On Sunday, the New York Times published an op-ed from Richard A. Friedman, Weill Cornell Medical College professor of clinical psychiatry, who asks, “How changeable is gender?” Though Friedman sets up his piece by discussing the biological underpinnings of gender identity and the experience of being transgender, he ultimately explains his “skepticism” about assisting transgender people to change their bodies to match their identities. “After all,” he concludes, “medical and psychological treatments should be driven by the best available scientific evidence — not political pressure or cherished beliefs.”
To justify his skepticism, Friedman distorts some studies and ignores others to arrive at conclusions that support his apparent biases against transition. Under the guise of medical opinion, he mimics the flawed talking points used by some of the biggest opponents of transgender equality:
The “Surgery Doesn’t Lower Transgender Suicide Rates” Myth
After explaining quite sensibly why gender identity likely exists on a spectrum just like sexual orientation, Friedman then suggests that gender identity might be “malleable,” setting up his doubt about “to what extent various strategies to change one’s body and behavior to match a preferred gender will give people the psychological satisfaction they seek.”
To answer this, Friedman claims “the data are all over the map.” After dismissing the wealth of studies that have found positive outcomes for transgender individuals who transition as “suboptimal” because they were “observational and most lacked controls,” he instead focuses on a study about suicide rates in Sweden often cited by opponents of transgender equality.
The study, he boasts, assessed suicide rates of transsexuals who had undergone transgender surgery “against controls.” What he doesn’t mention is that the controls were not transgender people who had not undergone surgery as one would expect, but in fact, the cisgender general population. “When the researchers controlled for baseline rates of depression and suicide, which are known to be higher in transsexuals, they still found elevated rates of depression and suicide after sex reassignment.” All that the research actually shows is that surgery did not alleviate all mental health issues; it does not actually provide any information about the impact of that surgery.
Friedman also fails to mention that the mortality rate in the study was only statistically significant for people who underwent surgery before 1989. For all those who had their surgery after that (1989–2003), the increased mortality was not statistically significant. Though he briefly acknowledges the impact that stigma, discrimination, and violence might instead be playing, he brushes this possibility aside to assert, “The outcome studies suggest that gender reassignment doesn’t necessarily give everyone what they really want or make them happier.” The Swedish study, the only example he cites, suggests no such thing. In fact, the researchers say as much in a disclaimer: “No inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism” because “things might have been even worse without sex reassignment.”
The “Most Trans Kids Just Turn Out To Be Gay” Myth
Friedman then proceeds to talk about children and adolescents, for whom, he claims, “the experience of gender dysphoria is itself often characterized by flux.” He cites research like Dr. Richard Green’s study from the 1980s and a 2008 study by Madeleine S. C. Wallein from the VU University Medical Center in the Netherlands, which found that many young people who seem to express gender dysphoria grow out of it. “This strongly suggests that gender dysphoria in young children is highly unstable and likely to change,” he asserts, acknowledging there’s no way of knowing what causes the change.
But, he warns, the fact that not all trans kids persist in their identity should guide how parents respond. “So if you were a parent of, say, an 8-year-old boy who said he really wanted to be a girl, you might not immediately accede to your child’s wish, knowing that there is a high probability — 80 percent, in some studies — that that desire will disappear with time.”
There is nothing in these studies to warrant this dangerous encouragement for parents to reject their kids’ identities. In fact, the studies suffer from major flaws that suggest otherwise. Kelley Winters, who studies and writes about transgender medical policy, explains that the criteria for diagnosing Gender Identity Disorder in Children (GIDC) are not particularly consistent. Many recent studies rely on diagnosing children “on the basis of gender nonconforming behavior, with no evidence that they identified as other than their birth-assigned gender.” Thus, children who are actually distressed about their gender identity — the “persisters” — are grouped along with larger numbers of effeminate male-identified boys and masculine female-identified girls — the “desisters.”
Thus, these studies might actually be proving the opposite of what Friedman wants them to. The fact that, in these overbroad samples of gender non-conforming kids, researchers do find persisters suggests that the benefit of the doubt ought to favor these kids who might actually be trans. After all, as this population has been studied more, researchers have learned that they actually identify as consistently and innately with their gender identity as their cisgender peers. Parents risk nothing by letting kids express themselves however they might, but could cause great harm by rejecting the identities of kids who actually feel distress over their gender. The “it’s just a phase” stereotype, as Winters calls it, “has underpinned policies that keep gender dysphoric children in the closets of their birth-assigned gender.”
The “Children Shouldn’t Be Experimented On” Myth
Following up on his dangerous warning to parents, Friedman proceeds to express doubts about the treatment options available for young people. “Much can be done to help alleviate depression or anxiety without necessarily embarking on gender change,” he suggests, focusing on the symptoms and not the problem.
Puberty suppression has become one of the primary ways of helping distinguish between persisters and desisters. This gives children the opportunity to continue exploring their sense of identity without suffering the permanent consequences of undergoing puberty as the wrong sex should they turn out to be trans. But Friedman isn’t having it. “Puberty suppression is presumed reversible, and can be stopped if the adolescent’s gender dysphoria desists. But the risks of this treatment are not fully understood. Even more troubling, some doctors appear to be starting reassignment earlier.”
That’s actually not true. The most recent research has found that puberty suppression is a “fully reversible medical intervention.” The young people who choose not to undergo puberty had no health consequences and were able to successfully transition later. None in the study expressed any regret from the delay and most had overcome the mental health consequences related to the original onset of their gender dysphoria.
Friedman is adamant, however, that children should either not be trusted or humored when they express gender dysphoria. “But if anything marks what a child really is, it is experimentation and flux. Why, then, would one subject a child to hormones and gender reassignment if there is a high likelihood that the gender dysphoria will resolve?” He also takes umbrage that he might be expressing an anti-trans bias.
The “Maybe Ex-Trans Therapy Is Just Fine” Myth
“Clinicians who take an agnostic watch-and-wait approach in children with gender dysphoria have been accused by some in the transgender community of imposing societal values — that boys should remain boys and girls remain girls — on their patients and have compared them to clinicians who practice reparative therapy for gays,” Friedman admits. “I think that criticism is misguided.”
Instead, he believes that even though ex-gay therapy has been debunked as ineffective and often harmful, “there is no comparable data in the area of gender dysphoria.” Since gender identity is fluid and there are so few comparative studies of gender non-conforming children, there’s no way of knowing if discouraging that non-conformity is actually problematic.
Except, there is such research. The World Professional Association for Transgender Health (WPATH), which sets standards for the health care of transgender people, has explained, “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success, particularly in the long term. Such treatment is no longer considered ethical.”
Dr. Simon D. Pickstone-Taylor similarly rejected ex-trans therapy in a 2003 letter to the editor in the Journal of the American Academy of Child & Adolescent Psychiatry, noting that such treatment is “something disturbingly close to reparative therapy for homosexuals.” Even if children “become good actors,” he explained, “this form of therapy only helps to reinforce the message that they get from society that their instinctual gender identification is fundamentally wrong. This further erodes their self-esteem and increases the psychopthology that is normally seen in these children.”
Conversely, Pickstone-Taylor noted, children who are allowed to express their cross-gender behavior “grow in self-confidence, their comorbid symptoms decrease, and interestingly, extreme cross-gender behavior is reduced.” This ironic last point reflects “children finally being treated in a truly supportive way” and “having the confidence to release their tight and preferential grip on their instinctual opposite-gender interests and behaviors and experiment with others.”
Friedman has no research to demonstrate any benefit to attempting to suppress a child’s gender expression. Still, he bases his skepticism for affirming transgender kids on the “best available scientific evidence.” If he had actually cited that evidence in his op-ed, instead of disregarding it to support his own biases, he may have drawn a different conclusion.