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The U.K.’s Cass report says social factors and online influencers may be partly behind a surge in biological girls referred to gender clinics
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It’s considered one of the most important and perplexing developments in the field of transgender medicine over the past 15 years: The startling surge in gender-distressed children being referred to gender clinics, especially biological girls.
The most furiously contested suggestion is that some young people are identifying as trans because of a “social contagion” spread through peers and social media.
A sweeping report released last week said greater acceptance of trans identities alone can’t explain the rapid increase in numbers, or why the “very altered profile” of adolescents presenting with gender dysphoria today — from predominantly biological males, to biological females — “is unlike that in any prior historical period.”
“Peer influence during this stage of life is very powerful,” reads the Cass report, a massive U.K. review of child and adolescent gender care that found evidence supporting the use of puberty blockers and cross-sex hormones in youth is remarkably threadbare.
Peer influence during this stage of life is very powerful
“As well as the influence of social media, the review has heard accounts of female students forming intense friendships with other gender-questioning or transgender students at school, and then identifying as trans themselves.”
Gender-distressed minors and their parents spoke to the researchers “about online information that describes normal adolescent discomfort as a possible sign of being trans and that particular influencers have had a substantial impact on their child’s belief and understanding of their gender.”
Led by prominent British pediatrician Hilary Cass, the review doesn’t come down on either side of the “social contagion” debate. Even the term causes “particular distress to some in the trans community,” researchers said. It’s neither “all trans people are born that way” nor “it’s all social contagion,” they wrote. “Simplistic explanations of either kind … do not consider the wide range of factors that can lead young people to present with gender-related distress and undervalues their experiences.”
But some worry that many teens may be interpreting their mental or emotional distress as gender dysphoria — and adults are affirming them — based on what they’re seeing on social media. In blogs and studies published in peer-reviewed journals, “de-transitioners” have described being pulled into transitioning by Tumblr, YouTube videos and online communities.
Others argue that there’s no evidence to support that “transness” is somehow socially contagious, or that a TikTok video can “totally destabilize” a child’s gender identity. The theory that young girls are especially susceptible, some researchers have argued, doesn’t hold up to scrutiny. Dozens of psychological organizations, as well as the Canadian Professional Association for Transgender Health have rejected use of the phrase “rapid onset gender dysphoria.”
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Toronto pediatrician Dr. Joey Bonifacio, a leading expert in the field of gender medicine, said the effects of social and peer pressure can’t be ignored.
The Cass report wasn’t a surprise for “thoughtful professionals who provide this care,” said Bonifacio, an adolescent medicine specialist at St. Michael’s Hospital and former medical director of SickKids’ gender clinic. “Since 2014, we’ve noticed this upward trend in overall referrals and from certain demographics, namely biological females and those who are neurodivergent.”
Since 2014, we’ve noticed this upward trend in overall referrals and from certain demographics, namely biological females and those who are neurodivergent
Neurodiversity incudes conditions such as autism spectrum disorder and ADHD. Some studies suggest trans and gender-diverse people are three to six times more likely to be autistic than cisgender individuals. Despite often being highly articulate and intelligent, the challenges they face “can sometimes make it hard for these young people to express how they are feeling about their internal sensations, their gender identity and their sexual identity,” according to the Cass review.
Bonifacio agrees with Cass that “we have to avoid extremes — ‘all these youth are transgender and will continue to identify as another gender for the rest of their life,’ or ‘it’s all due to social influence,’” he said.
Many young people have benefited from social, medical or surgical transitioning, but an increasing number of others “have not only stopped their transition but have also regretted it as well,” he said.
“Many of these youth will say they have been harmed,” and that social factors influenced their reasons for transitioning, Bonifacio said.
What does surprise, and trouble him about the Cass review is the response. Instead of a “thoughtful and considered discussion,” many professional organizations are doubling down on consensus statements that are based on limited studies involving mainly birth-assigned males who experienced gender distress since early childhood, and with fewer complex mental health problems.
One Canadian study found that, of 174 youth aged 15 and younger referred for puberty blockers to one of 10 gender clinics in Canada, 82 per cent were born female.
Two-thirds of those referred had at least one other diagnosis other than gender dysphoria, such as anxiety, depression, ADHD or autism.
In England, referrals for puberty blockers and cross-sex hormones have increased more than 100-fold in little over a decade. In Ottawa, the gender diversity clinic at the Children’s Hospital of Eastern Ontario once saw one to two patients a year. The clinic now cares for 400 to 500 children and teens over the course of a typical year.
The Cass review explored various factors that could be driving the increase and demographic switch, like generational beliefs around gender identity. Gen Zs and younger Millennials have different beliefs about the “fluidity and mutability of gender than older generations,” Cass said. “Attitudes have changed at speed.”
Researchers are also investigating whether exposure to different hormones during pregnancy might affect gender identity, or whether there is a unique “transgender brain.”
But Generation Z, people born between 1995 and 2009, and Generation Alpha (the generation born since 2010) have grown up with unprecedented online access, bringing not just “huge advantages” but also new risks, the Cass researchers said.
Online experience may have an effect on sense of self and expectations of puberty
In a focus group, one gender-diverse youth remarked that “a lot of trans people make YouTube videos which I think is a (major) informational source for a lot of people.”
In later childhood and into early puberty, “online experience may have an effect on sense of self and expectations of puberty,” the Cass group said.
Several parents of natal girls reported that “their children had been through a period of trans identification” before recognizing that they were not trans, but same-sex attracted females.
“People are making body discomfort a bigger problem than it is. They make you think that you’re supposed to be the other gender because you’re uncomfortable,” said Alex, who began medically transitioning from female to male at age 16. Alex, who asked not to be fully identified for privacy reasons, stopped taking testosterone at 21 and is now de-transitioning.
“It’s like, instead of pushing Victoria’s Secret and you have to be skinny and a size zero, now they’re saying, ‘Oh, you can just be a boy. You can just change your sex,’” Alex said in an interview with National Post.
“There is pressure on boys as well — that being a feminine boy might just mean you’re born in the wrong body, instead of letting both sets of kids know they can be masculine and feminine, no matter their birth sex.”
Cass found that the sharp rise in referrals to gender clinics, and the gender skew, parallels a rise in broader mental health problems in both boys and girls, with the most striking increase in girls. Their mental distress could be showing itself through gender dysphoria, reviewers said, the same way distress can express itself through an eating disorder.
On average, girls had higher depressive symptoms scores compared with boys.
Biological factors might be playing a role in the surge in gender-questioning children, but biological factors haven’t changed in the last 10 years and can’t explain the disproportionate number of birth-registered females now identifying as trans or gender-diverse, the Cass reviewers said.
While there’s greater societal acceptance, “The exponential increase in numbers within a five-year time frame is very much faster than would be expected for the normal evolution of acceptance of a minority group,” they said.
It’s also possible that more liberal use of puberty blockers and a “lower threshold for medicalization” has influenced more young people to seek treatment, they said.
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