The "Sissy Boy Syndrome" and Desistance

The more I read, the worse it got.

Q: How often do gender nonconforming children stop being gender nonconforming by adolescence or adulthood?

A: Often.

If that’s all you wanted to know, you can stop reading. But if you want to know about the awful, politicized science on desistance, keep going.

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In 1987, psychiatrist Richard Green published The “Sissy Boy Syndrome” and the Development of Homosexuality. It was received as groundbreaking. Green followed 66 AMAB (assigned male at birth) people with feminine behavior and compared them to a control group of conventionally masculine boys. As he put it, “Our boys would have preferred being girls.” While there had been previous studies similar to it, none quite matched the quality or detail Green put into this. To this day, The “Sissy Boy Syndrome” is cited by professionals in the field of childhood gender and sexual development.

In 1991, Eve Kosofsky Sedgwick, a scholar in the field of gender studies, published “How to Bring Your Kids up Gay”. She felt differently about Green’s book.

Green is obscenely eager to convince parents that their hatred and rage at their effeminate sons is really only a desire to protect them from peer-group cruelty — even when the parents name their own feelings as hatred and rage (391-2). Even when fully one quarter of parents of gay sons are so interested in protecting them from social cruelty that, when the boys fail to change, their parents kick them out on the street. Green is withering about mothers who display any tolerance of their sons’ cross-gender behavior (373-5). In fact, his bottom-line identifications as a clinician seem to lie with the enforcing peer group: he refers approvingly at one point to “therapy, be it formal (delivered by paid professionals) or informal (delivered by the peer group and the larger society via teasing and sex-role standards)” (388).

Green spoke approvingly of conversion therapy, now denounced as unethical by every major organization in the field. He repeatedly referred to the only transgender woman in his cohort as a man, going so far as to put “[sic]” after she refers to her past self as a girl.

This might be uninteresting had it stayed in the past. In 2008, a study conducted by major names in the field of childhood gender development (Drummond et al., 2008) repeatedly referred to a transgender man who had been living as a boy for years and was in the process of a legal name change as a girl. One of the authors, Kenneth Zucker, has received massive amounts of criticism for previously defending conversion therapy and using a modified form of it on gender-variant children. In 1990, Zucker said that preventing children from becoming transgender or gay is best because “a homosexual lifestyle in a basically unaccepting culture simply creates unnecessary social difficulties.” Until relatively recently, he worked at a gender clinic in Toronto where he performed something uncomfortably close to conversion therapy. NPR gave one example of his technique as follows:

Carol decided to seek professional help. Bradley's school referred her to a psychologist in Toronto named Dr. Ken Zucker, who is considered an expert in gender identity issues. After several months of evaluation, Zucker came back with a diagnosis. Bradley, he said, had what Zucker called gender identity disorder…

So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. He explained that unless Carol and her husband helped the child to change his behavior, as Bradley grew older, he likely would be rejected by both peer groups. Boys would find his feminine interests unappealing. Girls would want more boyish boys. Bradley would be an outcast.

Destroy variance in human behavior; make them conform. Don’t teach children to be resilient; teach them to be compliant.

Kenneth Zucker isn’t a no-name. He led the American Psychological Association’s group on Sexual and Gender Identity Disorders in 2012. He’s the editor-in-chief of the Archives of Sexual Behavior. He’s a member of the committee on Disorders of Sex Development at the World Professional Association for Transgender Health. He led a major gender clinic in Toronto. And he’s conducted numerous studies on gender nonconforming children that are cited on the regular.

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Zucker’s method is premised on a few ideas. One is that gender variant behavior in children is liable to stop later in life. All available evidence agrees with this. What is less clear is that forcing children to give up the things they love just so others don’t make fun of them is a good idea. Zucker claims it is, and he has his experience to back him up, but that isn’t much. Richard Green defended conversion therapy for gay men, claiming that it obviously works. We now know that conversion therapy doesn’t work and is harmful, sometimes deadly so.

What’s worse is that Zucker’s methods have grown beyond his control. The claim that gender variant children tend to become fairly typical by adolescence or adulthood has morphed into the idea that children and adolescents who display all the hallmarks of being transgender are also very likely to stop (or desist) being transgender. This claim is repudiated by study after study, but at the same time, the studies share some blame.

“A follow-up study for boys with gender identity disorder” (Singh, 2012) says it has a cohort of 139 AMAB people with GID (gender identity disorder) in the abstract, but on page 71 it acknowledges that 51, or over a third, of the cohort didn’t actually meet the diagnosis threshold. “Psychosexual Outcome of Gender-Dysphoric Children” (Wallien & Cohen-Kettenis, 2008) was marginally better, with 75% of the cohort meeting the criteria for GID. In the earlier mentioned 2008 study (Drummond et al., 2008), 60% of the cohort were able to be diagnosed with GID. In The “Sissy Boy Syndrome” and the Development of Homosexuality, while there was no relevant diagnosis the beginning of the study, 15 of the 66 people in the “feminine” group never expressed any desire to be a woman, seemingly contrary to his claim that those “boys would have preferred being girls.” When Ristori and Steensma gathered up these studies and a few others to try to develop a desistance rate in “Gender dysphoria in childhood” (Ristori & Steensma, 2016), they found 85.2% of the collective children desisted in their gender variant behavior. Later in that study, they said the children had “gender dysphoric feelings,” a claim that’s not necessarily true.

This has led to a repeated claim: the vast majority of transgender children and adolescents stop being transgender by adulthood. In a nutshell, “it’s just a phase.” This is not backed up by the data. Very few of the studies provide enough information to speak only of those who had actual diagnoses. The one I could find (Wallien & Cohen-Kettenis, 2008) provided a persistence rate for children with GID somewhere between 40% and 50%, the uncertainty caused by being unclear how many of the people with actual diagnoses were lost to follow-up. The fact that it’s only one study, combined with the uncertain rate and the small sample in the study (56 with a diagnosis), means it’s hard to draw strong conclusions. In another study (de Vries et al., 2010) a cohort of 70 adolescents on puberty blockers all stuck around to continue hormone therapy a few years later.

To my knowledge, every study on the topic has concluded that the strength of the gender dysphoria is correlated with the persistence rate. This has led to the phrase “consistent, insistent, persistent” as a short way of saying that if a child has strong and consistent gender dysphoria, they are very likely to stay persistent. In other words, if a child or adolescent is insistently transgender, there’s a good chance they are.

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Writing in his book Trans Kids and Teens, Elijah C. Nealy explains that when it comes to transgender and gender nonconforming (TGN) children, ‘contemporary best practices recommend that clinicians and parents create “space” for a child’s gender diversity and not attempt to correct or punish their self-expression.’ If this is the case, then why is Zucker held up as such an expert? “Gender dysphoria in childhood” (Ristori & Steensma, 2016) lays out three models for treating TGN children. The first is as follows:

The first approach focuses on working with the child and caregivers to lessen cross-gender behaviour and identification, to persuade the child that the ‘right gender’ is the one assigned at birth (Giordano, 2012), to decrease the likelihood that GD will persist into adolescence, and prevent adult transsexualism.

Zucker falls into the first category, and, contrary to some claims, not the second category:

The second approach is focused on dealing with the potential social risks for the child (Byne et al., 2012). Because its aim is to allow the progress of the GD in the child to unfold in a natural way, it is often referred to as ‘watchful waiting’ (Drescher, 2013). Counselling based on this approach may include interventions that focus on the co-existing problems of the child and/or the family; helping parents and the child to bear the uncertainty of the child’s psychosexual outcome; and providing psychoeducation to help the child and the family to make balanced decisions regarding topics such as the child’s coming out, early social transitioning, and/or how to handle peer rejection or social ostracism. In practice, the child and parents are encouraged to find a balance between an accepting and supportive attitude toward GD, while at the same time protecting the child against any negative reactions and remaining realistic about the chance that GD feelings may desist in the future. Parents are encouraged to provide enough space for their child to explore their gender dysphoric feelings, while at the same time keeping all future outcomes open (e.g., de Vries & Cohen-Kettenis, 2012; Di Ceglie, 1998, 2014).

Zucker is definitely not in the second category, but this study notes that

children often seem to become distressed if their preferences and/or behaviours are blocked (Richardson, 1999). At present, interventions aimed to lessen GD are referred to as unethical by the World Professional Association for Transgendered Health (WPATH: Coleman et al., 2011) and many other international professional organizations.

It might feel bizarre that Zucker is given a place of honor despite this, but it’s not. Some have accused transgender people of politicizing science by attacking Zucker and researchers and clinicians like him, but the opposite is true: science has been political all along. It is hard to see Richard Green openly defend the idea of eliminating the possibility of being gay or transgender in The “Sissy Boy Syndrome” and think that he is an entirely neutral observer. No, a clinical practice aimed at making everyone obey social norms is not politically neutral. What transgender people have done, time and again, is point out how the people in charge are hurting them. If that’s politicizing science, then I suppose I’m happy to politicize science.

Zucker stands in a long tradition of cisgender scientists doing science on—not with, but on—transgender subjects. Parallel to this is a long tradition of heterosexual scientists doing science on homosexual subjects. “Deviant gender-role behavior in children: Relation to homosexuality” (Bakwin, 1968) argued that there is “a high risk of homosexuality in children with deviant gender-role behavior” and provided methods which are “designed to encourage gender appropriate behavior and to prevent homosexuality” as if homosexuality and gender variance are diseases to be cured. That’s how they saw it. Until 1973 homosexuality was considered a mental disorder by the APA, and after removing that, they added transsexualism and Gender Identity Disorder, pathologizing people who behaved in a way that wasn’t gender conforming.

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Science is fantastic, in part, because it is self-correcting and perpetually open to criticism. I would like to criticize the idea that science is self-referential, that good science does not care about “non-scientific” pressures. If this is the case, then good science barely exists, and much of what we call science was never science in the first place. The pressures of publish or perish, the incentive to find studies which will get funding, the shelving or refusal to do studies which only reaffirm existing studies, not to mention the constant p-hacking to find an interesting conclusion; it goes on and on. It’s not only that. The history of science is littered with what we now see as blatant racism and sexism. The measurement of skull sizes to argue that Black people are less intelligent than white people, the diagnosing of “hysteria,” the belief that women are underdeveloped men; it goes on and on. These ideas were not formed in a non-political vacuum. Science never operated in a non-political vacuum.

Acknowledging reality is not a denigration of science. I love science. I would never have had the will to read so many pages on this topic if I didn’t. I intended this to be a review of the literature, but it didn’t turn out that way, because I love science. I want science to be better all the time, and one way it can be better is by being sensitive to the demographics it works with. This is not a wild request. It is a request which would’ve helped ward off the aforementioned sexist and racist errors. It is a request which would’ve made the Tuskegee syphilis experiment a no-go. Today, it is a request that cisgender researchers, when they do research on transgender topics, listen to what transgender people think, feel, and want. That is not radical; that is better science.

I also don’t want anyone to hate science. I’ve put effort into trying to get people to understand science better, because science deserves to be understood. This includes understanding where science falters. In a better world, science leans less towards upholding dominant cultural beliefs and more towards subjecting those beliefs to the perpetual criticism of the scientific method. A better world is possible.

Scientists aren't infallible, but they are important. Science isn’t always right, but it can be better. I want people to be aware of where and how it can be better, and learn to notice these things on their own.

Although, if all you want to know is how often gender nonconforming children stop being gender nonconforming, the answer is often.

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REFERENCES

Bakwin, H. (1968). Deviant gender-role behavior in children: Relation to homosexuality. Pediatrics, 41(3), 620-629.

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2010). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.

Drummond, K. D., Bradley, S. J., Peterson-Badali, M., & Zucker, K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental psychology, 44(1), 34.

Green, R. (1987). The “sissy boy syndrome" and the development of homosexuality. Yale University Press.

Nealy, E. C. (2019). Trans Kids and Teens: Pride, Joy, and Families in Transition. WW Norton & Company.

Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13-20.

Sedgwick, E. K. (1991). How to bring your kids up gay. Social Text, (29), 18-27.

Singh, D. (2012). A follow-up study of boys with gender identity disorder (Doctoral dissertation, University of Toronto).

Wallien, M. S., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child & Adolescent Psychiatry, 47(12), 1413-1423.

Zucker, K. J. (1990). Treatment of gender identity disorders in children.