Geschlechtsumwandlungstreib – the drive for sex transformation.
This word was invented by Max Marcuse in 1913.
From Transgender History by Susan Stryker.
You can buy Transgender History:
from Seal Press (support women’s publishing)
from Barnes and Noble (support brick and mortar stores)
from Amazon (support books)
This is a follow-up case study of a Japanese boy with both Asperger’s syndrome and gender dysphoria. It is the first long-term follow-up case study we have for a child with autism and gender dysphoria.
The young man no longer had gender dysphoria at the 11-year follow-up.
This is a highly significant case study; we know that most children with gender dysphoria desist around puberty, but we have had no data on what happens to children with both autism and gender dysphoria.
We need more studies to find out how common this is for children with autism and gender dysphoria.
In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?
As the authors say, “Careful long-term clinical observation and further studies are needed.”
More details on the boy’s gender dysphoria:
[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.
After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”
You can also read more about his earlier gender dysphoria in this previous case study.
More details on the change at puberty:
“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.
In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”
Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.
*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)
Original Source:
This is a case report of two Turkish boys with autism and gender dysphoria. Unlike this earlier study of two boys with autism, the boys in this study verbalized a clear desire to be a girl.
In the earlier case study, the boys had cross-gender interests, but probably did not have gender dysphoria. In this case study, however, the boys had cross-gender interests and gender dysphoria.
This study followed the boys for at least four years, so we know that the gender dysphoria was not transient.
We do not, however, know if their gender dypshoria will persist. Most children with gender dysphoria desist around the time of puberty. What happens with children with autism? Are they more or less likely to persist in their gender dysphoria? How should parents and educators handle their gender dysphoria? Is their gender dysphoria different from gender dysphoria in neurotypical children? How common is gender dysphoria among children with autism?
In the first of these two cases the patient was treated with behavior modification, encouraging separation from the mother, and establishing a bond with his father. His cross-gender behavior continued. In the second case his parents tried to establish a good bond with his father, but again, his cross-gender behaviors have continued.
The author of this study suggests that gender dyshoria in children with autism may be underreported and might be interpreted as unusual interests rather than actual gender dypshoria. At this point, however, we don’t have enough data to know if that is the case. This is a case study of only two children.
This case study does, however, show that children with autism can have genuine gender dypshoria, like the Swedish teenage girl in this case study and the Japanese boy in this one.
“This case study, which is a preliminary attempt to report the developmental pattern of cross-gender behaviour in autistic children, tries to underline that (1) diagnosis of GID in autistic individuals with a long follow-up seems possible; and (2) high functioning verbally able autistic individuals can express their gender preferences as well as other personal preferences.
Finally, this report points to the need for further study of gender identity development as well as other identity problems in individuals with high functioning autism.”
(Emphasis mine)
Original Source:
More details about the case studies:
Case 1 – 10 year old boy with autism:
“One year after the referral [for autism], when he was aged 6 years, he started to show improvements in spontaneous speech and imitative play, and displayed more interest in his peers and other people. At the same time, his mother reported some cross-gender behaviours such as wearing his mother’s dresses, putting lego bricks in his socks under his heels and pretending to have high-heel shoes. Along with the improvement in spontaneous speech and imitative behaviour, he started to state his disappointment about his gender. Sometimes, he prayed and begged God to make his penis disappear. After these verbal expressions, he shared his fantasy about his wish to become a bride, married to a man from the age of 8 years. He never shows interest in male activities, he always avoids rough-and-tumble play and prefers to play with girls. Although he has shown some improvement in his social relatedness and language, his social difficulties in terms of reciprocal relationships with peers and sustaining a conversation with others still remain. Despite the eclectic treatment approaches (behavioural modification, encouraging separation from his mother and establishing a bond between him and his father), his cross-gender behaviours show a persistent pattern.”
Case 2 – 7 year old boy with autism:
He started to use phrases at age 4 years [he was referred to the clinic at age 3 for autism], showed improvement in social relationships and sharing interests with peers at nursery school. He also started some make-believe play. At the same time, he had shown persistent attachment to his mother’s and some significant female relative’s clothes and especially liked to make skirts out of their scarves. After age 5 years, he started to ‘play house’ and ‘play mother roles’. This was the most persistent and most pervasive pattern of his play, and he pushed his therapist as well as his peers and family members to ‘play house’ with him. He avoids rough-and-tumble play and likes to share his interests with one or two of his female classmates. His parents were worried about his behaviour and tried to prevent it, but he reacted aggressively. He started to state his desire to grow up as a woman (like his mother). He gave up his attachment to some feminine objects, but still shows persistence in playing the ‘mother roles’ and expresses his desire to be a woman. Although there are some improvements in terms of social relatedness, language and the disappearance of stereotypical behaviours, his social interaction pattern is still inappropriate for his age. His parents have tried to establish good bonding between him with his father as a identification object. Despite this, his cross-gender behaviours are persistent.
This is a 1997 case of a Swedish teenager who had autism as well as symptoms of gender dysphoria, selective mutism, and obsessive compulsive disorder (OCD).
Treatment with clomipramine decreased her symptoms of OCD and mutism, but not her symptoms of gender dysphoria.
Unlike this earlier case study of two American boys, this patient had clear symptoms of gender dysphoria:
“At the age of 8 years, B had started to claim that she was a boy. She refused to wear girls clothing and jewelery. B corrected persons if she was being addressed as ‘she’ and used her brothers’ shaving machine. At twelve years of age, B refused to visit the girls toilet but was forbidden by the parents to use the boys toilet. She has now been told to use the one and only gender neutral toilet in the school.”
And, at follow up:*
“She refuses to wear women’s clothes or to appear in swimsuit on the beach. Moreover, she claims that she is a boy, although she has discontinued the habit of correcting peers for addressing her ‘her’.”
The authors discuss three possible ways to interpret her symptoms of gender dysphoria and the implications for treatment.
First they suggest that the gender dysphoria could be part of the autism, specifically a “ritualized and obsessive-compulsive behavior of a kind which is commonly seen in autistic syndromes.”
The authors suggest that autism makes social and sexual relationships difficult, although people with autism are attracted to others. The expression of these feeling may be unusual. “A minority of people with autism display a variety of paraphilic behaviour, e.g., exhibitionism, voyeurism and fetishism, and the desire for a beloved person may find expression in an obsessive manner.”
Gender dysphoria then might be “a paraphilic consequence of the impairment in social interaction” due to her autism. In that case the proper response would be “similar to the one employed when encountering other sexual manifestations with autistic people: a gradual firm correcting of the behavior in the direction of gender concordant behavior, but without anger or distress.”
The authors do not discuss the possibility that the gender dysphoria could be part of the autism in some other, non-sexual way. They should have.
Second, they suggest that the gender dysphoria might be seen as an obsessive-compulsive disorder and separate from the autism. In that case the proper treatment would be clomipramine.
There have been cases where patients with obsessional gender dysphoria were successfully treated with lithium carbonate, but the symptoms were different from the ones in this case.**
More importantly, in this case, treatment with clomipramine relieved the symptoms of OCD and mutism, but not the gender dysphoria. In fact, her symptoms of gender dysphoria increased, although it may be that they only became more apparent – for one thing she was talking more.
Third, they suggest that the gender dysphoria could be viewed as a disorder on its own and not a symptom of autism or OCD. In that case, the proper approach would be to treat both the autism and the gender dysphoria. When the teenager was of age,*** she would then be eligible for sex reassignment surgery.
They caution that “this patient suffers from a putative risk factor (autism), which has to be seriously considered before any intervention can be performed. “
As with other case studies, this is about one person. We can only draw limited conclusions from it.
It does show, however, that a person with autism can have symptoms of gender dysphoria. Further, in this case, the symptoms were probably not caused by OCD, as treatment for OCD did not relieve her gender dysphoria.
We could use further research to determine the relationship between gender dysphoria and autism and the best way to treat children and teenagers who have both.
Original Source:
*It’s not perfectly clear in the case report, but the therapists seem to have seen her initially at age 12 and the follow-up seems to have been at age 14.
***The first reference I can find to using puberty blockers for teenagers with gender dysphoria is a case study of one teenager in 1998, a year after this case study. Thus at the time of this case study, medical transition would not have begun before age 18. (Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent.)
This is a 1996 case study of two boys with autism who had cross-gender interests, but probably did not have gender dysphoria.
Both boys liked dolls, although the way they played with them was not typical. In addition, one of the boys liked to imitate the scenes of cartoons with female characters. Both boys cross-dressed and created long hair with cloth.
Neither of them played with other children of either sex. One boy ran around and screamed until the other children left and the other fought with others if they bothered him.
Neither of them expressed a dislike of being a boy or a desire to be a girl – although, on the other hand, their language was limited.
The parents of one of the boys thought they might have reinforced his interest in dolls. They had been so excited to see him using toys of any sort that they bought dolls for him.
The mother of the other boy was anxious about her son’s cross-dressing and reluctant to discuss it.
The authors suggest that for these boys the cross-dressing may represent an unusual preoccupation rather than a sign of gender identity. “This preoccupation may relate to a need for sensory input that happens to be predominantly feminine in nature (silky objects, bright and shiny substances, movement of long hair, etc.).”
The authors suggest that cases like these could lead to misdiagnosing gender dysphoria:
“These cases also point to the potential for confusion of primary gender identity disorders with preoccupations in high-functioning individuals with autism.”
They make recommendations for treatment in cases like these:
“Rather than a narrow focus on altering the preoccupation, a broad intervention addressing social, communication, and play skill development appears to be important. Thus, identifying other interests in the children to be developed in the context of social situations may aid social skill development by increasing opportunities for interactive play. Parents and others working with the children may need help in understanding the nature of feminine preoccupations in boys and in destigmatizing these interests.”
The authors conclude by saying:
It is our hypothesis that the feminine preoccupations of these children with autism may have resulted from an inherent predisposition toward unusual interests combined with the boys’ social environment. The sensory aspects of the feminine objects may have contributed to the development of these preoccupations. It seems less likely that the feminine interests are related to issues of gender roles/confusion. This report points to the need for future study of the complex interplay of environmental and neurobiologic factors affecting gender identity roles and preoccupation in autism.
More Details About the Boys’ Cross-Gender Interests and Behavior
The first patient was five years old.
“Although his parents report no truly imaginative play, M.C. will imitate the scenes from a video having to do with female cartoon characters (e.g. Cinderella, Snow White, and Ariel). He likes to hold Barbie dolls, but frequently will rip off the dolls’ heads and play with parts of the doll, particularly the hair. He enjoys bright, shiny objects. He often dresses up using female clothing and uses towels or other fabric to fashion long hair for himself. M.C. demonstrates little interest in male toys or other toys in general.”
The second patient was three and a half years old.
“His favorite toys are a Minnie Mouse doll and a Barbie doll although his play consists mostly of shaking the hair of the Barbie doll. He enjoys wearing his sister’s or mother’s clothing, including high heeled shoes, bras, and underwear. He often puts a shirt over his head and acts as if it is long hair.”
More Details about the Patients
The first patient lived with his parents and older brother. There was nothing unusual about his birth, although his later medical history included “hospitalization for dehydration/gastroenteritis and right inguinal hernia repair.”
Behaviorally, “M.C.’s speech is characterized by short sentences which are often stereotyped. He recently began requesting objects by pointing. His parents report that he is an active, impulsive, moody child with a good memory. M.C. frequently engages in perseverative motor activities. He is generally a loner. When with other children he frequently runs around and screams until the children go away.”
The second patient lived with his mother, older sister, fraternal twin, and his mother’s boyfriend. The pregnancy and birth were complicated. The patient had also had frequent upper respiratory infections and ear infections and a hospitalization for reactive airway disease and pneumonia.
In terms of his development, “although he learned the words to several songs at an early age, he did not begin using phrases until approximately 3 years of age. C.W. is described as a loner who does not play with others. He engages in perseverative activities such as opening and shutting doors as well as running his hand repeatedly through water. He watches commercials, music videos, and ‘Wheel of Fortune’ on television. He fights with others if they bother him, and screams if unable to do what he wants.”
More Details about the Patients’ Treatments
The first patient was treated with special education services after kindergarten and consultation with a school specialist in autism. His communication skills improved and his interests broadened somewhat. However, he was still interested in dolls and requested a Pocahontas doll for his birthday.
In the second case, the boy was enrolled in a school program that included special education services. His mother had a home consultation visit with a specialist in autism. He continues to cross-dress, although his mother only allows it when he comes home from school.
Original Source:
A 1981 study of autistic children found that gender identity was related to “mental age, chronological age, communication skills, physical skills, social skills, self-help skills and academic/cognitive skills.”
The study looked at 30 children and gave them the Michigan Gender Identity Test. The goal was to see if they could demonstrate a sense of gender identity.
This study is not available online, however, I was able to get some more information on it from another study (Case study: cross-gender preoccupations with two male children with autism.)
According to Williams et al., Abelson’s study indicated that “the establishment of gender identity in children with autism (as demonstrated by recognizing one’s own self as a boy or a girl) appeared to be dependent on mental age and cognitive abilities, and was correlated with the establishment of other social and self-help skills. Abelson expressed some optimism that many children with autism have the ability to recognize themselves as boys and girls, and thus form effective ties with the identified group, which leads to more acceptable social interaction patterns.”
Original Source:
This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.
QUICK OVERVIEW
The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.
Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.
Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.
7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.
Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.
Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit. Again, we need to be sure to provide support during and after transition.
THE INCREASE IN TEENAGE PATIENTS
The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.
Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.
This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.
Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.
This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.
It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.
“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”
Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?
Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?
Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.
Are there more trans men than in the past? If so, why?
Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?
BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY
The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.
45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.
Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).
The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.
At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*
PSYCHIATRIC COMORBIDITIES
Diagnoses made by a mental health professional:**
35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)
24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)
10% had ADHD (2 trans men, 6 trans women)
7% had an autism spectrum disorder (2 trans men, 4 trans women)
5% had an eating disorder (2 trans men, 2 trans women)
7% of their patients had a substance abuse problem (2 trans men, 4 trans women)
26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.
Suicide attempts:
10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.
4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.
Psychiatric hospitalizations:
12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.
One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).
Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.
Mood, puberty blockers, and hormones:
One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***
One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)
Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)
One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)
Gender differences:
Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.
There were no significant gender differences in other mental health issues.
27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.
The most important issue is the number of suicide attempts.
Why were there four suicide attempts after the first visit to the clinic?
Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?
Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?
What about the trans man who stopped his hormones due to an eating disorder?
When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?
Could they have been prevented by more therapeutic support before treatment? during treatment?
Is there a way to identify which patients are at risk for suicide attempts during or after treatment?
It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.
We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?
Psychiatric comorbidities comparison
Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).
5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.
7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.
26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.
Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.
Why is the psychiatric comorbidity higher in the Vancouver patients?
The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.
They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.
In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.
Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.
It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.
A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.
As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?
Original Source:
*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.
** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.
***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.
This is a highly significant study showing that the population of teenagers referred for gender dysphoria is changing. It is noteworthy that this is happening in two different countries.
The sex ratio is changing:
The sex ratio of teenagers seeking help for gender dysphoria has changed at two clinics, one in Canada and one in the Netherlands.
Before 2006, more male than female teenagers sought transition at these clinics. Since 2006, they have seen more female teenagers than male teenagers.
Sex ratio for teenage patients at the Canadian Gender Identity Service:
Sex ratio for teenage patients at the Dutch Center for Expertise on Gender Dysphoria:
At the Canadian clinic, there was no change in the sex ratio of teenagers referred for psychiatric issues.* In both time periods, roughly two-thirds of their other patients were male.
According to the authors, “In adult samples [of transitioners], in almost all cases, the number of natal males either exceeds the number of natal females or the sex ratio is near parity.” Poland and Japan are exceptions; in those countries more females transition than males.
In addition, clinics for children with gender dysphoria have found that the number of males exceeds the number of females.
More teenagers are transitioning:
The number of teens of both sexes has increased over time, although the increase is larger for the female teenagers.
Increases at the Canadian clinic:
Female teenagers
Male teenagers
Increases at the Dutch clinic:
Female teenagers
Male teenagers
In other words, the Canadian clinic saw nearly nearly three times as many female teens in the past 8 years as they had seen in the previous thirty. The Dutch clinic saw nearly twice as many female teens in the past 8 years as they had seen in the previous seventeen.
Furthermore, “For many years in the Toronto clinic, the number of adolescent referrals was quite low. Between 1976 and 2003, for example, no more than five adolescents of one biological sex were assessed in a calendar year and, during this period, the number of males exceeded the number of females. Beginning in 2004, however, the number of adolescent referrals began to rise quite dramatically, which appears to be consistent with the observations of clinicians and researchers from other gender identity clinics.”
For earlier data on the increase in Canada, see this article.
Sexual orientation percentages have changed:
The Canadian clinic also looked at sexual orientation.
Sexual orientation of females:
Other could mean primarily attracted to males, bisexual, or asexual.
Sexual orientation of males:
Other could mean primarily attracted to females, bisexual, or asexual.
To put it another way, in the past most of the teenagers would have been gay if they weren’t transgender. If they transitioned, they would live their lives as straight people.
In 2006-2013 most of the male teenagers would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as lesbians.
One-third of the female teenagers in 2006-2013 would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as gay men.
What’s going on?
Why are we seeing more teenagers seeking help for gender dysphoria?
Why is the increase greater among female teens than males?
And why are we seeing a shift in the sexual orientation of these teens? Was it harder in the past to come out as transgender if you were seen as straight? Or is this a group of people who were less likely to have gender dysphoria in the past?
Has something changed in our environment that increases the number of people with gender dysphoria? What would affect more females than males? Why would it affect teenagers more than children (see this earlier article)? How would it fit with the changing percentages related to sexual orientation?
Is it just that there were always this many teenagers with gender dysphoria and now they are able to get care at an earlier age? How does that theory fit with the change in the sex ratio of teens applying to the clinic? with changes in their sexual orientation?
Clearly, we need more research to sort out these questions.
The authors speculate about possible explanations for the change in the sex ratio at their clinics.
They suggest that the general increase in patients might be due to a combination of destigmatization and more awareness of the biomedical treatments available to teens. However, they point out that this does not explain why more females would apply for treatment.
I don’t think we can know why the number of patients has increased without further research – research which is desperately needed.
The increase in the number of female patients at the Toronto clinic was not caused by a change in the severity of cases; they found that there was no significant relationship between severity of dysphoria and year assessed.
However, for male teens in Toronto, there was a weak correlation between severity of dysphoria and year assessed. “More recently assessed cases had moderately higher GD severity.” This only explained 6.7% of the variance. Therefore “it is unlikely that the recent inversion in the sex ratio can be accounted for by a substantive change in severity variation.”
On the other hand, they only have data on the severity of dysphoria starting in 2001 and the number of cases began increasing in 2004.
The change in the sex ratio was not due to females entering puberty at an earlier age; both clinics found no significant difference for the mean ages when females and males came to the clinic.
The sex ratio did not change due to the shift in sexual orientation. A logistical regression analysis did not find evidence for a sex x sexual orientation interaction.**
The authors suggest that perhaps the explanation for the change in the sex ratio is that it is harder for males to transition to a female role than for females to transition to a male one.
I find this unconvincing as this would have been true in the past when more male teenagers than females applied to their clinic. Nor would this hypothesis explain the shift in sexual orientation.
Here is their full explanation:
“Given that there is at least some overlap in the gender-variant developmental histories of early-onset individuals with GD and some gay men and lesbians, it might, therefore, be asked whether or not degree of stigmatization for gender-variant behavior might account for the recent inversion in the sex ratio of GD adolescents. It is well-known that cross-gender behavior in children is subject to more social stigma (e.g., peer rejection and peer teasing) in males than in females, in both clinic-referred adolescents with GD and in the general population[26–30]. Thus, it could be argued that it is easier for adolescent females to “come out” as transgendered than it is for adolescent males to come out as transgendered because masculine behavior is subject to less social sanction than feminine behavior. Some support for this was found in Shiffman’s [31] study of peer relations in adolescents with GD, in which adolescent males with GD reported more “social bullying” than adolescent females with GD. Given that a transgendered identity as an “identity option” has become much more visible over the past decade, it is conceivable, therefore, that such an identity option is easier for females to declare than it is for males because it does not elicit as much of a negative response. Thus, it could be argued that it is this sex difference in degree of stigmatization that accounts for the inversion in the sex ratio that we have identified in the two studies reported here. In other words, there are greater costs for a male to adopt a female gender identity in adolescence than it is for a female to adopt a male gender identity.”
A few more details about this study:
The first study looked at 328 teens (13-19) who were referred to the Toronto clinic between 1976 and 2013. The mean age at the time of referral was 16.66 years with no difference between the ages of males and females.
All of the teens met criteria for Gender Identity Disorder or Gender Identity Disorder Not Otherwise Specified. They were diagnosed using criteria in the relevant version of the DSM – this changed over time. The assessment of severity of dysphoria began in 2001.
The control group was 6,592 teens referred to their general clinic for psychiatric issues between 1999-2013. Eleven teens originally referred for psychiatric issues who were later referred to the Gender Identity Service were not included in this group.
The teens’ sexual orientation was determined by either clinical chart data or measurements on the Erotic Response and Orientation Scale and the Sexual History Questionnaire. This data was not available for five probands (aka people in this study).
The numbers for the sexual orientation of the teens at the Canadian clinic were:
1976-2005 (30 years)
2006-2013 (8 years)
The clinic did not have data on the sexual orientation of five of the teenagers.
The second study looked at data on 420 teenagers (13 and up) referred to the Dutch clinic between 1989-2013. Their mean age at the time of assessment was 16.14 and there was no significant age difference between males and females.
The second study did not include data on sexual orientation or a control group for comparison.
“The percentage of female adolescents from Amsterdam in the first time period did not differ significantly from the percentage of female adolescents from the Toronto clinic, and the percentage of female adolescents from Amsterdam in the second time period also did not differ from the percentage of female adolescents from the Toronto clinic, both χ2(1) < 1.”
This study is a follow-up to two earlier letters to the editor about changes in the teenage population at the clinic in Toronto: Is Gender Identity Disorder in Adolescents Coming out of the Closet? and Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, Sex Ratio, and Sexual Orientation.
The first letter discussed a rise in teenagers referred to the Canadian clinic between 2004-2007. The second letter discussed the continued increase in referrals from 2008-2011 and raises the question of a possible change in the sex ratio in 2008-2011.
Original Article:
* The Canadian clinic is the Gender Identity Service, within the Child, Youth, and Family Services (CYFS) at the Centre for Addiction and Mental Health in Toronto. The clinic in the Netherlands is the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam. This may explain why we have a comparison group for the Canadian patients with gender dysphoria, but not the Dutch ones.
** “In the cohort examined in Study 1, perhaps it could be argued that, in the first time period, the greater number of biological males than biological females was an artifact of there being two prominent subtypes of GD (androphilic and nonandrophilic) in the former, whereas the latter were predominantly of only one subtype (gynephilic), but that this shifted in the second time period, with a greater number of females with a nongynephilic sexual orientation. However, the logistic regression analysis shown in Table 4 did not provide evidence for a sex × sexual orientation interaction. It only showed that a nonandrophilic or nongynephilic sexual orientation increased the odds that a proband presented in the second time period, but sexual orientation did not interact with probands’ biological sex.”
This is a follow-up to an earlier letter to the editor calling for research and discussion on the subject of teenagers with gender dysphoria. The authors had seen a sharp increase in the number of teenagers referred to their Toronto clinic between 2004 and 2007.
You can read about some new, related data here.
In this letter, the authors report that:
Cases of teens with gender dysphoria are still increasing.
Between 2008-2011 the number of teenagers referred to their clinic increased even further.
Based on their graph, before 2000, they saw fewer than 20 teenagers in a four year period. From 2004-2007 they saw about 55 teens and from 2008-2011, they saw about 95. In other words, the number of teen patients they saw more than quadrupled.
By my calculations, about two-thirds of their teenage patients in the last 36 years came to the clinic between 2000 and 2011; over half came to the clinic in the last 8 years between 2004 and 2011.
In contrast, the number of cases of children with gender dysphoria increased sharply in 1988-1991, but has been reasonably stable since then.
Looking at their graph again, between 1988 and 2011 they saw 75 to 90 children in a four year period. The children who came to the clinic between 2004 and 2011 only make up 29% of the child patients they’ve seen in the past 36 years.
In 2008-2011, the number of teenagers at their clinic was larger than the number of children for the first time ever.
From 1976-2004, the number of children at their clinic was much higher than the number of teens. The number of teens increased greatly after 2004, but was still lower than the number of children at their clinic.
The sex ratio of their teenage patients may be changing.
For teenage patients, the sex ratio was close to even, ranging from 1.03:1 boys to girls in 2004-2007 to 3:1 in 1976-1979. There were two time periods when they saw more female teenagers than males: 1988-1991 and the most recent group in 2008-2011.
***Spoiler alert – a 2015 study found that the sex ratio has indeed changed from more boys to more girls. This was true for both this clinic and a Dutch one. More later.***
It is important to remember that the numbers of both male and female teenage patients increased starting in 2004.
The increase in female teenagers is much more striking. Based on the graph below they went from fewer than 10 patients every four years prior to 2000 to nearly 60 patients from 2008-2011.
However, male teenage patients also increased. They went from about 5-15 patients every four years prior to 2000 to about 35 patients from 2008-2011. In 2004-2007 the number of male and female teenage patients was nearly equal.
The authors also discuss the pattern of sex ratio by age. Putting the data from different time periods together, from ages 12-16, there were slightly more boys than girls. However, at age 17-18, there were more females than males, and at age 19-20, the sex ratio shifted again to 2.4 boys to 1 girl.
Sexual orientation
The authors had data on sexual orientation for 98% of the teenagers they saw.* Of these 76% of their female teenage patients were sexually attracted to females while 56.7% of their male teenage patients were sexually attracted to males.**
The sex ratio for child patients is different than for teenage patients.
The overall sex ratio for children was 4.49 boys to 1 girl. For 3 year olds, the sex ratio was 33 boys for every girl.***
From 1976-1996, over 75% of their child patients were boys, from 2001-2011 the percentage hovered around 75%.
What does this mean?
We don’t know why more teenagers are seeking help at this clinic. Are there more teenagers with gender dysphoria than in the past? If so, why? What would make gender dysphoria increase among teenagers and not among children? Are people with gender dysphoria simply able to get help at an earlier age?
As always, we need more research!
The authors provide some interesting insights:
“Regarding the increase in adolescent referrals, it is, of course, not clear if it reflects a true increase in prevalence (which can only be established via epidemiological studies) or if it simply reflects a greater willingness on the part of youth to come out as transgendered, perhaps because of the influence of social media in which there are dozens, if not hundreds, of websites and blogs that assist youth in understanding their own identity and its concomitant struggles. We have been impressed, for example, in recent years with youth describing to us that they never realized that their feelings could be named in a formal way (gender identity disorder, transgender, trans). One might infer that the Internet has made much more visible terminology used in technical journals.
Another parameter that has struck us as clinically important is that a number of youth comment that, in some ways, it is easier to be trans than to be gay or lesbian. One adolescent girl, for example, remarked, “If I walk down the street with my girlfriend and I am perceived to be a girl, then people call us all kinds of names, like lezzies or faggots, but if I am perceived to be a guy, then they leave us alone.” To what extent societal and internalized homonegativity pushes such youth to adopt a transgendered identity remains unclear and requires further empirical study. Along similar lines, we have also wondered whether, in some ways, identifying as trans has come to occupy a more valued social status than identifying as gay or lesbian in some youth subcultures. Perhaps, for example, this social force explains the particularly dramatic increase in female adolescent cases in the 2008–2011 cohort.
Another factor that has impressed us in accounting for the increase in adolescent referrals pertains to youth with gender identity disorder who also have an autism spectrum disorder. As noted by others (de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010), many clinicians are now reporting a co-occurrence of these two conditions.
More than 10 years or so ago, it was rare in our clinic to see an adolescent with gender identity disorder who also appeared to have an autism spectrum disorder. It is possible, therefore, that the apparent increase in the number of adolescents who present with a co-occurring autism spectrum disorder is contributing to the increase in the number of referrals. Over the past decade, a great deal of media attention has been given to the use of hormonal therapy to treat gender dysphoria in adolescents, including the use of “blockers” to either delay or suppress somatic puberty (Cohen-Kettenis, Steensma, & de Vries, 2011; Zucker et al., 2011). In the province of Ontario, its health care system relisted sex reassignment surgery as an insured medical treatment in 2008 after having been delisted in 1998 (Ministry of Health and Long-Term Care Processing Sites, 2008; Radio Canada, 2008). Perhaps the availability again of insurance coverage has led to more adolescents seeking treatment. Whatever the explanation for the increase in adolescent referrals, it appears that gender identity disorder in adolescents has come out of the closet, although there may be different closets from which to come out.”
A few more details about the data:
The children were significantly more likely to be living in two-parent homes than the teens (66% versus 46%).
Most of the patients were white; 80% of the children and 76% of the teens.****
The study included 577 children (3-12 years old) and 253 teens (13-20 years old).
The study excluded “26 boys referred for fetishistic cross-dressing and referred adolescents who were diagnosed with transvestic fetishism (without co-occurring gender dysphoria), gay youth, and youth who were ‘undifferentiated'”.
Original Source:
* 248 teenagers out of 253 total.
** The authors classified the teenagers as homosexual or nonhomosexual in relation to birth sex.
***It may be that parents are more worried about boys who are gender non-conforming than girls so more boys are referred to the clinic. By adolescence the teenagers might play more of a role in coming to the clinic.
**** Yup, we need more research on people with gender dysphoria who aren’t white.
You can read more in the follow-up study, Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria.
There is a short but important piece about the persistence of gender dysphoria in children.
In this Dutch clinic, they found that:
70% of the children they diagnosed with gender dysphoria did not return to the clinic and transition; they “desisted” in their gender dysphoria.
95% of the children who desisted as teens did not return to the clinic as adults.
27% of the children they diagnosed with gender dysphoria transitioned as teenagers, 3% did so as adults.
Of the children who returned to the clinic before adulthood, 75% came back before they were 14 years old and 25% came back when they were between 14 and 18.
Boys were more likely to desist from their gender dysphoria than girls; 73% versus 61,5%. Conversely, more female children with gender dysphoria went on to transition; 38.5% versus 27%.
This is in line with earlier studies that have found that most children diagnosed with gender dysphoria change their minds when they are older, usually at puberty.
It also provides a follow-up to the question of whether or not the children who changed their minds still had gender dysphoria. They had access to a free medical transition, but did not return for it. It is possible that some of them may still return, but so far 95% have not.
This data also demonstrates what the authors call a third “developmental pathway” for children with gender dysphoria. This group seems to go through a “period of questioning sexual identity” as adolescents before deciding to transition as adults.
The clinic looked at the records of 150 adults who were diagnosed with gender dysphoria as children. The adults were now between 19 and 38 years old (average age = 25.9, SD 4.03). The sample was the first 150 consecutive patients the clinic had diagnosed who were now adults.
The authors discuss past studies of persistence of gender dysphoria in children. In the past, the persistence rate has been only 16% across studies, however, the diagnoses of gender dysphoria may have included some children who were simply gender non-conforming in their behavior. They suggest that in the future persistence rates may be higher as clinicians use a stricter definition of gender dysphoria.
In addition, they suggest that persistence rates might be higher if we include patients who choose to transition as adults. In this study, the persistence rate would only have been 27% if they did not include the 3% who transitioned as adults.
I would add that this data on persistence includes children who had access to puberty blockers and early transition. We need studies to determine if this affects rates of persistence and desistance.
We also need more studies of the children who did not return to the clinic and transition. Why didn’t they return? Did they completely lose their gender dysphoria? Are they happy? If they lost their gender dsyphoria, how did that happen? If they didn’t lose it, how are they dealing with it?
We have one study of children who desisted in their gender dysphoria, but we need more. (Desisting and persisting gender dysphoria after childhood.)
Finally, the authors provide an interesting discussion of the patients who did not transition as teenagers but returned to transition as adults:
“The average age of the 5 individuals who re-entered the clinic in adulthood was 24 years (range 21–37). Despite their knowledge of the availability of treatment for adolescents and the fact that treatment is covered by insurance, they did not apply for treatment during adolescence. Four (3 natal males and 1 natal female) tried to live as gay or lesbian persons for a long time, and 1 natal male had autism spectrum disorder. He reported that he needed to solve other problems in his life before he could address his GD. The others reported not having any problems with being homosexual. Yet, after having intimate and sexual experiences with same (natal) sex partners, they came to realize that living as a homosexual person did not solve their feelings of GD, and they felt increasingly drawn toward transitioning. All also mentioned that they were somewhat hesitant to start invasive treatments, such as hormone therapy and surgeries.”
and:
“It would be worthwhile to know whether the GD of these “persisters-after-interruption” differs qualitatively or quantitatively from the GD of straight persisters and whether the groups differ in other respects. For instance, has the GD in the persisters-after-interruption group actually disappeared for some years or, as the reports of our young adults suggest, did they make a more or less conscious choice not to live according to their experienced gender? Knowing more about this developmental route would be clinically useful when counseling young people with GD.”
This data was presented in a letter to the editor.
Citation:
TRANS RESEARCH 