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The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria. The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria. Aitken M, 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 ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med **;**:**-**. © 2015 International Society for Sexual Medicine.
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ORIGINAL RESEARCH—LGBT
Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents
with Gender Dysphoria
Madison Aitken, MA,* Thomas D. Steensma, PhD,
†‡
Ray Blanchard, PhD,
§
Doug P. VanderLaan, PhD,*
Hayley Wood, PhD,* Amanda Fuentes, MA,* Cathy Spegg, MBA,
Lori Wasserman, MD,*
Megan Ames, PhD,* C. Lindsay Fitzsimmons, MA,* Jonathan H. Leef, MA,* Victoria Lishak, MA,*
Elyse Reim, MA,* Anna Takagi, MA,* Julia Vinik, PhD,* Julia Wreford, MA,*
Peggy T. Cohen-Kettenis, PhD,
†‡
Annelou L.C. de Vries, MD, PhD,
†,
**
Baudewijntje P.C. Kreukels, PhD,
†‡
and Kenneth J. Zucker, PhD*
*Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario,
Canada;
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands;
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands;
§
Department of
Psychiatry, University of Toronto, Toronto, Ontario, Canada;
IM/IT Corporate Applications, Centre for Addiction and
Mental Health, Toronto, Ontario, Canada; **Department of Child and Adolescent Psychiatry, VU University Medical
Center, Amsterdam, The Netherlands
DOI: 10.1111/jsm.12817
ABSTRACT
Introduction. The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears
to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to
one favoring natal females.
Aim. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio
of adolescents referred for gender dysphoria.
Methods. The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two
cohort periods (2006–2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study
2 was conducted on patients from a clinic in Amsterdam.
Results. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex
ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal
females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corre-
sponding change in the sex ratio of 6,592 adolescents referred for other clinical problems.
Conclusions. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex
ratio of adolescents with gender dysphoria. Aitken M, 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 ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex
ratio in clinic-referred adolescents with gender dysphoria. J Sex Med 2015;12:756–763.
Key Words. Gender Dysphoria; Gender Identity Disorder; Sex Ratio; Adolescents
Introduction
T
he prevalence of gender dysphoria (GD) [1]
is uncertain because of the absence of formal
epidemiological studies. As reviewed by Zucker
and Lawrence [2], prevalence has often been
gauged, at least in adults, by the number of indi-
viduals seeking out hormonal treatment and sex-
reassignment surgery at specialty clinics in
different regions or countries.
Information on the sex ratio of individuals with
GD is one element of these para-epidemiological
studies. In adult samples, in almost all cases, the
number of natal males either exceeds the number
756
J Sex Med 2015;12:756–763 © 2015 International Society for Sexual Medicine
of natal females or the sex ratio is near parity [2,
Table 3] (see also Kreukels et al. [3]).
1
The excep-
tions are studies from Poland and Japan, where the
sex ratio is inverted [4,5]. In clinic-referred child
samples, it has long been noted that the number of
males also exceeds the number of females. Wood
et al. [6], for example, reported a sex ratio of 4.49:1
of boys to girls (N = 577) ages 3–12 years from
their clinic in Toronto, Canada, which was signifi-
cantly higher than the sex ratio of 2.02:1 of boys to
girls (N = 468) in a specialty clinic in Amsterdam,
the Netherlands, but which also favored boys.
Regarding the sex ratio of adolescents referred for
GD, Wood et al. reported a sex ratio of 1.04:1 of
males to females (N = 253) from the Toronto clinic
for the years 1976–2011, which was virtually iden-
tical to the sex ratio of 1.01:1 of males to females
(N = 393) in the Amsterdam clinic (as cited in
Wood et al.).
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 (Figure 1). Beginning in 2004, however,
the number of adolescent referrals began to rise
quite dramatically [6], which appears to be consis-
tent with the observations of clinicians and
researchers from other gender identity clinics.
Starting in 2006, we noted that the number of
referred female adolescents with GD was now
exceeding the number of referred male adolescents
with GD in the Toronto clinic. Thus, there
appears to be an emerging inversion in the sex
ratio of adolescents with GD which, to our knowl-
edge, has not been documented formally in the
empirical literature.
In Study 1, we analyzed the sex ratio of the
Toronto clinic adolescents and, for comparative
purposes, used an administrative database that
contained information on the sex ratio of adoles-
cent males and females seen clinically for other
psychiatric concerns in our department. The use
of a clinical comparison group allowed us to test
the hypothesis that the temporal shift in the sex
ratio was specific to adolescents with GD but not
clinic-referred adolescents in general. In Study 2,
we analyzed the sex ratio of the Amsterdam clinic
adolescents to test for a temporal shift over the
same time period.
Study 1
Methods
Participants
The probands consisted of 328 adolescents (13–19
years of age) referred to a Gender Identity Service,
housed within the Child, Youth, and Family Ser-
vices (CYFS) at the Centre for Addiction and
Mental Health (CAMH) between 1976 and 2013.
Mean age at the time of assessment was 16.66 years
(standard deviation [SD] = 1.70), and there was no
significant difference in age between the males and
females, t(326) < 1. Depending on the year of
assessment, DSM-III, DSM-III-R, or DSM-IV
criteria were used to diagnose Gender Identity
Disorder (GID) or Gender Identity Disorder Not
Otherwise Specified (GIDNOS) (in DSM-III and
III-R, the diagnostic term was Transsexualism,
not GID, which was first used as the diagnostic
term in the DSM-IV). All probands met criteria
for either GID or GIDNOS. Beginning in 2001,
1
For ease of readability, we truncate hereafter the use of the
terms natal males and natal females to males and females,
respectively.
Figure 1 Number of adolescent pati-
ents assessed by sex and year
Sex Ratio of Adolescents with Gender Dysphoria 757
J Sex Med 2015;12:756–763
we measured the severity of GD in the probands
with the Gender Identity/Gender Dysphoria
Questionnaire for Adolescents and Adults
(GIDYQ-AA) (7). The GIDYQ-AA is a 27-item
questionnaire designed to capture multiple indica-
tors of gender identity and GD, including subjec-
tive, social, somatic, and sociolegal parameters.
Each item was rated on a five-point scale, ranging
from 1 to 5. A lower score indicates more GD.
Based on prior studies, a mean score 3.00 indi-
cated “casesness,” with excellent sensitivity and
specificity rates [7,8].
Probands were coded as males or females. The
controls consisted of 6,592 adolescents referred
for other reasons to the CYFS between 1999 and
2013. Controls were referred for many different
reasons, spanning the gamut of psychiatric issues
experienced by youth (e.g., mood and anxiety dis-
orders, disruptive behavior disorders, substance
use disorders, and pervasive developmental disor-
ders). Eleven additional controls were subse-
quently referred to the Gender Identity Service, so
they were not included as clinical controls. The
controls were also coded as males or females.
For the probands, we classified their sexual
orientation as follows: for males, androphilic
vs. nonandrophilic; for females, gynephilic vs.
nongynephilic, as is commonly done for adults
with GD (see Lawrence [9]). This was based either
on clinical chart data or two quantitative measures:
the Erotic Response and Orientation Scale and the
Sexual History Questionnaire [10].
Procedure
The sex of the probands was extracted from an
SPSS file. The sex of the controls was extracted
from an administrative database and converted to
an SPSS file. The database allowed us to eliminate
any duplicate health record numbers and, if such
duplicates were identified, only the first admission
was used. The administrative database of clinical
controls prior to 1999 was no longer accessible.
The study protocol was approved by the CAMH
Research Ethics Board (#004/2014).
Data Analysis
As noted in the Introduction, visual inspection of
the sex ratio for the probands indicated a change
starting in 2006, so, for some of the analyses
reported below, we created two time periods
(1999–2005 and 2006–2013). For both the pro-
bands and the controls, we used a binomial test to
see if there was a significant sex difference in the
proportion of referred males vs. females for each of
the two time periods. We also conducted a logistic
regression that tested for the presence of a
group × time period interaction for the proportion
of referred females.
Results
As noted earlier, there has been a general increase
in the number of referred adolescents (Figure 1).
The correlation between calendar year and the
number of cases assessed in that year was 0.76,
P < 0.001, based on the assumption of a linear rela-
tion between these variables (i.e., the number of
cases increases by roughly the same amount each
year and the graphed data approximate a straight
line). It can, however, be seen in Figure 2 that the
relation between calendar year and the number of
cases assessed was strongly curvilinear. An expo-
nential equation showed that 68% of the variance
in assessments was accounted for by calendar year
(vs. 58% for the linear model).
Table 1 shows the number and percentage of
males vs. females as a function of group × time
Patients
Year
Figure 2 Curvilinear relationship between number of pati-
ents assessed by year (1975–2013)
Table 1 Number and percentage of adolescent referrals
by group and time period
Time period 1999–2005 2006–2013
Group
Gender dysphoria
Males (N/%) 36 (67.9) 73 (36.1)
Females (N/%) 17 (32.1) 129 (63.9)
Sex ratio (M : F) 2.11:1 1:1.76
Clinical controls
Males (N/%) 1,601 (68.9) 2,828 (66.2)
Females (N/%) 721 (31.1) 1,444 (33.8)
Sex ratio (M : F) 2.22:1 1.96:1
758 Aitken et al.
J Sex Med 2015;12:756–763
period. Between 1999 and 2005, a two-tailed bino-
mial test showed that, for the GD group, there was
a greater percentage of males than females
(P = 0.013). In the same time period, for the clini-
cal controls, there was also a greater percentage of
males than females (P < 0.001). Between 2006 and
2013, a binomial test showed that, for the GD
group, there was a greater percentage of females
than males (P < 0.001) but, for the clinical con-
trols, there was a greater percentage of males than
females (P < 0.001). For the time period 1976–
1998, we only had data available on the GD group,
and a binomial test showed that there was a trend
for a greater percentage of males (N = 44) than
females (n = 29) to be referred (P = 0.101).
To examine whether there was evidence for a
group × time period interaction for the proportion
of referred males vs. females, we conducted a logis-
tic regression analysis. The predictor variables
were group (GD vs. controls) × time period
(1999–2005 vs. 2006–2013). We used indicator
coding for these categorical variables. The crite-
rion variable was the sex of the adolescent clients.
Table 2 shows the results of the logistic regres-
sion analysis. The regression equation was built in
two blocks: direct entry of group × time period
(main effects), followed by direct entry of the
interaction term for group × time period. It can
be seen that, in Block 2, there was a significant
group × time period interaction. It can be seen in
Table 1 that the percentage of referred females was
stable for the controls when comparing the two
time periods (1999–2005 vs. 2006–2013). In the
1999–2005 cohort, the percentage of referred GD
females was virtually identical to that of the clinical
control females but, in the 2006–2013 cohort, the
percentage of referred GD females was markedly
higher than the percentage of clinical control
females.
Table 3 shows the number and percentage of
adolescents with GD as a function of sex, sexual
orientation, and time period. We conducted a
logistic regression with sex and sexual orientation
as the predictor variables and time period as the
criterion variable. Table 4 shows that female sex
increased the odds that a proband presented in the
second time period by almost 300% and that a
nonandrophilic sexual orientation (for males) and
a nongynephilic sexual orientation (for females)
increased the odds that a proband presented in
the second time period by over 200%. However,
the sex × sexual orientation interaction was not
significant.
For the 234 probands for whom a GIDYQ-AA
was available, 223 (95.3%) met the criterion for
casesness. To examine whether or not there was a
relationship between severity of GD and year of
assessment, we calculated a Pearson correlation.
For females, the correlation was not significant,
r = 0.026. For males, the correlation was signifi-
cant, r =−0.26, P = 0.011, indicating that more
recently assessed cases had moderately higher GD
severity.
Study 2
Methods
Participants and Procedure
The probands consisted of 420 adolescents (13
years of age and older) referred to the Center of
Table 2 Logistic regression: proportion of adolescent
referred males vs. females by group × time period
Step β SE Wald df Exp(β) P
Block 1
Group 0.98 0.13 58.07 1 2.68 <0.001
Time period 0.16 0.05 8.60 1 1.17 0.003
Block 2
Group × time period 1.19 0.33 12.86 1 3.30 <0.001
Note: Group dummy coded where 0 = clinical controls and 1 = GD probands
and time period 1999–2005 = 0 and 2006–2013 = 1. Sex was dummy coded
as male = 0 and female = 1. Exp(β) is the same as the odds ratio
Table 3 Number and percentage of adolescent referrals
by sex, sexual orientation, and time period
Time period 1976–2005 2006–2013
Group
Males
Androphilic (N/%) 52 (66.7) 32 (43.8)
Nonandrophilic (N/%) 26 (33.3) 41 (56.2)
Females
Gynephilic (N/%) 39 (88.6) 82 (64.0)
Nongynephilic (N/%) 5 (11.4) 46 (36.0)
Note: Sexual orientation is in relation to birth sex. Data on sexual orientation
were not available for 5 probands
Table 4 Logistic regression: number of adolescent
referred males vs. females by sexual orientation
Step β SE Wald df Exp(β) P
Block 1
Sex 1.36 0.26 28.44 1 3.91 <0.001
Sexual orientation 1.11 0.27 16.57 1 3.05 <0.001
Block 2
Sex × sexual orientation 0.53 0.61 0.76 1 1.70 ns
Note: Sex was dummy coded as male = 0 and female = 1. Sexual orientation
was dummy coded as 0 = androphilic or gynephilic and 1 = nonandrophilic or
nongynephilic in relation to birth sex. Exp(β) is the same as the odds ratio
ns = not significant
Sex Ratio of Adolescents with Gender Dysphoria 759
J Sex Med 2015;12:756–763
Expertise on Gender Dysphoria at the VU Uni-
versity Medical Center in Amsterdam, the Neth-
erlands between 1989 and 2013. Mean age at the
time of assessment was 16.14 years (SD = 1.59),
and there was no significant difference in age
between the males and females, t(418) = 1.21. The
sex of the probands was extracted from an SPSS
data file. Extraction of the relevant data was
approved by the Research Ethics Board at the VU
University Medical Center.
Results
Between 1989 and 2005, the number of referred
male adolescents was 109 (58.6%), and the number
of referred female adolescents was 77 (41.4%) (an
M : F sex ratio of 1.41:1), a significant difference
using a binomial test, P = 0.023. Between 2006 and
2013, the number of referred male adolescents was
86 (36.7%), and the number of referred female
adolescents was 148 (63.3%) (an M : F sex ratio of
1:1.72), a significant difference using a binomial
test, P < 0.001. A χ
2
test showed a significant asso-
ciation between the sex distribution of the adoles-
cents and the two time periods, χ
2
(1) = 19.02,
P < 0.001.
The percentage of female adolescents from
Amsterdam in the first time period did not differ
significantly from the percentage of female adoles-
cents 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 χ
2
(1) < 1.
Discussion
In two independent samples, we found that there
was a significant temporal shift in the sex ratio of
clinic-referred gender-dysphoric youth, from a
ratio favoring males (prior to 2006) to a ratio
favoring females (2006–2013). In Study 1, we
showed that this inversion in the sex ratio was
specific to gender-dysphoric youth and not clinic-
referred adolescents in general. In Study 2, we
found an almost identical shift in the sex ratio of
adolescents assessed at the major gender identity
clinic for adolescents in the Netherlands,
2
thus
matching the findings from Toronto. The sex ratio
favoring females (between 2006 and 2013) is con-
sistent with at least two other recent reports
[11,12]. Becker et al. [11], in Hamburg, Germany,
reported an M : F sex ratio of 1:3.14 (n = 29) for
adolescents with GD assessed between 2006 and
2010 but did not have data for prior years as their
clinic had not yet been established. Spack et al.
(12), in Boston, reported an M : F sex ratio of
1:1.30 (n = 83) for adolescents with GD assessed
between 1998 and 2010 but did not provide data
on any changes in the sex ratio as a function of year
of assessment.
This inversion in the sex ratio of gender-
dysphoric youth is a new development, which
requires an explanation or set of explanations. The
inversion appears to correspond with, albeit inde-
pendently, an increase in the number of clinic-
referred GD youth in general. As noted in Study 1,
we found that there was a very strong curvilinear
correlation between number of cases assessed
annually and year of assessment for adolescents
with GD. This general increase in referrals for GD
is likely due to several factors: the increased
visibility of transgendered people in the media,
which likely contributes to at least a partial
destigmatization of GD; the wide availability of
information on the Internet about transgenderism
or GD, which also likely contributes to destig-
matization; and the increased awareness of the
availability of biomedical treatment for adoles-
cents, including the use of gonadotropin-releasing
hormone agonists to delay or suppress biological
puberty [13,14]. All of these factors have probably
made it easier for youth and their families to seek
out clinical care [15]. It is unclear, however, if these
factors per se would account for the inversion in the
sex ratio, which requires a more nuanced explana-
tion or set of explanations.
In Study 1, we did not find any indication that
there was a significant relationship in females
between severity of GD, as measured by the
GIDYQ-AA, and year of assessment for the time
period 2001–2013 (the period for which we now
had available for analysis this measure). Thus,
there was no evidence in females that the greater
number of referrals in recent years might be
accounted for by an increase in referrals of more
“mild” cases.
3
For males, however, there was a
weak correlation between severity and year of
assessment, but this accounted for only 6.7% of
the variance. Thus, it is unlikely that the recent
2
Prior to 2011, the Centre of Expertise on Gender Dys-
phoria was the sole specialty clinic for children and adoles-
cents in the Netherlands. In 2011, a satellite clinic was
opened in Leiden, but adolescents seen in that clinic were
not part of the Dutch data reported in this study.
3
We would like to thank two of the referees for suggesting
this possibility.
760 Aitken et al.
J Sex Med 2015;12:756–763
inversion in the sex ratio can be accounted for by a
substantive change in severity variation.
One possibility that might explain the inver-
sion of the sex ratio pertains to the well-known
normative sex difference in pubertal onset, in
which females begin puberty, on average, at an
earlier age than males [16]. On the assumption
that our adolescent females with GD began
puberty, on average, at an earlier age than our
adolescent males with GD, perhaps it could be
argued that this results in a relatively greater
salience of the incongruity between their felt
gender identity and their natal sex because this
incongruence began at an earlier age. As a result,
this might explain the greater number of adoles-
cent females presenting with GD than adolescent
males because they experienced a longer period of
distress related to the gender incongruence as a
result of an earlier onset of puberty. If this were
the case, we might have expected that the females
to present at an earlier age than the males.
However, in both studies, the mean age at assess-
ment did not differ significantly between the
females and the males.
A second possibility is related to sexual orienta-
tion. For a long time, it has been argued that sexual
orientation is more variable in biological males
than it is in biological females referred for GD. In
adults with GD, there tends to be a relatively equal
percentage of biological males with an androphilic
vs. a nonandrophilic sexual orientation [17,18].
In contrast, a substantial majority of biological
females have a gynephilic sexual orientation
[17,18]. In recent years, however, more biological
females with a nongynephilic sexual orientation
have been described in the literature (many of
whom identify as gay men after a gender transi-
tion) [19,20]. 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.
Might sociological or sociocultural factors
account for the recent inversion in the sex ratio? It
is well-known that individuals with GD who are
sexually attracted to members of their birth sex
have an early-onset (i.e., in childhood) history of
marked cross-gender (gender-variant) behavior, a
developmental parameter that is similar to that of
some gay men and lesbians [21], who also have a
childhood history of cross-gender behavior. Pro-
spective studies of GD in children suggest that the
degree of cross-gender behavior is predictive of
GD persistence into adolescence and adulthood,
with many of the desisters differentiating a same-
sex sexual orientation [22–24]. Nonetheless, there
is a good deal of overlap in the degree of child-
hood cross-gender behavior between individuals
with an early-onset of GD and some gay men and
lesbians. For example, Lee [25] noted that the
developmental histories of “butch lesbians” and
female-to-male transsexuals showed many simi-
larities, and it was difficult to predict, on an indi-
vidual basis, which “group” these females would
wind up in.
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 nega-
tive 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
Sex Ratio of Adolescents with Gender Dysphoria 761
J Sex Med 2015;12:756–763
adopt a female gender identity in adolescence than
it is for a female to adopt a male gender identity.
Corresponding Author: Kenneth J. Zucker, PhD,
Gender Identity Service, Child, Youth and Family Ser-
vices, Centre for Addiction and Mental Health, 80
Workman Way, 5th Floor, Toronto, Ontario M6J 1H4,
Canada. Tel: 4165358501; Fax: 4169794996; E-mail:
Ken.Zucker@camh.ca
Conflict of Interest: The author(s) report no conflicts of
interest.
Statement of Authorship
Category 1
(a)
Conception and Design
Kenneth J. Zucker; Madison Aitken; Thomas D.
Steensma
(b)
Acquisition of Data
Kenneth J. Zucker; Cathy Spegg; Thomas D.
Steensma
(c)
Analysis and Interpretation of Data
Kenneth J. Zucker; Ray Blanchard; Doug P.
VanderLaan; Thomas D. Steensma
Category 2
(a)
Drafting the Article
Kenneth J. Zucker
(b)
Revising It for Intellectual Content
Madison Aitken; Doug P. VanderLaan; Hayley
Wood; Amanda Fuentes; Lori Wasserman; Megan
Ames; C. Lindsay Fitzsimmons; Jonathan H. Leef;
Victoria Lishak; Elyse Reim; Anna Tagaki; Julia
Vinik; Julia Wreford; Peggy T. Cohen-Kettenis;
Annelou L. C. de Vries; Baudewijntje P. C. Kreukels
Category 3
(a)
Final Approval of the Completed Article
Kenneth J. Zucker; Thomas D. Steensma
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... Existing epidemiological studies of GD are predominantly of adolescents ≥15 years and adults, typically involving those who have accessed specialist gender clinics. The findings vary widely across studies, reflecting different methodologies and differences between countries in treatment availability, social acceptability, diagnostic criteria, and treatment eligibility criteria (Aitken et al., 2015;Skordis et al., 2020). Prevalence estimates of identifying as transgender ranged from 1:2000 (approximately 0.05%) in the Netherlands and Belgium (Olyslager & Conway, 2007) to 1.2% in New Zealand (Clark et al., 2014). ...
... This may relate to changing help-seeking attitudes, reduced stigma, increased visibility, and raised public awareness (Skordis et al., 2020). International studies also show a shift in the sex ratio of adolescent referrals from favouring assigned males at birth to favouring assigned females at birth (Aitken et al., 2015;de Graaf et al., 2017;Kaltiala et al., 2020). ...
... The higher rate of notification among assigned female referrals ≥12 years mirrors findings among gender clinics internationally. Clinics in Toronto and Amsterdam noted a significant change in the sex ratio of referred young people between two cohort periods (2006 andAitken et al., 2015;Kaltiala-Heino, 2020). Research by de Graaf et al. (2018) has indicated a similar shift in UK adolescent populations, compared with an equal split among younger children (<12 years), also reported elsewhere (e.g. ...
The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011–31 May 2013) to notify of young people (4–15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41–12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2–5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.
... As reported by, who looked at the number of children and adolescents in the years 1976-2004 who had to address the specific clinical gender identity disorder in Canada, there was a large increase in the number of children during the years 1988-1991, with the number stabilizing by 2004, in contrast to the number of adolescents which appeared to increase during the years 2004-2007 [3]. According to a parallel study by at the Canadian Clinic in 1976-2011, who studied the number of children and adolescents, the sex ratio, as well as their sexual orientation, showed the same results in number as in the study of but with an increase in adolescents in the years 2008-2011 [15,3]. In terms of gender ratio, children were found to have a sex ratio of 4.49: 1 boy: girls and adolescents 1.04: 1 boys: girls. ...
... In a comparative study between clinics in Canada and the Netherlands, in the years 1976-2013 for Canada and in the years 1989-2013 for the Netherlands, there was a marked increase in the number of adolescents and a change in the proportion between biological males and females, with females outnumbering males in the years 2006-2013 [15]. Sexual orientation was also studied, dividing adolescents into those with a homosexual (homosexual) and a non-homosexual (non-homosexual) orientation, for males, and a homosexual (homosexual) and a non-homosexual, non-homosexual (non-homosexual). ...
Article
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This paper is a literature review of scientific articles covering a period from 1970 to 2020. It addresses the issue of gender identity disorder in children, adolescents and young adults. The purpose of this paper is to present the issue of gender disorder, through the prism of modern psychological data. Reference is made to the etiology, the clinical picture.
... Most clinic-based studies demonstrate that the prevalence of adult TW (at-birth-assigned males) is consistently higher than the prevalence of adult TM (at-birth-assigned females) (Zucker, 2017). However, in the case of adolescents and children, growing evidence demonstrates a shift in the sex ratio, from favoring birth-assigned males to favoring birth-assigned females (Aitken et al., 2015). Aitken et al., for example, reported that in at least two gender identity clinics (Toronto and Amsterdam), and in the same periods, the TW/ TM ratios changed from 2.11:1 to 1:1.76 and from 2.21:1 to 1:1.72. ...
... A patriarchal system praises men and women who comply with their assigned roles and condemns those who refuse to comply; Fig. 2 The prevalence of transgender women (TW) among at-birth-assigned males (ABAM) and transgender men (TM) among at-birth-assigned females (ABAF) in each age group in Iran between 2012 and 2017 those who seek gender-affirmative treatments, regardless of their sex, are equally condemned under such a system. There is growing body of evidence, however, showing a shift in the sex ratio of adolescents with GD from one favoring boys (2.11: 1, before 2006) to one favoring girls (1: 1.76, 2006-13) in Canadian and Dutch samples (Aitken et al., 2015). A similar trend has been observed elsewhere (Zucker, 2017;Zucker et al., 2019). ...
Article
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Gender dysphoria (GD) is defined as a persistent and distressful incongruence between one’s gender identity and one’s at-birth-assigned sex. Sex reassignment has been religiously accepted for transgender individuals in postrevolutionary Iran since 1987; however, very little is known about how many individuals seek and receive such treatment annually. This study provides the first nationwide effort to assess the prevalence of GD in Iran as a function of diagnosis. The medical records of all transgender individuals referred to the Iranian Legal Medicine Organization between March 2012 and March 2017 were reviewed. All individuals diagnosed with GD were contacted. A total of 839 medical records meeting study criteria were received and evaluated. The prevalence of transgender individuals was estimated to be 1.46 per 100,000 Iranians with a transwoman (TW)/ transman (TM) ratio of 1:2. The mean age of individuals with GD at the time of referral was 25.22 (SD = 6.25) years for TW and 25.51 (SD = 5.66) years for TM. The findings are twofold. First, gender dysphoria is less prevalent in Iran than has been reported in Western countries. Second, the sex ratio is skewed toward at-birth-assigned females, which differs from what has been reported in Western countries. These findings have been interpreted in light of Iran’s legal system, which is based on Islamic penal codes. These findings are of utmost importance for both health providers and legislators, as it can illustrate a more accurate picture of the transgender population in Iran.
... It is also used as a general descriptive term referring to a person's discontent with assigned gender. In recent years, GD diagnoses have been increasingly made in child and adolescent services [3][4][5]. There has been a parallel increase in demand for gender transition interventions, particularly among natal females [3][4][5]. ...
... In recent years, GD diagnoses have been increasingly made in child and adolescent services [3][4][5]. There has been a parallel increase in demand for gender transition interventions, particularly among natal females [3][4][5]. Current clinical guidance for gender transition in adolescence follow the so-called 'Dutch model', where intervention is staged in accordance with a young person's age and stage of pubertal development [6,7]. The age at which a stage of intervention will be deemed appropriate is based partly on how reversible it is. ...
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It is unclear whether the literature on adolescent gender dysphoria (GD) provides sufficient evidence to inform clinical decision making adequately. In the second of a series of three papers, we sought to review published evidence systematically regarding the extent and nature of mental health problems recorded in adolescents presenting for clinical intervention for GD. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), we searched Ovid Medline 1946 –October week 4 2020, Embase 1947–present (updated daily), CINAHL 1983–2020, and PsycInfo 1914–2020. The final search was carried out on the 2nd November 2020 using a core strategy including search terms for ‘adolescence’ and ‘gender dysphoria’ which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 32 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (21). A few compared cohorts to normative or population datasets; most (27) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 45% to 96%, with a mean of 81%. More than a third of the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. Adolescents presenting for GD intervention experience a high rate of mental health problems, but study findings were diverse. Researchers and clinicians need to work together to improve the quality of assessment and research, not least in making studies more inclusive and ensuring long-term follow-up regardless of treatment uptake. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD.
... De Roo et al. 2016). Hinzukommt, dass die Zahl junger trans Personen zunimmt (Twist und de Graaf 2018), einhergehend mit einer Zunahme von Jugendlichen, die ihre weiblichen Geschlechtsmerkmale ablehnen (Aitken et al. 2015;de Graaf et al. 2018). Die genannten geschlechtsangleichenden Maßnahmen wollen daher in einer Phase genutzt werden, in der die reproduktiven Wünsche der Betreffenden zuweilen (noch) nicht absehbar sind. ...
Article
Zusammenfassung Einleitung Im Kontext von Trans gewinnen Fragen zur Reproduktion seit etwa zwei Jahrzehnten zunehmend an Bedeutung. Dabei geht es um Kinderwunsch und Fertilitätserhalt sowie um Schwangerschaft, Geburt und Elternschaft. Einflussreich sind hier jedoch nicht nur die reproduktionsmedizinischen Möglichkeiten, sondern auch die repronormativ geprägten Barrieren, die trans und nicht-cis Personen in unserer Gesellschaft daran hindern, ihren Kinderwunsch zu realisieren oder dies zumindest erheblich erschweren. Forschungsziele Der vorliegende Beitrag fragt daher aus interdisziplinärer Perspektive nach den Möglichkeiten und Grenzen der Reproduktion bei trans Personen. Methoden Zunächst werden der Begriff der Repronormativität eingeführt und das Konzept der reproduktiven Gerechtigkeit elaboriert. Diese konzeptuelle Analyse wird ergänzt um eine narrative Literaturübersicht, die interdisziplinäre Perspektiven berücksichtigt: Juristische und reproduktionsmedizinische sowie psychologische und soziologische Beiträge gehen ein. Ergebnisse Wir zeigen, wie repronormative Vorstellungen und gesetzliche Regelungen nicht-cis Personen in ihren reproduktiven Möglichkeiten einschränken und diskriminieren. Anknüpfend an den empirischen Forschungsstand zur Reproduktion bei trans Personen werden die praktischen Möglichkeiten der Fertilitätsprotektion im Kontext von Trans vorgestellt. Schlussfolgerung Auf Grundlage der Befunde argumentieren wir dafür, dass trans Person mit den gleichen reproduktiven Rechten ausgestattet werden wie cis Personen. Insgesamt soll eine öffentliche Diskussion zu Repronormativität und reproduktiver Gerechtigkeit gefördert werden, die Reproduktion nachhaltig für queere Menschen öffnet und erleichtert.
Article
Adolescents with gender dysphoria (GD) often have internalizing symptoms, but the relationship with affective bodily investment and emotion dysregulation is actually under-investigated. The aims of this study are: (1) the comparison of Self-Administrated Psychiatric Scales for Children and Adolescents’ (SAFA), Body Investment Scale’s (BIS), and Difficulties in Emotion Regulation Scale’s (DERS) scores between GD adolescents (n = 30) and cisgenders (n = 30), (2) finding correlations between body investment and emotion regulation in the GD sample, (3) evaluating the link between these dimensions and internalizing symptomatology of GD adolescents. In addition to the significant impairment in emotion regulation and a negative body investment in the GD sample, Spearman’s correlation analyses showed a relationship between worse body protection and impaired emotion regulation, and binary logistic regressions of these dimensions on each SAFA domain evidenced that they may have a role in the increased probability of pathological scores for depression. Our results focused on the role played by emotion regulation and emotional investment in the body in the exacerbating and maintenance of internalizing symptoms, in particular depression, and self-harming behaviors in GD adolescents.
Objectives: Gender service utilisation according to ethnicity is largely under-researched. The present research looked at demographics and service user-engagement according to ethnicity of young people accessing a gender service for children. Method: A total of 2063 (M = 14.19 years, SD = 2.59, assigned male = 556, 1495 assigned female = 1495, no-specification=12) referrals were included in the analysis. Self-defined ethnicity in financial years (FY) 2016-2017, 2018-2019, and referrer-defined ethnicity in FY 2020-2021 were compared between years, to the national UK-population, and child and adolescent mental health service (CAMHS) averages. Numbers of offered, attended and non-attended appointments were compared across the White and the ethnic minority population (EMP). Results: Across years 93.35% young people identified as White (higher than the CAMHS and national population averages); 6.65% as EMP. Service utilisation was similar in FY 2016-2017. In FY 2018-2019, the EMP subgroup was offered and attended more appointments compared to the White subgroup, 'did not attended' average was similar. Conclusions: The majority of young people self-identified with a White ethnic-background. Service engagement was comparable between the EMP and White ethnicity subgroups in 2016-2017, while the EMP group was offered and attended more appointments in 2018-2019. Due to the low EMP group numbers, findings need to be interpreted with caution.
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The article investigates scientific and journalistic discourses around differences in gender ratio among trans persons. The disparity between Poland and many other countries that was first noted in the 1980s was repeatedly associated with the different gender politics in the capitalist West and the (post) state-socialist East. Using Foucauldian methodology, the article claims that this discourse was constructed such that Poland's ratio-and consequently Poland's gender order-would always appear problematic, while Western countries were considered an invisible standard. Discourses around this ratio elucidate the role of heteronormativity and biological essentialism in the construction of the category of "transsexuality" in state-socialist Poland. The analysis also reveals that chronologies of LGBT and feminist movements had direct consequences for the theoretical and cultural spaces of trans identities.
Article
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BACKGROUND AND OBJECTIVES Concerns about early childhood social transitions amongst transgender youth include that these youth may later change their gender identification (i.e., retransition), a process that could be distressing. The present study aimed to provide the first estimate of retransitioning and to report the current gender identities of youth an average of 5 years after their initial social transitions. METHODS The present study examined the rate of retransition and current gender identities of 317 initially-transgender youth (208 transgender girls, 109 transgender boys; M=8.1 years at start of study) participating in a longitudinal study, the Trans Youth Project. Data were reported by youth and their parents through in-person or online visits or via email or phone correspondence. RESULTS We found that an average of 5 years after their initial social transition, 7.3% of youth had retransitioned at least once. At the end of this period, most youth identified as binary transgender youth (94%), including 1.3% who retransitioned to another identity before returning to their binary transgender identity. 2.5% of youth identified as cisgender and 3.5% as nonbinary. Later cisgender identities were more common amongst youth whose initial social transition occurred before age 6 years; the retransition often occurred before age 10. CONCLUSIONS These results suggest that retransitions are infrequent. More commonly, transgender youth who socially transitioned at early ages continued to identify that way. Nonetheless, understanding retransitions is crucial for clinicians and families to help make them as smooth as possible for youth.
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The present study reports on the construction of a dimensional measure of gender identity (gender dysphoria) for adolescents and adults. The 27-item gender identity/gender dysphoria questionnaire for adolescents and adults (GID YQ-AA) was administered to 389 university); students (heterosexual and nonheterosexual) and 73 clinic-referred patients with gender identity disorder. Principal axis factor analysis indicated that a one-factor solution, accounting for 61.3% of the total variance, best fits the data. Factor loadings were all >= 30 (median,.82; range,.34-96). A mean total score (Cronbach's alpha,.97) was computed, which showed strong evidence for discriminant validity in that the gender identity patients had significantly more gender dysphoria than both the heterosexual and nonheterosexual university students. Using a cut-point of 3.00, we found the sensitivity was 90.4% for the gender identity patients and specificity was 99.7% for the controls. The utility of the GIDYQ-AA is discussed.
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Formal epidemiological studies on the incidence and prevalence of gender identity disorder (GID) or transsexualism have not been conducted. Accordingly, crude estimates of prevalence have had to rely on indirect methods, such as parental endorsement of behavioral items pertaining to GID on omnibus questionnaires for children and youth or the number of adult patients seeking contra-sex hormonal treatment or sex-transformative surgery at hospital- or university-based gender clinics. Data from child and adolescent parent-report questionnaires show that the frequent wish to be of the other sex is quite low but that periodic cross-gender behavior is more common. In the general population, cross-gender behavior is more common in girls than it is in boys but boys are referred to gender identity clinics more frequently than are girls. Prevalence estimates of GID in adults indicate that it is higher in natal males than in natal females although this may be accounted for by between-sex variation in sexual orientation subtypes. Prevalence estimates of GID in adults based on clinic-referred samples suggest an increase in more recent cohorts. It remains unclear whether this represents a true increase in prevalence or simply greater comfort in the seeking out of clinical care as professionals become more attuned to the psychosocial and biomedical needs of transgendered people.
Article
Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group. This study aimed to provide a first overview by assessing demographic characteristics and developmental trajectories of a group of gender variant boys and girls referred to the specialised Gender Identity Clinic in Hamburg. Data were extracted from medical charts, transcribed and analysed using qualitative content analysis methods. Categories were set up by inductive-deductive reasoning based on the patients' parents' and clinicians' information in the files. Between 2006 and 2010, 45 gender variant children and adolescents were seen by clinicians; 88.9% (n = 40) of these were diagnosed with gender identity disorder (ICD-10). Within this group, the referral rates for girls were higher than for boys (1:1.5). Gender dysphoric girls were on average older than the boys and a higher percentage of girls was referred to the clinic at the beginning of adolescence (> 12 years of age). At the same time, more girls reported an early onset age. More girls made statements about their (same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions. More girls than boys revealed self-mutilation in the past or present as well as suicidal thoughts and/or attempts. Results indicate that the presentation of clinically referred gender dysphoric girls differs from the characteristics boys present in Germany; especially with respect to the most salient age differences. Therefore, these two groups require different awareness and individual treatment approaches.
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Locating specialized services for gender-nonconforming children and adolescents can be challenging. The following resource list-organized by U.S. and Canada geographical region-serves to help clinicians access the most up-to-date information on this special population and pass it along to their patients and families. [Pediatr Ann. 2014; 43(6):238-244.].
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The following article is founded in interview based social research conducted with an opportunistic sample of British and North American lesbians and female to male transsexuals (FTMs). The interviews were concerned with their accounts of experience and identity from childhood, through adolescence to adulthood. Located in relation to a current debate regarding similarity and difference between lesbians and FTMs, the article juxtaposes the identity accounts to facilitate a comparative analysis and suggests that processes of “othering” are utilised as a means through which similar life histories are differentially experienced and accounted for.
Article
The reactions of peers and teachers to sex-typed behaviors of 106 boys and 101 girls in preschool classrooms were examined. Boys received significantly more peer and teacher criticism for engaging in stereotypic feminine behaviors, but more favorable reactions when engaging in task behaviors. Girls received more teacher criticism when they played in role activities with groups of boys. Boys who showed cross-gender preferences were given significantly more peer criticism and fewer positive reactions. Girls with cross-gender preferences did not receive differential peer reaction.
Article
Objective: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence. Method: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence. Results: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls. Conclusion: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.