Category Archives: Children

Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, Sex Ratio, and Sexual Orientation – Review

This is a follow-up to an earlier letter to the editor calling for research and discussion on the subject of teenagers with gender dysphoria. The authors had seen a sharp increase in the number of teenagers referred to their Toronto clinic between 2004 and 2007.

You can read about some new, related data here.

In this letter, the authors report that:

Cases of teens with gender dysphoria are still increasing.

Between 2008-2011 the number of teenagers referred to their clinic increased even further.

Based on their graph, before 2000, they saw fewer than 20 teenagers in a four year period. From 2004-2007 they saw about 55 teens and from 2008-2011, they saw about 95. In other words, the number of teen patients they saw more than quadrupled.

usmt_a_675022_o_f0001g (1)

By my calculations, about two-thirds of their teenage patients in the last 36 years came to the clinic between 2000 and 2011; over half came to the clinic in the last 8 years between 2004 and 2011.

In contrast, the number of cases of children with gender dysphoria increased sharply in 1988-1991, but has been reasonably stable since then.

Looking at their graph again, between 1988 and 2011 they saw 75 to 90 children in a four year period. The children who came to the clinic between 2004 and 2011 only make up 29% of the child patients they’ve seen in the past 36 years.

In 2008-2011, the number of teenagers at their clinic was larger than the number of children for the first time ever.

From 1976-2004, the number of children at their clinic was much higher than the number of teens. The number of teens increased greatly after 2004, but was still lower than the number of children at their clinic.

The sex ratio of their teenage patients may be changing.

For teenage patients, the sex ratio was close to even, ranging from 1.03:1 boys to girls in 2004-2007 to 3:1 in 1976-1979. There were two time periods when they saw more female teenagers than males: 1988-1991 and the most recent group in 2008-2011.

***Spoiler alert – a 2015 study found that the sex ratio has indeed changed from more boys to more girls. This was true for both this clinic and a Dutch one. More later.***

It is important to remember that the numbers of both male and female teenage patients increased starting in 2004.

The increase in female teenagers is much more striking. Based on the graph below they went from fewer than 10 patients every four years prior to 2000 to nearly 60 patients from 2008-2011.

However, male teenage patients also increased. They went from about 5-15 patients every four years prior to 2000 to about 35 patients from 2008-2011. In 2004-2007 the number of male and female teenage patients was nearly equal.


The authors also discuss the pattern of sex ratio by age. Putting the data from different time periods together, from ages 12-16, there were slightly more boys than girls. However, at age 17-18, there were more females than males, and at age 19-20, the sex ratio shifted again to 2.4 boys to 1 girl.

Sexual orientation

The authors had data on sexual orientation for 98% of the teenagers they saw.* Of these 76% of their female teenage patients were sexually attracted to females while 56.7% of their male teenage patients were sexually attracted to males.**

The sex ratio for child patients is different than for teenage patients.

The overall sex ratio for children was 4.49 boys to 1 girl. For 3 year olds, the sex ratio was 33 boys for every girl.***

From 1976-1996, over 75% of their child patients were boys, from 2001-2011 the percentage hovered around 75%.

What does this mean?

We don’t know why more teenagers are seeking help at this clinic. Are there more teenagers with gender dysphoria than in the past? If so, why? What would make gender dysphoria increase among teenagers and not among children? Are people with gender dysphoria simply able to get help at an earlier age?

As always, we need more research!

The authors provide some interesting insights:

“Regarding the increase in adolescent referrals, it is, of course, not clear if it reflects a true increase in prevalence (which can only be established via epidemiological studies) or if it simply reflects a greater willingness on the part of youth to come out as transgendered, perhaps because of the influence of social media in which there are dozens, if not hundreds, of websites and blogs that assist youth in understanding their own identity and its concomitant struggles. We have been impressed, for example, in recent years with youth describing to us that they never realized that their feelings could be named in a formal way (gender identity disorder, transgender, trans). One might infer that the Internet has made much more visible terminology used in technical journals. 

Another parameter that has struck us as clinically important is that a number of youth comment that, in some ways, it is easier to be trans than to be gay or lesbian. One adolescent girl, for example, remarked, “If I walk down the street with my girlfriend and I am perceived to be a girl, then people call us all kinds of names, like lezzies or faggots, but if I am perceived to be a guy, then they leave us alone.” To what extent societal and internalized homonegativity pushes such youth to adopt a transgendered identity remains unclear and requires further empirical study. Along similar lines, we have also wondered whether, in some ways, identifying as trans has come to occupy a more valued social status than identifying as gay or lesbian in some youth subcultures. Perhaps, for example, this social force explains the particularly dramatic increase in female adolescent cases in the 2008–2011 cohort.

Another factor that has impressed us in accounting for the increase in adolescent referrals pertains to youth with gender identity disorder who also have an autism spectrum disorder. As noted by others (de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010), many clinicians are now reporting a co-occurrence of these two conditions.

More than 10 years or so ago, it was rare in our clinic to see an adolescent with gender identity disorder who also appeared to have an autism spectrum disorder. It is possible, therefore, that the apparent increase in the number of adolescents who present with a co-occurring autism spectrum disorder is contributing to the increase in the number of referrals. Over the past decade, a great deal of media attention has been given to the use of hormonal therapy to treat gender dysphoria in adolescents, including the use of “blockers” to either delay or suppress somatic puberty (Cohen-Kettenis, Steensma, & de Vries, 2011; Zucker et al., 2011). In the province of Ontario, its health care system relisted sex reassignment surgery as an insured medical treatment in 2008 after having been delisted in 1998 (Ministry of Health and Long-Term Care Processing Sites, 2008; Radio Canada, 2008). Perhaps the availability again of insurance coverage has led to more adolescents seeking treatment. Whatever the explanation for the increase in adolescent referrals, it appears that gender identity disorder in adolescents has come out of the closet, although there may be different closets from which to come out.”

A few more details about the data:

The children were significantly more likely to be living in two-parent homes than the teens (66% versus 46%).

Most of the patients were white; 80% of the children and 76% of the teens.****

The study included 577 children (3-12 years old) and 253 teens (13-20 years old).

The study excluded “26 boys referred for fetishistic cross-dressing and referred adolescents who were diagnosed with transvestic fetishism (without co-occurring gender dysphoria), gay youth, and youth who were ‘undifferentiated'”.

Original Source:

Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, Sex Ratio, and Sexual Orientation by Wood H, Sasaki S, Bradley SJ, Singh D, Fantus S, Owen-Anderson A, Di Giacomo A, Bain J, Zucker KJ. in J Sex Marital Ther. 2013;39(1):1-6.

* 248 teenagers out of 253 total.

** The authors classified the teenagers as homosexual or nonhomosexual in relation to birth sex.

***It may be that parents are more worried about boys who are gender non-conforming than girls so more boys are referred to the clinic. By adolescence the teenagers might play more of a role in coming to the clinic.

**** Yup, we need more research on people with gender dysphoria who aren’t white.

You can read more in the follow-up study, Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria.

More Than Two Developmental Pathways in Children With Gender Dysphoria? – Review

There is a short but important piece about the persistence of gender dysphoria in children.

In this Dutch clinic, they found that:

70% of the children they diagnosed with gender dysphoria did not return to the clinic and transition; they “desisted” in their gender dysphoria.

95% of the children who desisted as teens did not return to the clinic as adults.

27% of the children they diagnosed with gender dysphoria transitioned as teenagers, 3% did so as adults.

Of the children who returned to the clinic before adulthood, 75% came back before they were 14 years old and 25% came back when they were between 14 and 18.

Boys were more likely to desist from their gender dysphoria than girls; 73% versus 61,5%. Conversely, more female children with gender dysphoria went on to transition; 38.5% versus 27%.

This is in line with earlier studies that have found that most children diagnosed with gender dysphoria change their minds when they are older, usually at puberty.

It also provides a follow-up to the question of whether or not the children who changed their minds still had gender dysphoria. They had access to a free medical transition, but did not return for it. It is possible that some of them may still return, but so far 95% have not.

This data also demonstrates what the authors call a third “developmental pathway” for children with gender dysphoria. This group seems to go through a “period of questioning sexual identity” as adolescents before deciding to transition as adults.

The clinic looked at the records of 150 adults who were diagnosed with gender dysphoria as children. The adults were now between 19 and 38 years old (average age = 25.9, SD 4.03). The sample was the first 150 consecutive patients the clinic had diagnosed who were now adults.

The authors discuss past studies of persistence of gender dysphoria in children. In the past, the persistence rate has been only 16% across studies, however, the diagnoses of gender dysphoria may have included some children who were simply gender non-conforming in their behavior. They suggest that in the future persistence rates may be higher as clinicians use a stricter definition of gender dysphoria.

In addition, they suggest that persistence rates might be higher if we include patients who choose to transition as adults. In this study, the persistence rate would only have been 27% if they did not include the 3% who transitioned as adults.

I would add that this data on persistence includes children who had access to puberty blockers and early transition. We need studies to determine if this affects rates of persistence and desistance.

We also need more studies of the children who did not return to the clinic and transition. Why didn’t they return? Did they completely lose their gender dysphoria? Are they happy? If they lost their gender dsyphoria, how did that happen? If they didn’t lose it, how are they dealing with it?

We have one study of children who desisted in their gender dysphoria, but we need more. (Desisting and persisting gender dysphoria after childhood.)

Finally, the authors provide an interesting discussion of the patients who did not transition as teenagers but returned to transition as adults:

“The average age of the 5 individuals who re-entered the clinic in adulthood was 24 years (range 21–37). Despite their knowledge of the availability of treatment for adolescents and the fact that treatment is covered by insurance, they did not apply for treatment during adolescence. Four (3 natal males and 1 natal female) tried to live as gay or lesbian persons for a long time, and 1 natal male had autism spectrum disorder. He reported that he needed to solve other problems in his life before he could address his GD. The others reported not having any problems with being homosexual. Yet, after having intimate and sexual experiences with same (natal) sex partners, they came to realize that living as a homosexual person did not solve their feelings of GD, and they felt increasingly drawn toward transitioning. All also mentioned that they were somewhat hesitant to start invasive treatments, such as hormone therapy and surgeries.”


“It would be worthwhile to know whether the GD of these “persisters-after-interruption” differs qualitatively or quantitatively from the GD of straight persisters and whether the groups differ in other respects. For instance, has the GD in the persisters-after-interruption group actually disappeared for some years or, as the reports of our young adults suggest, did they make a more or less conscious choice not to live according to their experienced gender? Knowing more about this developmental route would be clinically useful when counseling young people with GD.”

This data was presented in a letter to the editor.


More Than Two Developmental Pathways in Children With Gender Dysphoria? by Steensma TD, Cohen-Kettenis PT in J Am Acad Child Adolesc Psychiatry. 2015 Feb;54(2):147-8.

Is Gender Identity Disorder in Adolescents Coming out of the Closet? – Review

The number of teenagers with gender dysphoria increased sharply at a Canadian clinic, starting in 2004.

The authors of this article call for more discussion and research on the subject of teenagers with gender dysphoria.

Are the numbers also increasing at clinics in other countries? If so, why?

Since this article was published in 2008, additional studies have suggested that there is indeed an increase in the number of teenagers being treated for gender dysphoria.

We still do not know why.

This graph shows the numbers of cases of gender dysphoria the Canadian clinic saw starting in 1976. * The top line shows cases of children, the bottom line shows cases of teenagers.



“For the adolescents, however, it is apparent that there has been a dramatic increase in referrals starting only in the most recent block, 2004–2007. Prior to this, the number of referred adolescents was comparatively small and always lower than the number of referred children. A line from the 1967 song “For What It’s Worth” by Buffalo Springfield goes: ‘There’s something happening here. What it is ain’t exactly clear’.”

The authors do not know what has caused this increase.

Is something causing more teenagers to develop gender dysphoria?

Or have Internet sites and media coverage made it possible for more teenagers to seek help for gender dysphoria?

And, in either case, have other clinics seen an increase in the number of adolescent patients with gender dysphoria?

We need to know what is going on so that patients can get the best care possible.

“If there is an increase, the importance of articulating the best practice model to care for these children and youth is even more acute (Zucker, in press). We found it curious that Oprah Winfrey chose as the “expert” for her show on transgendered children an M.A. level therapist who acknowledged on the program that she had never worked with a child who had GID. We would hope that all training programs in child and adolescent psychiatry give at least some minimal exposure to residents to basic principles of physical sex differentiation, an overview of normative gender development, review of diagnostic and assessment tools that have been developed for children and adolescents with GID, discussion of various etiological models, and consideration of extant therapeutic approaches. Perhaps one “team” could be assigned to handle referrals of children and adolescents with problems in their gender identity development. The more experience one has with a specific syndrome, the easier it is to appreciate the range in clinical presentation, including the range in associated psychopathology in the child and in the family.

If GID in adolescents is “coming out of the closet,” members of the child and adolescent psychiatry profession, the allied disciplines, and specialists in gender identity issues need to take the lead in providing exemplary care for these children and youth and their families with the same rigor as they do for children and youth with any other clinical problem.”


Original article:

Is Gender Identity Disorder in Adolescents Coming out of the Closet? by Zucker KJ, Bradley SJ, Owen-Anderson A, Kibblewhite SJ, Cantor JM in J Sex Marital Ther. 2008;34(4):287-90.


* Some patients who were assessed were excluded from these numbers: “We excluded children referred for fetishistic cross-dressing and we excluded referred adolescents who were diagnosed with transvestic fetishism (without co-occurring gender dysphoria), gay youth, and youth who were ‘undifferentiated.'”

A few notes:

1) If you’re wondering about the increases in the numbers of children referred to the clinic, the authors suggest this might have been related to changes in the 1987 Diagnostic and Statistical Manual of Mental Disorders (DSM). In that version of the DSM, the section on childhood gender dysphoria was moved to the section for conditions “Usually First Diagnosed in Infancy, Childhood, or Adolescence.” This might have brought it to the attention of medical professionals who treat children.

2) The authors point out that the media began talking about transgender children in the early 21st century. Oprah Winfrey had a show on the subject in 2004 and 20/20 had a similar one in 2007.

However, as they also point out, the media attention did not seem to cause a change in the numbers of children referred to their clinic.

Internet sites, however, might affect teenagers more than children.

3) The article does not give the name of the clinic. Based on the authors, it is in Toronto.

Related posts:

Information on transgender children and teens from the Hamburg Gender Identity Clinic in Germany.

Information on transgender teens from the Frankfort University Gender Identity Clinic in Germany.

Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study – Review, Part I

This is a fascinating study of a group of children with gender dysphoria. The authors interviewed them as teenagers when some of them had lost their gender dysphoria and some of them had not.

Most children diagnosed with gender dysphoria do not go on to transition; their gender dysphoria goes away. Gender dysphoria faded at puberty for 84% of the children in previous follow-up studies.*

In this study, the authors identified 53 Dutch speaking teenagers that their clinic had diagnosed with gender identity disorder before age 12.** Among these 53 teenagers, 55% had reapplied to the clinic for transition while 45% had not. The authors do not address the question of why their patients were more likely to still have gender dysphoria than in past studies.***

The authors interviewed only 25 of the 53 teenagers; 14 teenagers who applied for sex reassignment (7 male and 7 female) and 11 who did not (6 male and 5 female). They say that:

All adolescents were approached, orally or in writing, to participate in the study. Based on the principle of saturation in information (Glaser & Strauss, 1967), 25 adolescents were interviewed.

This limits the conclusions that can be drawn from the data, however, this is a qualitative study. It uses interviews to explore the development of gender dysphoria in these teenagers. This allows the authors to find directions for future research.****

Based on their interviews with the teenagers the authors found:

1. There were no differences in childhood behavior between the group that lost their gender dysphoria and the group that did not.

2. Both groups identified as the other gender as children, but when they were interviewed as teenagers, they explained it differently.

3. Both groups were uncomfortable with their bodies as children, but they explained it differently as teenagers.

4. The teenagers who requested transition were all attracted to people of their natal sex while the teenagers who no longer had gender dysphoria were mostly attracted to the opposite sex.

5. The years 10-13 were critical in the children’s development; this was when they either lost their gender dysphoria or became more dysphoric.

6. Important factors related to the development of adolescent feelings about gender were: changes in the social environment, the physical development of their bodies at puberty, and falling in love and discovering their sexual orientation.

7. For some of the girls whose gender dysphoria had faded, it was hard to transition back because they had worn boys’ clothing and been perceived as boys.

8. One of the teenagers they interviewed felt half female, half male. He did not want to transition.

The authors of the study conclude:

“Based on the significance most adolescents attribute to the period between 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development.

It is recommended to specifically address the adolescents’ feelings regarding the factors that came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g. to suppress further pubertal development).

As for the clinical management of children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our finding that some girls, who were almost (but not even entirely) living as boys in their childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredicatability of their child’s pychosexual outcome.

They may help their child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse. This attitude may guide them through uncertain years without the risk of creating the difficulties that would occur if a transitioned child wants to return to his/her original gender role.”

(Paragraphs and bold added by George Davis.)

Short version: Children should probably not transition socially before age 10. Parents and teachers should understand that the children may lose their gender dysphoria.

Therapists should work carefully with children who have gender dysphoria in the years between 10 and 13. Before giving them puberty blockers therapists should address the teenagers’ feelings about changing social relationships, puberty, and sexual development.

End of Part I of the Review of this study.

Original Article:

Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study by Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT in Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516

*The studies the authors cite followed a total of 246 children; only 39 of them had gender dysphoria after puberty, thus the overall persistence rate for the dysphoria was 16%. The persistence rate varied among the different studies from 2% to 27% (i.e. 73%-98% of the children stopped having gender dysphoria).

**The teenagers in the study were chosen from a total of 198 children who applied to their clinic between 2000-2007. The rest of the children did not meet the criteria for the study, although the authors don’t say if this was due to not being a teenager at the time of the study, not being diagnosed with GID, or not speaking Dutch.

***A few possibilities would be: a difference in the therapy given to the children (some therapies might be more effective than others), cultural differences in the countries where the studies were done (some cultures might make it harder to be gender non-conforming while others might make it easier to transition), a difference in the diagnostic methods (perhaps this clinic did a better job of diagnosing gender dysphoria), cultural differences in different eras, environmental differences in different eras (perhaps hormones are affecting children more now), or something about the way this study chose the 53 teenagers (this seems unlikely).

****A more serious question is that the authors do not say if they heard back from all of the teenagers they contacted. They cannot be sure that all of the teenagers who did not request further treatment were no longer dysphoric if they did not speak to them. This does not effect the results of their interviews, but it is an important issue.