Earlier
this year, a team of NHS researchers was asked to investigate why there has
been such a huge rise in the number of adolescent biological girls seeking
referrals to gender clinics.
The figures
alone do seem remarkable.
According
to a study commissioned by NHS England, 10 years ago there were just under 250
referrals, most of them boys, to the Gender Identity Development Service
(Gids), run by the Tavistock and Portman NHS foundation trust in London.
Last year,
there were more than 5,000, which was twice the number in the previous year.
And the largest group, about two-thirds, now consisted of “birth-registered
females first presenting in adolescence with gender-related distress”, the
report said.
The review
team is looking into the causes behind “the considerable increase in the number
of referrals” and the changing case mix, but is not expected to publish any
findings until next year.
Meanwhile,
clinicians and parents are trying to make sense of it themselves.
Over recent
months, the Guardian has interviewed 11 parents of gender-questioning
adolescent biological girls (some of whom have transitioned to become trans
boys), and six paediatricians and child psychiatrists, to discuss their views
and experiences. For many of them, it has been a difficult and emotionally
draining time.
Their
testimony reflects the lack of consensus within the medical profession about
how best to proceed if a child experiences gender dysphoria – and, in turn, how
this confusion contributes to the central dilemma faced by concerned parents:
how should they support their child during what may be the most challenging
period of their lives?
Do they
accept them changing their name, gender and pronouns at home and at school and
investigating medical options, or should they try to help their child to accept
their natal sex?
While some
parents said they had embraced their child’s decision and welcomed the societal
changes that had made this step possible, others felt confused by their child’s
desire to change their body.
Several
parents said they had been relaxed when their daughters initially began
identifying as non-binary, but became uneasy when they said they wanted to take
puberty blockers or cross-sex hormones and began binding their breasts.
Some spoke
of their anxiety and uncertainty about how to respond, particularly when their
child was unhappy.
The mother
of one girl who came out as trans at the age of 12 said it was “very difficult
to describe the feeling of being the parent of a trans-identified child”.
This mother
feared they were heading towards medical intervention that might prove
unnecessary. “As she got older … we had less control. Living with that fear is
one of the toughest experiences I’ve had.”
(Her child,
who recently started university, now describes herself as non-binary and uses a
gender-neutral name, but is happy to be referred to as she, and is no longer
seeking medical treatment.)
The
uncertainty parents felt was compounded by the highly polarised debate – within
the NHS, politics and the media – about how parents and professionals should
respond to children who express distress about their gender.
“We were
terrified of being accused of being bigoted,” said the woman, who asked to
remain anonymous to protect her child’s privacy.
“We felt we
were expected to accept her decision unhesitatingly. I felt so apologetic that
I was questioning whether my miserable teenage daughter was genuinely a boy,”
she said.
An ‘explosion’ in referrals
The rise in
the number of biological girls seeking referrals to Gids was set out in an
interim report by Dr Hilary Cass, the paediatrician commissioned to conduct a
review of the services provided by the NHS to children and young people
questioning their gender identity.
The trend
was confirmed by clinicians who spoke to the Guardian.
“In the
past few years it has become an explosion. Many of us feel confused by what has
happened, and it’s often hard to talk about it to colleagues,” said a
London-based psychiatrist working in a child and adolescent mental health unit,
who has been a consultant for the past 17 years.
Like all
NHS employees interviewed, she asked for anonymity due to the sensitivity of
the subject.
“I might
have seen one child with gender dysphoria once every two years when I started
practising. It was very niche and rare.” Now, somewhere between 10% and 20% of
her caseload is made up of adolescents registered as female at birth who
identify as non-binary or trans, with just an occasional male-registered
teenager who identifies as trans.
Another
senior child psychiatrist said girls who wanted to transition made up about 5%
of her caseload.
“In the
last five to 10 years we’ve seen a huge surge in young women who, at the age of
around 12 or 13, want to become boys. They’ve changed their name and they are
pressing … to have hormones or puberty blockers”
The
psychiatrist added: “Often those girls are children who are going through the
normal identity and developmental problems of adolescence and finding a
solution for themselves in this way.”
Greater
awareness of trans issues is likely to be one common-sense explanation for the
rise in requests for referrals.
“In the
same way, increased visibility and acceptance of trans people has led to a
gradual increase in young people who feel comfortable expressing their trans
identity. The most important thing is to recognise that this is not a problem
to be solved or a bad outcome to be avoided.”
The mother
of a 17-year-old A-level student (who came out as trans at 13, leaving a
handwritten letter for his parents on his bed) agreed: “It’s discussed so much
more – on Facebook and on social media. It’s no longer a taboo.”
She is
confident this was the right decision for her child. “I think I wondered if
this was a phase, but I didn’t look to dissuade him. As he began to socially
transition he was a different person. It has made him happier,” she said.
Her trans
son has a weekend job to pay for his private testosterone prescription, because
the NHS waiting list is too long, and the family is saving up for the £6,000
cost of breast removal.
“He would
like to get it done as close to his 18th birthday as possible, so he can start
afresh at university.”
Increased
awareness may well be a factor. But most of the research in this field has been
based on predominantly birth-registered males – not females.
The Cass
report explained that relatively little was known about the causes of gender dysphoria
in girls, or the outcomes for those who received treatment.
“At
present, we have the least information for the largest group of patients –
birth-registered females first presenting in early teen years,” it said.
“Since the
rapid increase in this group began around 2015, they will not reach late 20s
for another five-plus years, which would be the best time to assess longer-term
wellbeing.”
The NHS
review will help to shine some light on this issue – but it may be years before
a clear picture emerges.
Silence, disagreement and polarisation
The dilemma
for parents has hardly been helped by the confusing guidelines.
They are
puzzled by the conflicting advice they get from doctors and trans rights groups
about what their child may be going through.
Could it be
a temporary exploration of gender identity, potentially the manifestation of
other forms of distress? Or is it an innate experience for which treatment is
required?
The Cass
report revealed there was “a lack of agreement, and in many instances a lack of
open discussion” about the best approach to take.
“The disagreement and polarisation is
heightened when potentially irreversible treatments are given to children and
young people, when the evidence base underlying the treatments is
inconclusive,” it added.
Anyone
looking for clarity from NHS England’s most recent draft guidelines on how to
support under-18s experiencing what it calls “gender incongruence” may not find
it helpful.
Published
in October, the draft seems to put greater emphasis on the possibility that,
for some, particularly pre-pubescent, children, this may be a “transient
phase”.
It also
suggests it is not a “neutral act” to help children transition socially (by
using preferred names and pronouns) while they explore their gender identity,
and stresses that more research is needed to “gather further evidence on the
safety, potential benefits and harms” of puberty blockers.
In terms of
practical advice, it does not go much beyond that.
Many of the
parents who spoke to the Guardian admitted they struggled with the uncertainty
involved, even in cases where they acknowledged that medical transition may be
the correct outcome for some adolescent girls with gender dysphoria.
The
Tavistock stresses that there is no set treatment pathway, and only about 20%
of those referred to the service go on to be prescribed puberty blockers or
cross-sex hormones on the NHS (although long waiting lists mean some people
seek treatment in the private sector, or will receive treatment only when they
have progressed to adult NHS services at 18). Parental confusion has been
heightened by NHS England’s announcement in July that the Tavistock’s gender
identity clinic would close next year and be replaced by new regional centres.
This happened after the Cass review said the current model, with its long
delays, was leaving young people “at considerable risk” of poor mental health
and distress, and that having one clinic was not “a safe or viable long-term
option”.
Parental anxiety: ‘We went from nothing to
everything in three months’
With little
research to draw upon, no consensus among clinicians and confusing guidelines,
parents have differing explanations for what might have prompted their child’s
desire to identify as male.
Some point
to puberty, periods and unease with a changing body shape coinciding with the
interest in becoming gender non-conforming.
Others have
questioned whether their child’s autism might be a relevant factor. (The Cass
report stated that approximately one-third of children and young people being
referred to the Tavistock had autism or other types of neurodiversity.)
Possible
influences they cite include childhood bullying, sexual harassment and abuse
and the hyper-sexualisation of society, or a child’s early understanding of
sexism, making them feel it may be easier to live as a man than as a woman.
Some
believe the extended isolation children experienced during Covid is relevant
(for example, Google searches for “top surgery”, double mastectomies, soared
during this period).
Many are
aware of online content that has educated their children about gender, and of
the influence of YouTubers, Tumblr accounts and TikTok personalities where
individuals’ medical transitions are documented in detail (footage of
recoveries from double mastectomies and phalloplasty, or “bottom surgery”, has
been watched by hundreds of thousands).
A
20-year-old medical student who came out as a trans boy at 16, having told his
parents the year before that he was a lesbian, and who spent £8,000 on private
breast removal earlier this year, said the realisation was “a lightbulb
moment”. He had watched a lot of YouTube content on LGBTQ+ issues.
“From
watching that I was able to educate myself. I’d always felt that something was
not right. Everything made much more sense afterwards,” he said. His parents
were “incredibly supportive”.
But some
parents have been frustrated by the speed with which schools have adopted their
child’s new identity, without parental consent, uncertain about the
implications.
One father,
whose child came out as a trans boy three years ago at the age of 11, with the
approval of his estranged wife, said he had initially supported the decision.
However, had become increasingly sceptical about whether it was helping his
child. He said he felt disconcerted by the school’s readiness to adopt the
child’s male identity before any specialist assessment had occurred.
“We went
from nothing to everything in three months. I know now that a lot of the
explanations of what they were feeling came from an internet script. All my
concerns were minimised,” he said. “Everyone told me it was a totally benign
step to change names, and pronouns.
“The
school’s position was: ‘If you say you are a boy, you’re a boy,’” he said. “At
the time I was shocked, but I trusted them that it was a good idea.”
He
struggles with the new pronouns but agreed to the new male name, and
reluctantly bought, at the 11-year-old’s request, a crocheted penis and
testicles to wear inside their underwear.
“I’ve said
no to a chest binder and puberty blockers. I kept asking: ‘What’s wrong with
being a girl? What problem are we trying to fix?’” He said he believes the
decision was triggered by severe bullying in primary school, undiagnosed autism
and a few influential YouTubers.
“She’s
interested in boys now and describes herself as a gay boy. None of this has
made her happier.”
“We said:
‘OK, no matter what, we love you,’ and tried to be very neutral about it. She
told me she wanted to go to the GP to get a referral to the Tavistock, so we
went and we were referred. I was absolutely fine with gender non-conformity.”
But her
views on social, medical and surgical transition evolved as she did more
research. She said no when her child asked to speed up the process by going
private, which would have allowed them to start puberty blockers.
“My
daughter has barely spoken to me for three years because I haven’t continued
with the referral process. Parents are in a very difficult position.”
Two years ago, a grassroots support group started campaigning for “evidence-based care”. Called Bayswater Support, it now represents the parents of about 500 trans-identified adolescents – and its membership is growing rapidly.
The group
says around 70% of the children it represents were registered as female at
birth; 80% experienced bullying prior to identifying as trans and more than 50%
had come out as lesbian, gay or bisexual.
A
spokesperson said: “Our members commonly describe their child’s trans identity
as overshadowing factors such as poor mental health, neurodevelopmental
conditions like autism and ADHD, social factors like bullying and not fitting
in with their peer group, emerging same-sex attraction, serious safeguarding
issues – and often puberty itself.”
‘Trans kids weren’t as hotly debated then, it
was much less politicised’
There is
one thing that all sides on this debate would probably agree on: the increased
scrutiny of the subject has made life much harder for trans adolescents and
their families.
A
29-year-old charity worker who transitioned 13 years ago, in the summer after
sitting GCSEs, told the Guardian: “Trans kids weren’t as hotly debated then, it
was much less politicised. Trans people didn’t have that level of visibility –
and that might be seen as a negative, but it also meant that trans people were
left alone.”
He said he
now tried to avoid reading newspaper reports, and was suspicious of the
research into what might be causing an increase in the number of biological
girls wanting to identify as boys.
“I would
guess it’s because trans people are more able to find other trans people.
Research into the cause of a marginalised identity can make you feel nervous.
It makes me wonder: why would you want to ask that question?”
He said his
mother was very supportive of his decisions, and they had attended a summer
residential camp organised by the charity Mermaids. She paid for a private referral
and supported him through medical transition, including cross-sex hormones, a
hysterectomy and double mastectomy.
“Now she
talks to other parents to help them understand that if your child comes out as
trans, their life will be fine with the right support. I have a flat, a
partner, a good job – it is not all doom and gloom. Trans kids turn into trans
adults, and that’s fine. Of course there’s anxiety because it’s an unknown, but
keep talking.”
He said
that now he barely thinks about the process of transitioning, and does not have
an easy answer to what it means to be a man.
“I can’t
tell you, and I think if you asked my [male] partner, he wouldn’t know either.
I’m very comfortable living as a guy, I’ve done that for 15 years.”
Case studies
A
20-year-old student who describes herself as trans-adjacent spent five years
living as a boy, from the age of 13. She hadn’t had many close friends at
primary school and had been diagnosed with autism when she was 12. She spent a
lot of time on Tumblr following trans groups and became close to a friend at
her girls’ school who also came out as trans. Shortly after she came out as
trans, a third person in the year also came out; the two others have
subsequently medically transitioned, but she has decided not to.
“I don’t
know how much of it is because I am autistic. I felt I didn’t fit in with any
of the girls,” said the student, who now uses a gender-neutral name but said
she was happy to be described using she/her pronouns. She didn’t initially want
to tell her mother she was trans because of a misunderstanding they had when
she came out as gay at the age of 12.
“My mum
said: ‘That’s fine, but you’re too young to know.’ I think now what she was
trying to say was: ‘No matter what, we will accept you, but you’re really
young, you don’t need to worry about what box you’re in.’
“I think
then I took it much too literally. So I didn’t talk to her about being trans at
the start.
“I was
really struggling in secondary school. I think being a girl is hard for a lot
of people when you are going through puberty and you are really unhappy. It’s
quite easy to want to escape from that.”
She was on
antidepressants. Her parents began the process of a referral to the Tavistock,
but decided against pursuing it.
“I started
binding with duct tape because I didn’t have access to a breast binder. I
wanted my chest to be flat. I slept with it. It helped me alleviate a lot of my
distress. I still have pain in my ribs. I identified as trans masculine, as a
trans man.
“I wasn’t so obsessed with being referred to
as male but I did want the school to use he pronouns.”
She said:
“I think there might be people who identify as trans, who were like me, who
were just unhappy, and there are others who are just trans. There are people
who have medically transitioned and for whom that is completely the right
option. Trans people have existed for a very long time.”
The mother
of a 20-year-old trans student said the process had been stressful but, on
balance, she believed her child had become happier.
“My son, who was then my daughter, came out as a lesbian at 13 or 14. After they turned 15 my husband and I were called into school by my child’s year head, and it turned out to be for an announcement that my daughter was now my son. I think the meeting was done that way because my son was concerned particularly about how his dad would react, and he needed there to be other people there. His dad’s reaction was quite hostile. He said that, for one thing, my son was being ridiculous, and for another thing, about to ruin his life.
“I didn’t
understand everything, but I wanted to support him. I didn’t feel I should
interfere in my son’s treatment. Instead I got involved in helping him with the
practicalities of getting his name changed, speaking to the school about
toilets and changing rooms. He went on testosterone at 18. I don’t think he
will have surgery; the thought of it makes him quite anxious so I’m not sure
how actively he wants to pursue it. In any case he has passed as male for quite
some time now.”
She said
the increased awareness of trans issues via the media made it easier for
children who might be trans to communicate with others. “In the 90s, when trans
people began to be presented in the media it was very much done for shock
value. Things have changed since then.”
She said
the process had been stressful. “But in the end I realised that people make all
sorts of decisions in their lives that have long-term, knock-on effects that
can’t be imagined at the time the decision is made. I think transitioning has
been a positive step for my son. His mental health is much improved – he
socialises now rather than just hiding away.”
‘An
explosion’: what is behind the rise in girls questioning their gender identity?
By Amelia Gentleman. The Guardian, November 24, 2022.
A year
after moving to Bridge City, Texas, 8-year-old Samuel Kulovitz thought his life
couldn’t get any worse. He had made no friends in the swampy oil refinery town
and spent most of his time in his family’s mobile home. He missed Florida and
playing on the beach there with other children.
Then, at
age 11, Kulovitz started venturing onto social media. There, he came across a
cosplayer on Tumblr who said he realized he was a transgender boy from the
euphoria he felt while dressed as the hero of an online comic. Kulovitz was
transfixed. “I kept asking myself, ‘Why do you want to look like him?’” he told
Reuters. In the online community where Kulovitz spent more and more time, he
adopted the pronouns “he” and “him,” and he liked it.
When his
mother learned of his transgender identity, she was supportive and enrolled him
in therapy. He was diagnosed at age 12 with gender dysphoria, the distress that
comes from identifying as a gender different from the one assigned at birth.
Two and a
half years later, Kulovitz started on the hormone testosterone. He was thrilled
as he grew facial and chest hair, his voice dropped, and his menstrual periods
stopped.
Still, his
breasts were a constant source of distress, and his body ached from wearing a
chest binder. “I always thought, ‘I wish I could get rid of them,’ ” Kulovitz
said.
One day
during his junior year of high school, Kulovitz, then 16, was scrolling on his
phone when the TikTok account of a Miami surgeon who offered to “yeet the
teets” of young transgender people popped up. In videos with hip-hop music
playing in the background, Dr Sidhbh Gallagher provided detailed information
about top surgery to remove or modify breasts and displayed photos of her
satisfied gender-diverse patients, most of them young people, with shirts off
to show the results of the doctor’s work. “Come to Miami to see me and the rest
of the De Titty Committee,” she said in one of the videos.
Six months
later, in June 2021, Kulovitz was in Miami with his mother, who gave consent
for her son’s surgery and paid $10,000 out of pocket for it. He also had the letters
of support Gallagher required from his therapist and doctor. When Kulovitz woke
up after the procedure, “I felt euphoric,” he said. “I finally felt right in my
body.”
A question of influence
Thousands
of children who, like Kulovitz, were assigned female at birth have sought
gender-affirming care in recent years. And for reasons not well-understood,
they significantly outnumber those assigned male at birth who seek treatment.
As Reuters
reported in October, a growing number of the children receiving care at the
100-plus gender clinics across the United States are opting for medical
interventions – puberty-blocking drugs, hormones and, less often, surgery. And
they are doing so even though strong scientific evidence of the long-term
safety and efficacy of these treatments for children is scant.
That has
led to a split among gender-care specialists: those who urge caution to ensure
that only adolescents deemed well-suited to treatment after thorough evaluation
receive it, and those who believe that delays in treatment unnecessarily
prolong a child’s distress and put them at risk of self-harm.
The
outsized proportion of adolescents seeking treatment to transition from female
to male has sparked parallel concerns. Professionals in the gender-care
community agree that treatment of all transgender children should be supportive
and affirming. The question, for some, is whether peer groups and online media
may be influencing some of these patients to pursue medical transition, with
potentially irreversible side effects, at a time in their lives when their
identities are often in flux.
Corey
Basch, a professor of public health at William Paterson University in New
Jersey who researches health communication and teens’ use of social media, said
she fears that some adolescents are susceptible to making faulty self-diagnoses
without adequate input from medical professionals. “Teens are so incredibly
vulnerable to information overload and being pushed in one direction,” Basch
said. “They could be lacking the analytical skills to question who is giving
this advice and if their advice is valid.”
Adolescents
assigned female at birth initiate transgender care 2.5 to 7.1 times more
frequently than those assigned male at birth, according to the World
Professional Association for Transgender Health (WPATH), a 4,000-member
organization of medical, legal, academic and other professionals. Several
clinics in the United States told Reuters that among their patients, the ratio
was nearly 2-to-1, and similar phenomena have been documented in Europe, Canada
and Australia.
Not all of
these patients receive medical treatment. Their gender-affirming care may
entail adopting a name and pronouns aligned with their gender identity. It may
include counseling and therapy. But an increasing number are opting to take
hormones and have top surgery.
In October,
researchers at Vanderbilt University School of Medicine published a paper
showing a 389% increase in gender-affirming chest surgeries performed
nationally from 2016 to 2019 on patients under age 18. The total of 1,130
procedures during the period, nearly all of them for chest masculinization,
represents a weighted estimate based on records from more than 2,000 U.S.
medical facilities. Likewise, at least 776 chest masculinization surgeries were
performed on patients ages 13 to 17 with a gender dysphoria diagnosis over the
past three years, according to U.S. insurance claims analyzed for Reuters by
health technology company Komodo Health Inc. This is probably an undercount
because it does not include procedures paid for out of pocket.
The
predominance of patients assigned female at birth is a reversal from the past.
For years, when very few minors sought gender care, those assigned male at
birth accounted for the majority. But about 15 years ago, that began to change
as care became more accessible and the overall number of patients started
climbing, according to studies and interviews with gender-care specialists.
For
example, at Amsterdam University Medical Center’s gender clinic, a pioneer in
adolescent gender care, the proportions flipped. From 1989 to 2005, 59% of its
adolescent patients were assigned male at birth, the Dutch clinic reported in a
2015 study published in the Journal of Sexual Medicine. Since 2016, about 75%
of the clinic’s patients have been youths who were assigned female at birth.
A diversity of identities
Advocates
of transgender rights and clinicians who treat adolescents see nothing out of
the ordinary in the trend. While transgender children face significant
prejudice and threats of violence, they say, increasing social acceptance of
transgender identity has encouraged more children to seek treatment. At the
same time, this reasoning goes, society is generally less accepting of what it
deems an effeminate boy than of a masculine girl, and the greater stigma that
those assigned male at birth face may make them less likely to pursue
treatment, reducing their share of the patient population.
These
children may not necessarily identify as transgender, but more broadly as
gender diverse. A growing list of terms reflects this diversity of gender
identities: agender, nonbinary, gender fluid, polygender, demiboy and demigirl.
“There’s been an explosion in the
gender-expansive model,” said Dr Michelle Forcier, a professor of pediatrics at
Brown University’s Alpert Medical School who has specialized in the care of
transgender and gender-diverse patients. “Folks may feel freer and safer to
express and take on a more diverse identity because the social conversation has
been put out there.” For these patients, she said, “the moral and ethical thing
to do is to give them a list of options that might help them achieve their
gender goals.”
But other
gender-care providers and some parents are skeptical. In interviews with
Reuters, they expressed worry that some adolescents assigned female at birth
may be dealing with significant mental health issues in addition to questions
about their gender identity, or may be seeking to transition as a refuge in a
culture of internalized misogyny, body hatred and early sexualization of girls.
“Girls have
a harder time with the physical and emotional changes that come with the onset
of puberty,” said Dr Erica Anderson, a clinical psychologist, transgender woman
and former board member of WPATH. “And I think there is an element of truth
that males have it better in many quarters of society than females.”
For all
children, experts say, adolescence is a search for identity, when they try on
various personas, appearances and interests and move beyond family to seek
validation from peers. Anderson, who treats transgender and gender-questioning
youth in her private practice in Berkeley, California, said she’s concerned
that medically transitioning has become the default choice for too many girls
who are uncomfortable with their bodies, struggling to fit in socially or
dealing with mental health issues.
“Kids do
try things on and not everything sticks. They experiment,” she said. “I do not
believe that we have an obligation to accept at face value everything a young
person says to us.”
Anderson
and other clinicians say the danger is that adolescents receive medical
treatment, do not experience relief from their distress, and perhaps end up
regretting the irreversible results of hormone therapy and top surgery.
Treatment guidelines issued by WPATH and other medical groups rely heavily on
research from the Netherlands that studied children who exhibited persistent
gender dysphoria from an early age and who had no serious psychiatric issues
before receiving puberty blockers, hormones or surgery.
The good and the bad
The role of
peer influence and social media looms large in discussions about the gender
imbalance among transgender youth patients.
In recent
years, young transgender people have enthusiastically embraced social media to
tell their stories. On platforms such as TikTok and Instagram, young people
receiving gender treatment regularly share with followers – sometimes numbering
in the tens of thousands – details about taking medications and having surgery.
Their presence is augmented by doctors who use social media to communicate
directly with potential patients.
Many
patients, like Kulovitz, and doctors who treat them say social media can be a
source of helpful advice and information for minors questioning their gender
identity and can reduce their isolation by connecting them to others with
similar experiences.
But some
prominent clinicians also say that along with those benefits, social media may
lead some youths to mistake mental health problems or uncertainty about their
identity for gender dysphoria.
In its new
Standards of Care, published in September, WPATH acknowledged for the first
time that “social influence” may impact an adolescent’s gender identity. The
organization recommends that youths undergo an in-depth evaluation in part so
that clinicians “can discern between a person’s gender identity that is marked
and sustained and an identity that might be socially influenced,” according to
Dr Eli Coleman, director of the University of Minnesota Medical School’s
Institute for Sexual and Gender Health who oversaw the update of WPATH’s guidelines.
Some
patients may see others touting huge improvements in their quality of life
after transitioning, and so they think, “‘I’m having these same problems, and
transitioning to a different gender will help me feel better,’” said Dr Laura
Edwards-Leeper, a clinical psychologist in Oregon who specializes in treating
transgender children. She was a co-author of WPATH’s new Standards of Care for
adolescents.
Parents of
40 gender-diverse children told Reuters they were concerned that their children
came out only after they hit puberty, often at the same time as their friends
and after their use of social media had increased. For many, their worries were
compounded when clinicians swiftly affirmed their childrens’ transgender
identities and recommended medical intervention without fully assessing whether
other potential underlying causes of distress were present.
Kelly, a
43-year-old parent who asked that her full name not be used to protect her
family’s privacy, told Reuters that her child was heavily into highly
sexualized anime and transgender online forums when the 12-year-old started
experimenting, seemingly overnight, with being a transgender boy. The child’s
therapist encouraged medical intervention, Kelly said, but while Kelly
supported social transition outside the home, she made it clear that her child
would have to wait until she was 18 for hormones and top surgery.
After
several years of living as a boy and using “he” and “him” pronouns, Kelly’s
child, now 18, is back to using her female name, dressing in feminine clothing
and using “she” and “her” pronouns. “We would have lost our daughter if we had
followed what the therapist was telling us to do,” the mother said.
No
definitive research has established a link between social media use and gender
identity among youths. Still, gender-care experts say the possible influence of
social media and peer groups highlights the necessity of comprehensive
assessments before referring patients for medical treatment. The problem, they
say, is that some clinics, facing a flood of patients, lack the mental health
staff and patience needed to do such evaluations to determine whether a patient
has persistent gender dysphoria and that medical treatment is in their best
interests.
“These
evaluations are more important than ever,” Edwards-Leeper said, because “many
of these adolescents are learning about gender dysphoria for the first time
online or from friends.”
In Finland,
which was early to embrace gender care for minors, Dr Riittakerttu Kaltiala,
chief psychiatrist at the Tampere University Hospital Department of Adolescent
Psychiatry, noticed a few years ago that the profile of patients seeking to
medically transition was shifting. Many showed no signs of gender dysphoria
until puberty, were mostly assigned female at birth – reaching 90% of patients
by 2017 – and often belonged to similar social circles in school and online. In
some cases, she said, patients described personal experiences with exactly the
same details.
That these
teens were possibly emulating each other didn’t bother Kaltiala. “That is
perfectly normal” in adolescence, she told Reuters. What did bother her was
that many of the teens had concluded quickly that they were transgender and
viewed their identity as fixed, attempting to cut short the process of identity
formation that typically lasts years.
She also
encountered a handful of young patients who regretted medically transitioning.
“They have said, ‘I was so sure that you could not have changed my mind. I was
so confident that this is the way, but nevertheless I think it was a mistake,’
” Kaltiala said. “I take that really seriously. It’s a horrible situation for
everybody.”
Her
concerns prompted a team of mental health professionals running Finland’s two
adolescent gender clinics to ask the country’s national healthcare council to
evaluate the evidence supporting youth gender care. In their request, they told
the board that clinicians were under growing pressure to make increasingly
complex medical decisions on treating transgender youths without enough
scientific or expert guidance.
In 2020,
the council concluded that “in light of available evidence, gender reassignment
of minors is still an experimental practice.” Now, psychosocial support is the
first-line treatment for most adolescents with gender dysphoria. Medical
interventions are possible in Finland on a case-by-case basis if, after
psychotherapy, the patient’s gender-related anxiety persists, personality
development appears stable and no severe mental health disorders would
complicate treatment.
Resisting the ‘fad’ narrative
Transgender
advocates and some doctors reject the idea that social media and peer influence
may play a role in the predominance of female-to-male transitions among
adolescent patients. They say that it feeds a dangerous transphobic myth, and
that opponents of gender care weaponize this false “fad” narrative to limit
children’s access to treatment.
“One of the
false narratives is that young people are being lured in and directed somehow
against their will to become transgender, which is not at all the case,” said
Dr Dan Karasic, professor emeritus of psychiatry at the University of
California San Francisco and lead author of the mental health chapter in
WPATH’s new Standards of Care.
He said
opponents of children’s gender care erroneously conflate young patients undergoing
medical treatment for persistent, longstanding gender dysphoria with “somebody
who has a text chat with someone and is left with some confusion about who they
are.”
Prisha
Mosley is one of several people who told Reuters that, in hindsight, they think
the medical professionals who helped them transition should have evaluated them
more thoroughly and advised against medical treatments they now regret.
Starting in
her early teens, Mosley, who was assigned female at birth, struggled with
anorexia, anxiety and depression. She attempted suicide by drowning, and a
sexual assault added to her trauma.
Isolated
and miserable, she sought friends online, where she met a group of people on
Tumblr who told her that if she hated her body, felt suicidal and didn’t fit in
with her gender, she was transgender. “I wanted to do the treatment that would
fix that,” Mosley, now 24, told Reuters.
Mosley
socially transitioned, adopting a male name and pronouns and coming out to her
mother with a PowerPoint presentation.
But that,
as well as therapy and the help of a specialist in pediatric eating disorders,
did not ease her distress. In January 2015, she was hospitalized after cutting
her wrist with a knife, her medical records from Cone Health in Greensboro,
North Carolina, show.
Later that
year, Mosley said, a therapist diagnosed her with gender dysphoria after a
single visit. By July, Mosley began treatment with testosterone under the care
of her doctor at Cone. The hormone immediately boosted her energy, and her
appetite improved. But her depression and suicidal thoughts persisted.
Cone Health
spokesperson Doug Allred would not comment on Mosley’s case specifically. He
said the health system’s gender-affirming care is based on established
guidelines and provided to patients who undergo psychological assessment and
have parental consent. “An individual’s perspective about their
gender-affirming care can sometimes change,” he said.
Mosley’s
mother, Christine Bourgeois-Mosley, said that she struggled for years to accept
Mosley’s identity, but she consented to gender treatment because of her child’s
persistent suicidal thoughts. Mosley’s therapist, Shana Gordon, and her
physician at Cone, Dr Martha Perry, assured the family that it was the right
thing to do, both Mosley and her mother said. Gordon and Perry declined to
comment on Mosley’s care.
When Mosley
turned 18, she had surgery to remove her breasts. Her mother objected to the
surgery, but accompanied Mosley anyway. “What was I going to do, let her go by
herself?” Bourgeois-Mosley said.
Mosley said
the physical transition did not alleviate her depression; she continued to cut
herself. Her mental health began to improve only after several years of
behavioral therapy. At 22, she stopped taking testosterone and determined that
she regretted transitioning.
“I decided
that I didn’t want to be a woman before I had ever even experienced being a
woman,” said Mosley, who is now studying psychology at a community college in
Michigan. “Now I feel like I will never entirely know.”
Mosley
suffers from painful vaginal atrophy, marked by dryness and inflammation of the
vaginal walls, a common side effect of testosterone that she said she didn’t
fully understand when her doctor warned her about it. She is undergoing laser
treatments to remove the facial and body hair brought on by testosterone, and
she hopes to be cleared for breast reconstruction.
Mosley said
she wishes her doctors had focused more on her mental health instead of
endorsing her desire to change her body. “I just took the cure that was handed
to me,” she said, “and I ruined my life.”
The surgical route
The main
components of medical treatment for transgender youths are puberty blockers,
hormones and surgery. Clinicians say many adolescents seeking to transition
show up after the onset of puberty, making puberty blockers impractical.
Treatment for those assigned female at birth may start with testosterone. Over
time, the hormone can cause male-pattern baldness, high blood pressure, an
enlarged clitoris and the vaginal atrophy that plagues Mosley. The long-term
effects on fertility are unclear.
Some of
these young patients opt for surgery. When they do, it’s almost always top
surgery. A common bottom surgery they
would have – phalloplasty to create a penis – is expensive and has a high rate
of complications. Many hospitals do not perform genital surgeries on patients under
18.
Top
surgery, by comparison, is less complicated and less risky. Surgeons warn
patients about scarring, loss of lactation, possible loss of sensation in the
nipples, along with routine post-operative risks like slow wound healing.
Prices typically range from $5,000 to $30,000 or more. Some insurers cover the
procedure for gender dysphoria patients as young as 13.
Top surgery
is a particular target for opponents of gender care, who object to allowing
minors to undergo life-altering procedures at such a young age. Some children’s
hospitals and doctors providing top surgery have reported being harassed and
threatened online for treating adolescents.
After
receiving an “overwhelming number of violent threats” in August, Dr Scott
Mosser of the Gender Confirmation Center in San Francisco announced he had
paused accepting new adolescent patients for gender surgery. In a statement
posted on his website, Mosser said: “We are profoundly disturbed by the extent
to which misinformation, prejudice and fanaticism threaten trans, nonbinary and
gender expansive people’s access to life-saving care.”
Within the
gender-care community, top surgery is considered a safe and effective way to
alleviate a major source of anguish in transgender boys. WPATH’s new guidelines
say that chest dysphoria is associated with higher levels of anxiety and
depression in patients assigned female at birth, and that testosterone does
little to alleviate this distress. Without specifying a recommended minimum
age, the organization says top surgery “can be considered in minors when
clinically and developmentally appropriate.”
Floor
Hurlbert was a middle-school student in Connecticut when, around the start of
puberty, they began to suffer from severe chest dysphoria. Pained by their
appearance, Hurlbert avoided taking showers and removed a full-length mirror
from their room. Wearing a chest binder was uncomfortable and didn’t ease their
distress. “I knew people were looking at me and perceiving me in a way I didn’t
like,” Hurlbert said.
Hurlbert
wasn’t interested in taking testosterone. They only wanted top surgery, and
they got it soon after turning 18. “It was like a huge source of my mental
health issues were not there anymore,” said Hurlbert, now a 19-year-old college
student. “I could feel happy about myself and how I looked.”
Research on long-term outcomes for patients who undergo top surgery as minors is limited. In its guidelines, WPATH cites two small studies published in recent years that it says “demonstrated good surgical outcomes, satisfaction with results, and minimal regret during the study monitoring period.” Both studies followed up with patients an average of about 1.5 years after surgery.
A menu of options
Amid the
debate over whether social media is influencing adolescents to seek top
surgeries, some surgeons are using online platforms to tap rising demand for
the procedures.
Top Surgery
Specialists of New York City and Los Angeles has Instagram accounts that
feature photos of young people proudly displaying their scars after top
surgery.
Dr Tony
Mangubat, a Seattle plastic surgeon who has more than 200,000 followers on
TikTok @TikDocTony, often tags his posts with the hashtag “#teetusdeletus.” In
his videos, he answers questions like “What is the perfect age to have top
surgery?” (“My youngest patient was 15,” Mangubat replied) and “Hey Doc, how
old do I have to be to start T,” short for testosterone. (“You start T, really,
when you’re ready,” Mangubat responded, and advised patients to talk to their
doctors).
Top Surgery
Specialists and Mangubat did not respond to requests for comment.
Gallagher,
the doctor who performed Kulovitz’s top surgery, posts bare-chested selfies
from her patients – who often refer to themselves as “Gallagher guys” –
frolicking on sun-drenched beaches. She also posts images of parents standing
in the lobby of her Miami office next to their children, who wear unbuttoned
“nip-reveal shirts” that show their red incision scars. “Supportive moms are
the best!” Gallagher writes in photo captions.
Gallagher
describes to her 273,000 TikTok followers the options she offers for “designer”
chests. Top surgery can include torso
“masculoplasty” to smooth out feminine curves. For the nonbinary, Gallagher can
remove the nipples altogether: “No Nips, No problem,” as one post’s text
display puts it. And for the gender fluid, she offers “non-flat” surgery,
leaving enough breast tissue so that on some days patients can have a “perky
breast” with cleavage and on other days they can bind their breasts.
Half a
dozen of Gallagher’s patients who were minors when they got top surgery,
including Kulovitz, told Reuters they were very pleased with the results. They
also said they appreciated how Gallagher publicly champions their right to a
body that aligns with their gender identity.
Gallagher’s
marketing tactics have caught the attention of organizations critical of
gender-affirming care for minors. In February, five of these groups, made up of
parents, medical professionals and people who have detransitioned, filed a
complaint with the Federal Trade Commission, asking the agency to investigate
Gallagher over the way she communicates with young people on social media. The
complaint alleges that Gallagher and her medical practice are “engaged in
unfair, false and deceptive practices in the aggressive advertising and
marketing to minors of their plastic surgery services, namely mastectomies of
healthy female breasts, as proven safe, effective and medically necessary.” One
of the groups’ members said she was alarmed when her child, who was following
Gallagher on social media, told her about wanting surgery by the doctor.
Two lawyers
filed a similar complaint earlier this year with the Florida Attorney General’s
Office alleging that Gallagher is improperly marketing surgery to teens on
TikTok and Instagram, in particular to “children with mental health disorders.”
The FTC and
the Florida attorney general’s office did not respond to requests for comment.
More
generally, Florida is among several conservative-run states opposed to
gender-affirming care for minors that have sought to limit access to treatment.
In early November, two Florida medical boards approved draft rules to ban
puberty blockers, hormones and gender-affirming surgeries for minors. Patients
already in treatment and children enrolled in clinical trials could continue to
receive care. The rules are scheduled to take effect in the coming weeks.
It’s not
unusual for plastic surgeons to share information with prospective patients on
social media. But some gender-care specialists say that using graphic patient
photos and lighthearted videos aimed at minors online glosses over potential
complications and life-altering consequences.
“It seems
like they’re almost trying to recruit people based on really flashy videos that
minimize the risks,” said Dr Marci Bowers, a transgender woman who is a gender
surgeon and president of WPATH. “For those who are genuinely concerned that
people are being swept in by this ‘social contagion,’ these kinds of videos are
not helpful,” she said. “I wish we could police them, but I just don’t know of
any good way to do that other than to appeal to good taste.”
‘A beautiful feeling’
When the
then-7-year-old Samuel Kulovitz moved with his mother and stepfather to Bridge
City from West Palm Beach, Florida, he found himself in a “sad and depressing”
flood-prone Gulf Coast town with no sidewalks and few places to swim, often
cloaked in the sulfurous emissions of ubiquitous oil refineries. The brainy
child, who struggles with sensory and auditory processing issues, was quickly
ostracized, a frequent target of teasing and bullying. Outside school, he spent
his time in the family’s mobile home, reading, playing video games and hanging
out with his mom.
The panic
of puberty, a training bra and menstrual periods only worsened his isolation –
until he started exploring social media. There, he said, he finally realized
the main source of his unhappiness: He was transgender.
Inspired by
the cosplayer he found on Tumblr, he walked to Walgreens one day, bought a gift
card and ordered a chest binder online. “The first time I put it on, it was a
beautiful feeling,” he said. “It was the most euphoric I had ever been in my
life.”
He kept his
newfound gender identity from his parents, fearful of how they would react.
Then one day, while riding with his mother in her car, he passed out. Tisha
Kulovitz rushed him to a local hospital, where doctors told her that her
12-year-old was malnourished from an eating disorder and had been binding his
breasts.
At first, “I was completely blindsided,” Tisha said. “I think we initially even blamed the internet.”
But after she began doing her own online research on transgender children, she concluded it was important to support her child. She enrolled him in gender therapy, found him a psychiatrist to help treat his eating disorder, depression and sensory and auditory processing issues and took him to a transgender support group located out of town, driving him the 30 miles each way once a month. In the summer, he attended a gender-inclusive camp where everyone was encouraged to experiment with any identity they wanted. “My mom was my hero through all of this,” said Kulovitz. “I wouldn’t be alive without her.”
After a
diagnosis of gender dysphoria and more than two years of therapy, Kulovitz went
on testosterone at age 14. The masculinizing effects gave him a big confidence
boost.
Kulovitz
was still the only transgender student he knew of when, as a high-school
freshman, he felt emboldened enough to start the school’s first LGBTQ club. At
first, nobody came. But over time, the club had grown to include 30 students,
half of whom identified as transgender, nonbinary or gender fluid. “I was like,
‘Wow so great you are here, I’m glad y’all feel comfortable,’ ” he said.
As a junior
in high school, he discovered Dr Gallagher on social media. Two months later,
for Valentine’s Day, his mother gave him a virtual consultation with the
doctor, scheduled during his school lunch break. Gallagher “was super cool and
affirming,” Kulovitz said. “She put all my anxieties to rest.”
Today,
Kulovitz identifies as a transgender man who is gay. In August, he started
college on a full scholarship in a small Texas town about a four-hour drive
from Bridge City. The university doesn’t offer LGBTQ housing, so Kulovitz, who
changed his gender marker to male on his birth certificate when he
transitioned, shares a dorm room with a cisgender male football player.
He is
pleased to be living in a community that includes more LGBTQ people, and has
made fast friends with a cisgender young woman with whom he goes shopping for
vintage clothes. For now, he has no interest in dating or pursuing a romantic
relationship – and no interest in bottom surgery. “It’s an intense procedure,
and at this point in time I don’t think it’s right for me,” he said.
He also has
dialed back on social media after deciding he was spending too much time
scrolling on his phone. “I hated how it made me feel,” he said. “It was like
quitting a drug.”
Last
January, on his 18th birthday, he deleted TikTok from his phone.
A gender
imbalance emerges among trans teens seeking treatment. By Michelle Conlin, Robin Respaut and Chad
Terhune. Reuters, November 18, 2022.
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