Clinics that treat gender nonconforming youth have noticed two clear trends over the past 20 years or so. First, the number of total youth seeking treatment has steadily increased: What began as a tiny trickle of patients from the 1970s through the ’90s saw an uptick in the early 2000s and has become a steady stream of cases today. Second, during the post-2000 period, the gender balance of youth seeking treatment seems to have changed. According to anecdotal reports from clinicians and a handful of small studies of transgender youth, trans youth clinics in North America and Europe have seen a shift from a majority of transfeminine patients (assigned male at birth) to a majority of transmasculine patients (assigned female) now. In contrast, studies of adult trans patients thus far have either documented a majority of trans women or roughly equal numbers of trans women and trans men.
Why has the ratio of transfeminine to transmasculine youth seeking treatment changed, and what does this shift mean? Unsurprisingly, the opponents of transgender rights have a theory: Blogs from this contingent weave a story that transness is a social mania that seeps into the minds of young “girls” and, Svengali-like, causes them to believe that they are trans. Of course, devotees of science and research-based medicine don’t have the same freedom to take an interesting phenomenon and spin a conspiracy around it. Still, it’s worth asking what we actually know about the changes in who is seeking treatment for gender dysphoria, and what experts in transgender medical care think that a shift might signal.
Dr. Johanna Olsen-Kennedy works with gender nonconforming and transgender children and youth at Children’s Hospital in Los Angeles, the largest transgender youth clinic in the U.S. “I’m not sure I’ve specifically read any research related to a shift in gender balance, but I feel like it’s a very common anecdotal report from most clinics that work with trans youth,” she explained, continuing:
There have been soft papers, observational papers, describing more people presenting for care at a younger age. At our clinic, the balance was about 50/50 when I started [7-8 years ago], and it’s shifted to be maybe 65-to-70 percent transmasculine today. We also see a different trajectory for our transfeminine and transmasculine patients, such that more of the younger kids under 12 are transfeminine/trans girls, and then we see transmasculine patients coming in for care at or slightly after pubertal development. This is unfortunate because what happens is, because of the age, it’s often dismissed as just an adolescent phase.
Olsen-Kennedy speculates that genital dysphoria may be more common in young trans girls because a penis is such a central part of what society associates with being a man. She thinks dysphoria in young trans men might be more likely to show up around puberty because we culturally associate breasts and menstruation so closely with women. However, she stressed that there’s much more research to be done on transgender people in general and trans youth in particular, and that we shouldn’t be reading too much into who clinics see regarding the larger trans population, especially during a time when information about transgender people and access to care is expanding rapidly.
“When you look at the earlier studies [of the make-up of adult trans populations], what you see is that they’re collecting data on genital surgery,” Olsen-Kennedy explained. “But the reality is that it’s easier to surgically create a vagina than it is a penis—there’s just no way of knowing how many trans men there always were that studies missed.”
Dr. Joshua Safer is the director of the Endocrinology Fellowship Training Program at Boston Medical center and an associate professor at Boston University School of Medicine whose research focuses on the biological underpinnings of gender identity. While he’s heard the arguments suggesting that a shift in gender balance at clinics serving trans youth means that children are being pushed into being trans, he’s emphatic that there’s no evidence to support the idea that a person’s gender identity can be changed.
“I know that parents out there think ‘If I let my kid experiment then somehow my kid will brainwash himself or herself to go down this challenging path,’ ” he said. “But if your kid’s not trans, they won’t end up identifying as trans. One of the big things I push is that the evidence is for gender identity being biological—as scientists we should be thinking about it as, okay, the biology is what it is, and so then what’s the treatment approach?”
Safer is one of the authors of a 2015 literature review published in Endocrine Practice that concluded that, although the mechanism that determines gender identity isn’t known, there are multiple sources of evidence all leading toward the conclusion that gender identity is biological and fixed rather than social and capable of being changed. While he finds the question of why clinics are seeing more transmasculine youth interesting, he does not believe it sheds any light on the deeper issue of why some people are transgender in the first place.
There are many reasons why the early history of treatment for trans youth may have brought in more trans girls than trans boys. Treating gender diversity in children and adolescents is a relatively new field, and its history mingles with that of early efforts to cure homosexuality and effeminacy in boys. In the 1950s and ’60s, curing homosexuality and preventing what was then called transsexualism was the stated goal of practitioners who worked with youth we might now consider trans or potentially trans. This changed very slowly, and as the existence of successfully transitioned trans people slowly trickled out into the public sphere, the cases that were covered in the press were almost universally trans women, not trans men.
At the same time, boyish behavior in female-assigned children, including dressing as boys, was far less stigmatized than femininity or cross-dressing in those assigned male. The lack of any information in the public about medical treatment options for trans men, combined with the social release valve of being more easily able to dress in male clothing, might account for why clinics that offered medical treatment were seeing many more trans women before awareness of trans men began to spread. There may be other reasons, or a variety of factors that contributed to the recent shift. Both Safer and Olsen-Kennedy stressed that although understanding why clinics are seeing more transmasculine youth is an interesting scientific question that merits further study, individual and family decisions should be made on a case-by-case basis.
So should we, ultimately, care one way or the other about a trend towards a higher proportion of transmasculine youth seeking treatment in clinics that do this work? For individual trans people, the question of how and when and why people seek treatment for gender dysphoria is largely irrelevant to our personal decisions about our own medical care. For trans people who are in distress, the first concern should be treating that distress in ways that are ethical and take the most up to date research into account.
On a macro level, however, questions about how and when and why trans people seek treatment are very important—but not because a shift in the numbers undermines the validity of trans identities. They’re important because trans people’s ability to seek treatment is impacted by all sorts of factors, including proximity to providers, familial support, and internalized transphobia. The numbers of trans people seeking treatment has been increasing across the board, but we know that there are many trans people who are still unable to access care. Knowing more about who’s coming in to clinics may lead to understanding more about who is still slipping through the cracks, and that information can be used to help more trans people get the treatment they need.