11 January 2016

Do trans- kids stay trans- when they grow up?

Following the closure of the CAMH Gender Identity Clinic for children, I have been receiving requests for what the science says.  Do kids grow out of wanting to change sex, or does it continue when they are adults?

In total, there have been three large scale follow-up studies and a handful of smaller ones. I have listed all of them below, together with their results. (In the table, “cis-” means non-transsexual.) Despite the differences in country, culture, decade, and follow-up length and method, all the studies have come to a remarkably similar conclusion: Only very few trans- kids still want to transition by the time they are adults. Instead, they generally turn out to be regular gay or lesbian folks. The exact number varies by study, but roughly 6090% of trans- kids turn out no longer to be trans by adulthood.

Count
 Group
Study
2/16
4/16
10/16
gay
trans-/crossdress
straight/uncertain
Lebovitz, P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.
2/16
2/16
12/16
trans-
uncertain
gay
Zuger, B. (1978). Effeminate behavior present in boys from childhood: Ten additional years of follow-up. Comprehensive Psychiatry, 19, 363–369.
0/9
9/9
trans-
gay
Money, J., & Russo, A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.
2/45
10/45
33/45
trans-/crossdress
uncertain
gay
Zuger, B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.
1/10
2/10
3/10
4/10
trans-
gay
uncertain
straight
Davenport, C. W. (1986). A follow-up study of 10 feminine boys.  Archives of Sexual Behavior, 15, 511–517.
1/44
43/44
trans-
cis-
Green, R. (1987). The "sissy boy syndrome" and the development of homosexuality. New Haven, CT: Yale University Press.
0/8
8/8
trans-
cis-
Kosky, R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.
21/54
33/54

trans-
cis-

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

3/25
6/25
16/25
trans-
lesbian/bi-
straight
Drummond, K. D., Bradley, S. J., Badali-Peterson, M., & Zucker, K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44, 34–45.
17/139
122/139
trans-
cis-
Singh, D. (2012). A follow-up study of boys with gender identity disorder. Unpublished doctoral dissertation, University of Toronto.
47/127
80/127
trans-
cis-
Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582–590.


*For brevity, the list uses “gay” for “gay and cis-”, “straight” for “straight and cis-”, etc.


44 comments:

  1. Thank you. This is a wonderful resource.

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  2. Thanks for posting the evidence. What a shame identity politics trumps science.

    Ray Hames

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    Replies
    1. Evidence? I'd prefer to see the studies and their methodologies. My understanding is that these were studies of gender non-conforming children, most of which wouldn't be trans anyway. That there as large a percentage of these kids who do turn out to be trans should be an indicator that the issue is real and deserves to be taken seriously.

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    2. Are you really saying that only kids who don't desist should be included in a study of how many kids desist? I cannot imagine how (or why) you would do such a study, but it would obviously prove nothing if you did.

      The burden of proof is on the trans-affirmative approach. Where are the longitudinal studies that show its outcomes?

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    3. The whole point of full references is to enable you to see the studies and their methodologies. Go for it, but don't complain that a short article for average people doesn't do all the work for you.

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  3. Thanks for the nice info at a glance

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  4. Hello Dr Cantor, Could you provide any links to the studies so that we can have a more in-depth understanding of the data collection and analysis? Many thanks

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    1. You can just google the titles,

      https://www.ncbi.nlm.nih.gov/pubmed/18981931

      https://www.ncbi.nlm.nih.gov/pubmed/18194003

      etc

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  5. Hello Dr Cantor, I was wondering if you could provide any links to the entire studies? I'm interested to find out more. Many thanks, Sian

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  6. Without access to the original data, informed analysis is of course impossible.But I can't help thinking of the long-standing received wisdom that virtually all homosexual males are "effeminate" as children, two thirds of them losing those attributes by adulthood--but NOT changing their homosexual orientation. The first thought that this brings to mind, then, is that (in today's constant blather over such things) that many children who find their traits on one side of the gender-spread may leap to the conclusion that they are trans--only to discover the error in later years. Perhaps at least a partial explanation?
    F. Christensen
    Professor Emeritus

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    1. I don't know what "long-standing received wisdom" you are talking about, but no social science study has ever shown all homosexual males to be effeminate as children. Only a minority are.

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    2. The original data isn't inaccessible. If you Google the titles they're all within means. Here it took me about three or four minutes but I've got the address to every study listed.

      https://www.ncbi.nlm.nih.gov/pubmed/23702447

      https://www.ncbi.nlm.nih.gov/pubmed/18194003

      https://www.ncbi.nlm.nih.gov/pubmed/19586166

      https://www.researchgate.net/publication/23449293_Psychosexual_Outcome_of_Gender-Dysphoric_Children

      http://europepmc.org/abstract/med/3614045

      http://psycnet.apa.org/record/1987-97006-000

      https://link.springer.com/article/10.1007/BF01542316

      https://www.ncbi.nlm.nih.gov/pubmed/6693867

      http://psycnet.apa.org/record/1979-33886-001

      http://www.comppsychjournal.com/article/0010-440X(78)90019-6/references

      https://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.128.10.1283

      There now you can make an informed analysis.

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  7. These are studies of GNC children, not 'trans.' This is the kind of thing that got Zucker in trouble.

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    Replies
    1. The five most recent studies make reference to gender identity disorder/gender dysphoria in their titles, so I don't think the subjects were simply GNC children.

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  8. If you look at the actual studies, they were done with gender-nonconforming children, not children who expressed that they actually were the other gender. This article is no more than clickbait trying to mislead people for political gain.

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    Replies
    1. This is a lie. Which I've seen repeated often by the way, whenever people referenced these studies.

      In the Singh 2012 study of 139 subjects (link to full PDF below), 88 children fulfilled the *complete* diagnostic criterion of Gender Identity Disorder, which includes strong cross-sex identification.

      Of those, 12 persisted. That's 13.6% persistence rate and 86.3% desistance rate. And that's among those who completely fulfill the criteria / have strong cross-sex identification.

      From the 51 children who partially met the GID criterion (some of whom nevertheless had significant cross-sex identification as mentioned in the study), 5 persisted. That's 9.8% persistence rate, 90.2% desistence rate.

      The study:
      https://tspace.library.utoronto.ca/bitstream/1807/34926/1/Singh_Devita_201211_PhD_Thesis.pdf

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    2. Dr. Cantor, are you the author of the above comment, dated 27 April 2017 at 16:43, beginning with , "This is a lie."? I need to know for correct attribution. Thank you.

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    3. No, my replies appear under my own name.

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    4. Anyone who writes comments as not identifiable should not be considered valid.
      Transgender can be identified.
      Either child born with birth abnormality of penis and vagina or in reverse of identifiable abnormality. Penis on top with vagina below. Vaginal cavity with penis growth below skin. Very painful in adult hood. Not visible to naked eye. Ultra sound might detect however series of issues arise.
      Breast growth upon males as aging occurs might indicate vaginal cavity closed as infant cause menstrual issues much later. Few study this field of abnormalities.
      I have seen conditions personally.
      Most have no idea severity or medical concerns which can arise from complications later. Transgender sciences are at infancy
      It was common for medical doctors to close any vaginal cavity upon infants who were not ideal born.
      Birth sex chosen by doctor.
      Some had vaginal cavity with very small penis.
      Amephrodites occur stigmatized and hatred wrought upon them for being different.
      Cause parents who fail to check if sexual partner is relative.
      If first cousin higher the chance of abnornailty.
      If direct relative of sibling greater magnitude of abnormality.
      Males with 4 breats.
      Female appearence and breasts with penis but no vagina.
      DNA could prevent much disorder and identify the one you want to have children with is your sister but your father slept with her mother on that sales trip you never knew about.
      Face facts.
      My DNA matches 854 persons across globe so far.
      My family screwed like bunnies.
      Anywhere or anyone.
      Do not think this is minimal.
      It is everywhere.
      People simply do not talk about these factors.
      My DNA published was published on ancestry.com to identify family.
      My book is listed everywhere.
      Songs of Frost by Michael Collins
      It is not poetry for light hearted. Truthful hard reality of life.

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  9. Much of this summary doesn't even add up - literally.

    Straight / gay / bi: sexual orientation

    Cis / trans/cd: gender identity/presentation

    Two separate things (cis can be gay or straight, trans can be gay or straight), so the numbers for each need to total 100% of the population separately.

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    Replies
    1. According to a trans organization (Mermaids) 'cis' people are happy with gender AND attracted to opposite sex

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    2. "For brevity, the list uses “gay” for “gay and cis-”, “straight” for “straight and cis-”, etc"

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  10. "regular gay or lesbian folks"
    :-/

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  11. For the early studies, it is probably a fair criticism to say that the children may not have had gender dysphoria. They may have been in treatment because they were gender non-conforming and their parents were concerned about it.

    However, the more recent studies talk about children who feel they should be or are a different gender.

    In addition, Wallien et al. and Steensma et al. are studies from the Amsterdam clinic. This is the clinic that pioneered the use of puberty blockers in adolescents with gender dysphoria; they are not at all anti-trans.

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    Replies
    1. Whether or not they're anti trans, their result is potentially misleading. Of the 54, 12 kids in the study never actually got a GID diagnosis, so if youre talking about if kids diagnosed with GID "stay trans" the result from that study was actually 50:50. It's also worth noting that a further 6 of the respondents who were diagnosed, weren't available to be contacted, and so their parents filled out a questionnaire on their behalf

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    2. 50:50 still strikes me as very high.

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  12. People are mixing up Gender Non Conforming Only Children, GNC Only, (usually as defined by their parents) and transgender children (those who show strong cross gender desires and associated Gender Dysphoria, GD).

    Now GNC Only (little or no transgender desires and the associated GD) will fairly often, but not always by any means, end up bi-sexual, gay or lesbian as adolescents and adults.

    GNC with strong GD will retain that into adolescence and adulthood and at some stage transition or die, that 30%-40% suicide attempt rate is no mistake.

    So it is important to separate them, which to be fair for a young child can take a few years to work out, hence the WPATH ’support and wait and see’ approach.

    The longer a child expresses transgender desires and has GD the more likely they will retain that. But, an important but, a child with strong GD may not be a ‘typical’* ‘sissy boy’ or ‘tomboy’. though they will almost certainly show some clear GNC behaviour of some kind and strongly express transgender wishes and show suffering if they are thwarted.

    The other issue is the treatment of some GNC Only kids, who if you do the ‘drop the Barbie’ stuff to them means you are making them act ‘straight’, which is cruel and if not actual SOCE is pretty close.

    GNC Only behaviour by itself will not ‘make’ someone transgender, which seems to be the fear by some.
    GD plus GNC means they are transgender and almost certainly will not change and if you try you are playing Russian roulette with their lives. There is only one treatment for GD that works.

    So the issue is selection and that is not that hard. A 2012 study on CAMH children showed the only statistically significant factor (logistic regression) was the strength of (their combined GNC/GD) scores. So their own tests showed good measures to predict outcomes, which were a lot higher that the commonly stated ‘80% desist’ (based on lumping the two groups together).

    A rough ‘back of the envelope’ calculation shows that maybe only 5% of GNC Only kids will become transgender. BUT, maybe as much as 80% to 90% of GNC + strong GD ones will persist.

    The majority, by far, are of course GNC Only with transgender children being a small minority.

    *And what is a typical ‘sissy boy’ or ‘tomboy’ anyway? This is usually just parent paranoia and their absurd social ‘norms’.

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  13. Cannot use this level of analysis as having any scientific validity. Must dig into methods and clarify integrity of diagnosis, especially noting the year span of the studies. Then submit it for peer review. At most, this begs for further examination which of course, it always good!

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  14. A debunking for the last study listed: https://gidreform.wordpress.com/2014/02/25/methodological-questions-in-childhood-gender-identity-desistence-research/

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  15. I've reviewed the first Cohen-Kettenis study and their definition of "persistence" was if the person reported for for transitional surgery as an adult. They also included in desisters, those who dropped out of the study. So methods and operational definitions need to be carefully looked at. I'd like to see the numbers for those who were insistent, persistent and consistent since the mid 90's and see what their follow up outcome was.

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  16. What I take from these studies is that it would appear that as time as gone on, we narrow down the defintions of GNC+GD, we get greater diagnostic specificity and reliability for 'persistence'. This is a hopeful sign that we may yet have a set of diagnostic criteria that reliably differentiate the two populations. Dr. Kelly Winters noted in her talk on the subject, referenced in the link above by "no", that anatomic dysphoria correlated with persistence. I have noted this anecdotally, talking to a number of parents of GNC kids, both desisters and persisters. This needs to be explored further.

    The other item that the listed research shows is that desisting seems to slow down, if not stop entirely around the ages ten to thirteen, suggesting that a rethink of the puberty blocking protocols now in vogue is in order. It may be more desirable to phase in cross-sex HRT at an earlier age with properly screened clients:

    https://sillyolme.wordpress.com/2011/02/28/age-of-innocence/

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  17. The most important part of the Steensma study is that he identified two groups and the the main characteristic of the "desisters" were being gender non-conforming (wanting to have the role of the other sex - being able to behave like a boy/girl) and the persisters felt they were in the "wrong body" (I am simplifying the study).
    So, what we have is a difficult in diagnosing a children with less than 13 yo - we can say that they are gender non-conforming, but not transgender.

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  18. Then the answer to this question is the vast majority of these kids do not transition. So why is there a difference between kids and adults? I would just say that most adults do not have the therapy available that kids have and that their dysphoria is never dealt with in the same way. Either way the culprit is dysphoria and cutting off healthy body parts, helping people pretend they are the opposite sex and giving lifelong hormones instead of better cognitive care to deal with underlying issues is a disgraceful way to say we are 'treating' anyone. If we can get big pharma to investigate dysphoria for a real cure and stop the trans activists then we could really say we are on the right track. Sorry to upset people but this is the truth.

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    1. For me, this is tantamount to saying we need a cure for homosexuality--which is what the protocol was before it was determined to be biological. No trans child/adult chooses a life that is difficult, marginalized and exposes them to violence.

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    2. Thank you Jane. A sensible attitude - enabling young people, at a very sensitive and often confusing age, to make life-changing decisions of this sort is crazy. I don't think anyone is suggesting we need a cure for homosexuality. Gender and sexuality are not the same thing. But allowing a child to grow, mentally and emotionally, before embarking on irreversible and massively life-changing procedures seems like good sense to me.

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    3. @ lisa: Exactly. I don't think James believes that to be desirable, but there is clearly a political imperative growing towards suppression of HSTS transsexualism in favour of gender-conforming homosexuality. It is not a good thing

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  19. Whoa! This blog looks just like my old one! It's on a completely different subject but
    it has pretty much the same layout and design. Outstanding choice of colors!

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  20. It is truly a great and helpful piece of info.

    I am happy that you simply shared this useful info with us.
    Please keep us up to date like this. Thanks for sharing.

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  21. Most of these studies took place before the Tavistock Gender identity clinic opened in London. Presumably other countries opened clinics around the same time? The European Professional Association for Transgender Health started in Dec 2013 - AFTER all these studies.
    How do you expect a child to transition if there is no medical help available? The only available help would be assistance to desist.
    It's a bit like saying pilots don't exist because none of Napolean's troops flew a plane.
    Have these children been followed up recently now that gender clinics are actually available? Did they transition as adults?

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  22. Very good write-up. I certainly appreciate this website.

    Continue the good work!

    ReplyDelete
  23. I pay a visit each day a few websites and sites to read articles, but
    this website gives feature based content.

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  24. James,

    All but 4 of these studies are over 30 years old. Given that there is plenty of evidence to the effect that culture does influence outcome in transsexual persistence (see below), the earlier studies should be taken with a pinch of salt. Of the others, Wallien shows 43% ; Drummond applies ONLY to girls; Singh, while noting desistance in the sample, stresses the importance of severity of childhood GD in predicting adult GD; and Steensma again concludes 'Intensity of early GD appears to be an important predictor of persistence of GD.'

    So the proper conclusion actually should be that, while a majority of GD-displaying children do desist, this is related to the intensity of the childhood GD itself. In other words, for some it is a passing phase and for others, it's an indicator of their future sex/gender presentation. The clinician's role is to determine which is being presented, before proceeding with any therapy. This will probably involve a 'wait and see' approach.


    Now there is a big problem in the West in that there is a clear bias amongst clinicians that 'being "gay" is a better outcome'. There is no statistical data to support this, nor, as far I am aware, and as you know I research this, is there a consistent position as to what constitutes a 'better outcome'. Clinicians like Bailey and Zucker, both of whom I respect, have made this claim and neither have any material evidence to support it. Their case seems to be 'avoiding a lifetime of hormones and surgery is better', which is superficially reasonable, but only so. We ALL face a lifetime on hormones, otherwise we should not be human. Further, in cultures where transsexualism is far more obvious than in the West, genital surgery (GRS) is very rarely sought. This suggests that an alternative solution would be to allow people to live as their desired sex, without any requirement for GRS, either legally or in terms of social pressure.

    (I would point out that Dr Winter of UHK has often said that he is perplexed that people claiming to research transsexualism do not do so in parts of the world where it is an everyday, obvious occurrence. In many parts of SE Asia, one will encounter transsexuals on a daily basis even in remote communities; one does not have to seek them out or wait for them to be referred to a clinic, in order to interview them. I agree with him.)

    In these cultures there is no requirement, social or legal, for trans people to have GRS in order to live in the gender they desire to. In these cultures, one sees far more transsexual expression and it has frequently been stated to me that about 80% of GNC children will grow up trans, not gay males or lesbians; this is more-or-less the inverse of the reported position in the West. I accept that this is an anecdotal figure but it is certainly borne out by observation. The corollary is that there is a fair bit of adult desistance, in the 35-up age range, but since GRS is so rare, this, at least in MtF, is not so much of an issue.

    This tells us, as I opined above, that culture is everything. It was once normal, in the West, to suppress homosexuality in favour of heterosexuality; now we appear to be suppressing HSTS transsexualism in favour of gender-conforming homosexuality. (I know you understand that there are two types of TS and we are ONLY discussing HSTS here; others please read up on this.)

    I can't for the life of me see how deliberately suppressing transsexualism in favour of gender-conforming homosexuality is any more acceptable or morally justifiable than suppressing homosexuality in favour of heterosexuality. If anything needs to change it is society's prescriptive attitudes; we might say 'some women have dicks, get over it.'

    The only valuable measure should be the individual's life satisfaction and it is not, whether they like it or not, a 21st-century clinician's role to shoehorn individuals into conforming to social expectations.


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  25. Several commentators have suggested that many of the desisters were not actually suffering from gender dysphoria. This may well be the case. If so, however, it reinforces the necessity of making an accurate diagnosis the first time round, because it seems to me there is a lamentable tendency to over-diagnose GID, and to put these young people onto the hormone/surgery treadmill without carefully assessing the situation.
    The other point is the high proportion who ended up as non-trans heterosexuals rather than homosexuals. As I understand it, among adult transsexuals, sexual orientation and perceived sexual identity tend to diverge in about half the cases. In other, they are like a male colleague of mine who said the he had always felt like a woman, but at the same time, had always been sexually attracted to women.
    If that is the case with adult transsexuals, then we should not be surprised if those trans kids who grow out of their GID do not automatically end up as homosexuals or lesbians, but as normal heterosexuals.

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    Replies
    1. Actually, the entire (alleged) criticism is moot. There was a study which had a sample of gender dysphoric kids AND a sample of gender non-conforming kids. Upon follow-up, their desistance rates were nearly identical (and both were over 50%).

      If all the desistance cases (or most of the desistance case) came from the only the gender non-conforming group, then it would be valid to criticize the study for blurring the groups to look like desistance happened among the gender dysphorics as much as the gender non-conforming. However, the (alleged) criticism is demonstrably false: The study compared the two groups explicitly, demonstrating their outcomes to be the same. It is simply not the case that desistance cases are accounted for by people who are gender non-conforming rather than gender dysphoric.

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