Tag Archives: gender dysphoria in children

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins – Review

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A “was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth 

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

 

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

 

Original Source:

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins by Urs Hepp, Gabriella Milos, and Hellmuth Braun-Scharm in Int J Eat Disord. 2004 Mar;35(2):239-43.

 

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Review – Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report

This is the earliest (1997) case study of someone with both gender dysphoria and an eating disorder.

Eating disorders are rare in children and in males, so an eating disorder in a boy is very unusual.

The boy’s mother had “abnormal eating habits and attitudes” and had been diagnosed with anorexia while she was pregnant with him. The boy had always been small for his age and did not get enough calories due to “extreme faddiness [picky eating] and the failure of the family to eat regular meals.” He was diagnosed with gender identity disorder when he was ten.

The boy developed a severe eating disorder at age 12 after a doctor suggested that he be given hormones to induce puberty.

In his case it looks like his gender dypshoria triggered his eating disorder, but he probably had a predisposition to problems with eating.

Treatment focused on three things: building up his weight, therapy with his family, and therapy with the patient around gender issues. In addition, a teacher was involved to prevent bullying at school. The boy refused the hormone treatments to induce puberty.

The patient’s weight improved steadily until his size was normal for his age and height, but the therapists thought he might relapse in the future due to family conflict and social prejudice.

In this case what worked was a combination of therapy for both the eating disorder and the gender dysphoria, along with family issues.

As always, it is important to remember that this is a case study of just one person. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

More details on the case:

The boy had been gender non-conforming since he was three and had stated that he wished to be a girl. At age 10 his weight dropped and he was referred to a psychiatrist who diagnosed him with gender identity disorder. He was being bullied at school for being gender non-conforming and developed depression, abdominal pain, and headaches.* He was also dealing with severe conflicts between his parents and an older brother with behavior problems.

At that time, therapists helped him develop coping strategies to deal with the bullying and counseled his parents. His eating, weight, and mood improved quickly.

At age 12, his weight dropped rapidly and he had cold extremities and no signs of puberty. He was living on water biscuits and low calorie orange squash (sweet fruit juice) while exercising up to five hours a day.

He was diagnosed with anorexia “in a context of long-standing eating problems and marital disharmony,” with the doctor’s recommendation of hormones to induce puberty as a “significant precipitant.”

“… he admitted feeling uncertain about hormone treatment. He wanted the comfort of acceptance by his social peer group, but felt happiest and most at ease in a feminine role. After the issue of hormone treatment was raised, B. briefly attempted to control and even deny cross-gender behaviors as if forcing himself to conform to male sex stereotypes. His behaviour soon returned to being highly effeminate. He dressed in female clothing and jewellery whenever he could, wore make-up and stylized his hair into a long pony-tail. His interests were hairdressing, fashion magazines, and knitting. At school he associated only with girls and was physically nauseated at the idea of having to play contact sports like rugby with other boys.”

Treatment included individual therapy related to his gender dysphoria:

“Individual work with B. was difficult because of his high level of denial. Over a period of time he began to focus on his dilemma between social conformity which would allow acceptance by others and his acknowledgement of his own revulsion at the idea of his developing male sexuality. In therapy he recognized that he had attempted to delay puberty by restricting his calorie intake. His anxiety about puberty related to his fear of the development of male secondary sex characteristics, the acquisition of a male sex drive, and potential loss of slimness. He was troubled and confused by homosexual and heterosexual fantasies. Exploration of these themes allowed some gradual resolution. Over a period of several months, he began to see some positive benefits from the eventual development of secondary male sex characteristics and to recognize that these changes did not necessarily preclude the continuance of cross-gender behaviour which was an undeniable part of his identity.”

A teacher at his school was also involved to “provide a contact in school who could help B. with teasing and tactfully educate other staff members about his special needs.”

His weight improved steadily and stabilized at 95 percent expected weight for his age and height.

Original Source:

Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report by E. Waters and L. Whitehead in Clin Child Psychol Psychiatry July 1997 vol. 2 no. 3 463-467.

 

*The narrative is a little confusing, but this seems to have happened before the resurgence of his eating problems at age 12.

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood – Review of a case study

This is a follow-up case study of a Japanese boy with both Asperger’s syndrome and gender dysphoria. It is the first long-term follow-up case study we have for a child with autism and gender dysphoria.

The young man no longer had gender dysphoria at the 11-year follow-up.

This is a highly significant case study; we know that most children with gender dysphoria desist around puberty, but we have had no data on what happens to children with both autism and gender dysphoria.

We need more studies to find out how common this is for children with autism and gender dysphoria.

In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?

As the authors say, “Careful long-term clinical observation and further studies are needed.”

More details on the boy’s gender dysphoria:

[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”

You can also read more about his earlier gender dysphoria in this previous case study.

More details on the change at puberty:

“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”

Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.

 

*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)

Original Source:

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood by Tateno M, Teo AR, Tateno Y, in Psychiatry Clin Neurosci. 2015 Oct;69(10):658.

Gender identity problems in autistic children – Review of a case study

This is a case report of two Turkish boys with autism and gender dysphoria. Unlike this earlier study of two boys with autism, the boys in this study verbalized a clear desire to be a girl.

In the earlier case study, the boys had cross-gender interests, but probably did not have gender dysphoria. In this case study, however, the boys had cross-gender interests and gender dysphoria.

This study followed the boys for at least four years, so we know that the gender dysphoria was not transient.

We do not, however, know if their gender dypshoria will persist. Most children with gender dysphoria desist around the time of puberty. What happens with children with autism? Are they more or less likely to persist in their gender dysphoria? How should parents and educators handle their gender dysphoria? Is their gender dysphoria different from gender dysphoria in neurotypical children? How common is gender dysphoria among children with autism?

In the first of these two cases the patient was treated with behavior modification, encouraging separation from the mother, and establishing a bond with his father. His cross-gender behavior continued. In the second case his parents tried to establish a good bond with his father, but again, his cross-gender behaviors have continued.

The author of this study suggests that gender dyshoria in children with autism may be underreported and might be interpreted as unusual interests rather than actual gender dypshoria. At this point, however, we don’t have enough data to know if that is the case. This is a case study of only two children.

This case study does, however, show that children with autism can have genuine gender dypshoria, like the Swedish teenage girl in this case study and the Japanese boy in this one.

“This case study, which is a preliminary attempt to report the developmental pattern of cross-gender behaviour in autistic children, tries to underline that (1) diagnosis of GID in autistic individuals with a long follow-up seems possible; and (2) high functioning verbally able autistic individuals can express their gender preferences as well as other personal preferences.

Finally, this report points to the need for further study of gender identity development as well as other identity problems in individuals with high functioning autism.”

(Emphasis mine)

Original Source:

Gender identity problems in autistic children by N. M. Mukaddes in Child: Care, Health and Development Volume 28, Issue 6, pages 529–532, November 2002.

More details about the case studies:

Case 1 – 10 year old boy with autism:

“One year after the referral [for autism], when he was aged 6 years, he started to show improvements in spontaneous speech and imitative play, and displayed more interest in his peers and other people. At the same time, his mother reported some cross-gender behaviours such as wearing his mother’s dresses, putting lego bricks in his socks under his heels and pretending to have high-heel shoes. Along with the improvement in spontaneous speech and imitative behaviour, he started to state his disappointment about his gender. Sometimes, he prayed and begged God to make his penis disappear. After these verbal expressions, he shared his fantasy about his wish to become a bride, married to a man from the age of 8 years. He never shows interest in male activities, he always avoids rough-and-tumble play and prefers to play with girls. Although he has shown some improvement in his social relatedness and language, his social difficulties in terms of reciprocal relationships with peers and sustaining a conversation with others still remain. Despite the eclectic treatment approaches (behavioural modification, encouraging separation from his mother and establishing a bond between him and his father), his cross-gender behaviours show a persistent pattern.”

Case 2 – 7 year old boy with autism:

He started to use phrases at age 4 years [he was referred to the clinic at age 3 for autism], showed improvement in social relationships and sharing interests with peers at nursery school. He also started some make-believe play. At the same time, he had shown persistent attachment to his mother’s and some significant female relative’s clothes and especially liked to make skirts out of their scarves. After age 5 years, he started to ‘play house’ and ‘play mother roles’. This was the most persistent and most pervasive pattern of his play, and he pushed his therapist as well as his peers and family members to ‘play house’ with him. He avoids rough-and-tumble play and likes to share his interests with one or two of his female classmates. His parents were worried about his behaviour and tried to prevent it, but he reacted aggressively. He started to state his desire to grow up as a woman (like his mother). He gave up his attachment to some feminine objects, but still shows persistence in playing the ‘mother roles’ and expresses his desire to be a woman. Although there are some improvements in terms of social relatedness, language and the disappearance of stereotypical behaviours, his social interaction pattern is still inappropriate for his age. His parents have tried to establish good bonding between him with his father as a identification object. Despite this, his cross-gender behaviours are persistent.

Case study: cross-gender preoccupations in two male children with autism

This is a 1996 case study of two boys with autism who had cross-gender interests, but probably did not have gender dysphoria.

Both boys liked dolls, although the way they played with them was not typical. In addition, one of the boys liked to imitate the scenes of cartoons with female characters. Both boys cross-dressed and created long hair with cloth.

Neither of them played with other children of either sex. One boy ran around and screamed until the other children left and the other fought with others if they bothered him.

Neither of them expressed a dislike of being a boy or a desire to be a girl – although, on the other hand, their language was limited.

The parents of one of the boys thought they might have reinforced his interest in dolls. They had been so excited to see him using toys of any sort that they bought dolls for him.

The mother of the other boy was anxious about her son’s cross-dressing and reluctant to discuss it.

The authors suggest that for these boys the cross-dressing may represent an unusual preoccupation rather than a sign of gender identity. “This preoccupation may relate to a need for sensory input that happens to be predominantly feminine in nature (silky objects, bright and shiny substances, movement of long hair, etc.).”

The authors suggest that cases like these could lead to misdiagnosing gender dysphoria:

“These cases also point to the potential for confusion of primary gender identity disorders with preoccupations in high-functioning individuals with autism.”

They make recommendations for treatment in cases like these:

“Rather than a narrow focus on altering the preoccupation, a broad intervention addressing social, communication, and play skill development appears to be important. Thus, identifying other interests in the children to be developed in the context of social situations may aid social skill development by increasing opportunities for interactive play. Parents and others working with the children may need help in understanding the nature of feminine preoccupations in boys and in destigmatizing these interests.”

The authors conclude by saying:

It is our hypothesis that the feminine preoccupations of these children with autism may have resulted from an inherent predisposition toward unusual interests combined with the boys’ social environment. The sensory aspects of the feminine objects may have contributed to the development of these preoccupations. It seems less likely that the feminine interests are related to issues of gender roles/confusion. This report points to the need for future study of the complex interplay of environmental and neurobiologic factors affecting gender identity roles and preoccupation in autism.

More Details About the Boys’ Cross-Gender Interests and Behavior

The first patient was five years old.

“Although his parents report no truly imaginative play, M.C. will imitate the scenes from a video having to do with female cartoon characters (e.g. Cinderella, Snow White, and Ariel). He likes to hold Barbie dolls, but frequently will rip off the dolls’ heads and play with parts of the doll, particularly the hair. He enjoys bright, shiny objects. He often dresses up using female clothing and uses towels or other fabric to fashion long hair for himself. M.C. demonstrates little interest in male toys or other toys in general.”

The second patient was three and a half years old.

“His favorite toys are a Minnie Mouse doll and a Barbie doll although his play consists mostly of shaking the hair of the Barbie doll. He enjoys wearing his sister’s or mother’s clothing, including high heeled shoes, bras, and underwear. He often puts a shirt over his head and acts as if it is long hair.”

More Details about the Patients

The first patient lived with his parents and older brother. There was nothing unusual about his birth, although his later medical history included “hospitalization for dehydration/gastroenteritis and right inguinal hernia repair.”

Behaviorally, “M.C.’s speech is characterized by short sentences which are often stereotyped. He recently began requesting objects by pointing. His parents report that he is an active, impulsive, moody child with a good memory. M.C. frequently engages in perseverative motor activities. He is generally a loner. When with other children he frequently runs around and screams until the children go away.”

The second patient lived with his mother, older sister, fraternal twin, and his mother’s boyfriend. The pregnancy and birth were complicated. The patient had also had frequent upper respiratory infections and ear infections and a hospitalization for reactive airway disease and pneumonia.

In terms of his development, “although he learned the words to several songs at an early age, he did not begin using phrases until approximately 3 years of age. C.W. is described as a loner who does not play with others. He engages in perseverative activities such as opening and shutting doors as well as running his hand repeatedly through water. He watches commercials, music videos, and ‘Wheel of Fortune’ on television. He fights with others if they bother him, and screams if unable to do what he wants.”

More Details about the Patients’ Treatments

The first patient was treated with special education services after kindergarten and consultation with a school specialist in autism. His communication skills improved and his interests broadened somewhat. However, he was still interested in dolls and requested a Pocahontas doll for his birthday.

In the second case, the boy was enrolled in a school program that included special education services. His mother had a home consultation visit with a specialist in autism. He continues to cross-dress, although his mother only allows it when he comes home from school.

 

Original Source:

Case study: cross-gender preoccupations in two male children with autism by Williams PG, Allard AM, Sears L. in J Autism Dev Disord. 1996 Dec;26(6):635-42.

 

 

 

 

The development of gender identity in the autistic child – Extremely Brief Review

A 1981 study of autistic children found that gender identity was related to “mental age, chronological age, communication skills, physical skills, social skills, self-help skills and academic/cognitive skills.”

The study looked at 30 children and gave them the Michigan Gender Identity Test. The goal was to see if they could demonstrate a sense of gender identity.

This study is not available online, however, I was able to get some more information on it from another study (Case study: cross-gender preoccupations with two male children with autism.)

According to Williams et al., Abelson’s study indicated that “the establishment of gender identity in children with autism (as demonstrated by recognizing one’s own self as a boy or a girl) appeared to be dependent on mental age and cognitive abilities, and was correlated with the establishment of other social and self-help skills. Abelson expressed some optimism that many children with autism have the ability to recognize themselves as boys and girls, and thus form effective ties with the identified group, which leads to more acceptable social interaction patterns.”

Original Source:

The development of gender identity in the autistic child by Abelson AG in Child Care Health Dev. 1981 Nov-Dec;7(6):347-56.

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.