Emerging Evidence in Adolescent Gender-Development and the Importance of Translational Public Health Communications.

“Trans youth know who they are” is a pithy slogan used by many health advocates; a declaration that transgender and gender diverse (trans) adolescents understand their identities with the same strength as their cisgender peers, meaning their peers who are not trans. This slogan affirms the role trans youth may have as epistemic peers in matters related to their identities and the decisions made in collaboration with their families and medical professionals, in accessing medically necessary transition-related health care (TRH). It is not just rhetoric, though, and research is beginning to confirm what trans patients, their families, their advocates, and their providers have long asserted. Among the most recent investigations into the development of trans youth is a longitudinal study conducted by deMayo et al, within the Trans Youth Project at the University of Washington in Seattle, were published in 2025 by the Society for Research in Child Development¹.

In this study, deMayo et. al examined the trajectories of gender development in transgender children and adolescents, compared to those of their cisgender peers. The published findings suggest, as the aforementioned slogan implies, that TGD adolescents’ identities are developmentally similar to those of their cisgender peers. This study demonstrates that gender variance among people of all ages is not only not a mental illness, but it is a naturally occurring variance. One might wonder why the published findings have received little discussion in the media, along with other recently published pieces of literature on the safety and efficacy of medically necessary care for TGD youth^2–6. While the factors are hard diverse and likely impossible to qualify with certainty, this paper attributes these oversights to two critical factors: capacity and bias.

Addressing the first factor, translational public health reporting can be a slow, didactic process and is not particularly attention-grabbing in the contemporary media landscape. In the fast-media landscape and during an administration whose actions ensure there is no shortage of public health crises for experts to confront and contextualize, journalists and editors will necessarily be forced to cover stories that feel more “urgent to the mainstream reader”. There are also logistical barriers. The present study is some 166 pages long, and its contents are complex and require literacy in previous literature in this area to fully appreciate. This sets a high barrier to entry for readers and demands significant investment by public health experts to assess and communicate.

These barriers are compounded by a historically rooted (though slowly changing) trend in public health reporting to deprioritize issues of TGD health and human rights, as well as a cooccurring failure to substantively invest in the proliferation and career support of experts from the effect patient population, TGD people themselves. And despite the immense scope of attacks against trans people in the United States (U.S.) across nearly every domain of public life, the issue of trans health for many journalists and editorial staff remain as “special issue”. In an environment where the FDA is rejecting Moderna’s mRNA vaccine application, Robert F Kennedy Jr. is claiming a keto diet can cure schizophrenia, the  Trump administration continues to gut the U.S. public health infrastructure, the existential threats posed to trans people seem to some to be an afterthought to regular reporting slates. Of course, the exception would appear to be reporting on the threats and epistemic violence of this administration against trans people. Short of indicting the public health media figures who hold such cisnormative biases, this paper proposed a reinvestment not only in resources but in the careers of trans public health experts, in keeping with best practices from the field of community public health. These barriers are compounded by a historically rooted (though slowly changing) trend in public health reporting to deprioritize issues of TGD health and human rights.

Still, the current administration and conservative lawmakers continue to push dangerous policies limiting the bodily autonomy of TGD people of all ages, rooted in rhetoric dripping with misinformation and inflammatory language. Misinformation is being peddled not only about the safety and efficacy of transition-related healthcare, but gender variance itself, which conservative lawmakers have incorrectly described as a pathology, a mental illness, or a disease⁷. Anti-trans politicians position TGD adolescents, and even adults, as highly impressionable and subject to the supposed corrupting influence of “gender ideology”.

TGD identities are being pathologized in this way to undermine the positive and potentially lifesaving impacts of evidence-based transition-related care. This narrative also paves the way for policy shifts intended to institutionalize gender-conversion practices as the default “treatment” for gender dysphoria. Such policies rely on the delegitimization of TGD youth’s understanding of their own identities and characterizing gender variance itself as a mental illness that must be resolved. Research such as deMayo et al.’s study is critical because it robustly challenges the ideological myth that conservative lawmakers need to uphold.

Gender, Identity, and Transition-Related Care.

Despite conservative politicians’ claims that TGD “children” are undergoing irreversible surgery, the truth is far less dramatic than conservative alarmism would have the public believe. Not all TGD people access transition-related care. TGD youth do not undergo any form of medical treatment until they reach a certain milestone of pubertal development^2,8–11, marked by what researchers, scientists, and providers call “Tanner Stage 2”, the second stage of human pubertal development. Most adolescents reach this milestone at around the age of 12.  However, this age-marker is a generalization and is subject to individual variation, influenced by a number of social, ethnic, genetic, and epigenetic factors.

If puberty begins earlier than the typical age, they’re said to have “precocious puberty”. In such a case, they may receive treatment with FDA-approved puberty-pausing medications^12–15. Which are the same medications post-pubertal TGD youth may access, and for the same purpose – temporarily pausing pubertal development. These medications are safe, effective, and largely reversible^10,15,16. Depending on the patient, the next stage of treatment generally involves “pubertal induction” using partially reversible gender-affirming hormones^2,17–19. Some patients may utilize an “anti-androgen, which may complement “feminizing” therapy with estradiol or could be taken on its own.

PTRH is innately connected to a person’s expression of their gender, playing a role similar to endogenous puberty in the embodiment of cisgender people’s gender.  While the operative distinction may be that trans youth require exogenous hormonal treatments, this distinction is moot, as many cisgender people of all ages access what might be called “gender affirming care”, for diverse but similar reasons^20–22. However, cisgender epistemic authority over their gender identity is automatically validated and uncontested compared to the degree of scrutiny TGD people’s identities receive. A cisgender girl’s declarations that she is in fact a girl are given implicit and automatic weight, not because being cisgender is developmentally more “natural”, but because this modality of gender conforms with dominant cultural stereotypes regarding a person’s assigned sex and gender. TGD adolescents, however, are not afforded that degree of epistemic empowerment, because their gender challenges a dominant yet shrinking set of stereotypes around sex and gender. This diminishment of the epistemic authority of trans adolescents over their own identities is one of the primary conceptual pillars underlying the restriction of this care for trans adolescents²³.

Gender cognition, our ability to recognize, describe, and differentiate our gender, is a critical aspect of human identity development^1,24,25. Quoting from deMayo et al.:

Awareness of one's own identity and reliable self‐categorization (along with the labeling of other people's gender) typically emerge between ages 2 and 3, with some variability (Etaugh et al., 1989; Fagot, 1985; Fagot et al., 1986; Leinbach & Fagot, 1986; S. K. Thompson, 1975; Weinraub et al., 1984).

Growing up in a society saturated in gendered stereotypes, children’s understanding and discernment of the social gender constructs around them develops from an early age, as does their ability to recognize and relate to those stereotypes. This primes adolescents to continue assessing and exploring their relationship to gender as they grow, and even if they lack the language to describe their gender variance, they may still recognize a dissonance between their experience of gender and the stereotypes associated with their assigned gender.

deMayo et al.’s Study.

To investigate this question, researchers conducted a longitudinal study, meaning they assessed the development of a relatively stable group of participants over a period of time. To understand and assess the developmental trajectories of adolescents’ gender identities, researchers utilized cisgender adolescents as a control group. The researchers described the mental health of transgender and cisgender participants as being comparable during the study.

The study followed 912 participants for an average of 6 years, collecting information regarding the adolescents’ identities from both adolescents themselves and their parents between 2013 and 2024. Authors report that overall participant retention was high (between 89 – 95%). These 900+ participants were divided into three groups. The first group was composed of transgender youth who initiated social transition medical by the age of 12, though this group did not include nonbinary TGD participants, due to researchers’ narrow inclusion criteria and dominant cultural attitudes at the time research began. The second group consisted of siblings of participants in Group 1, who identified as cisgender at the beginning of the study. The third group was composed of age and gender matched cisgender youths unrelated to Groups 1 and 2.

All three groups were assessed using a uniform series of metrics, though participants received some group-specific questions, such as questions regarding transition milestones being administered to TGD participants. Coders were not provided participants’ assigned sex at birth, aside from in complex cases where this information was key to proper coding. This likely reduced potential bias when assessing and coding responses. Participants’ responses were coded by multiple independent individuals. Among these coders, the paper’s authors report high inter-rater reliability, meaning coders or “raters” often came to the same or highly consistent assessments. This is yet another strength of the study’s findings, which are rooted in strong and rigorously assessed data. 

Groups 2 and 3 served as important points of comparison, providing insights into how factors such as societal context or family characteristics may/may not influence development. The use of sibling and non-familial cisgender groups enabled researchers to assess and rule out the influence of factors such as societal context, home environment, and proximity to gender diversity on development. Researchers describe the important role of the sibling group:

Inclusion of the Recruited as Transgender group's siblings allows us to infer that differences between participant outcomes among youths in the two groups are likely not due to being raised in different household contexts, local communities, or political environments. Additionally, the Recruited as Siblings group is a useful comparison to the Recruited as Cisgender group (an unrelated comparison group of initially cisgender youths, described in the next section) because it provides information on whether there are systematic differences in long‐term outcomes between children who grow up in a family that is actively supporting a transgender child and those who do not.53

Surveying parents of adolescent participants also provided vital insights into factors that could have influenced adolescents’ development. The authors of the paper argue that parental influence on gender was not observed, based on comparisons between gender trajectories of Groups 1 and 2 (the “recruited as transgender” and sibling groups), along with parents’ accounts. 

 

The average age of the earliest observed “cross-gender” behavior, reported by parents of transgender youth, was 3 years of age. On average, this observed “cross-gender” behavior precedes social transition by 3.5-5 years. During early discussions with parents, researchers found that adolescents’ gender nonconformity emerged early in their development and that it often came as a surprise to parents. Many of the surveyed parents described not being aware that a child could be transgender at the time their child was first exhibiting these behaviors, nor did they always recognize certain behaviors as being inherently transgressive of gender norms at the time of observation. Few families reported thinking their child was transgender right away. Some families even explained to researchers that they initially reacted negatively and tried to “stop” adolescents’ gender nonconforming behavior. The researchers reasoned that if parents were encouraging gender nonconformity, they might have observed higher rates of transgender identities amongst sibling the group. The authors state:

…most of the Recruited as Siblings youths – who grew up in the same families as the Recruited as Transgender youths – are cisgender. Presumably, if parents were encouraging gender nonconformity, in general, we might see a higher rate of transgender identity among the siblings.

[. . .]

In discussions with parents—during early study visits—they often told us that their child's gender nonconformity emerged early and that it came as a surprise.

[. . .]

Almost none of the families reported thinking their child was transgender right away.

[. . .]

These stories and accompanying materials suggest to us that most of these youth had an internal experience of gender quite early.56

 

Important Findings Regarding Adolescent Gender-Development.

Because researchers benefited from insights from both adolescents and parents, it was possible to extrapolate that most transgender participants had internal experiences of their gender quite early – often predating the disclosure of their identities to their caregivers. Researchers report that the results were similar regardless of whether it was parents or adolescents who conveyed this information.

deMayo et al.’s study found that among participants, there was a general trend of stability in gender, and the stability of gender was roughly equivalent between both transgender and cisgender participants. Among youths in the Recruited as Transgender group whose most recent visit was at age 18 or older, 85% were still identifying as the recruitment gender. Put another way, transgender adolescents’ gender was as stable as cisgender adolescents’, with over 80% of adolescents showing stability in their gender identity throughout the study.

Transgender adolescents demonstrated similar trajectories in gender development as the other two groups, and transgender adolescents were no more or less likely to demonstrate gender change than their siblings or adolescents in the unrelated control group. When adolescents did report a gender change, most reported a shift towards a nonbinary gender identity. Gender change didn’t automatically mean “detransition” or reidentifying with their assigned gender, but often meant a shift in identity while remaining within the broad category of being TGD.

deMayo et al.’s published findings also challenge assumptions regarding the fixed nature of cisgender identities. A modest but significant number of participants assumed to be cisgender at the time of recruitment experienced shifts in gender. Some participants assumed to be cisgender at recruitment did undergo a shift in gender identity. Just under 10% of adolescents in Group 3 and a little over 15% in Group 2 self-reported a current gender other than their recruitment gender. The authors describe these statistics as being higher than one may predict based on assumptions drawn from developmental psychology research regarding gender dating back to the 1950s.

This question has generally not been asked in children assumed to be cisgender or without history of significant gender nonconformity, presumably because the field of developmental psychology has typically conceptualized gender identity as a stable trait.

[...]

In contrast, researchers in clinical psychology and psychiatry have, on several occasions, asked if children who showed notable gender nonconformity later grow up to be transgender…

[. . .]

…we included youths who, at the start of the study, were cisgender and (as far as we were made aware) did not have gender histories that had suggested to their families that they would be anything other than cisgender later. Yet within this sample…several have gone on to identify as nonbinary and/or transgender, allowing us to examine the relation between childhood gender nonconformity and later gender trajectories in this group of youths—in addition to those who showed significant gender nonconformity, on whom most past work on this question has focused.

A majority of participants in the Recruited as Transgender group reported initiating medical intervention during the study, with 86% having started puberty suspension (PS) and 68% having started gender-affirming hormones (GAH). Treatment discontinuation was rare: 1% of participants who initiated PS later stopped, and an additional 1% who began both PS and GAH subsequently discontinued these interventions (page 40). On average, participants began PS at 11.2 years of age, a timing that closely aligns with clinical guidelines recommending PS only at or after Pubertal Tanner Stage 2, while the mean age of GAH initiation was 13.2 years.

deMayo et al.’s Critiques of Prior Research.

Research made significant efforts to contextualize their findings in comparison to prior research efforts in this area, as they likely challenge many of the findings and parameters of past research efforts. deMayo et al. make several key points:

…87.9% of youths in all three groups are currently the same gender that they were at the beginning of the study (91.0% according to parent report).

[. . .]

Our data suggest that most socially transitioned transgender youth will persist in their gender identity into adolescence and that they are not more likely than cisgender youth to show fluctuations in their gender identity throughout childhood and adolescence (though some do). 63

[. . .]

Even if some parents may have initially reacted negatively to their child's insistence that they were a different gender, they eventually came to support a social transition. These youth have also grown up in an era in which social transitions were significantly more accepted and visible than when past work was conducted. This level of acceptance may have allowed them to feel comfortable in their genders without as much shame about, or pressure to change, their identities as they might have in previous generations.

[. . .]

Youths in our sample may also have shown stronger gender nonconformity on average than youths in clinical samples (Olson, 2016), many of whom did not actually insist that they were the other binary gender (Zucker & Bradley, 1995), which was common among youths in our sample. 65

deMayo et al. offer important context regarding contemporary extrapolations from past research efforts in this area, where cisgender developmental pathways of gender were prioritized, because they were more common and aligned with cultural biases. Such biases may have influenced how behavior and development were evaluated and described. Nuanced and affirming assessments of gender nonconformity were likely lacking or potentially consolidated into the normative behavior of adolescents assumed to be cisgender. deMayo et al. further caution that it may be inappropriate to apply outdated research to the present day, as it is marked by an outdated framing of gender diversity as being pathological. Prior research, therefore, is skewed by the pretextual bias that gender variance must be treated and/or discouraged, rather than diversity to be affirmed. The authors note:

Many of the clinics and investigators conducting this research specifically offered treatments aimed at changing a child's gender identity and/or behavior (Bakwin, 1968; Green, 1987; Rekers et al., 1976; Zucker & Bradley, 1995) or expressed skepticism and caution about allowing children to change genders before puberty (Steensma & Cohen‐Kettenis, 2011).

Researchers also expressed caution regarding the fact that children and adolescents in past desistance research may not be diagnostically comparable to the adolescents transitioning today, and prior research could not account for the greater access to care that TGD adolescents of today may benefit from.

It is also difficult to determine whether children in the clinical samples of past work were qualitatively different from or similar to the transgender children who are coming out in higher numbers in the present day (Temple Newhook et al., 2018), which has led to debate and confusion (Tannehill, 2017; Winters, 2019; Winters et al., 2018; Zucker, 2018)…few children in older clinical samples actually insisted that they were another gender (Zucker et al., 1999; Zucker & Bradley, 1995), whereas most of the youth socially transitioning today are identifying with a gender that differs from their assigned sex.

The societal context in which transgender youth are growing up today has also changed drastically since the 1970s—early 2010s, when most past work with clinical samples was conducted: the general public is much more aware and accepting of transgender youth today (despite persistent anti‐trans sentiment, including from politicians).

Relatedly, some transgender youths—and many youths in our sample—have access to medical treatments that would not have been available for many youths prior to 2010, meaning they have had the opportunity to present comfortably in their gender identities without it being obvious to others that they are transgender…50

If read critically, researchers analysis of prior research offers a warning regarding the interpretation and application of prior “evidence” into persistence and desistance may be limited by preexisting biases for cisgender development and diagnostic inconsistencies.

The utility of this prior research may be limited not only by the biases of researchers but also by the fact that many of the youth in those studies may not be diagnostically comparable enough to present-day TGD patients. deMayo et al. further describe why often cited studies of “desistance” may be methodologically inappropriate to draw contemporary conclusions from regarding persistence and access to PTRH:

…studies from the two largest clinics publishing data on this topic found that between 12% and 39% of youths who could be reached for follow-up persisted in showing gender dysphoria as adolescents or adults, while the rest came to identify as what we might call cisgender today (Zucker & Bradley, 1995; Green, 1987; Wallien & Cohen-Kettenis, 2008; Steensma et al., 2013a; Drummond et al., 2008; Singh et al., 2021). Interpreting these data is complicated by uncertainty about whether the youths in those studies all had “cross-sex” identification in childhood or not [i.e., did the assigned males in these studies identify as girls, or rather as boys who had feminine interests? (Olson, 2016; Temple Newhook et al., 2018)]. It thus remains unclear whether this same pattern—in which only a minority of gender‐nonconforming children persist in gender dysphoria and/or identify as transgender as adolescents or adults—will apply to a sample of youths who unambiguously identified as transgender (i.e., a member of a gender category that does not align with their assigned sex) in childhood and who actually lived in line with that gender identity early in life (i.e., socially transitioned)

Where do we go from here?

A single study on its own can be powerful, but a single study cannot be taken as definitive proof that no TGD adolescent will ever detransition or will undergo shifts in identity. No study is perfect, and limitations should never be ignored simply because the findings are favorable. While the researchers sought to control for the study’s limitations and were disciplined in not overstating the implications or generalizability of their findings.

Situating this study in the broader literature, though, this study stands as a robust and powerful addition to the canon of scientific research on the gender development of TGD youth. This study’s findings complement evidence that shows rates of regret and detransition generally remain low. Other research also suggests that detransition may not be permanent or caused by a change in identity, as it may be influenced by external factors.

As the current administration continues to bombard TGD people with continued attacks, intended to push TGD people out of public life altogether,  it is all the more important that we work to elevate research efforts such as this study. Public health experts must continue the slow but meaningful translational work of taking emergent research and making it more digestible and accessible to the general public, as well as policymakers.