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Sex Ratio in Children and Adolescents Referred to the Gender Identity Development Service in the UK (2009–2016)

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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-018-1204-9
LETTER TOTHEEDITOR
Sex Ratio inChildren andAdolescents Referred totheGender Identity
Development Service intheUK (2009–2016)
NastasjaM.deGraaf1,2· GuidoGiovanardi1,3· ClaudiaZitz1· PollyCarmichael1
Received: 12 February 2018 / Accepted: 21 March 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Introduction
Over the last decade, several child and adolescent gender iden-
tity services have reported an increase in young people who
seek help with incongruence between the experienced gender
identity and the gender to which they were assigned at birth
(Aitken etal., 2015; Wood etal., 2013). Many of those, but not
all, would meet the diagnostic criteria for gender dysphoria
(GD) (APA, 2013). It has been suggested that this increase
is mostly due to an influx of birth-assigned females coming
forward. Aitken etal. (2015) reported a significant temporal
shift in the sex ratio of clinic-referred gender-diverse youth to
Toronto and Amsterdam, from a ratio favoring males prior to
2006, to a ratio favoring assigned females from 2006 to 2013.
The national Gender Identity Development Service (GIDS)
in the UK is the largest child and adolescent specialist gen-
der service in the world, seeing young people up to the age of
18. Historically, more birth-assigned males were presenting
to GIDS in childhood and adolescence (Di Ceglie, Freedman,
McPherson, & Richardson, 2002). However, in a more recent
study, adolescent referrals to GIDS favored birth-assigned
females (de Graaf etal., 2017; Holt, Skagerberg, & Dunsford,
2016).
Gender-diverse young people often present with psycho-
logical difficulties. Compared to children, a greater percent-
age of gender-diverse adolescents have psychological difficul-
ties in the clinical range (Steensma etal., 2014). The level of
psychological well-being for birth-assigned males and females
referred in childhood are often comparable (Steensma etal.,
2014). In adolescents, however, gender differences in psycho-
logical functioning are noted more frequently. The literature
suggests that birth-assigned males tend to show more internaliz-
ing difficulties in the clinical range than birth-assigned females
(de Vries, Steensma, Cohen-Kettenis, VanderLaan, & Zucker,
2016). However, more recently, increased psychopathology
was also reported for gender-diverse birth-assigned females
(de Graaf etal., 2017; Kaltiala-Heino, Sumia, Työläjärvi, &
Lindberg, 2015).
The current study aimed to examine the sex ratio in the num-
ber of children and adolescents referred to GIDS over the past
7years and to investigate whether any gender differences can be
found in terms of psychological functioning and age at referral.
Method
For this retrospective review of GIDS referrals, exemption
for ethics was confirmed by external and local ethics commit-
tees affiliated with the Tavistock and Portman NHS Research
and Development Department. Between January 1, 2009,
and December 31, 2016, a total of 4506 young people, aged
between 1 and 18years, were referred to GIDS. Age at refer-
ral and birth-assigned gender were collected at time of refer-
ral. The sex ratio for children and adolescents was tested for
significance using the binomial test. Age at referral was ana-
lyzed per year using independent t tests. The Child Behavior
Checklist (CBCL), which was completed by the parent during
the assessment phase, was used to measure internalizing and
externalizing clinical range scores (T scores > 63) (Achenbach
& Edelbrock, 1983). The CBCL data were analyzed by birth-
assigned gender in children and adolescents using a chi-square
test with a two-tailed p value. CBCL data were available for
39% of all child cases. In the adolescent sample, 60% had a
completed CBCL. One explanation for the high number of
missing CBCL data could have to do with service users not
* Nastasja M. de Graaf
ndegraaf@tavi-port.nhs.uk
1 Gender Identity Development Service, Tavistock
andPortman NHS Foundation Trust, 120 Belsize Lane,
LondonNW35BA, UK
2 Department ofMedical Psychology, Center ofExpertise
onGender Dysphoria, VU University Medical Center,
Amsterdam, TheNetherlands
3 Department ofDynamic andClinic Psychology, Faculty
ofMedicine andPsychology, Sapienza University ofRome,
Rome, Italy
Archives of Sexual Behavior
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always returning questionnaires when receiving these after their
first appointment. The higher percentage of missing data in the
child group could relate to the fact that a greater proportion of
younger children may not be seen as frequently as adolescents,
and possibly dropout during the assessment phase.
Results
Characteristics of GIDS referrals, of which the vast majority
(84%) were adolescents, are shown in Table1. A significant
difference by the binomial test, p < .001, showed that the sex
ratio in children favored birth-assigned males (M/F, 1.31:1),
whereas in adolescents referrals favored birth-assigned females
(M/F, 1:2.12), binomial test, p < .001. Interestingly, in both
children and adolescents, the average increase rate of referrals
was higher for birth-assigned females, as displayed in Fig.1.
For age at referral in children, birth-assigned males were,
on average, referred at a younger age, t(717) = 4.05, p < .001,
whereas in adolescents birth-assigned females were younger,
t(3785) = − 2.91, p < .005. No significant differences were
found over time, which indicates that the age at referral for
birth-assigned males and birth-assigned females in children and
adolescents has remained stable over the last 7years.
With regard to psychological functioning, a signifi-
cantly greater percentage of adolescents had Internalizing
problems in the clinical range compared to children, χ2(1,
N = 1696) = 12.02, p < .001. For this comparison, however,
there is a sex difference: the difference between children and
adolescents is significant only for birth-assigned females, χ2(1,
N = 1127) = 11.17, p < .001, and not for birth-assigned males,
χ2(1, N = 569) = .37, p = .54. On the other hand, Externalizing
problems were significantly more prevalent in children than
in adolescents, χ2(1, N = 1696) = 39.92, p < .001. For adoles-
cents, a greater percentage of birth-assigned females showed
Internalizing problems in the clinical range compared to birth-
assigned males, χ2(1, N = 1468) = 16.47, p < .001, whereas a
significantly greater percentage of birth-assigned males scored
in the Externalizing clinical range compared to birth-assigned
females, χ2(1, N = 1468) = 4.36, p < .05. For children, no sig-
nificant gender differences were found on both Internalizing,
χ2(1, N = 228) = .01, p = .91, and Externalizing scales, χ2(1,
N = 228) = .00, p = 1.0.
Discussion
The UK has witnessed an unprecedented increase in referrals
of gender-diverse young people seeking professional help. Both
in children and adolescents the rise in referrals was steeper for
birth-assigned females compared to birth-assigned males. This
has resulted in an inversion in sex ratio in adolescent referrals
and an evening out of birth-assigned male and female refer-
rals in childhood. While the overall number of birth-assigned
female referrals has increased, the age at which referrals were
made did not change over time.
Table 1 Characteristics of
GIDS referrals and CBCL
scores
CBCL Child Behavior Checklist
Children (< 12years) Adolescents (12–18years)
(N = 719) (N = 3787)
Assigned males Assigned females Assigned males Assigned females
2009–2016
Total N408 311 1210 2577
Sex ratio 56.7% 43.3% 32.0% 68.0%
Increase in referrals year on year
2009N10 2 24 15
2010% (N) 90% (19) 250% (7) 83% (44) 220% (48)
2011% (N) 53% (29) 71% (12) 0% (41) 63% (78)
2012% (N) 3% (30) 42% (17) 88% (77) 81% (141)
2013% (N) 3% (31) 29% (22) 56% (120) 57% (221)
2014% (N) 77% (55) 64% (36) 54% (185) 42% (314)
2015% (N) 87% (103) 114% (77) 58% (293) 102% (689)
2016% (N) 27% (131) 79% (138) 45% (426) 55% (1071)
Average % increase 48.6% 92.7% 54.9% 88.6%
Mean age at referral (M, SD) 8.27 (2.27) 8.97 (2.34) 15.59 (1.40) 15.45 (1.32)
CBCL clinical range (N) 119 109 450 1018
Internalizing problems % (N) 52.1% (62) 50.5% (55) 55.8% (251) 67.0% (682)
Externalizing problems % (N) 35.3% (42) 34.9% (38) 20.2% (91) 15.6% (159)
Archives of Sexual Behavior
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Compared to international data reported by other gender
identity clinics, the sex ratio of the child referrals in the UK was
more in line with the child sex ratio reported by the Amster-
dam clinic (1.25:1, N = 860) than with the Toronto clinic, which
reported a larger proportion of birth-assigned males referred
in childhood (4.33:1, N = 624) (Steensma, Cohen-Kettenis, &
Zucker, 2018). While across all three clinics birth-assigned boys
were significantly younger than the referred girls in childhood,
the mean age of the children referred in Toronto was signifi-
cantly younger at referral compared to Amsterdam and the UK.
As suggested by de Vries etal. (2016), these outcomes could
reflect that there are cultural differences between North America
and Europe, specifically with regard to tolerance or acceptance
of gender-diverse behavior, particularly in birth-assigned boys.
For adolescents, our findings reflect the general trend of an
inversion in sex ratios reported both in Amsterdam and Toronto
(in Amsterdam: 1:1.72, N = 234; in Toronto: 1:1.76, N = 202;
Aitken etal., 2015), in the U.S. (1:1.4, N = 180; Reisner etal.,
2015), and more pronounced in Germany (1:2.9, N = 39;
Becker, Ravens-Sieberer, Ottová-Jordan, & Schulte-Markwort,
2017) and Finland (1:6.8, N = 49; Kaltiala-Heino etal., 2015).
There are various explanations put forward in the literature
contemplating the increase in birth-assigned females. Some
have suggested that differences in normative sex development,
in which birth-assigned females experience pubertal changes at
an earlier age than birth-assigned males, might have an impact
on the greater number of adolescent birth-assigned females
coming forward (Aitken etal., 2015). However, as the increase
in birth-assigned female referrals was found across the age
range, arguments around timing of puberty cannot fully explain
the rising number of birth-assigned females. Several clinical
observations suggest that pre-pubertal young people, specifi-
cally girls, may experience adversity toward puberty (Harris,
2004; Lesko, 2012; Pinto, 2007). Therefore, rather than the
experience of puberty, could we argue that birth-assigned
females in childhood are increasingly more worried about the
thought of puberty?
Other arguments regarding the influx in birth-assigned
females suggest that, given the increased awareness and vis-
ibility of declaring trans identities, “coming out” in this context
may be easier for birth-assigned females than it is for birth-
assigned males (Aitken etal., 2015). This argument can be
supported by the claim that gender-variant behavior in birth-
assigned males may be more exposing and can lead to social
stigma (Shiffman etal., 2016).
Additionally, the digitalization of the ways in which young
people and society communicate should not be underestimated.
Social media is increasingly used as a platform to seek peer
group belonging and support, especially by adolescent girls
(Barker, 2009). In the current context, with increasingly more
birth-assigned females referred to gender services present-
ing with psychopathology, could we argue that influences of
socially constructed views of “femininity” and “masculinity”
and the way these are being displayed on social media may have
an impact on the increase of birth-assigned female referrals,
especially for those who do not feel they fit this stereotype?
AFAB = assigned fema le at birth; AMAB = assigned male at birth
*Indicates p< .05 which shows a significant increase of referrals compared to the previous year
2009 2010 2011 2012 2013 2014 2015 2016
Adolescents F15 48 78 141 221 314 689 1071
Adolescents M24 44 41 77 120 185 293 426
Children F2712 17 22 36 77 138
Children M10 19 29 30 31 55 103 131
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Adolescents F
Adolescents M
Children F
Children M
*
*
**
*
*
*
*
*
*
*
*
*
*
*
*
*
Fig. 1 Number of GIDS referrals per year for child (< 12 years) and
adolescent (12–18 years) birth-assigned females and birth-assigned
males. AFAB assigned female at birth, AMAB assigned male at birth.
*Indicates p < .05 which shows a significant increase in referrals com-
pared to the previous year
Archives of Sexual Behavior
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Psychopathology in adolescent birth-assigned females is a
topical issue which is currently reported by various interna-
tional gender identity clinics (de Graaf etal., 2017; Kaltiala-
Heino etal., 2015). Not only adolescent girls, also a greater
percentage of referred birth-assigned males presented with
externalizing problems in the clinical range in adolescence,
which could reflect the current changing climate. Whereas
adolescents tend to report more behavioral and emotional
problems than children, in our sample, a greater percentage
of children had externalizing problems in the clinical range
compared to the adolescents. When comparing these findings
to previously published outcomes from the Toronto clinic and
the Amsterdam clinic (Steensma etal., 2014), a greater percent-
age of children in the UK had internalizing and externalizing
problems in the clinical range. The increase in psychopathology
mirrors a general trend of young people in the UK, especially
in adolescent girls (Lessof etal., 2016). A new phenomenon,
however, is the increase in referred birth-assigned females in
late childhood, which is also reported by other gender iden-
tity clinics (Steensma etal., 2018). With the influx of birth-
assigned females starting in childhood, we might expect to see
an increase in behavioral problems in children, especially those
aged 10–12years.
The steep increase in birth-assigned females seeking help
from gender services across the age range highlights an emerg-
ing phenomenon. It is important to follow birth-assigned
females’ trajectories, to better understand the changing clinical
presentations in gender-diverse children and adolescents and to
monitor the influence of social and cultural factors that impact
on their psychological well-being.
Compliance with Ethical Standards
Conflict of interest The authors declare there is no conflict of interest.
There was no sponsor involved in this Letter. The authors disclose that
there are no prior publications or submissions with any overlapping in-
formation of this kind.
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... www.nature.com/scientificreports/ Regarding the shift in the sex ratio with a preponderance toward aF 12,22,23,27,28 , no definite explanations have been offered, even though several possible explanations have been discussed. In a British study, Aitken et al. 23 conclude that the inversion of sex ratio in adolescents observed after 2006, appears to correspond with an increase in the number of clinic-referred youth with GD in general. ...
... Another hypothesis concerns that the earlier puberty onset in aF might have an impact on the increased numbers of adolescent aF coming forward, given that GD is often intensified during puberty 29 . However, as the increase of aF has been reported also among older adolescents, timing of puberty could only explain a smaller part of the increase 27 . More importantly, a number of studies have also suggested that there are greater social costs for aM to come out as transgender 23,27 , and that aM adolescents with GD are more often bullied because of their gender presentation, which may delay their process 22 . ...
... However, as the increase of aF has been reported also among older adolescents, timing of puberty could only explain a smaller part of the increase 27 . More importantly, a number of studies have also suggested that there are greater social costs for aM to come out as transgender 23,27 , and that aM adolescents with GD are more often bullied because of their gender presentation, which may delay their process 22 . ...
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Background: Since the 1990s, there has been a growing corpus of evidence on Lesbian, Gay, Bisexual, Trans, Intersex and other Sexual and Gender Minority (LGBTI+) youth. However, most of these studies were conducted in the North America, and it remains unclear whether their findings can be generalised to other countries and cultures. The third goal of the Irish LGBTI+ National Youth Strategy 2018-2020 was to develop the research and data environment to better understand the lives of LGBTI+ young people. This study aimed to draw the landscape of existing research on LGBTI+ youth in Ireland and other European countries, and identify research and data gaps that need to be addressed. Method: Using a scoping review technique, we employed a multi-method search to identify research outputs and databases on LGBTI+ young people in peer-reviewed and grey literature. Identified outputs were screened against pre-set inclusion criteria, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines; then, several types of information were extracted from studies meeting inclusion criteria. We used standardised methods to evaluate the quality of each outputs. Finally, research and data gaps were identified. Results: 4,603 records were found. Following screening, 126 outputs were entered to the analysis. The studies and databases varied largely in method and quality. Important evidence gaps were found on the health and needs of transgender and intersex youth; the sexual health of LGBTI+ youth; and their employment and career opportunities. The predominant ‘victim’ narrative in the vast majority of existing studies need to be balanced with investigating positive predictors of well-being and evidence-based good practice for improving LGBTI+ youth lives. Conclusion: Some areas of LGBTI+ youth lives have a thin or practically non-existent evidence base. Identified research and data gaps need to be addressed by methodologically sound studies.
... The evidence base informing best practice for the care of children and young people (CYP) (<18 years) with gender dysphoria (GD) is continually developing (Coleman et al., 2012;Hembree et al., 2017). In addition to increases in referral rates to specialised gender services in recent years (Giovanardi, 2017), there also appear to be changes in referral patterns observed both in the UK (de Graaf, Giovanardi et al., 2018) and internationally (Aitken et al., 2015;Kaltiala et al., 2020). Additionally, a significant proportion of referred CYP have co-occurring conditions such as autism spectrum disorder or mental health difficulties (Chen et al., 2018;Spack et al., 2012). ...
... Additionally, as noted by Steensma and Cohen-Kettenis (2015), some young people may return to a gender clinic later in life to seek treatment, having been unable to pursue treatment for various reasons at an earlier age. Some of the included studies had small cohorts and these small sample sizes may reflect the lower numbers of referrals of CYP to clinics prior to the significant increase in referrals noted in many countries around 2014 to 2015 (de Graaf, Giovanardi et al., 2018). Only three studies focused on child (<12 years) samples so it will be important for future research to improve understanding of outcomes over time for younger cohorts of gender diverse children. ...
Background Children are presenting in greater numbers to gender clinics around the world. Prospective longitudinal research is important to better understand outcomes and trajectories for these children. This systematic review aims to identify, describe and critically evaluate longitudinal studies in the field. Method Five electronic databases were systematically searched from January 2000 to February 2020. Peer-reviewed articles assessing gender identity and psychosocial outcomes for children and young people (<18 years) with gender diverse identification were included. Results Nine articles from seven longitudinal studies were identified. The majority were assessed as being of moderate quality. Four studies were undertaken in the Netherlands, two in North America and one in the UK. The majority of studies had small samples, with only two studies including more than 100 participants and attrition was moderate to high, due to participants lost to follow-up. Outcomes of interest focused predominantly on gender identity over time and emotional and behavioural functioning. Conclusions Larger scale and higher quality longitudinal research on gender identity development in children is needed. Some externally funded longitudinal studies are currently in progress internationally. Findings from these studies will enhance understanding of outcomes over time in relation to gender identity development in children and young people.
... In adolescents, however, the vast majority (74%) of the study sample were assigned female at birth, which resembles the current sex ratio of referrals to GIDS (de Graaf, Giovanardi, Zitz, & Carmichael, 2018). Recent literature on gender diverse adolescents continue to report an increasing number of birth-assigned females presenting to gender identity services reporting more psychological difficulties compared to those assigned male at birth (de Graaf, Cohen-Kettenis, et al., 2018;de Graaf, Giovanardi, et al., 2018;de Vries et al., 2016;Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015). Why more birth-assigned females tend to present to gender identity services in adolescence, and why they report more psychological difficulties than birth-assigned males, remains unclear. ...
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Gender diverse individuals who do not conform to society’s binary gender expectations are more likely to experience difficulties in acceptance and in recognition of gender, compared to binary-identifying transgender people. This may accentuate the feeling that their gender identity is not socially recognized or validated. This study aimed to investigate psychological functioning among gender diverse adolescents and adults who identify beyond the binary gender spectrum. In both study populations, 589 clinically-referred gender diverse adolescents from the UK (n = 438 birth-assigned females and n = 151 birth-assigned males), and 632 clinically-referred gender diverse adults from the Netherlands (n = 278 birth-assigned females and n = 354birth-assigned males), we found that a higher degree of psychological problems was predicted by identifying more strongly with a non-binary identity. For adolescents, more psychological problems were related to having a non-binary gender identity and being assigned female at birth. In the adult population, experiencing psychological difficulties was also significantly related to having a stronger non-binary identity and having a younger age. Clinicians working with gender diverse people should be aware that applicants for physical interventions might have a broader range of gender identities than a binary transgender one, and that people with a non-binary gender identity may, for various reasons, be particularly vulnerable to psychological difficulties.
... In 2017 I wanted to explore the reasons for the almost sudden cultural emergence of the "trans child" in the UK, and why the increase in referrals had disproportionally involved girls. Since 2011 the girlboy split at the Tavistock GIDS was roughly 50/50 but by 2019 the sex ratio had changed so that 76% of referrals were girls (De Graaf et al, 2018). I also wanted to examine the affirmative model and postmodern gender identity theory not only for its implications for safe and effective services for children at the GIDS but also more generally In 2018, I co-edited a volume critically appraising the affirmative model, postmodern gender identity theory, and the impact of medicalisation on children (Brunskell-Evans & Moore, 2018). ...
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The medical “transition” of children with “gender dysphoria” is increasingly normalized in North America, Western Europe, Australia, New Zealand, and the United Kingdom. Although each country has specific national gender identity development services, the rationale for prescribing hormone treatment is broadly similar. A minority rights paradigm underpinned by postmodern theory has gained traction in the past 10 years and has been successful in influencing public policy, the education of pediatricians, endocrinologists, and mental health professionals. In this view, any response other than an affirmation of the child’s claim to be the opposite sex or “born in the wrong body” is understood as a denial of their human rights to have their “outer” body match their authentic “inner” self. The postmodern paradigm has brought about a concomitant shift in the classification of the patient from a child who suffers “gender dysphoria” to a child who is “transgender”. Yet the practice of putting children on a medical pathway brings severe, life-long consequences including bone/skeletal impairment, cardiovascular and surgical complications, reduced sexual functioning, and infertility. Examination of postmodern “transgender” health care reveals it is rarely expert, evidenced-based or objective but on the contrary, is highly politicized and controversial. Although the High Court in the United Kingdom has ruled those children 16 years and under cannot consent to hormone treatment, several lobby groups, as well as the NHS Tavistock and Portman Hospital Trust Gender Identity Development Service (GIDS), have been granted legal permission to challenge the ruling. With the example of the United Kingdom, I demonstrate that if the appeal is successful, children’s rights to protection from bodily and psychological harm will continue to be abused by the postmodern social justice paradigm which, in the very name of upholding children’s rights, violates them.
... A survey of the Center of Expertise on Gender Dysphoria of Amsterdam revealed that the number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015 (Wiepjes et al., 2018). The Gender Identity Development Service (GIDS) in London, the largest in the world for gender variant minors, witnessed an increase from 51 referrals in 2009 to 1,766 in 2016 (De Graaf, Giovanardi, Zitz, & Carmichael, 2018). Reasons for this increase are much debated (Zucker, 2019), but it is likely that now that society became more accepting, more people are identifiying as transgender or non-binary, fewer are closeted. ...
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An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to pro- vide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two condi- tions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at deal- ing with socio-relational and identity problems are discussed.
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The number of persons with gender incongruence referred to health care is increasing, but national data on the incidence of gender incongruence are lacking. The aim of this study was to quantify the development in number of individuals with gender incongruence over time and to estimate the national incidence in Denmark. Historical descriptive cohort study. Individuals older than 18 years with legal sex‐change in their person registration number were achieved from Statistics Denmark, and the National Health Register provided data on contact diagnoses related to gender‐identity conditions. By combining these two data sources, we made estimates on incidence and incidence rates for individuals with gender incongruence in Denmark through a 41‐year period 1980–2020. Through 1980–2020, the annual number of legal sex‐changes increased in individuals assigned female at birth from 5 to approximately 170 and among individuals assigned male at birth from 10 to approximately 150. The cumulative number of legal sex‐changes at the end of 2019 was 1275 assigned female at birth and 1422 assigned male at birth and 66% of the legal sex‐changes were in individuals below 30 years. Correspondingly, the annual number of contacts with the healthcare system due for gender‐identity‐related conditions increased from 30 during 1990–1999 to around 500 in 2017 (both genders combined), with a 10‐fold increase from 2010 to 2017. The number of legal sex‐changes and healthcare contacts due to gender‐identity‐related diagnoses increased substantially over the last 40 years with a more than 10‐fold increase during the last decade. This calls for research on possible explanations for this increase, for research on the short‐term and long‐term health consequences of hormonal and surgical treatment regimens and for ensuring adequate healthcare facilities.
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Em 2013, o Conselho Federal de Medicina publicou o Parecer n. 8/2013, autorizando intervenções hormonais em menores de 18 anos com diagnóstico do até então denominado “transtorno de identidade de gênero”. Essas diretrizes foram ampliadas pela Resolução n. 2.265/2019, do mesmo órgão, que autorizou cirurgias irreversíveis a partir dos 18 anos de idade e não mais 21. Em 2018, consonante, o Conselho Federal de Psicologia emitiu a Resolução n. 1/2018, na qual exige, sob pena de punição disciplinar, que os profissionais validem identidades trans e travestis, independentemente de suas idades. Este artigo visa a despertar uma reflexão sobre o impacto da abordagem de “afirmação de gênero” no geral e dessas normas, em particular, nos direitos já conquistados das crianças e adolescentes.
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Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this.
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The year 10 students who took part in the Longitudinal Study of Young People in England (LSYPE2) in 2014 have been growing up in a rapidly changing environment. The previous cohort of year 10 students, who were interviewed in 2005, lived in a world in which the UK economy had seen 13 years of uninterrupted growth in GDP, and social media and the fast and constantly connected mobile devices that many now take for granted had not yet been fully integrated into young people’s lives. As such, it is perhaps unsurprising that the attitudes and behaviours of year 10 students in 2014 were markedly different to those in 2005. The findings from LSYPE2 are complex and would merit further investigation. However, two fundamental themes emerged from our analyses: • Year 10 students in 2014 were markedly more ‘work focused’ than their counterparts in 2005 • There were signs that the mental wellbeing of year 10 students – particularly that of girls – had worsened and that young people felt less control over their own destinies
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This study examined peer relations in adolescents with gender dysphoria, clinical controls, and nonreferred controls. Specifically, we examined group differences in 2 types of bullying experienced (gender identity/sexuality vs. “general” forms), numbers of same- and opposite-sex friends (relative to birth sex), and the influences of bullying and friends on behavioral and emotional problems. Participants (N = 158; M age, 16.94 years, SD = 1.82) completed measures of gender dysphoria, bullying, numbers of same- and opposite-sex friends at school and in the community, and behavioral and emotional problems. The gender-dysphoric and clinical control adolescents reported significantly more behavioral and emotional problems relative to the nonclinical adolescents. When examining the 2 major forms of bullying, the gender-dysphoric adolescents reported more gender/sexual bullying than the 2 other groups, but both the gender-dysphoric group and the clinical control group reported more general bullying than the nonclinical controls. The gender-dysphoric adolescents had fewer same-sex friends, but more opposite-sex friends, compared with controls. In the gender-dysphoric group, gender bullying, general bullying, and fewer same-sex friends at school were all significantly correlated with a greater number of self-reported behavioral and emotional problems. Strategies for reducing behavioral and emotional problems among adolescents with gender dysphoria are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
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This study is the third in a series to examine behavioral and emotional problems in children and adolescents with gender dysphoria in a comparative analysis between two clinics in Toronto, Ontario, Canada and Amsterdam, the Netherlands. In the present study, we report Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) data on adolescents assessed in the Toronto clinic (n = 177) and the Amsterdam clinic (n = 139). On the CBCL and the YSR, we found that the percentage of adolescents with clinical range behavioral and emotional problems was higher when compared to the non-referred standardization samples but similar to the referred adolescents. On both the CBCL and the YSR, the Toronto adolescents had a significantly higher Total Problem score than the Amsterdam adolescents. Like our earlier studies of CBCL data of children and Teacher's Report Form data of children and adolescents, a measure of poor peer relations was the strongest predictor of CBCL and YSR behavioral and emotional problems in gender dysphoric adolescents.
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This paper presents findings of a detailed service audit of cases seen at a specialist service for children and adolescents with gender identity disorders. The audit looked at clinical features, associated features, demographic characteristics and complexity of the cases. Data were extracted from patient files of the first 124 cases seen by the service. Clinical features were assessed based on DSM-IV criteria (American Psychiatric Association, 1994) and associated features were based on the clinical features list of the Association of Child Psychology and Psychiatry (ACPP) data set (Berger et al., 1993). A range of results is presented documenting the occurrence and frequency of different clinical features at different ages. These include the finding that stereotypically gendered clothing (i.e. boys cross-dressing and girls refusing to wear skirts) is more significant in pre-pubertal children, whereas dislike of bodily sexual characteristics becomes more predominant in post-pubertal children. The most common associated features were relationship difficulty with parents/carers (57%), relationship difficulty with peers (52%) and depression/misery (42%). Gender identity problems have wide-reaching implications for children and their families and problems may become more entrenched with the onset of puberty. Although specialist support and co-ordination of services becomes essential particularly at this time, interventions in childhood may have the function of preventing difficulties becoming more severe during adolescence. http://web.archive.org/web/20070525044205/http://www.symposion.com/ijt/ijtvo06no01_01.htm
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Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development. Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013. The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common. The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
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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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Purpose: Adolescence marks a transition point in the development of gender experience and expression. Although there is growing awareness about various gender identities in health research, only limited data on the prevalence of adolescent gender variance in the general population exists. Methods: German female and male adolescents (n = 940) aged 10–16 participating in the nationally representative “Health Behaviour in School-aged Children” (HBSC) Hamburg survey were asked to report their current gender experience (identification as both feminine and masculine) and gender expression (gender role as girl or boy). Two overall categories and five subcategories on gender experience and expression were established based on previous research. Results: In total, 4.1% of the adolescents’ responses were rated as variant in gender experience and 3.0% as nonconforming in expression. Both variant experiences and nonconforming expression together were present in only 0.9% of adolescents. Gender variance was more strongly present in girls as well as in younger age groups. In detail, 1.6% reported an incongruent, 1.1% an ambivalent, and 1.5% no gender identification. Another 8.0% of the responses could be rated as only somewhat congruent. Conclusions: Fluidity between clearly congruent or incongruent pathways is present in adolescence, including variant as well as possibly still developing (only somewhat clear) gender experiences, whereas clearly incongruent identification and nonconforming expression were less frequent. Understanding adolescent gender development as multidimensional is important in order to identify the needs of those who do not fit into the current understanding of either female or male.
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Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exist to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the present study aimed to fill this gap. A retrospective cohort study of electronic health record data from 180 transgender patients aged 12-29 years seen between 2002 and 2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM with MTF youth on mental health outcomes. The sample (N = 360) had a mean age of 19.6 years (standard deviation, 3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared with cisgender matched controls, transgender youth had a twofold to threefold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p < .05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use. Transgender youth were found to have a disparity in negative mental health outcomes compared with cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.