Persistence of Transgender Gender Identity Among Children and Adolescents

Between 2.5% and 8.4% of children and adolescents worldwide identify as transgender or gender-diverse and rates are increasing over time.¹  This increase is accompanied by a rise in the number of families seeking advice on how to address gender concerns among their children and adolescents.^2–4  Many providers have limited experience caring for this population and it can be difficult for them to provide advice and treatment.^5–7 

A number of effective interventions are available to assist transgender children and adolescents. Parental support for social transition, which can include changing the youth’s hair, clothes, behavior, pronouns, and/or name to better align with the patient’s perceived gender identity, is associated with improved emotional outcomes.^8–10  Use of gonadotropin-releasing hormone analogs to temporarily pause further development in peripubertal youth and give them time to explore and confirm their gender identity before starting any other treatments is associated with improved global functioning, reductions in behavioral and emotional problems, and decreased rates of depression and suicidal ideation among transgender and gender-diverse youth who have not completed puberty.^9–11  Gender-affirming hormones can help older adolescents align their body and experienced gender, producing improved quality of life, body satisfaction, and mental health among transgender youth.^12–15  However, use of gender-affirming hormones is associated with permanent changes to the patient’s fertility and appearance and is restricted to adolescents who can understand the risks and benefits of gender-affirming hormones.^9,10  Treatment guidelines suggest that almost all adolescents have the mental capacity to provide informed consent to treatments with irreversible effects by age 16, and some patients as young as 14 can demonstrate this capacity.^9,13,16,17 

Despite efforts to help patients and families to balance the risks and benefits of treatment and protect adolescents from harm, some youth will experience a change in gender identity after starting gender-affirming hormones and express regret over the irreversible effects of treatment. Concern over future regret has led some providers to object to gender-affirming treatment and question the ability of minors to truly consent/assent to these treatments.¹⁸  Some members of the judiciary in the United Kingdom and United States state legislatures have expressed similar concerns and restricted or prohibited access to gender-affirming care for minors.^19,20  For example, 3 states in the United States have passed laws prohibiting gender-affirming medical care for minors and 21 others are considering similar laws.

Estimating the long-term risks associated with treatment is difficult because it is unclear how often patients experience regret after treatment. Studies examining persistence of gender identity found that only 20% of youth engaged in gender-nonconforming behavior before puberty will report a transgender gender identity as an adult, suggesting that gender identity can be transient during childhood and adolescence.^21–24  Persistence is associated with increased intensity of gender-related dysphoria, assertion of gender identity cognitively versus affectively, and degree of social transition.^21–25  Among prepubertal transgender patients, 100% of patients with a complete social transition, 60.1% with a partial transition, and 25.6% of patients who had not socially transitioned reported a transgender identity 7 years later.^22,23 

Among adults with a history of gender-nonconforming behavior during childhood, both cis-gender and transgender adults identified at age 10 to 13 years, the typical onset of puberty, as a key time for consolidation of gender identity, with few changes occurring after this time.^22,23 Among peri- or postpubertal transgender youth receiving gender-affirming medications at specialized gender clinics, 1.9% to 3.5% of patients discontinued treatment.^9,11,26,27  Among adolescents obtaining gender-affirming hormones from the United States Military Health System, 25.6% stopped treatment within 4 years of starting.²⁸  These studies did not assess reasons for discontinuing treatment.

Most adults who stop gender-affirming hormones report doing so for reasons unrelated to a change in gender identity, such as pressure from family, difficulty obtaining employment, or discrimination.²⁶  Also, some patients who experience a change in gender identity and stop treatment do not express regret with the experience.^29–31 

Reports of increased stability of gender identity after puberty, high treatment continuation rates, and low levels of regret after discontinuation suggest that regret after starting gender-affirming hormones is a relatively rare event. However, stability of gender identity before and after puberty among children and adolescents has not been assessed in a prospective manner.

In this issue of Pediatrics, Olsen et al³² describe the persistence of gender identity during the first 5 years of enrollment in a cohort of transgender children who completed a social transition before age 12. This study provides a detailed look at stability of transgender gender identity before and after the onset of puberty.³²  The high persistence rates in this prospective study confirm previous findings and suggest that regret after starting gender-affirming treatment should be an uncommon event. This low risk of regret after gender-affirming treatment should reassure providers when recommending gender-affirming interventions to their patients. The low risk of regret should also inform the actions of legislators attempting to substitute their judgment for the judgment of patients, parents, and providers by denying transgender adolescents access to this evidence-based and potentially life-saving treatment.