Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria
Madison Aitken MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorThomas D. Steensma PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorRay Blanchard PhD
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
Search for more papers by this authorDoug P. VanderLaan PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorHayley Wood PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorAmanda Fuentes MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorCathy Spegg MBA
IM/IT Corporate Applications, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorLori Wasserman MD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorMegan Ames PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorC. Lindsay Fitzsimmons MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJonathan H. Leef MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorVictoria Lishak MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorElyse Reim MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorAnna Takagi MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJulia Vinik PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJulia Wreford MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorPeggy T. Cohen-Kettenis PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorAnnelou L.C. de Vries MD, PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Child and Adolescent Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorBaudewijntje P.C. Kreukels PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorCorresponding Author
Kenneth J. Zucker PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Corresponding Author: Kenneth J. Zucker, PhD, Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, 80 Workman Way, 5th Floor, Toronto, Ontario M6J 1H4, Canada. Tel: 4165358501; Fax: 4169794996; E-mail: [email protected]Search for more papers by this authorMadison Aitken MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorThomas D. Steensma PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorRay Blanchard PhD
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
Search for more papers by this authorDoug P. VanderLaan PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorHayley Wood PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorAmanda Fuentes MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorCathy Spegg MBA
IM/IT Corporate Applications, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorLori Wasserman MD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorMegan Ames PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorC. Lindsay Fitzsimmons MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJonathan H. Leef MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorVictoria Lishak MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorElyse Reim MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorAnna Takagi MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJulia Vinik PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorJulia Wreford MA
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Search for more papers by this authorPeggy T. Cohen-Kettenis PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorAnnelou L.C. de Vries MD, PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Child and Adolescent Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorBaudewijntje P.C. Kreukels PhD
Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
Search for more papers by this authorCorresponding Author
Kenneth J. Zucker PhD
Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Corresponding Author: Kenneth J. Zucker, PhD, Gender Identity Service, Child, Youth and Family Services, Centre for Addiction and Mental Health, 80 Workman Way, 5th Floor, Toronto, Ontario M6J 1H4, Canada. Tel: 4165358501; Fax: 4169794996; E-mail: [email protected]Search for more papers by this authorAbstract
Introduction
The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females.
Aim
We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria.
Methods
The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006–2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam.
Results
Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems.
Conclusions
Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria. Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med 2015;12:756–763.
References
- 1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington, VA: American Psychiatric Press; 2013.
10.1176/appi.books.9780890425596 Google Scholar
- 2Zucker KJ, Lawrence AA. Epidemiology of gender identity disorder: Recommendations for the standards of care of the World Professional Association for Transgender Health. Int J Transgenderism 2009; 11: 8–18.
10.1080/15532730902799946 Google Scholar
- 3Kreukels BPC, Harldsen IR, De Cuypere G, Richter-Appelt H, Gijs L, Cohen-Kettenis PT. A European network for the investigation of gender incongruence: The ENIGI initiative. Eur Psychiatry 2012; 27: 445–450.
- 4Baba T, Endo T, Ikeda K, Shimizu A, Honnma H, Ikdeda H, Masumori N, Ohmura T, Kiya T, Fujimoto T, Koizumi M, Saito T. Distinctive features of female-to-male transsexualism and prevalence of gender identity disorder in Japan. J Sex Med 2011; 8: 1686–1693.
- 5Godlewski J. Transsexualism and anatomic sex ratio reversal in Poland. Arch Sex Behav 1988; 17: 547–548.
- 6Wood H, Sasaki S, Bradley SJ, Singh D, Fantus S, Owen-Anderson A, Di Giacomo A, Bain J, Zucker KJ. Patterns of referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, sex ratio, and sexual orientation [Letter to the Editor]. J Sex Marital Ther 2013; 39: 1–6.
- 7Singh D, Deogracias JJ, Johnson LJ, Bradley SJ, Kibblewhite SJ, Owen-Anderson A, Peterson-Badali M, Meyer-Bahlburg HFL, Zucker KJ. The gender identity/gender dysphoria questionnaire for adolescents and adults: Further validity evidence. J Sex Res 2010; 47: 49–58.
- 8Deogracias JJ, Johnson LL, Meyer-Bahlburg HFL, Kessler SJ, Schober JM, Zucker KJ. The gender identity/gender dysphoria questionnaire for adolescents and adults. J Sex Res 2007; 44: 370–379.
- 9Lawrence AA. Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults. Arch Sex Behav 2014; 39: 514–545.
- 10Zucker KJ, Bradley SJ, Owen-Anderson A, Kibblewhite SJ, Wood H, Singh D, Choi K. Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. J Sex Marital Ther 2012; 38: 151–189.
- 11Becker I, Gjergji-Lama V, Romer G, Möller B. Merkmale von Kindern und Jugendlichen mit Geschlechtsdysphoria in der Hamburger Spezialsprechstunde. Prax Kinderpsychol Kinderpsychiat 2014; 63: 486–509.
- 12Spack NP, Edwards-Leeper M, Feldman HA, Leibowitz S, Mandel F, Diamond DA, Vance SR. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129: 418–425.
- 13Cohen-Kettenis PT, Steensma TD, de Vries ALC. Treatment of adolescents with gender dysphoria in the Netherlands. Child Adolesc Psychiatr Clin N Am 2011; 20: 689–700.
- 14Zucker KJ, Bradley SJ, Owen-Anderson A, Singh D, Blanchard R, Bain J. Puberty-blocking hormonal therapy for adolescents with gender identity disorder: A descriptive clinical study. J Gay Lesbian Ment Health 2011; 15: 58–82.
10.1080/19359705.2011.530574 Google Scholar
- 15Hsieh S, Leininger J. Resource list: Clinical care programs for gender-nonconforming children and adolescents. Pediatr Ann 2014; 43: 238–244.
- 16Sizonenko PC. Normal sexual maturation. Pediatrician 1987; 14: 191–201.
- 17Blanchard R, Clemmensen L, Steiner BW. Heterosexual and homosexual gender dysphoria. Arch Sex Behav 1985; 16: 139–152.
- 18Nieder TO, Herff M, Cerwenka S, Preuss WF, Cohen-Kettenis PT, De Cuypere G, Haraldsen IRH, Richter-Appelt H. Age of onset and sexual orientation in transsexual males and females. J Sex Med 2011; 8: 783–791.
- 19Bockting W, Benner A, Coleman E. Gay and bisexual identity development among female-to-male transsexuals in North America: Emergence of a transgender sexuality. Arch Sex Behav 2009; 38: 688–701.
- 20Meier SC, Pardo ST, Labuski C, Babcock J. Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Arch Sex Behav 2013; 42: 463–474.
- 21Bailey JM, Zucker KJ. Childhood sex-typed behavior and sexual orientation: A conceptual analysis and quantitative review. Dev Psychol 1995; 31: 43–55.
- 22Singh D. A follow-up study of boys with gender identity disorder. Unpublished doctoral dissertation, University of Toronto, Toronto, Ontario, 2012.
- 23Steensma TD, McGuire JK, Kreukels BPC, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. J Am Acad Child Adolesc Psychiatry 2013; 52: 582–590.
- 24Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender dysphoric children. J Am Acad Child Adolesc Psychiatry 2008; 47: 1413–1423.
- 25Lee T. Trans(re)lations: Lesbian and female to male transsexual accounts of identity. Women's Stud Int Forum 2001; 24: 347–357.
- 26Cohen-Kettenis PT, Owen A, Kaijser VG, Bradley SJ, Zucker KJ. Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross-national, cross-clinic comparative analysis. J Abnorm Child Psychol 2003; 31: 41–53.
- 27Fagot BI. Consequences of moderate cross-gender behavior in preschool children. Child Dev 1977; 48: 902–907.
- 28Green R, Williams K, Harper J. Cross-sex identity: Peer group integration and the double standard of childhood sex-typing. In: J Samson, ed. Childhood and sexuality. Montreal: Editions Etudes Vivantes; 1980: 542–548.
- 29Wallien MSC, Veenstra R, Kreukels BPC, Cohen-Kettenis PT. Peer group status of gender dysphoric children: A sociometric study. Arch Sex Behav 2010; 39: 553–560.
- 30Zucker KJ, Wilson-Smith DN, Kurita JA, Stern A. Children's appraisals of sex-typed behavior in their peers. Sex Roles 1995; 33: 703–725.
- 31Shiffman M. Peer relations in adolescents with gender identity disorder. Unpublished doctoral dissertation, University of Guelph, Guelph, Ontario, 2013.
