Sex Ratio Flipped: Toronto and Amsterdam Teen Gender Clinics Saw Girls Outnumber Boys From 2006

Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria

Cohort & registry studies Rising diagnoses & social influence

Authors: Madison Aitken, Thomas D. Steensma, Ray Blanchard, Doug P. VanderLaan, Hayley Wood, Amanda Fuentes, Cathy Spegg, Lori Wasserman, et al.
Journal: The Journal of Sexual Medicine
Year: 2015
Source: https://doi.org/10.1111/jsm.12817

Summary

Researchers from gender clinics in Toronto and Amsterdam checked whether the mix of boys and girls referred for gender dysphoria in their teens had changed. Across 748 referrals, both clinics showed the same pattern. Before about 2006 more teens born male were referred. From 2006 to 2013 teens born female clearly outnumbered them. Among Toronto teens referred for other mental health problems, the balance of boys and girls hardly moved, suggesting something specific to gender referrals. Referral numbers also rose steadily. This was one of the first published reports of the shift later seen around the world. It reliably shows a change in who was referred to two clinics, but cannot say why. The authors suggested social and cultural reasons, but did not test them.

Key findings

The study looked at 748 teenagers referred for gender dysphoria to clinics in Toronto (328 teens, 1976–2013) and Amsterdam (420 teens, 1989–2013).
In Toronto, 1999–2005 saw about 2 boys referred for every girl (36 boys, 17 girls). In 2006–2013 this flipped to about 1.8 girls for every boy (73 boys, 129 girls).
In Amsterdam, 1989–2005 saw 1.4 boys for every girl (109 boys, 77 girls). In 2006–2013 it flipped to 1.7 girls for every boy (86 boys, 148 girls).
Among Toronto teens referred for other problems, the balance barely changed (about 2.2 boys per girl, then 2 boys per girl), so the shift was specific to gender referrals.
Toronto referral numbers rose strongly year after year between 1976 and 2013.
In Toronto, the share of teens born female who were not attracted only to females rose from 11.4% before 2006 to 36.0% in 2006–2013.
The authors suggested social and cultural reasons for the flip, but did not test them.

Abstract

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.

Conclusion

In both the Toronto and Amsterdam clinics the sex ratio of adolescents referred for gender dysphoria inverted from favouring natal males before 2006 to favouring natal females in 2006–2013, with no matching change among adolescents referred to the Toronto service for other clinical problems. The authors offer sociological and sociocultural explanations for this recent inversion.

Methodological limitations

Counts referrals, not how common dysphoria is: Referral numbers reflect who seeks help, public awareness, referral routes and clinic capacity. They cannot show how many young people in the population have gender dysphoria.
Only two clinics: Results from Toronto and Amsterdam may not apply to other clinics or countries, though later reports from other clinics found similar shifts.
Cut-off chosen after seeing the data: The 2006 dividing line was picked by looking at the data, and the earlier periods differ between clinics (1999–2005 in Toronto, 1989–2005 in Amsterdam).
Small numbers in the early period: Toronto's 1999–2005 group had only 53 teens, so the starting ratio is imprecise.
Explanations not tested: The social and cultural reasons the authors suggest are guesses. The study collected nothing on social media, friends' influence, other mental health conditions or other possible causes.
Little clinical detail: The analysis covers mostly sex, age, year of referral and sexual orientation. It has no information on other mental health conditions, when dysphoria began, diagnosis or what happened later.
Sexual orientation recorded by clinic staff: Attraction was categorised in clinic records, and how this was recorded may have changed over the decades.
Data end in 2013: The study comes before the steepest rises later reported by many clinics, so it only captures the start of the trend.

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Summary

Key findings

Abstract

Conclusion