’s social transition rated them just as mentally healthy as their non-gender-dysphoric siblings. Furthermore, parents’ reports suggested that the socially transitioned gender dysphoric children were not less mentally healthy than a random sample would be expected to be.

This research falls far short of negating or explaining the findings we have reviewed above. First, it was relatively small, including only 73 gender dysphoric children. Second, families were recruited via convenience sampling, increasing the likelihood of various selection biases. For example, it is possible that especially mentally healthy families volunteer for this kind of research. Third, the assessment was a brief snapshot; we would expect socially transitioned gender dysphoric children to be faring better at that snapshot compared with children struggling with their gender dysphoria. (There is little doubt that at first, gender dysphoric children are happier if allowed to socially transition.) Young gender dysphoric children do not show that many psychological or behavior problems, aside from their gender issues. The aforementioned study by Kenneth Zucker’s research group showed that mental health problems, including suicidality, increased with age. Perhaps this won’t happen with Olson’s participants, but it’s too soon to know.

Why Is Gender Dysphoria Associated with Mental Problems, Including Suicidality?

 We don’t know.

The current conventional wisdom is that gender dysphoria creates a need for gender transition that, if frustrated, causes all the problems. That is a convenient position for pro-transition clinicians and activists. But they simply don’t know that this is true. Furthermore, both our past experience studying mental illness scientifically and specific findings related to gender dysphoria suggests the conventional wisdom is unlikely to be correct.

As an example, Leelah Alcorn’s suicide (like most suicides) was tragic, but she appears to have had problems that were not obviously caused by her gender dysphoria. She posted as Joshua (her male identity) on Tumblr:

“I’m literally such a bitch. shit happens in my life that isn’t even really that bad and all I do is complain about it to everyone around me and threaten to commit suicide and make them feel sorry for me, then they view me as sub-human and someone they have to take care of like a child. then when they don’t meet my each and every single expectation I lash out at them and make them feel like shit and like they weren’t good enough to take care of me. since I can only find imperfections in myself I try my hardest to find imperfections in everyone around me and use them as a way to one up myself and make others feel bad to make myself look better.”

Sophisticated causal analysis of mental illness and life experiences has invariably shown that things are more complex than previously assumed. For example, although depression is certainly caused by adverse life experiences, those vulnerable to depression have a tendency to generate their own stressful life experiences. So it’s not as simple as depression being caused by life experiences alone. Also, depression has a considerable genetic influence. Similarly, women with borderline personality disorder (BPD) report that they have experienced disproportionate childhood sexual abuse (CSA), and many clinicians and researchers have assumed that CSA causes BPD. But one just can’t assume the causal direction goes that way–one must eliminate alternative possibilities. Recent sophisticated studies suggest that, in fact, CSA does not cause BPD.

Research to understand the link between gender dysphoria, various mental problems (including suicidality), and completed suicides will take time. There is already plenty of reason, however, to doubt the conventional wisdom that all the trouble is caused by delaying gender transition of gender dysphoric persons. We have already mentioned the fact that transitioned adults who had been gender dysphoric (i.e., “transsexuals”) have increased rates of completed suicide. Their transition did not prevent this, evidently. Suicide (and threats to commit suicide) can be socially contagious. Thus, social contagion may play an important role in both suicidality and gender dysphoria itself. Autism is a risk factor for both gender dysphoria and suicidality. No one, to our knowledge, believes that gender dysphoria causes autism.


Parents with gender dysphoric children almost always want the best for them, but many of these parents do not immediately conclude that instant gender transition is the best solution. It serves these parents poorly to exaggerate the likelihood of their children’s suicide, or to assert that suicide or suicidality would be the parents’ fault.


Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., & Zucker, K. J. (2016). Self-harm and suicidality in children referred for gender dysphoria. Journal of the American Academy of Child & Adolescent Psychiatry55(6), 513-520.

Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one6(2), e16885.

Marshall, E., Claes, L., Bouman, W. P., Witcomb, G. L., & Arcelus, J. (2016). Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature. International review of psychiatry28(1), 58-69.

Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic reviews30(1), 133-154.

Van Kesteren, P. J., Asscheman, H., Megens, J. A., & Gooren, L. J. (1997). Mortality and morbidity in transsexual subjects treated with cross‐sex hormones. Clinical endocrinology47(3), 337-343.