Singal’s Florida: You’re very wrong about trans kids

UPDATE (4/20/22): This article was updated to respond to spurious recommendations from the Florida Department of Health, which assert the same debunked claims this article fact-checks.

Having learned that the mainstream publication The Atlantic has paid professional anti-trans concern troll Jesse Singal to write about trans issues, I want to address his well-worn arguments before he can make them. To do so, I will assert and then substantiate a few things:

  1. The Diagnostic and Statistical Manual of Mental Disorders (DSM) IV Gender Identity Disorder (GID) diagnosis is critically flawed and has harmed people.
  2. A DSM-5 Gender Dysphoria (GD) diagnosis is very different from the DSM-IV concept of GID.
  3. Pretending that DSM-IV GID research directly applies to those with a DSM-5 GD diagnosis is irrational and harmful.

Jesse Singal has enjoyed a great deal of support from anti-trans groups including those of the political right, the alt-right, and a small fraction of anti-trans self-identified feminists. Singal’s anti-trans articles all conflict with at least one of the above three facts. These anti-trans movements, who collectively refer to themselves as “gender critical,” exist to obscure the above three facts in pursuit of reducing the number of trans people that exist today.

Point One: The DSM-IV GID

To understand the problems with the DSM-IV GID, and perhaps better understand why the trans community has fought against it so hard for so long, we need to begin with the DSM-III’s conceptualization of GID:

DSM-III conceptualization of GID and GD: dysphoria about one’s phenotype

The DSM-III’s understanding of GID meant that one had to express dysphoria regarding their phenotype. Merely being gender nonconforming (GNC) alone was not enough to diagnose a kid with GID. Some sexologists were frustrated with this situation as they wanted a way to put GNC kids into “treatments” designed to make them behave more stereotypical in their gender expression.

Citing Green & Zucker to target non-transsexual GNC people for a GID diagnosis

Anti-LGBT activist George “Rent Boy” Rekers 1, who was caught by the NY Times after having spent two weeks with a male sex worker from, teamed up with Dr. Green to produce a study titled, Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child. In fact, Green facilitated this study by sending “deviant” gender expressing kids to Rekers for him to study. This “research” was the foundation for Green and Rekers’ Sissy Boy Syndrome, a “study” that found that putting a group of mostly non-GD GNC kids (with a few GD kids mixed in) through “treatments” designed to make them act more stereotypically male, produced a group with a few GD kids mixed in. Yes, you read that correctly. A group made up of mostly non-GD kids produced a group of mostly non-GD kids. Specifically, it found that around 80% of the study participants did not have GD after their “treatments.” Remember this 80% number because it shows up over and over again in anti-trans literature.

Worse, this “study” was later implicated in the death of one of its subjects.

Nonetheless, Green’s friend, Dr. Zucker, and Zucker’s colleagues at the government-run CAMH gender clinic populated the DSM-IV Workgroup and set to work turning the Sissy Boy Syndrome framework into a diagnostic category: the DSM-IV GID. This wasn’t a secret. Those involved with the Workgroup published papers and periodic updates explaining their goals:

Change 2: “Elimination of the stated desire to be of the other sex as a distinct criterion.”

These sexologists made it clear that they supported a diagnostic framework that minimized phenotype dysphoria and instead centered itself on nonconforming gender behavior. In fact, this was accomplished in the DSM IV:

DSM-IV criteria for GID

Under the DSM-IV, one need only be GNC to receive a GID diagnosis. This resulted in numerous “transgender” studies using the above Sissy Boy Syndrome-derived metric.

Point 2: DSM-IV GID and the DSM-5 GD

When the American Psychiatric Association issued the DSM-5, the DSM-IV category, GID was removed. Many media outlets wrongly reported that GID was being renamed GD, leading many laypeople to believe that GID was basically the same thing as GD. This is a mistaken belief; GID and GD represent two different groups:

GID group: mostly comprised of those who experience anxiety because they are, in some way, gender non-conforming as well as a relative few who are debilitated by a mismatch between their gender orientation2 and their phenotype.

GD group: comprised of those who are debilitated by a mismatch between their gender orientation and their phenotype.

Unscrupulous writers like Singal proclaim that around 80% of GD kids will stop having GD based on old GID studies that found that most kids with GID do not wind up having GD. Never mind that most GID kids didn’t have GD in the first place. To drive the point home regarding the difference between GID within a DSM-IV context and GD within a DSM-5 context, here are both categories:

DSM-5 Gender Dysphoria
DSM-IV Gender Identity Disorder

The point is that many who had a DSM-IV GID diagnosis will not qualify for a DSM-5 GD diagnosis because being gender-nonconforming alone is not enough to get a DSM-5 GD diagnosis. Let’s consider just how many kids this difference affects. When asked how many kids Dr. Zucker “treated” at his gender identity clinic for GD, he said that a full 70% of them did not have gender dysphoria in the first place. In fact, these children came into his care merely because they were GNC:

Dr. Zucker: “70% of the children we see are sub-threshold for GD”

In its heyday, Zucker’s GID clinic was one of the busiest and most prominent clinics of its type in the world and the vast majority of kids Zucker’s clinic “treated” didn’t have GD in the first place. Nonetheless, GID kids were treated for GID with behavioral therapies designed to make these kids behave in more stereotypical ways. Under the DSM-5, the only kids Zucker would be able to treat would be the 30% that did, in fact, have GD.

Shortly after the DSM-5 was published, Dr. Zucker’s boss was blindsided by a reporter asking him if Zucker’s clinic would continue their DSM-IV-centered “treatment” of kids. When Zucker’s boss said no, the reporter cited a statement by Zucker claiming that he intended to continue his DSM-IV era “treatments.” Shortly thereafter, Zucker was fired and anti-trans movements across the globe repeated the lie that a cabal of powerful trans activists somehow/someway forced Zucker out and that children would be the worse for it.

Point 3: Pretending that DSM-IV GID = DSM-5 GD is Irrational

An anti-trans site called Transgender Trend recently published a slick booklet targeting schools. The propaganda this booklet spreads is rooted in the notion that a DSM-IV GID diagnosis is exactly the same thing as a DSM-5 GD diagnosis. Consider the following fact claim in terms of what you now know about the differences between a DSM-IV GID and the DSM-5 GD, particularly where the 80% desistance rate originates from:

Neither claim is true.

And yet, this claim is even found in the #1 bestseller in Gay & Lesbian Philosophy on Amazon, When Harry Became Sally: Responding to the Transgender Moment by Ryan T. Anderson:

The book claims:

In the past 10 years, dozens of pediatric gender clinics have sprung up throughout the United States. In 2007, Boston Children’s Hospital “became the first major program in the United States to focus on transgender children and adolescents,” as their own website brags.

A decade later, over 45 gender clinics had opened their doors to our nation’s children—telling parents that puberty blockers and cross-sex hormones may be the only way to prevent teen suicides.

Never mind that according to the best studies—the ones that even transgender activists themselves cite—80 to 95 percent of children with gender dysphoria will come to identify with and embrace their bodily sex.

Never mind that 41 percent of people who identify as transgender will attempt suicide at some point in their lives, compared to 4.6 percent of the general population. Never mind that people who have had transition surgery are nineteen times more likely than average to die by suicide.

These statistics should stop us in our tracks. Clearly, we must work to find ways to effectively prevent these suicides and address the underlying causes. We certainly shouldn’t be encouraging children to “transition.”

Anderson both claims and insinuates that in 2017, most kids with GD will stop having GD, that transition itself leads to suicidal feelings and that because of these things, good people should try to prevent kids from being trans. These are lies. What’s more, they’re dangerous lies that the author was made aware of.

Certain ideological circles like to perpetuate the long-debunked lie that transition makes people suicidal. The 41% suicidal ideation rate referred to in the above book section seems to be referring to a study that found that trans people who were not supported attempted suicide at a rate of 41%. The study Anderson cites notes: “Based on prior research and the findings of this report, we find that mental health factors and experiences of harassment, discrimination, violence, and rejection may interact to produce a marked vulnerability to suicidal behavior in transgender and gender non-conforming individuals.” Backing up this claim are statistics finding a greater burden of suicidal ideation among those who face specific types of discrimination:

Why would Anderson –an author clearly aware of this study– hide this context in his admonition that “[w]e certainly shouldn’t be encouraging children to ‘transition.'”? Embedded in Anderson’s malevolent –and there is no other word for his disregard of life– is the claim that in 2017, “80 to 95 percent of children with gender dysphoria will come to identify with and embrace their bodily sex.” The only research asserting something like this is research on groups of DSM-IV GID kids, specifically the disco-era Sissy Boy Syndrome.

Statement by one of those Anderson exploited.

Pretending that DSM-IV GID research applies to a DSM-5 GD diagnosis is more than irresponsible, it’s possibly deadly. We’re no longer talking about a mixed group of non-GD GNC kids with a relative few GD kids mixed in; we’re talking about a group comprised of 100% GD kids. People like Anderson and groups like Transgender Trend are actively preying on vulnerable parents, who are oftentimes both worried and confused. They lie, telling them that DSM-IV GID research proves that around 80% of DSM-5 GD kids will stop being transgender, facilitating the placement of these kids directly into the at-risk pool.

We may never know the suffering these ideological hucksters cause as they target vulnerable children and families. Remember the Sissy Boy Syndrom kid that killed himself after receiving GID-IV style “treatment”? The kid’s name was Kirk Murphy, and, according to Murphy’s doctor, was, “an exceptionally effeminate child who played exclusively in a feminine role; who exhibited overwhelmingly feminine gestures, vocal inflections and gait; and who desperately wanted to be a girl.”

Promoting DSM-IV GID data as if it were DSM-5 GD data isn’t only irrational, it’s dangerous. We are no longer talking about a mixed DSM-IV GID group comprised of 70% non-GD GNC kids and 30% GD kids, we’re talking about a DSM-5 GD group comprised of GD kids. Lying about this fact will result in needless and avoidable trauma and possibly death.

UPDATE: April 20, 2022

The Florida State Department of Health issued a “statement” it claimed to be “guidance” to parents and providers urging them to withhold care, based on the exact claims this article debunks.

Every claim asserted by the Florida State Health Dept., with the exception of its initial link to the US Dept. of Health and Human Services, is spurious. Below is a review of the cited references Florida used to rationalize their claims:

Low-Quality Evidence: This is a paper, published in a religious journal by a Washington University “researcher.” His name is Paul W. Hruz and he made headlines for “blurring the lines between religious freedom and medicine” when it comes to trans care. Washington University issued the following statement about Hruz bad-faith “medical” activism:

Dr. Hruz is NOT a member of our DSD team, NOR is he an expert in transgender health as he has never taken care of a transgender person. Dr. Hruz admits that he has not treated any transgender patients, patients with gender dysphoria, conducted peer-reviewed research about gender identity, transgender people, or gender dysphoria; and is not a psychiatrist, a psychologist, nor mental health care provider of any kind, who could speak knowledgeably of transgender health.”

The following is a paragraph from the Hruz paper cited by Florida:

“Low-Quality Evidence”

Clearly, Hruz understands the difference between DSM-IV and DSM 5 cohorts, and yet, Hruz’s 2019 “study” cites old DSM-IV data to make claims about post-2019 DSM 5 trans kids. What Hruz is doing is called lying. Moreover, Hruz’s “study” cites his own qualitative estimations as to the worth of trans research using the “Grading of Recommendations, Assessment, Development and Evaluations” system that was recently demonstrated to produce highly biased findings.

The International Review of Psychiatry: this is particularly disingenuous as the cited study is about the ways DSM-IV GID and DSM 5 GD are different and it was within that context that the study remarked on the fact that old DSM-IV GID data showed that many GID kids would stop having GID. At no point does this study claim “that 80% of those seeking clinical care will lose their desire to identify with the nonbirth sex.” This is another lie.

“International Review of Psychiatry”

One review concludes: this is a 2018 study on DSM 5 trans kids. As this study was published only 5 years after the clinical formation of the cohort (remember, the DSM 5 was published in 2013), at that time it was correct to note that “hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.”

Merck Manual: citing this Manual is interesting because it both directly undercuts the conclusions the Florida Health Dept. draws while also using long-outdated language and DSM IV data to make claims about DSM 5 cohorts. The definition of gender dysphoria the Merck Manual uses comes from the DSM IV and focuses on gender role dysphoria rather than phenotype dysphoria, which is the essential symptom around which the symptomatology of the DSM 5 cohort is organized. Nevertheless, the Merck Manual uses the DSM 5 standards for diagnosing gender dysphoria in children and states that after the onset of puberty:

[I]t is recognized that attempts to force the child to accept the birth-assigned gender role is usually traumatic and unsuccessful. Therefore, the predominant treatment modality is psychologic support and psychoeducation for children and their parents, using a gender-affirmative model as opposed to a gender-pathologizing model. This affirmative approach supports the child in the gender expressed, sometimes including social transition prior to puberty.

For post-puberty kids with DSM 5 gender dysphoria, the Merck Manual goes on to note:

In early adolescents, puberty-blocking agents are more commonly used today. Agents such as leuprolide (gonadotropin releasing hormone agonists) prevent the production of testosterone and estrogen, thereby “blocking” the progression of puberty. These agents may be employed at Tanner Stage II of development, enabling additional time for evaluation of the gender dysphoric youth (see Endocrine Society Guidelines, 2017). If the gender-dysphoric youth wishes to continue with full transition, puberty-blocking agents are discontinued and gender-affirming hormones (previously known as cross-sex hormones) are employed, enabling the onset of puberty in the experienced gender.

Citing the source of the above medical recommendations –the Merck Manual— the Florida Health Dept. instructs parents and providers to do the exact opposite for post-pubertal kids:

The Florida Dept. of Health then concern trolls about how the Dept. is terribly concerned about trans surgeries on children, which is something that was never ethical to do in the first place, even as right-wing propagandists continue to claim otherwise. Citing guidelines from the federal Centers for Medicare and Medicaid Services, Sweden, Finland, the United Kingdom, and France, the Florida Dept. of Health correctly notes that nobody believes it to be ethical to perform trans surgeries on children. Again, performing trans surgeries on children was never ethical in the first place. Essentially, this bit of concern trolling is asserting that Florida is taking a brave stand against a practice that doesn’t exist in the ethical world of trans care the US Dept. of Health and Human Services outlined.

Finally, the Florida Dept. of Health ends their recommendations on a point that we agree with and endorse: “children and adolescents should be provided social support by peers and family and seek counseling from a licensed provider.”

Here, I think it is important to note that the AMA recently commented about the dangers of playing politics with the lives of trans kids:


I thought about adding to the above list something about a fake syndrome this anti-trans movement has created and attempted to legitimate, but a good debunking of this fake syndrome called “Rapid Onset Gender Dysphoria” was already done over on the Advocate. I encourage you to take a look.

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  1. Dr. Rekers was a founding member of the Family Research Council and served on the board of the National Association for Research and Therapy of Homosexuality (NARTH).
  2. Within transgender discourse, one’s “gender orientation” references an individual’s subjective and primary experience phenotype. Likewise, Judith Butler contextualized this experience as being one’s “primary experience of the body”.
Cristan Williams is a trans historian and pioneer in addressing the practical needs of underserved communities. She started the first trans homeless shelter in Texas and co-founded the first federally funded housing-first homeless program, pioneered affordable health care for trans people in the Houston area, won the right for trans people to change their gender on Texas ID prior to surgery, started numerous trans social service programs and founded the Transgender Center as well as the Transgender Archives. She has published short stories, academic chapters and papers, and numerous articles for both print and digital magazines. She received numerous awards for her advocacy and has presented at universities throughout the nation, served on several governmental committees and CBO boards, is the Editor of the TransAdvocate, and is a founding board member of the Transgender Foundation of America and the Bee Busy Wellness Center.