The practices of ‘affirmation’, social transition and chest binding are often promoted as harmless as they do not involve any medical treatment or intervention. Here we look at the evidence of the safety and potential effects of these very recent developments which have quickly become widespread.

For an analysis of the ‘gender affirmative’ or ‘affirmation’ approach, see related article Johanna Olson-Kennedy and the US Gender Affirmative Approach and download this publication by Civitas for an essay on Affirmation by Stephanie Davies-Arai.

What is a social transition?

A social transition is when someone decides to live in the role of their chosen sex. This can involve a name change and use of different pronouns. A person’s new gender can be expressed by the use of hairstyles and clothes. It can be full-time, only exhibited in certain settings or just at home. These transitions do not involve any medical, physiologic or hormone intervention.

Social transition is currently controversial in clinical psychology and psychiatry, but is increasingly being pursued by parents. More and more paediatricians, therapists and teachers are supporting these transitions. Schools are increasingly accommodating the social transition of pupils with name changes, uniforms and toilet provision. There are some examples of social transitions occurring in children as young as 2-3 years old.

It is unknown how many children have already socially transitioned or if these children do so under the guidance of gender specialists or do so independently. We recently submitted a Freedom of Information (FOI) request to the children’s gender identity clinic (Tavistock).  We asked how many children referred last year had already undergone a social transition before attending their first appointment. We are told they do not hold any records of this information.

It may appear harmless and easily welcomed as a beneficial approach that can relieve gender dysphoria symptoms in children. However, it is currently unclear what the long-term psychological effects will be for children who undergo social transitions for some or all of their childhood and how this impacts on the development of their sense of self.

What evidence is there that social transitioning is helpful?

A study was published in 2016 that is often cited as proof that gender affirmation within the family and allowing children to socially transition will resolve their gender dysphoria. It is used to support the concept that gender dysphoria is not an inherent part of being transgender. This sets it apart from many other disorders because if someone is depressed, for example, he or she is, almost by definition, distressed as a result of the depression. In contrast, the distress that accompanies gender dysphoria arises as a result of a culture that stigmatises people who do not conform to gender norms.

The study looked at depression and anxiety scores of 73 pre-pubescent children who had been supported by their parents to socially transition. They compared this to age-matched non-transgender siblings and non-transgender peers. No major differences were seen in depression or anxiety in any of these groups. Slightly higher levels of anxiety were shown in the trans group but still only a low level. This contrasted with other studies that have shown that transgender kids who don’t socially transition do show elevated depression and anxiety. Link to study is here.

However, this study is often misinterpreted because it does not mean social transitioning itself stops the depression or anxiety. It could simply mean that supportive and loving parents reduces the risk. There is no data here on outcomes for gender dysphoria in children with supportive parents who promote a gender non-conforming lifestyle but WITHOUT denying the reality of their biological sex.

  • This study also does not prove that gender dysphoria is a not a mental health pathology any different from any other body dysphoria. It simply shows that gender dysphoria is relieved by support and/or social transition as measured by symptoms such as depression and anxiety. An anorexic who was supported and validated in their desire to lose weight may well also present with reduced levels of depression and anxiety. This remains untested as such a study would rightly be deemed unethical.
  • This study does not tell us about longer term outcomes of socially transitioning. All these children are pre-pubescent (ages 3-12yrs). This is a time when depression and anxiety levels are generally fairly low anyway. They rise steeply when children hit adolescence. We do not know how these children will fare during this high risk phase and beyond when the consequences of transitioning will really start to hit them. Follow up studies will be done but we won’t see those results for at least another 5 years.
  • There are also some major limitations inherent in the design of this study. Depression and anxiety scores are based on surveys carried out by their parents. It is likely there will be some unconscious reporting bias here as parents who have decided to actively support social transition will really want their transgender kids to be seen as psychologically healthy.
  • It must also be noted that the transgender children in this study are among the first to convince their parents and society to let them socially transition so young. These children may well be unusually articulate/emotionally aware. We can’t rule out some unknown confounding factor that is unique to this ‘first mover’ group that will not been seen as socially transitioning becomes more common and widespread.

The fact still remains that the move towards gender affirmation in children is not an evidence-based approach and is experimental. Long-term studies are urgently needed in this area.

What little evidence we do have indicates that affirmation and social transition may fix a child into an identity they may have grown out of if left alone. The findings of a 2013 research study by Dr Thomas Steensma from the Netherlands indicated that social transition is the most powerful predictor of persistence of childhood gender dysphoria. There is now strong evidence that puberty blockers also increase persistence, as evidenced by the results of the Tavistock GIDS Early Intervention study:

44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones.

A paper by De Vries (2012) warns of the danger that a young child who is unduly affirmed may not really understand the concept of natal sex:

‘Another reason we recommend against early transitions is that some children who have done so (sometimes as preschoolers) barely realize that they are of the other natal sex. They develop a sense of reality so different from their physical reality that acceptance of the multiple and protracted treatments they will later need is made unnecessarily difficult. Parents, too, who go along with this, often do not realize that they contribute to their child’s lack of awareness of these consequences’.

Tavistock GIDS Consultant clinical psychologist Bernadette Wren also expressed the need for caution in her paper for the Journal of Clinical Child Psychology and Psychiatry (2019):

‘It is my belief that we need to make creative opportunities for the open, accepting exploration of the gender experience and gender expression of these younger children; my fear is that to proceed to a full emphatic social transition may hamper their development’.

Under the globally established model of ‘watchful waiting’ – where children were not affirmed as the opposite sex or socially transitioned – around 80% grew out of these feelings during puberty.

Evidence suggests that affirmation and social transition followed by puberty blockers may prevent this natural resolution of gender dysphoria in the adolescent years. 

Chest binding

This is an increasingly popular way for females to flatten the appearance of their breasts. Social media and magazines like Cosmopolitan are full of advice on chest binding for young people.  As a result it is now very common practice for young females in the transgender community.

Some children have been known to use duct tape wrapped tightly around their torso. Alternatively chest binders and/or multiple sports bras can be used to achieve a flatter profile. Known health risks associated with chest binding include compressed or broken ribs, punctured or collapsed lungs, back pain, compression of the spine, damaged breast tissue, damaged blood vessels, blood clots, inflamed ribs and heart attacks. Link to article here.

A recent study has been conducted to assess the health impact of chest binding in the transgender community. Of the 1800 participants with experience of binding, 51.5% reported daily binding. Over 97% reported at least one of 28 negative outcomes attributed to binding. Compression methods associated with symptoms were commercial binders (20/28), elastic bandages (14/28) and duct tape or plastic wrap (13/28). Larger chest size was primarily associated with dermatological problems.

Chest binding results in difficulties in breathing so will affect levels of activity and overall health in females who choose to bind their breasts. Schools in the UK have been advised to offer longer P.E. breaks to accommodate this. Link here.

See related article Breast Binding, Sexual Objectification & Grooming