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

Archives of Sexual Behavior

April 2018
47(1)

DOI:10.1007/s10508-018-1204-9

Authors:

Guido Giovanardi

Sapienza University of Rome

Claudia Zitz

Tavistock and Portman NHS Foundation Trust

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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

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

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

1 3

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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Jul 2024

Christian Lindner

Zusammenfassung: Im Artikel „Sturm und Drang im Würgegriff der Medien – Die Leiden der jungen Generation am eigenen Geschlecht“ in der Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (Jahrgang 51, Heft 5) setzen sich die Kollegen Korte und Tschuschke mit der Frage auseinander, inwiefern der Anstieg von Abweichungen im Geschlechtsidentitätserleben bei Jugendlichen „auch ein Resultat kultureller und vor allem medientechnologischer Umbrüche ist“. Die Autoren beziehen kritisch Stellung zum geplanten deutschen „Selbstbestimmungsgesetz“, zu sozialer Transition bei Kindern und Jugendlichen, zur sogenannter Pubertätsblockade sowie zur Hormontherapie bei Jugendlichen, und rechtfertigen den Vorzug eines genderkritischen gegenüber dem eines transaffirmativen Therapieansatzes. Obgleich der Artikel einige interessante Hypothesen aus dem Blickwinkel u. a. der Kulturwissenschaft und Philosophie einbringt, kann er doch auf Grund des transkritischen Grundtenors zur Verunsicherung von Kolleg_innen in der Behandlung von trans*Personen beitragen. Dies ist auf sprachliche Mittel, irreführende und fehlerhafte Zitate und unvollständige bzw. inkorrekte Schilderung von Fakten zurückzuführen. Die vorliegende Arbeit möchte sich daher kritisch mit dem zur Diskussion gestellten Artikel der Autoren Korte und Tschuschke befassen und bedient sich dabei einer sprachkritischen Untersuchung sowie einer Überprüfung der von den Autoren angeführten Fakten, Daten und Quellen. Sie möchte versuchen, Kolleg_innen dazu zu ermuntern, sich mit geschlechtsdysphorischen Kindern und Jugendlichen in einen gemeinsamen, partizipativen, trans*respektvollen Behandlungsprozess zu begeben und den von den Autoren Korte und Tschuschke im Artikel wenig beachteten, großen Zwischenbereich zwischen „genderkritischer“ und „transaffirmativer“ Haltung auszuloten.

Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service

Article

May 2024

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data from the Center of Expertise on Gender Dysphoria in Amsterdam (1988-2016)

Article

Full-text available

Feb 2018

This is a Letter to the Editor, so no Abstract.

Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: a clinical comparison study between four clinics

Article

Full-text available

Jul 2018
EUR CHILD ADOLES PSY

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.

Longitudinal Study of Young People in England cohort 2: health and wellbeing at wave 2

Article

Full-text available

Jul 2016

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

Behavioral and Emotional Problems as a Function of Peer Relationships in Adolescents With Gender Dysphoria: A Comparison With Clinical and Nonclinical Controls

Article

Full-text available

Dec 2015

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)

Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis

Article

Full-text available

Jun 2016
EUR CHILD ADOLES PSY

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.

Children and Adolescents Referred to a Specialist Gender Identity Development Service: Clinical Features and Demographic Characteristics

Article

Full-text available

Jan 2002

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

Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development

Article

Full-text available

Apr 2015
Child Adolesc Psychiatr Ment Health

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.

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

Article

Full-text available

Jan 2015
J SEX MED

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.

Prevalence of Adolescent Gender Experiences and Gender Expression in Germany

Article

Feb 2017
J ADOLESCENT HEALTH

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.

Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study

Article

Jan 2015
J ADOLESCENT HEALTH

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.