Tag Archives: trans kids

Where to Call if you Need Help

This is not a political blog, but I think we all need a reminder to take care of ourselves right now. Reach out for help – there are people who want to help you.

And to parents who read my blog, please tell your kids you love them and will fight for them.

Sources of Help:

Trans Lifeline for trans people:

  • US number: 1-877-565-8860
  • Canadian number: 1-877-330-6366
  • and their website.

The Trevor Lifeline for LGBTQ youth (US) – 1-866-488-7386 and their website.

National Suicide Prevention Lifeline (US): 1-800-273-TALK (8255) and their website.

The International Association for Suicide Prevention – their website has an interactive map with phone numbers and locations of crisis centers.

From Maria Shriver’s blog, Powered by Inspiration.

Two Years After My Suicide Attempt, I’m Still Living and Sharing

“Waking up two years ago gave me opportunities, some of which seem obvious but some of which I’m still discovering. I have the opportunity to continue the life I began and do the things I want to do. I have the opportunity to offer help to people who would have helped me if only I had shared what was going on.”

Read more here.

Finally, some helpful tips from the website Recommendations for Reporting on Suicide:

Suicide Warning Signs

  • Talking about wanting to die
  • Looking for a way to kill oneself
  • Talking about feeling hopeless or
    having no purpose
  • Talking about feeling trapped or
    in unbearable pain
  • Talking about being a burden
    to others
  • Increasing the use of alcohol or drugs
  • Acting anxious, agitated or recklessly
  • Sleeping too little or too much
  • Withdrawing or feeling isolated
  • Showing rage or talking about seeking revenge
  • Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. Warning signs are associated with suicide but may not be what causes a suicide.

What to Do

If someone you know exhibits warning signs of suicide:

  • Do not leave the person alone
  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt
  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255)
  • Take the person to an emergency room or seek help from a medical or mental health professional.
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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.

Review of Gender identity disorder in a girl with autism – a case report

This is a 1997 case of a Swedish teenager who had autism as well as symptoms of gender dysphoria, selective mutism, and obsessive compulsive disorder (OCD).

Treatment with clomipramine decreased her symptoms of OCD and mutism, but not her symptoms of gender dysphoria.

Unlike this earlier case study of two American boys, this patient had clear symptoms of gender dysphoria:

“At the age of 8 years, B had started to claim that she was a boy. She refused to wear girls clothing and jewelery. B corrected persons if she was being addressed as ‘she’ and used her brothers’ shaving machine. At twelve years of age, B refused to visit the girls toilet but was forbidden by the parents to use the boys toilet. She has now been told to use the one and only gender neutral toilet in the school.”

And, at follow up:*

“She refuses to wear women’s clothes or to appear in swimsuit on the beach. Moreover, she claims that she is a boy, although she has discontinued the habit of correcting peers for addressing her ‘her’.”

The authors discuss three possible ways to interpret her symptoms of gender dysphoria and the implications for treatment.

First they suggest that the gender dysphoria could be part of the autism, specifically a ritualized and obsessive-compulsive behavior of a kind which is commonly seen in autistic syndromes.” 

The authors suggest that autism makes social and sexual relationships difficult, although people with autism are attracted to others. The expression of these feeling may be unusual. A minority of people with autism display a variety of paraphilic behaviour, e.g., exhibitionism, voyeurism and fetishism, and the desire for a beloved person may find expression in an obsessive manner.”

Gender dysphoria then might be “a paraphilic consequence of the impairment in social interaction” due to her autism. In that case the proper response would be “similar to the one employed when encountering other sexual manifestations with autistic people: a gradual firm correcting of the behavior in the direction of gender concordant behavior, but without anger or distress.”

The authors do not discuss the possibility that the gender dysphoria could be part of the autism in some other, non-sexual way. They should have.

Second, they suggest that the gender dysphoria might be seen as an obsessive-compulsive disorder and separate from the autism. In that case the proper treatment would be clomipramine.

There have been cases where patients with obsessional gender dysphoria were successfully treated with lithium carbonate, but the symptoms were different from the ones in this case.**

More importantly, in this case, treatment with clomipramine relieved the symptoms of OCD and mutism, but not the gender dysphoria. In fact, her symptoms of gender dysphoria increased, although it may be that they only became more apparent – for one thing she was talking more.

Third, they suggest that the gender dysphoria could be viewed as a disorder on its own and not a symptom of autism or OCD. In that case, the proper approach would be to treat both the autism and the gender dysphoria. When the teenager was of age,*** she would then be eligible for sex reassignment surgery.

They caution that “this patient suffers from a putative risk factor (autism), which has to be seriously considered before any intervention can be performed. “

As with other case studies, this is about one person. We can only draw limited conclusions from it.

It does show, however, that a person with autism can have symptoms of gender dysphoria. Further, in this case, the symptoms were probably not caused by OCD, as treatment for OCD did not relieve her gender dysphoria.

We could use further research to determine the relationship between gender dysphoria and autism and the best way to treat children and teenagers who have both.

Original Source:

Gender identity disorder in a girl with autism – a case report by Landén M., Rasmussen P. in Eur Child Adolesc Psychiatry. 1997 Sep;6(3):170-3.

*It’s not perfectly clear in the case report, but the therapists seem to have seen her initially at age 12 and the follow-up seems to have been at age 14.

**Skoptic syndrome: the treatment of an obsessional gender dysphoria with lithium carbonate and psychotherapy.

***The first reference I can find to using puberty blockers for teenagers with gender dysphoria is a case study of one teenager in 1998, a year after this case study. Thus at the time of this case study, medical transition would not have begun before age 18. (Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent.)

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.

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.