Tag Archives: Canada

Anorexia nervosa and gender dysphoria in two adolescents – Review of a case study

This is a case history of two Canadian teenagers with severe eating disorders. Both teens had had other psychiatric problems, and in one case the problems were quite severe.

Both teens developed gender dysphoria as time went on. In both cases, they were treated successfully for their disordered eating without being treated for gender dysphoria.

It is not clear exactly what the relationship is between the eating disorders and the gender dysphoria in these two cases.

It is important to remember that this is a case study of two people. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

Case 1

The first patient identified as a very feminine gay male when he entered therapy. He was out to his friends and family and they were accepting of his sexual orientation. He was in a monogamous gay relationship.

The patient was 16 and for the past three years he had had “vomiting, food restriction, and body image distortion, perceiving his body to be overweight.” These problems became so severe that he was admitted to a hospital program.

He had insomnia, depression, problems concentrating, and a low energy level. In the past he had been diagnosed with anxiety. He had cut himself in middle school. His family’s history included substance abuse, depression, and bipolar disorder.

The patient had had body image issues since he was six. He “wanted to stay small, feminine, petite, lean, and thin. He reported that he also disliked his ‘wide torso and broad shoulders’ and wished his face shape was more round to be more in keeping with a feminine ideal.”

However, he did not wish to transition to be a woman. He did not want to physically be a female and was not upset about being a male. Rather he wanted to appear feminine and “assume the female role in a relationship.”*

After his hospital stay, the patient entered an out-patient therapy program that “focused on body and self-acceptance, along with enhancing self-efficacy. The family was involved in order to support his eating, and to accept his sexuality and gender identity.”

With this support “he was able to maintain his weight and left his relationship with his male partner who was emotionally abusive.”

Then, after about a year of treatment, the patient said he wanted to transition to living as a female. He did not want surgery, just blockers and hormones. At that point he had already regained a healthy weight and was not restricting his food. He was referred to a gender transition clinic at his request.

Because he was turning 18, his treatment at the pediatric eating disorder clinic ended.**

Case 2

The second patient was a 13 year old girl with a past history of obsessive-compulsive disorder (OCD), generalized anxiety disorder, and post-traumatic stress disorder from sexual abuse by her father. She had also self-harmed and considered suicide. Her family’s history included depression.

At the time she came to the clinic she had anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). She was taking fluoxetine and olanzapine.

She had been hospitalized twice before for her eating disorder and had a “two year history of food restriction, a rigid eating schedule, and body image preoccupation…She described becoming distressed after eating foods she considered were unhealthy, which prompted her to forgo these foods entirely. She also reported excessive exercise due to a desire to be muscular.”

The patient refused therapy, but came in for medical visits and to see the psychiatrist. She had trouble eating more, so they asked her mother to help, but after six months the mother suggested residential treatment and the daughter agreed. The patient’s fluoxetine dose was increased.

The patient began to talk about wanting to be a boy. She also thought that sex was gross. She wanted to stay at a low weight in order to prevent breast growth and menstruation. Therapists raised the question of her trauma and how it might affect her feelings, but she did not want to discuss it.

“Mother was not accepting of the patient’s desire to be a boy and therapy with the psychiatrist was focused on mother taking a more neutral stance.”

After a year, and after she had been fully weight-restored for several months, she began to dress as a boy and use a boy’s name. She hated her breasts and sometimes hit them or thought about cutting out the fat, but she did not want to have surgery. She said that she no longer had eating problems, her only problem was wanting to be a boy. She wanted to take puberty blockers. Her mother was not in agreement and the girl dropped out of treatment.

Gender dysphoria and eating disorders in these case studies

It is difficult to figure out what these case studies mean. Rather than gender dysphoria causing an eating disorder, these patients seem to have developed gender dysphoria over time while recovering from eating disorders.

The authors suggest that as the patients regained weight, their bodies changed and this made the gender dysphoria intensify. I find this unconvincing.

In the first case, the patient was concerned about his wide shoulders and angular face; gaining weight would not have changed his shoulders or made his face more angular.

More importantly, the patient was clear at the beginning of treatment that he was a man and was not distressed by being male. Saying that he wanted to transition to a female but not have surgery was not a question of symptoms intensifying or becoming more prominent. It was a dramatic change – he went from not having gender dysphoria to having it.

In the second case, it seems likely that surviving childhood sexual abuse caused the patient’s disgust with sex and hatred of her breasts, as well as her depression, anxiety, and habit of spraying her body with Lysol.*** Both the eating disorder and the gender dysphoria could be interpreted as ways of dealing with these feelings.

Why or how exactly the patients developed gender dysphoria during this time is unclear. This question is an important area for future research.

The relationship between gender dysphoria and eating disorders is unclear in these two cases, but it looks like the eating disorders were not caused by the gender dysphoria. In the first case, the patient had the distorted perception that he was overweight; this is a symptom of anorexia rather than gender dysphoria. In the second case, the patient had been sexually abused as a child and had many psychiatric disorders, including OCD. Her eating disorder could be explained by a combination of trauma and genetic factors.

What is clear is that in these two cases, the patients were successfully treated for eating disorders before any gender issues were addressed.

Stay tuned for more case histories related to eating disorders and gender dysphoria.

Original Source:

Anorexia nervosa and gender dysphoria in two adolescents by Couturier J, Pindiprolu B, Findlay S, Johnson N in Int J Eat Disord. 2015 Jan;48(1):151-5.

 

* No, I don’t know what that means either.

** I can’t figure out the math here. He was 16, but after 11 months he said he wanted to be a girl. Then they say he left their program because he was turning 18 and had been having therapy continuously for 18 months.

*** No doubt there were genetic and hormonal factors as well, but I think it’s fair to point to the abuse as a cause.

Advertisements

Review of Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.

QUICK OVERVIEW

The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.

THE INCREASE IN TEENAGE PATIENTS

The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.

0

Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?

BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY

The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*

PSYCHIATRIC COMORBIDITIES

Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.

 

*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria – Review

This is a highly significant study showing that the population of teenagers referred for gender dysphoria is changing. It is noteworthy that this is happening in two different countries.

The sex ratio is changing:

The sex ratio of teenagers seeking help for gender dysphoria has changed at two clinics, one in Canada and one in the Netherlands.

Before 2006, more male than female teenagers sought transition at these clinics. Since 2006, they have seen more female teenagers than male teenagers.

Sex ratio for teenage patients at the Canadian Gender Identity Service:

  • 1999-2005 – 68% male, 32% female
  • 2006-2013 – 36% male, 64% female

Sex ratio for teenage patients at the Dutch Center for Expertise on Gender Dysphoria:

  • 1989-2005 – 59% male, 41% female
  • 2006-2013 – 37% male, 63% female

At the Canadian clinic, there was no change in the sex ratio of teenagers referred for psychiatric issues.* In both time periods, roughly two-thirds of their other patients were male.

According to the authors, “In adult samples [of transitioners], in almost all cases, the number of natal males either exceeds the number of natal females or the sex ratio is near parity.” Poland and Japan are exceptions; in those countries more females transition than males.

In addition, clinics for children with gender dysphoria have found that the number of males exceeds the number of females.

More teenagers are transitioning:

The number of teens of both sexes has increased over time, although the increase is larger for the female teenagers.

Increases at the Canadian clinic:

Female teenagers

  • 46 in 30 years (1976-2005)
  • 129 in 8 years (2006-2013)

Male teenagers

  • 80 in 30 years (1976-2005)
  • 73 in 8 years (2006-2013)

Increases at the Dutch clinic:

Female teenagers

  • 77 in 17 years (1989-2005)
  • 148 in 8 years (2006-2013)

Male teenagers

  • 109 in 17 years (1989-2005)
  • 86 in 8 years (2006-2013)

In other words, the Canadian clinic saw nearly nearly three times as many female teens in the past 8 years as they had seen in the previous thirty. The Dutch clinic saw nearly twice as many female teens in the past 8 years as they had seen in the previous seventeen.

Furthermore, “For many years in the Toronto clinic, the number of adolescent referrals was quite low. Between 1976 and 2003, for example, no more than five adolescents of one biological sex were assessed in a calendar year and, during this period, the number of males exceeded the number of females. Beginning in 2004, however, the number of adolescent referrals began to rise quite dramatically, which appears to be consistent with the observations of clinicians and researchers from other gender identity clinics.”

For earlier data on the increase in Canada, see this article.

Sexual orientation percentages have changed:

The Canadian clinic also looked at sexual orientation.

Sexual orientation of females:

  • 1976-2005 – 89% primarily attracted to females; 11% other
  • 2006-2013 – 64% primarily attracted to females; 36% other

Other could mean primarily attracted to males, bisexual, or asexual.

Sexual orientation of males:

  • 1976-2005 – 67% primarily attracted to males, 33% other
  • 2006-2013 – 44% primarily attracted to males, 56% other

Other could mean primarily attracted to females, bisexual, or asexual.

To put it another way, in the past most of the teenagers would have been gay if they weren’t transgender. If they transitioned, they would live their lives as straight people.

In 2006-2013 most of the male teenagers would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as lesbians.

One-third of the female teenagers in 2006-2013 would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as gay men.

What’s going on?

Why are we seeing more teenagers seeking help for gender dysphoria?

Why is the increase greater among female teens than males?

And why are we seeing a shift in the sexual orientation of these teens? Was it harder in the past to come out as transgender if you were seen as straight? Or is this a group of people who were less likely to have gender dysphoria in the past?

Has something changed in our environment that increases the number of people with gender dysphoria? What would affect more females than males? Why would it affect teenagers more than children (see this earlier article)? How would it fit with the changing percentages related to sexual orientation?

Is it just that there were always this many teenagers with gender dysphoria and now they are able to get care at an earlier age? How does that theory fit with the change in the sex ratio of teens applying to the clinic? with changes in their sexual orientation?

Clearly, we need more research to sort out these questions.

The authors speculate about possible explanations for the change in the sex ratio at their clinics.

They suggest that the general increase in patients might be due to a combination of destigmatization and more awareness of the biomedical treatments available to teens. However, they point out that this does not explain why more females would apply for treatment.

I don’t think we can know why the number of patients has increased without further research – research which is desperately needed.

The increase in the number of female patients at the Toronto clinic was not caused by a change in the severity of cases; they found that there was no significant relationship between severity of dysphoria and year assessed.

However, for male teens in Toronto, there was a weak correlation between severity of dysphoria and year assessed. “More recently assessed cases had moderately higher GD severity.” This only explained 6.7% of the variance. Therefore “it is unlikely that the recent inversion in the sex ratio can be accounted for by a substantive change in severity variation.”

On the other hand, they only have data on the severity of dysphoria starting in 2001 and the number of cases began increasing in 2004.

The change in the sex ratio was not due to females entering puberty at an earlier age; both clinics found no significant difference for the mean ages when females and males came to the clinic.

The sex ratio did not change due to the shift in sexual orientation. A logistical regression analysis did not find evidence for a sex x sexual orientation interaction.**

The authors suggest that perhaps the explanation for the change in the sex ratio is that it is harder for males to transition to a female role than for females to transition to a male one.

I find this unconvincing as this would have been true in the past when more male teenagers than females applied to their clinic. Nor would this hypothesis explain the shift in sexual orientation.

Here is their full explanation:

“Given that there is at least some overlap in the gender-variant developmental histories of early-onset individuals with GD and some gay men and lesbians, it might, therefore, be asked whether or not degree of stigmatization for gender-variant behavior might account for the recent inversion in the sex ratio of GD adolescents. It is well-known that cross-gender behavior in children is subject to more social stigma (e.g., peer rejection and peer teasing) in males than in females, in both clinic-referred adolescents with GD and in the general population[26–30]. Thus, it could be argued that it is easier for adolescent females to “come out” as transgendered than it is for adolescent males to come out as transgendered because masculine behavior is subject to less social sanction than feminine behavior. Some support for this was found in Shiffman’s [31] study of peer relations in adolescents with GD, in which adolescent males with GD reported more “social bullying” than adolescent females with GD. Given that a transgendered identity as an “identity option” has become much more visible over the past decade, it is conceivable, therefore, that such an identity option is easier for females to declare than it is for males because it does not elicit as much of a negative response. Thus, it could be argued that it is this sex difference in degree of stigmatization that accounts for the inversion in the sex ratio that we have identified in the two studies reported here. In other words, there are greater costs for a male to adopt a female gender identity in adolescence than it is for a female to adopt a male gender identity.”

A few more details about this study:

The first study looked at 328 teens (13-19) who were referred to the Toronto clinic between 1976 and 2013. The mean age at the time of referral was 16.66 years with no difference between the ages of males and females.

All of the teens met criteria for Gender Identity Disorder or Gender Identity Disorder Not Otherwise Specified. They were diagnosed using criteria in the relevant version of the DSM – this changed over time. The assessment of severity of dysphoria began in 2001.

The control group was 6,592 teens referred to their general clinic for psychiatric issues between 1999-2013. Eleven teens originally referred for psychiatric issues who were later referred to the Gender Identity Service were not included in this group.

The teens’ sexual orientation was determined by either clinical chart data or measurements on the Erotic Response and Orientation Scale and the Sexual History Questionnaire. This data was not available for five probands (aka people in this study).

The numbers for the sexual orientation of the teens at the Canadian clinic were:

1976-2005 (30 years)

  • 52 males primarily attracted to males
  • 26 males in the “other” category
  • 39 females primarily attracted to females
  • 5 in the “other” category

2006-2013 (8 years)

  • 32 males primarily attracted to males
  • 41 males in the “other” category
  • 82 females primarily attracted to females
  • 46 females in the “other” category

The clinic did not have data on the sexual orientation of five of the teenagers.

The second study looked at data on 420 teenagers (13 and up) referred to the Dutch clinic between 1989-2013.  Their mean age at the time of assessment was 16.14 and there was no significant age difference between males and females.

The second study did not include data on sexual orientation or a control group for comparison.

“The percentage of female adolescents from Amsterdam in the first time period did not differ significantly from the percentage of female adolescents from the Toronto clinic, and the percentage of female adolescents from Amsterdam in the second time period also did not differ from the percentage of female adolescents from the Toronto clinic, both χ2(1) < 1.”

This study is a follow-up to two earlier letters to the editor about changes in the teenage population at the clinic in Toronto: Is Gender Identity Disorder in Adolescents Coming out of the Closet? and Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, Sex Ratio, and Sexual Orientation.

The first letter discussed a rise in teenagers referred to the Canadian clinic between 2004-2007. The second letter discussed the continued increase in referrals from 2008-2011 and raises the question of a possible change in the sex ratio in 2008-2011.

Original Article:

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria by Aitken M1, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries AL, Kreukels BP, Zucker KJ in J Sex Med. 2015 Mar;12(3):756-63. doi: 10.1111/jsm.12817. Epub 2015 Jan 22.

* The Canadian clinic is the Gender Identity Service, within the Child, Youth, and Family Services (CYFS) at the Centre for Addiction and Mental Health in Toronto. The clinic in the Netherlands is the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam. This may explain why we have a comparison group for the Canadian patients with gender dysphoria, but not the Dutch ones.

**  “In the cohort examined in Study 1, perhaps it could be argued that, in the first time period, the greater number of biological males than biological females was an artifact of there being two prominent subtypes of GD (androphilic and nonandrophilic) in the former, whereas the latter were predominantly of only one subtype (gynephilic), but that this shifted in the second time period, with a greater number of females with a nongynephilic sexual orientation. However, the logistic regression analysis shown in Table 4 did not provide evidence for a sex × sexual orientation interaction. It only showed that a nonandrophilic or nongynephilic sexual orientation increased the odds that a proband presented in the second time period, but sexual orientation did not interact with probands’ biological sex.”

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.

usmt_a_675022_o_f0002g

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.

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.

usmt_a_309785_o_f0001g

 

“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.

A review of “Gender Identity Disorder in Twins: A Review of the Case Report Literature”

The data on twins suggests that there is a genetic component to gender dysphoria.

It also suggests that other factors are involved in developing gender dysphoria.

Unfortunately, the data is weak because it is mostly made up of case studies.

In addition, the data on identical twins and the data on fraternal twins were collected in different ways.

It is possible that this review overestimates the influence of genes due to the way the data was collected.

I had thought that writing this review would be quick and easy; genes are involved, but they are not the only factor. The truth is that the data is flawed and we don’t have conclusive proof yet. What we do have is a suggestion that genes are involved in gender dysphoria and a need for more research in this area.

Data on twins with gender dysphoria is hard to collect because it is rare. This review is an important one and it shows that there are good reasons to keep looking for possible genetic links to gender dysphoria. It also shows that there are good reasons to look for non-genetic factors that play a role in developing gender dysphoria.

Now you have the summary of the results, back to the study. Why does it mattter if many of the reports on identical twins came from case studies?

Using case studies means that there is a possibility of selection bias.

People may be more likely to publish interesting cases. For example, the review includes one case study where both identical twins had gender dysphoria, but only one had schizophrenia. In another case study both identical twins had anorexia, but only one had gender dysphoria. These cases are interesting, but they may not be typical.

This can become a more serious problem if therapists are more likely to be interested in cases of twins who are both trans. Alternatively, there could be a selection bias in favor of writing about identical twins where only one twin is trans. Some therapists might unconsciously look for cases of twins that fit their own theory about the cause of gender dysphoria. (Read more about case studies and selection bias here.)

The results of this review suggest that there is a selection bias that favors identical twins over fraternal twins. In other words, people write up and publish cases of identical twins more often than fraternal twins.

This is not because trans people don’t have fraternal twins; the studies that reviewed clinic records found 19 sets of fraternal same-sex twins and only 7 sets of identical twins. Only 27% of the twins in this group were identical twins. This is not surprising; fraternal twins are more common than identical twins in the general public.

The other studies, in contrast, reported on 16 sets of identical twins and only 2 sets of fraternal twins. A whopping 89% of the twins in this group were identical twins.

The key to figuring out if gender dysphoria is genetic is to compare identical twins and fraternal twins. If identical twins are more likely to both have gender dysphoria than fraternal twins, you have a good case for a genetic contribution. So if the sets of identical twins are chosen in a different way from the sets of fraternal twins, you have a problem.

In fact, for this study most of the data on identical twins is coming from case reports; there might be a selection bias involved there. Almost all of the data on fraternal twins, however, is coming from comprehensive reviews of clinic records.

Reviews of case studies include a number of other problems.

You can’t be sure people are being diagnosed in the same way; you may not be looking at the same phenomenon. This review looked at people diagnosed by different therapists in at least ten different countries.* The dates of the studies ranged from 1956 to 2011. Some of the twins were children or teens, some were adults.

There may also be cultural or environmental differences that are relevant. For example, one of the case studies is of a pair of identical twins in Iran. Both twins are trans. We know that many people feel pressured to transition in Iran; what if that is a factor in this particular case? What if in another country, only one of the twins would have transitioned?

The era of the study might also affect gender dysphoria. For example, the Belgian clinic noticed that two of the fraternal twins with gender dysphoria they found had been born after in vitro fertilization. If IVF is a factor in gender dysphoria, it will only affect later cases.**

The data in case studies is not uniform; this makes it hard to compare. For example, one study discussed birth weights while another focused on relationships with parents.

This review of studies did include three sets of twins who were found in a method that did not have a selection bias or problems with inconsistent collection of data.

1) Zucker looked at the records of 561 patients who went to a Canadian clinic for gender dysphoria between 1976 and 2011 and found 25 sets of twins. The patients were all under 12 years old.

They found no cases where both twins had gender dysphoria.

2) Heylens and De Cuypere looked at 3 sets of adult twins from the 450 patients who went to a Belgian gender clinic between 1985-2011 plus 3 sets of non-adult twins who went to the Belgian gender clinic for children and teenagers.

They found only one case where both of the twins had gender dysphoria: a set of identical twins who were female-to-male transgender (FtM).

3) Vujovic et al reviewed all the cases of gender dysphoria who were treated at a Serbian clinic between 1987 and 2006. Out of 147 people, one trans man and one trans woman had a fraternal twin. Neither of their twins had gender dysphoria.

If we exclude case studies because of possible bias, we end up with no genetic component to gender dysphoria in trans women. None of the clinics found pairs of male twins who both had gender dysphoria.

The problem with this approach is that identical twins who are both male-to-female transsexuals exist. They just didn’t show up at these three clinics. Presumably, they are very rare.

Using the clinic studies for trans men we would have one set of identical Belgian twins who both had gender dysphoria, and one set of identical Canadian twins who did not. In addition, we would have three sets of fraternal twins where only one twin had gender dysphoria. This is not enough data.

So it makes sense to look at the data from individual case studies; we just need to be cautious about interpreting it. It is possible that it would over or underestimate the genetic component to gender dysphoria.

What was the data, then?

The authors searched the literature and put their data from the three clinics together with data from 17 different case reports and studies.***

They found:

FtMs with identical twins

3 sets of identical twins who both had gender dysphoria (37.5%)

5 sets of identical twins where only one of the twins had gender dysphoria (62.5%)

FtMs with fraternal twins

5 sets of fraternal twins where only one of the twins had gender dysphoria (100%)

MtFs with identical twins

6 sets of identical twins where both twins had gender dysphoria (40%)

9 sets of identical twins where only one twin had gender dysphoria (60%)

MtFs with fraternal twins

16 sets of fraternal twins where only one twin had gender dysphoria (100%)

Based on this data, identical twins with gender dysphoria are more likely than fraternal twins or the general public to have a twin with gender dysphoria. This suggests a genetic component to gender dysphoria.

However, most of the time, only one identical twin has gender dysphoria. This suggests other factors are involved in gender dysphoria.

At this point, we have no idea what the other factors involved might be. The case reports don’t give enough information on the twins to figure it out. The information they give is inconsistent; one study reported on the age of the first period while another talked about whether or not the mother was domineering. In addition, we may be comparing apples and oranges; for example, one study looked at an adult male American Indian in 1976, another looked at 13 year old American females in 1992.

The authors of the review conclude:

“The etiology of GID is a complex process of biopsychosocial components with unexplained interactions. Twin literature on GID supports the contribution of genetic factors to the development of gender identity with a higher tendency in males than in females.****

Since sample size is still limited and genotype studies are lacking, conclusions must be drawn with caution.

Therefore, detailed registers of GID twins, preferably on MZ twins discordant for GID and DZ twins are needed, to gain more decisive information about the influence of genetic vs. environmental factors in the development of GID.

The authors of the study combine the data from studies of MtF and FtM twins for the statistical analysis. This gives them 9 pairs of identical twins where both twins had gender dysphoria (39%) and 14 pairs of identical twins where only one twin had gender dysphoria (61%). This is contrasted with 21 sets of fraternal twins where only one twin had gender dysphoria (100%). The difference is statistically significant.

This might be problematic since the mechanism that causes gender dysphoria in trans women is probably different from the mechanism that causes gender dysphoria in trans men. The genes are also probably different.

On the other hand the question here is whether or not gender dysphoria is inheirited, so perhaps this works.

Another problem is the possibility of selection bias. It looks like people are over-reporting cases involving identical twins. This might affect comparisons between identical twins and fraternal twins.

In addition, the total size of the group used in their statistical analysis is small and includes disparate groups – males and females, adults and children, people in different countries, and people living in different eras.

In the end, we’re left with weak evidence for a genetic component to gender dysphoria. We can’t prove it, but there is an excellent case for doing more studies in this area.

There is also an excellent case for future studies looking at what factors make one identical twin have gender dysphoria and one not. This seems to be the more common outcome than for both twins to have gender dysphoria.*****

Original Review:

Gender Identity Disorder in Twins: A Review of the Case Report Literature by Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T’Sjoen G in J Sex Med. 2012 Mar;9(3):751-7.

 

*Authors of the studies were from Belgium, Canada, Germany, Iran, Israel, the Netherlands, Serbia, Switzerland, the United Kingdom, and the United States. In addition, one author seemed to be from Scandinavia, possibly either Norway or Sweden.

**Using IVF means that the parents were infertile. It might be that the parents were older or that they had something wrong with their reproductive systems. It could be that the parent’s age or fertility problems affected the children rather than the IVF procedure.

***In some cases, it is hard to tell from the title if an article was a study or case report or an article on gender dysphoria that includes information on a case. Then again, the sub-title of this study is “A review of the case report literature,” so maybe they were all case reports.

**** I think the idea that there is a higher tendency in males than females is overstated. There were only 8 pairs of identical FtM twins and I doubt the 2.5% difference in the frequency of FtM versus MtF identical twin pairs who both have gender dysphoria is significant.

***** There may be selection bias in the cases of identical twins from the case reports. However, the clinic studies did find six sets of identical twins. In five of these six pairs, only one twin had gender dysphoria. Specifically, they found four pairs of identical male twins where only one twin had gender dysphoria, one pair of identical female twins where only one twin had gender dysphoria, and one pair of identical twins who were both FtM. So it looks like it is more common for only one identical twin to have gender dysphoria.

Emphases added are mine, including in the quote from the original review of the literature.