What happens when the New York Times gets a professor of clinical psychiatry to look at the research on transgenderism and gender identity? Well, apparently the professor gets every study he looked at wrong.
The op-ed by Richard Friedman, a professor of clinical psychiatry at Weill Cornell Medical College, was supposed to be a scientific dive into the empirical research on gender identity. So it's alarming that the article got practically all the research it cited wrong — at times misunderstanding basic definitions surrounding trans issues, and sometimes flatly misinterpreting the studies it cited. But what's even worse is how Friedman uses his misinterpretations to justify very harmful practices for trans kids.
1) Friedman conflates gender identity and expression
The most alarming errors in the article come from the section discussing the research on children's gender identity — and how it conflates gender identity and expression.
First, some quick background: There's a difference between gender identity and expression. Gender identity is someone's personal identification as a man, a woman, or a gender outside of societal norms. Gender expression refers to characteristics and behaviors a person identifies with that can be viewed as masculine, feminine, a mix of both, or neither.
For transgender people, the focus is gender identity: Trans people identify with a gender different from the one assigned to them at birth. This is what triggers gender dysphoria, a state of emotional distress caused by how the gender someone was designated at birth conflicts with their gender identity.
For gender nonconforming people, the focus is gender expression: Gender nonconforming people express their gender in a way that differs from societal expectations — for example, androgynous people or feminine men may consider themselves to be gender nonconforming. Gender dysphoria has nothing to do with gender expression.
Friedman looks at research that analyzed both identity and expression, but attempts to apply the research's findings only to gender identity. He writes:
If gender identity were a fixed and stable phenomenon in all young people, there would be little to argue about. But we have learned over the past two decades that, like so much else in child and adolescent behavior, the experience of gender dysphoria is itself often characterized by flux.
Several studies have tracked the persistence of gender dysphoria in children as they grow. For example, Dr. Richard Green's study of young boys with gender dysphoria in the 1980s found that only one of the 44 boys was gender dysphoric by adolescence or adulthood. And a 2008 study by Madeleine S. C. Wallein, at the VU University Medical Center in the Netherlands, reported that in a group of 77 young people, ages 5 to 12, who all had gender dysphoria at the start of the study, 70 percent of the boys and 36 percent of the girls were no longer gender dysphoric after an average of 10 years' follow-up.
THIS strongly suggests that gender dysphoria in young children is highly unstable and likely to change. Whether the loss of gender dysphoria is spontaneous or the result of parental or social influence is anyone's guess. Moreover, we can't predict reliably which gender dysphoric children will be "persisters" and which will be "desisters."
First of all, the studies don't actually look at gender dysphoria exclusively or find that its severity fluctuates over time, as Friedman claims. As Twitter user oatc pointed out, the Green study looked at feminine boys, not necessarily children who were assigned male at birth but identified as girls. And the other study Friedman cited looked at kids who are gender dysphoric and gender nonconforming, not just gender dysphoric children. So it's impossible to separate out the findings and only apply them to trans kids with dysphoria, as Friedman attempts to do.
This is, experts who follow these issues closely have told me, a very common mistake in analyses of gender research. A lot of old studies look at outdated definitions or mix up concepts like gender identity and expression. So when people like Friedman come along and try to apply these findings to our current understanding of gender identity, they end up — perhaps inadvertently — conflating different concepts.
So what does the evidence actually say? Diane Ehrensaft, director of mental health at UCSF Benioff Children's Hospital's Child and Adolescent Gender Center, previously told me that parents and doctors can watch for consistence, persistence, insistence, and history of gender nonconformity to reliably evaluate early on if a child is trans. Despite what Friedman suggests, it's very much possible.
"We can't say with 100 percent accuracy, but we can get a good picture very early on," Ehrensaft said. "In my training as a developmental psychologist, the very theory is that by age 6 you should know your gender or there's something wrong with you."
She added, "When kids whose gender matches the sex on their birth certificates say, 'I know my gender,' nobody questions that. They say, 'Oh, of course. You should.' But if a kid says, 'I know my gender' but it's not the sex on their birth certificate, people ask, 'Oh, how could you possibly know that?' How can we have both at the same time?"
2) The article completely blunders its evaluation of gender-affirming medical procedures
The suicide rate among trans people is horrifying: A 2014 study by the Williams Institute and American Foundation for Suicide Prevention found that 46 percent of trans men and 42 percent of trans women have attempted suicide at some point in their lives, compared with 4.6 percent of the general population. The major cause of this is severe, untreated gender dysphoria, which can lead to depression and suicidal ideation.
Friedman suggests that this isn't actually true, and gender-affirming treatments aren't successful in treating "excess morbidity and mortality" among trans people:
Dr. Cecilia Dhejne and colleagues at the Karolinska Institute in Sweden have done one of the largest follow-up studies of transsexuals, published in PLOS One in 2011. They compared a group of 324 Swedish transsexuals for an average of more than 10 years after gender reassignment with controls and found that transsexuals had 19 times the rate of suicide and about three times the mortality rate compared with controls. 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.
This study doesn't prove that gender reassignment per se was the cause of the excess morbidity and mortality in transsexual people; to answer that, you would have to compare transgender people who were randomly assigned to reassignment to those who were not. Still, even if hormone replacement and surgery relieve gender dysphoria, the overall outcome with gender reassignment doesn't look so good — a fact that only underscores the need for better medical treatments in general for transgender individuals and better psychiatric care after reassignment.
It's not just that the "study doesn't prove that gender reassignment per se was the cause of the excess morbidity and mortality in" trans people. The study in fact finds the direct opposite. The abstract — you don't even have to read the full study to find this — explicitly states that gender-affirming treatments are successful in "alleviating gender dysphoria."
What Friedman's analysis gets wrong is that it uses the cited study to gauge whether trans people were completely cured of dysphoria and possess suicide rates equal to the general population after treatment. But of course this doesn't actually happen. These are people who have been dealing with dysphoria for potentially decades — that's going to have a long-term effect on people's mental health even if gender-affirming treatments alleviate some of their symptoms. (Not to mention that other factors, such as discrimination, can also contribute to depression and suicidal ideation.)
To appreciate how wrongheaded Friedman's approach is here, let's look at another medical condition — heart disease. Let's say a 45-year-old man has really bad heart disease, leading a doctor to prescribe medication that relieves the risk of a heart attack. This person lives a pretty normal life for three decades, then dies of a heart attack at the age of 75. Does his death to a heart attack mean the medication was ineffective? Not at all. It very likely reduced the risk of heart attack, allowing him to live to 75 instead of having a fatal heart attack at, say, 55 or 65. It would be foolish to suggest this man should have never taken his heart medication just because it couldn't fully prevent his lifelong condition from eventually catching up to him.
Yet that's essentially what Friedman does. Because gender-affirming treatments don't fully cure all the problems that might come with being trans or severe dysphoria, Friedman concludes that "the overall outcome" for gender-affirming treatments "doesn't look so good." It's a conclusion that lets perfect be the enemy of good.
3) The column argues for attitudes that literally hurt children
All of these errors matter not just because they're printed by a major newspaper that should know better. The worst part is Friedman uses these errors to suggest that parents and doctors might be right in letting children suffer from severe dysphoria just in case something changes down the line — and implies that conversion therapy (or "reparative therapy," as he calls it) may be okay for trans children.
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.
I think that criticism is misguided. First, there is abundant evidence that reparative therapy is both ineffective and often harmful, while there is no comparable data in the area of gender dysphoria. Second, unlike sexual orientation, which tends to be stable, gender dysphoria in many young people clearly isn’t. Finally, when it comes to gender dysphoria, the evidence for therapeutics are simply poor to start with: There are no randomized clinical trials and very few comparative studies examining different approaches for this population.
But there is abundant evidence that these types of actions — and conversion therapy in particular — are harmful to trans children. When parents tell a trans boy that they won't let him embrace the gender he identifies with, they are essentially telling him that they can't accept him for who he is. That kind of rejection is very harmful: The 2011 National Transgender Discrimination Survey (NTDS) found trans and gender nonconforming people who are rejected by their families are nearly three times as likely to experience homelessness, 73 percent more likely to be incarcerated, and 59 percent more likely to attempt suicide.
This is similar to the evidence that led medical organizations to reject conversion therapy for gay, lesbian, and bisexual kids (and some to reject it for trans youth, too). These organizations have cited, for example, research by San Francisco State University that found that LGBTQ children who were rejected by their families, compared with those who weren't rejected by their families, were eight times more likely to attempt suicide, nearly six times as likely to report high levels of depression, more than three times as likely to use illegal drugs, and more than three times as likely to have unprotected sex. The point being that refusing to accept children for who they are has seriously detrimental consequences.
This is why doctors who are actually involved in gender issues — like Ehrensaft of UCSF Benioff Children's Hospital's Child and Adolescent Gender Center — advocate for keeping an open, supportive environment for dysphoric children. Not all trans children need to go through gender-affirming treatments when they're young, but many can be greatly helped by parents and doctors who are open to the possibility that a child is trans and could benefit from treatments like puberty blockers that let children grow up and flesh out their identity before biology imposes a harder-to-reverse course.
But to get parents and doctors who are that open-minded, people need to understand trans issues and gender dysphoria. The New York Times doesn't help achieve that when it prints error-ridden articles like Friedman's for millions of people to read.