The Myth of “True Trans”

A Concept Without Diagnostic Foundation

In the public debate around gender medicine, one phrase often escapes scrutiny: “true trans.” It is used to describe an ostensibly rare category of people whose sense of belonging to the opposite sex is deemed so deep and immutable that medical transition becomes not only justified, but necessary. Yet this category, as reassuringly simple as it may appear, has no reliable diagnostic basis.

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From Mid-Century Sexology to Modern Clinics

The concept emerged in mid-20th-century sexology. David Cauldwell first used “transsexual” in 1949, and Harry Benjamin’s The Transsexual Phenomenon (1966) drew a distinction between “true transsexuals” and other groups. These classifications were based largely on subjective criteria—persistence of desire, intensity of distress, and perceived “femininity” or “masculinity”—not on any biological marker or objective psychological test.

Cases such as Jan Morris, whose transition was chronicled in the 1970s, helped cement the public image of the “true transsexual” as a clearly identifiable phenomenon. In reality, this image was built on anecdote, clinical impression, and selective case histories, not replicable science.

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Cass Review: Clinical Caution and Epistemic Limits

Dr Hilary Cass’s 2024 independent review of gender identity services for children and young people stands as the most comprehensive modern appraisal of this field in the UK. While she acknowledged that some individuals may benefit from medical transition, she also admitted there is no reliable way of knowing which patients might be in that category:

“We don’t know which young people are going to go on and have an enduring trans identity.”

The evidence for puberty blockers and cross-sex hormones in adolescents was judged to be weak, with no high-quality studies showing clear benefits in terms of mental health, body satisfaction, or reduction of dysphoria. NHS England has since restricted puberty blocker prescriptions to research settings, a decision consistent with these uncertainties.

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Diagnostics Without Precision

Current diagnostic frameworks—Gender Dysphoria (DSM-5) and Gender Incongruence (ICD-11)—are descriptive rather than predictive. They classify a present state but do not identify which individuals will persist in that state over time.

Research into developmental trajectories has shown substantial rates of desistance, especially in pre-pubertal children. Long-term studies report desistance rates ranging from 60% to over 85% in early-onset cases. A recent German study confirmed that many adolescents referred for gender distress later desist, underscoring the variability of outcomes (Our Duty, 2024).

Detransition—where individuals cease or reverse their transition—remains under-researched and likely under-reported. The largest surveys indicate that a significant proportion do not inform their clinicians when they desist, meaning official figures are incomplete. This makes any claim to reliably identify “true trans” individuals untenable.

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The Ethical Dilemma

When applicability cannot be discerned, the ethics of administering irreversible physical interventions become highly questionable. Medicine has long operated on the principle that benefits must clearly outweigh risks, yet here, benefits are neither consistently demonstrable nor reliably predictable.

The Cass Review explicitly recommends holistic, multidisciplinary assessment and research-embedded pathways. This approach acknowledges the uncertainty and complexity of the cases, resisting the temptation to treat subjective certainty as a diagnostic tool.

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Why Has “True Trans” Persisted?

Why, then, has the idea endured in medical circles? Several factors may explain it:

• Clinical expedience: For decades, clinicians faced with persistent cases may have defaulted to the “true trans” label as a way to justify intervention, particularly when other treatments failed.

• Activist pressure: Advocacy groups have often opposed strict gatekeeping, framing it as a barrier to care.

• Professional culture: In some specialties, affirming patient self-perception without deep diagnostic challenge has become the path of least resistance.

• Narrative appeal: The “true trans” archetype offers a compelling, simplified story—one that spares clinicians the discomfort of uncertainty.

Yet simplification can be dangerous. When a concept lacks empirical definition, it cannot safely underpin irreversible medical decisions—especially in minors.

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Conclusion

The notion of “true trans” may have served as a clinical shorthand, but it has never been a scientifically validated category. Modern evidence, as summarised in the Cass Review, shows that we cannot reliably distinguish between those whose gender distress will persist and those whose distress will resolve or evolve.

Until that changes—if it ever does—medical ethics demand that we recognise the limits of our knowledge. The “true trans” label should be retired, and clinical decision-making should be guided by demonstrable evidence, not by an unproven archetype.

For clarity of thought and language, clinicians and commentators alike would do well to adopt precise, sex-based terminology, as outlined in Our Duty’s language guide, to avoid embedding assumptions that the science cannot sustain.