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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
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
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,
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.
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
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.
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.
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
CBCL Child Behavior Checklist
Children (< 12years) Adolescents (12–18years)
(N = 719) (N = 3787)
Assigned males Assigned females Assigned males Assigned females
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
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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... 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 [2][3][4]. There has been a parallel increase in demand for gender transition interventions, particularly among natal females [2][3][4], and including pre-adolescents [5]. ...
... In recent years, GD diagnoses have been increasingly made in child and adolescent services [2][3][4]. There has been a parallel increase in demand for gender transition interventions, particularly among natal females [2][3][4], and including pre-adolescents [5]. Such transitions have increasingly involved the use of puberty suppression, cross-sex hormones and surgical procedures, usually in accordance with the so-called 'Dutch model', where intervention is staged in accordance with a young person's age and stage of pubertal development [6]. ...
... 3. What is the pattern of age at (a) onset (b) referral (c) assessment (d) treatment? 4. What is the pattern of mental health problems in this population? ...
Full-text available
It is unclear whether the research literature on adolescent gender dysphoria (GD) provides sufficient evidence to adequately inform clinical decision making. In the first of a series of three papers, this study sought to systematically review published evidence regarding: the prevalence of GD in adolescence; the proportions of natal males/females with GD in adolescence and whether this changed over time; and the pattern of age at (a) onset (b) referral and (c) assessment. 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 2 nd 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-verified 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 de-duplication), 38 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 (26). A few compared to normative or population datasets; most (31) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). No population studies are available, so prevalence is not possible to ascertain. There is evidence of an increase in frequency of presentation to services, and of a shift in the natal sex of referred cases: those assigned female at birth are now in the majority. No data were available on age of onset. Within the included samples the average age was 13 years at referral, 15 years at assessment. 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 78%. Almost half 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. The increase in clinical presentations of GD,
... The rise in international referrals to child and adolescent gender services over recent years (Aitken et al., 2015;de Graaf et al., 2018;Kaltiala-Heino et al., 2018Aitken et al., 2015de Graaf et al., 2019;Kaltiala-Heino et al., 2018) has increased research interest in adolescent transgender health. However, little has been explored regarding service user engagement in relation to ethnicity. ...
... Such enculturation by parents or caregivers may cause young people from EMP groups to encounter barriers in accessing gender services out of perceived fear of stigma, discrimination, and prejudice from their community. By contrast, the child's adopted culture placed them at the centre of attention and care (Fernando, 2012) through Western philosophy which is mostly centralised around individualism, independence, self-sufficiency, and assertiveness (Dwivedi and Verma, 1996;Fernando, 2012), this may be a contributing factor to the higher number of young people from White ethnicities seen at Services (as has been previously reported e.g., De Graaf et al., 2018(de Graaf et al., 2019). ...
... stress model, young people occupying a dual minority status are at an increased risk of experiencing micro-and macroaggressions that may, in some cases, effectuate mental health difficulties (Balsam et al., 2011;Meyer, 2003). Moreover, individuals from EMP groups may experience challenges in terms of their gender exploration due to cultural, ethnic and or community beliefs and values regarding gender appropriate behaviour (de Graaf et al., 2019)(de Graaf et al., 2018. ...
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.
... 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. ...
Full-text available
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.
... Several studies have highlighted significant growth in the number of youths presenting as transgender or trans 1 in daily life. [1][2][3] In addition, popular media portrayals of trans youths have increased knowledge of this population in the general public and stimulated debate about models of care and treatment. [4][5][6][7] In line with this, research has demonstrated that the number of referrals to specialized services for trans youths has increased worldwide. ...
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Background Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population. Aim The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender. Outcomes Gender expression in trans binary youths and non-binary youths. Methods The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019–June 2021. Results The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants’ experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants. Clinical Implications These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender. Strengths & Limitations This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy. Conclusion The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;XX:XXX–XXX.
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.
In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent processes can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
The development of gender identity in children from around the age of 3 years is described. Wishes for transgender identity are distinguished from gender-atypical behaviour. Reasons for the recent rise in transgender referrals in the early teen years are discussed. The now widely used protocol developed by the Amsterdam group for assessing transgender children and young people and, where appropriate, offering them puberty blockers, cross-sex hormones and sex reassignment surgery is described. Evidence for the effectiveness of this approach is considered. The competence of young people to give consent to these procedures is discussed. Finally, proposals are made for topics urgently requiring further research.
Importance: Increasing numbers of transgender and gender diverse children and adolescents have been referred to gender identity clinics in Sweden in the past decade, and previous studies have found an association between media attention and referral counts. Whether the tone of media stories is associated with referrals is not yet known. Objective: To investigate whether positive or negative media coverage on transgender and gender diverse issues is associated with referral counts to child and adolescent gender identity clinics. Design, setting, and participants: In this cross-sectional study, referrals counts were collected from all 6 specialized gender identity clinics in Sweden, along with information on referral date, sex assigned at birth, and birth year. Participants were all individuals younger than 19 years, referred to a gender identity clinic between January 1, 2017, and December 31, 2019. Data were analyzed from May 2020 to September 2021. Exposures: Exposures included 3 major media events related to transgender health care in 2019; 1 event was categorized as positive and 2 events were categorized as negative press coverage. Main outcomes and measures: Referral counts before and after each of the 3 major media events were assessed, and the moderating association of sex assigned at birth and age was examined with stratified analyses. Weekly referral counts and trends were assessed with interrupted time series analysis. Results: Among 1784 referrals (359 referrals [21.4%] among individuals aged <13 years; 1034 referrals [72.1%] among individuals assigned female at birth and 401 referrals [27.9%] among individuals assigned male at birth), a negative association between media coverage and referral counts was found for the first of the negative media events. In the 3 months following the event, referrals decreased by 25.4% (95% CI, -31.9% to -18.9%) overall, by 32.2% (95 CI, -41.8% to -22.8%) for individuals assigned female at birth, and by 25.3% (95 CI, -32.4% to -18.3%) for individuals aged 13 to 18 years. In the interrupted time series analysis, a mean weekly decrease of 3% in the referrals was observed in the extended time interval of 39 weeks (incidence rate ratio, 0.97; 95 CI, 0.95 to 0.99). For the other 2 media events, no changes in referral counts or time trends were observed. Conclusions and relevance: These findings suggest that an event of negative media coverage on transgender-specific health care was negatively associated with access to health care for transgender children and adolescents; therefore, nuanced and accurate media coverage, as well as increased awareness of these mechanisms among key stakeholders, is essential.
In the past few years, there has been a very significant rise in the number of children and young people seeking treatment for gender dysphoria This area is the subject of much discussion, as evidenced in a recent court case in the UK which examined competence and capacity of young people to consent to potentially irreversible interventions. Clinicians involved in gaining consent to puberty blockers for gender dysphoric young people, must understand the evidence in this area and be aware of the heavy burden of accountability placed upon them.
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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.
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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.
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.
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.