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.
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.
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'”.
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.