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Comment by Manuel_D | Hacker News Reader

The issue with this framing is that it ignores blockers' influence on desistence rates. Without blockers, 60-90% of kids presenting with gender dysphoria desist in cross sex gender identity by adulthood. But when put on blockers, nearly 100% continue living as the cross sex gender.

Even with a suppressed puberty, being transgender is extremely hard with high rates of depression and suicide. Any responsible analysis of the aggregate benefits of prescribing blockers needs to factor in the rates of desistence with and without blockers, but proponents of blockers almost always try to frame this discussion as though all kids with gender dysphoria persist in a cross sex gender. And indeed many try to claim that desistence is a "myth", despite most research into the topic.

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This is why I hate online "debates". Because over and over people will repeat the same stuff that have been debunked thousands of times before.

The DSM criteria for gender dysphoria aren't particularly useful when you are diagnosing kids that play with dolls despite not expressing a trans identity or wish to switch sexes by themselves.

In addition to that, when you are dealing with a conversion therapist it is only natural to depress, but this doesn't mean that it's healthy for you eeither mentally or physically. This is something that was forced onto me as well.

Finally, you seem to be considering transitioning to be inherently something that should be avoided, otherwise why would less kids desisting be considered a negative?

The same criteria used to approve patients for puberty blockers were used in the study. Heck, the author of the study helped write the DSM criteria for gender dysphoria. This is not at all "debunked", as much as activists try to insist that it is

Transition is indeed something that should be avoided if a patient can become comfortable in a same sex gender identity, because even with a suppressed puberty trans people have negative health outcomes across a variety of measures. To say that transition is best avoided if possible isn't a moral judgment against trans people, it's an accurate statement about the disparities in health outcomes.

This is a simplistic model, but imagine trans people have 10% risk of suicide if they don't get blockers, 5% if they do, and cis people have 1%. If I have a cohort of 10 patients with gender dysphoria 8 will desist and 2 will persist without prescribing blockers. And if you do prescribe blockers all of them will persist and transition. The former achieves the optimal health outcomes for the group as a whole. Again this is hugely simplistic, as suicide is not the only healthcare outcome we care about, but it illustrates that desistence rates are relevant to measuring whether blockers improve overall health outcomes.

Of course ideally we'd be able to know which patients will and won't persist. Psychologists attempted to do this for decades, but were never able to reliably predict which patients would and would not persist. People like to point to the extremely low rates of desistence among people prescribed puberty blockers as proof that psychiatrist are predicting correctly. But of course it's also consistent with blockers serving as a determining factor in persistence, and not merely offering "time to think".

The fact that you think 90% desistence is credible discredits you.

Most people who pass by a bus stop don't get on a bus, but if they stop and wait at a bus stop then the probability they soon get on a bus is above 90%. Do you think standing at a bus stop caused them to get on a bus?

First of all, thank you for being upfront about the fact that your rejection of these studies is not based on their methodology, but because your don't like their results.

It's more like I have two different buses. When kids get on bus A, ~80% of them arrive at destination X and 20% at destination Y. When kids bet on bus B, 2% of them arrive at destination X and 98% of them arrive at destination Y. It sure looks like bus B isn't merely affording the kids "time to think" but is in fact altering their destination, does it not?

The patients in the study are diagnosed with the same criteria for gender dysphoria in the DSM. Heck, the author in the study I linked wrote the criteria for gender dysphoria in the latest iteration of DSM. I'm always puzzled by people who insist that the study was including patients that weren't actually experiencing gender dysphoria.

It's less that I "don't like" the results and more that the results are completely unrealistic. Trans people tend to make friend groups with other trans people, and I trust that they would notice if on average 90% of their friends stopped being trans.

I don't get your bus analogy. Surely the people who get on bus B which goes to destination Y do so because they want to get to destination Y? The act of getting on the bus doesn't cause them to want to go its destination.

It's not the child picking the bus. The choice of whether a medical professional chooses to affirm a patient or take a neutral, observational stance is a choice made by the medical professional, not the patient.

And how does that choice seem to affect the outcome? When gender dysphoric children are met with a neutral model of care that primarily seeks to observe the child, about 4 in 5 desist by young adulthood. When they're affirmed, and especially if put on chemical treatment to suppress puberty, 98% or more persist with a trans identity. Even with a suppressed puberty, transgender people experience worse health outcomes than cis people across a variety of measure. To say that the former approach is a better healthcare outcome in aggregate is not a denigration of trans people but a recognition of the challenges they face. To justify affirmation, the improvement has to be demonstrated not only against an adult transition, but also against the population that desist and live life as cis people.

The studies presented above took a sample of the patients that visited a a clinic that voiced distress of their gender over the span of a period of time - the majority of them meeting the criteria for gender dysphoria in the DSM - and tracked which of them desisted or persisted in expressing a non-cis gender identity decades or more after the fact (average time from first visit to last follow up was 13 years). The lowest rate of desistance was 70%, 3 out of the 4 were above 80%.

To call the results of a study "unrealistic" indicates that one already knows a "realistic" result would be. This is essentially admitting to bias approach to the data: if it doesn't conform to your predetermined "real" result, and your criticism is solely based on that and not any methods in the study. By comparison, the studies that show extremely low rates of desistance are either studies with kids on blockers, or they are not cohort studies. E.g. studies recruiting respondents from the internet is vastly more susceptible to reporting bias than taking the group of patients visiting a gender clinic over the course of a year.

If you want to actually post and discuss a study finding high rates of persistence under a neutral model of care, I'd be very interested in reading. But my approach towards deciding what a realistic result is leans more heavily towards published research than anecdotal claims.

> Without blockers, 60-90% of kids presenting with gender dysphoria desist in cross sex gender identity by adulthood. But when put on blockers, nearly 100% continue living as the cross sex gender.

You say "most research" shows this. From which source(s) do you draw these claims? If I recall correctly there were a lot of methodological issues with drawing this type of conclusion from those studies.

This is one of the more recent studies: https://pmc.ncbi.nlm.nih.gov/articles/PMC8039393/

The desistence rate for this study was 87%. Most other studies fall in the range of >70%

> At the time of follow-up, using different metrics (e.g., clinical interview, maternal report, dimensional measurement of gender dysphoria, a DSM diagnosis of GID, etc.), these studies provided information on the percentage of boys who continued to have gender dysphoria (herein termed “persisters”) and the percentage of boys who did not (herein termed “desisters”).2 Of the 53 boys culled from the relatively small sample size studies (Bakwin, Davenport, Kosky, Lebovitz, Money and Russo, Zuger), the percentage classified as persisters was 9.4% (age range at follow-up, 13–30 years). In Green (47), the percentage of persisters was 2% (total n = 44; Mean age at follow-up, 19 years; range, 14–24); in Wallien and Cohen-Kettenis (52), the percentage of persisters was 20.3% (total n = 59; Mean age at follow-up, 19.4 years; range, 16–28); and in Steensma et al. (51), the percentage of persisters was 29.1% (total n = 79; Mean age at follow-up, 16.1 years; range, 15–19). Across all studies, the percentage of persisters was 17.4% (total N = 235), with a range from 0 to 29.1%.3

You can find studies that find a very low rate of desistence, in the single digits. But those are among children that were put on puberty blockers.

Those studies were mostly from the 80s-2000s when things were really different. Kids were often referred just for being gender nonconforming (like boys playing with dolls), not necessarily having serious gender dysphoria. Plus the treatment back then was often trying to make kids more "gender typical" - which obviously might push some kids toward appearing to "desist" even if they still had gender issues. Many of the kids in those studies didn't even meet what we'd now consider the criteria for gender dysphoria. So saying "80% of trans kids desist" might be more like "80% of gender nonconforming kids don't turn out to be trans" - which is pretty different.

The majority of the sample met the criteria for gender dysphoria as listed in the DSM. Gender non-conforming behavior is just one criterion, multiple of which need to be met to categorized as gender dysphoric. This is the same set of criteria that a medical professional would use to approve a patient for puberty blockers.

The predominant approach back then was not to suppress incongruent gender identity. The approach was to take a neutral stance and neither foster not suppress the patient's gender identity, called "watchful waiting".

> The predominant approach back then was not to suppress incongruent gender identity. The approach was to take a neutral stance and neither foster not suppress the patient's gender identity, called "watchful waiting".

The clinic involved in this study actively was known for conversion therapy. Zenneth Zucker is one of the authors and is famous for it.

https://en.wikipedia.org/wiki/Kenneth_Zucker#Therapeutic_int...

The head of the child and adolescent gender identity clinic at Toronto’s Centre for Addiction and Mental Health, Dr. Kenneth Zucker, has made a career promising the parents of intersexed and transgender children that he can make them “normal”. His method, called reparative therapy, in which children are pushed into assigned gender roles and discouraged from behaving or dressing in a way that’s counter to their ‘assigned’ sex, was once standard practice, but in recent years, has been increasingly scrutinized. A 2003 report in the Journal of the American Academy of Child and Adolescent Psychiatry called his techniques “something disturbingly close to reparative therapy for homosexuals,” and author Phyllis Burke has questioned the idea that transgendered children should be treated as mentally ill, saying, “The diagnosis of GID in children, as supported by Zucker and [his colleague J. Michael Bailey] Bradley, is simply child abuse.”

https://www.queerty.com/dr-kenneth-zuckers-war-on-transgende...

I imagine a conversion therapy clinic would issue a study that their conversion therapy works. I wonder how long those kids stayed "desisted" or if they were just pressured into the closet again only to transition later in life.

Kenneth Zucker won over half a million dollars in a defamation lawsuit over these false claims. Your own link covers his successful defamation lawsuit, but you seem to have ignored this:

> After his dismissal, Zucker sued CAMH for defamation and wrongful dismissal.[3] In October 18, CAMH settled with Zucker for $586,000 in damages, legal fees, and interest and released an apology for the report falsely stating he called a patient a "hairy little vermin".[3][46] CAMH removed the report from its website and apologized, and replaced it with a summary of the report which has not survived a move to its new website.

Is it intellectually honest to post CAMH's accusations against Zucker, but neglect to mention that they were sued, paid out a settlement, apologized, and removed this report?

And again, what about the other three studies that all saw desistance rates over 70%? Even if you want to ignore Zucker's results on the grounds that he practiced "conversion therapy" (despite winning his defamation case...) it's not the only study conducted on desistance rates absent puberty blockers.

> I wonder how long those kids stayed "desisted" or if they were just pressured into the closet again only to transition later in life.

You don't need to wonder, just read the study: they followed up with patients over a decade later. By comparison, much of the research attempting to study the benefits of puberty blockers only follow up 1 or 2 years later, yet few seem to point out that this is a small duration of time in the context of a child's entire future adult life.

I'm sorry, I don't want to spend my whole friday evening getting into this.

For me, the topic is personal because I was one of those young transgirls who was forced to go through male puberty. I transitioned the moment I was 18. I'm in my thirties now and still trans and still a woman. There's aspects of my body that are still permanently altered by the fact that I was forced to go through male puberty. I still resent the adults in my life, particularly the psychiatrist who strung me a long for years while I had to go through body horror. I would have done literally anything for hormone blockers back then.

I'm sure this is personal for you too. That's why you spend so much effort replying. Maybe we can see common ground? Neither of us want children to be forced to go through the wrong puberty.

Anyways, hope you have a good evening

A child put on blockers that would have desisted absent hormonal intervention is also a child that goes through the "wrong puberty". Chances are a good number of your psychiatrist's patients that became comfortable in their same sex gender, who would have been put on blockers and set on a track towards transition if your psychiatrist took a permissive approach towards hormonal intervention. Any responsible cost-benefit analysis of blockers has to weigh the effect it has on persistence rates.

And the cohort studies among gender dysphoria patients that don't receive blockers do show a majority desistence. This isn't just Zucker's practice finding majority rates of desistence. And your personal stake is still no justification to repeat defamatory statements about him.

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