Is being trans a social fad among teenagers? (Patreon)

[This is a transcript with references.]

Should transgender teens transition? This rather personal question occupies a prominent place in the American culture war. One the one side you have people claiming that it’s a socially contagious fad among the brainwashed woke who want to mutilate your innocent children. On the other side there are those saying that it’s saving the lives of minorities who’ve been forced to stay in the closet for too long. And then there are normal people, like you and I, who think both sides are crazy and could someone please summarise the facts in simple words, which is what I’m here for.

So what’s going on? Is it true that the number of teenagers who identify as transgender is rising rapidly? What’s gender affirming care? Does it work? And why are some countries, like Sweden, Finland, and the UK, rolling back gender affirming treatments for children? That’s what we’ll talk about today.

The vast majority of humans are born with an unambiguous biological sex that’s either male or female. While there *are some intersex conditions, they are rare. For the most part, biological sex in humans is fairly simple:

People with XX chromosomes are biologically female, have ovaries and grow breasts. People with XY chromosomes are biologically male, have testicles and leave the toilet seat up. It’s more difficult for some fish who can change their sex, but there are few fish among my subscribers, so with apologies to all the fish who may be watching, I’ll leave this complication aside.

Gender identity is as difficult as sex is simple. Gender refers to our internal sense of being female, male, or something else. As everything internal, it’s subjective and hard to properly define. Gender identity comes about by a mix of genes, acquired biological traits, environmental and social factors, and cultural expectations.

When someone’s perceived gender doesn’t align with their biological sex, we’ve come to call them “transgender”. The other case, when sex aligns with gender, is often called “cisgender”. Transgender people may feel like they are trapped in the wrong body. Not all, but some of them, are distressed by this experience, and develop what is called “gender dysphoria”,  a recognized psychological condition which might severely limit their quality of life.

Some transgender people prefer not to draw a distinction between sex and gender, and instead distinguish between their experienced gender and the “assigned gender” or the “gender assigned at birth”. For the rest of the video we’ll do the same.

Being transgender is neither new nor necessarily detrimental to mental health, it’s just a not-very-common variation of normal human development. Personally I find it highly questionable there is such a thing as normal human development to begin with. Have you ever seen a normal human? I haven’t. More seriously, records of transgender people date back thousands of years. Several cultures, for example in India and Thailand, have communities of a third, neutral, gender.

Unfortunately, transgender people have historically been stigmatised in many societies, have been ridiculed, been targets of violence, and been forced to fit into the binary masculine-feminine pattern. In many places this is still happening, and in some countries, such as Indonesia and Nigeria, being transgender is still illegal.

The combination of social and physical challenges makes the lives of transgender people, especially young ones, difficult. A 2017 survey of 125 thousand American high school students found that transgender students were much more likely to report having suffered sexual violence while on a date, a problem that affects more than one in five, and about one in three reported having attempted suicide, that’s more than three times higher than the suicide risk among cis women.

This is why, starting in the 1970s, the medical profession took steps to prevent psychological distress of transgender people, the Dutch leading the way. This isn’t a history channel, so I won’t go through all the twists and turns, let me just tell you how gender dysphoria is defined today.

Psychiatrists classify mental disorders using the Diagnostic and Statistical Manual of Mental Disorders, DSM for short. Its latest edition is the DSM-5-TR, that’s a 2022 update. It specifies gender dysphoria in children as a “a marked incongruence between one’s experienced or expressed gender and assigned gender, of at least 6 months’ duration” that is accompanied by “a strong desire to be of the other gender or an insistence that one is the other gender, or some alternative gender different from one’s assigned gender”. It must be associated with significant distress, and at least five other symptoms such as a strong preference for toys or clothes stereotypically used by the other gender, or a strong dislike of one’s sexual anatomy.

That is the diagnosis of gender dysphoria, now let’s talk about the self-identification as transgender. The share of people who identify as transgender in the developed world is typically around half a percent. For example, in the 2021 UK government census, about 0.5 percent of people older than 16 answered “No” to the question of whether their gender is the same as their sex registered at birth. The US Census Bureau did a similar survey in 2021 and saw 0.6 percent identifying as transgender. A 2021 census in Canada, among people aged 15 and older, saw 0 point 1 9 percent identify as transgender and 0 point 1 5 percent as non-binary.

Curiously, though,  the fraction is considerably higher among teenagers than among adults. For example, last year a survey from the Williams Institute at UCLA found that in the age group 13 to 17, the percentage of Americans who identify as transgender is about 1 point 4 percent, more than twice as high as that among adults. And while the percentage of adults that identify as transgender has remained roughly stable, that among teenagers has almost doubled from 2016 to 2021.

It’s a steep increase. In the United States, the number of gender clinics which treat children has grown from basically none to more than 100 in 15 years, just like the wrinkles in my face, a good reminder that correlation is not causation. According to data collected by the American health tech company Komodo Health for Reuters, the number of insured children aged 6 to 17 diagnosed with gender dysphoria in the US has increased from 15,000 in 2017 to 42,000 in 2021, so roughly a factor two to three. About six-thousand of them are either on puberty blockers or undergoing hormone therapy. One expects the true numbers to be somewhat higher because they didn’t count cases that were not covered by insurance but it’s probably not a huge difference.

To put these numbers into context, there are about 25 million children in the US in that age group, which means we’re talking about roughly three in a ten-thousand children who are taking medication for gender dysphoria. So we may be looking at a steep increase, but the total numbers are small.

Still, it’s puzzling and not an exclusively American phenomenon either. The same has been observed in the UK, where the number of referrals to the British Gender Identity Development Service has increased by more than a factor of 20 from 2011 to 2020. It’s also been seen in Sweden and in Canada and pretty much everywhere where they’ve collected numbers.

Curiously enough, the big bulk of the increase comes from children assigned female at birth, wishing to transition to male. This is weird because in earlier generations the ratio was the other way round or approximately equal. The same thing has been observed in the Netherlands, in Spain, the UK, Canada, Sweden, and is also the case in the USA: Most of the increase in gender dysphoria reports comes from girls.

Pretty much no one questions this. What is more controversial is the question whether the typical age of girls to report gender dysphoria is also changing and if so, why. In 2018, the American physician Lisa Littman argued, in a paper based on survey results among parents, that the girls being referred to gender clinics in recent years are different from those of earlier generations. They show an onset of gender dysphoria during adolescence but without prior symptoms, a combination that was previously basically unheard of.

Littman dubbed it “rapid onset of gender dysphoria” and suggested that it’s a case of social contagion. Adolescent girls get the idea from social media or their peers, or both, and come to believe they want to be men, hoping it will improve their lives.

Superficially, the hypothesis makes sense. According to data from the World Health Organisation, adolescent girls are twice as likely as boys to suffer from mental health problems such as depression and anxiety so they’re more likely to have a problem to solve in the first place. Littman speculates that girls that age are more vulnerable to social contagion than boys though there’s little evidence to back this up.

Littman’s paper was strongly criticised for not being a scientific study but a collection of experience reports from parents. The parents were recruited among frequent visitors to websites who are sceptical that transgender self-identification among teenagers is genuine. This means the sample is unlikely to be representative. Indeed, Littman herself writes in her paper that it’s a “descriptive, exploratory study.” She describes what those parents say. What to conclude from that is a different story.

A paper that came out in August last year claimed to have found evidence for the *absence of this rapid onset symptom. However, this paper was also strongly criticised for severe shortcomings, such as, most importantly for phrasing their survey questions in an ambiguous way and creative methods of interpreting their data.

The brief summary of this controversy is that at the moment there is no conclusive evidence neither for nor against the existence of rapid onset gender dysphoria, though it seems to be supported by anecdotal reports from doctors working in clinics who treat the children. The steep increase in the number of girls reporting gender dysphoria is however clearly evident in the data.

Another issue that physicians have brought up is that many of the adolescent children assigned female at birth, who are now presenting with gender dysphoria have other psychological problems, too.

So what happens to those children who are diagnosed with gender dysphoria? The treatment regime is called “gender affirming care”. It starts with the child adopting a new name and pronouns that fit their chosen gender. They begin to change their appearance and join groups that belong to their gender. For example, if you want to be a girl, you join the physics club.

At the age of 10 or so, they begin taking puberty blockers, which are drugs which prevent the onset of puberty and stop the development of secondary sexual characteristics, such breasts, body hair, or collections of sanitary pads from every possible brand in existence, which is what’s happened in our household. Puberty blockers are used to prevent the dysphoria from getting worse and also to give the children time to make up their mind. The medication is typically given as injections, either monthly or every three months, or through an implant placed under the skin of the upper arm which needs to be replaced every twelve months.

If the children and their parents wish to go forward, then at the age of 15 or so they proceed with hormone therapy to induce puberty of the newly chosen gender. This means those assigned male at birth take drugs to block testosterone and instead increase oestrogen levels. Those assigned female at birth instead suppress oestrogen and take testosterone.

At least in previous cohorts, most children who took puberty blockers continued with hormone therapy. According to estimates from the Netherlands as much as 95 percent. Some of them might eventually choose surgery, to reshape genitals and breasts, or remove internal organs. But surgeries are almost always delayed until adult age. They are basically unheard of in children and very rare in teens.

The American health care system isn’t exactly known for being affordable, so you won’t be surprised to hear that the costs for gender affirming care in the US can be substantial. Costs for hormone therapy are typically 100-200 dollars  a month, plus expenses for the doctor's visits and the counselling. Surgery starts at 3000 to 10000 dollars for top surgery, whereas bottom surgery typically costs around 25,000 dollars, and let’s be clear that those innocent-sounding euphemisms mean they’re cutting off parts of the anatomy that will never come back.

This is only the cost for the surgery itself, not the care they’ll need afterwards. There are no reliable numbers on the total cost, but experience reports that you find online say the total expenses for gender affirming care can exceed 100 thousand US dollars, even with insurance coverage.

Okay, so some people are making a lot of money with this. Does it at least work?

Puberty blockers work in the sense that they block puberty. Side effects include but are not limited to weight gain, headaches, reduced growth, and a significant decrease in bone density. The effects of those drugs are often described as being reversible, in the sense that normal development resumes once children stop taking them, but this is a dangerous oversimplification.

There are few long-term studies on people who have been taking puberty blockers, but those that exist show that bone density is unlikely to entirely recover, which means a life-long increase of the risk to break bones. Other studies have suggested that taking puberty blockers increases the risk of heart problems and may result in genital underdevelopment or fertility complications. Though I have to warn you that at the moment none of those studies are particularly conclusive because sample sizes are small.

On top of this comes the psychological problem that not entering puberty when all your peers do isn’t easy to cope with either.In 2016, the American Food and Drug Administration ordered makers of puberty blockers to add a warning about mental health problems to the drugs’ label after they received several reports of suicidal thoughts in children who were taking them.

So clearly you want to have a good reason to put your child through this. Unfortunately, the evidence that puberty blockers actually improve the mental health of children presenting with gender dysphoria is slim.

Some studies have found a small benefit in the reduction of suicidal tendencies, but these studies didn’t have control groups, so the benefit might have come simply from receiving a treatment and being cared for. Other studies have found that puberty blockers given to kids with severe and persistent gender dysphoria had no significant effect on thoughts of self-harm, or body image.

The UK’s National Institute for Health did a systematic review of the literature in 2020 and found that the results of the reviewed studies were “of very low certainty” and that the studies “suggest little change with [puberty blockers] from baseline to follow-up” in gender dysphoria, mental health and psychosocial impact. They also say that, quote “studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance,” end quote.

Let’s then look at hormone therapy that replaces the hormones of the assigned gender with that of the chosen gender. This is usually done at the age of 16 to 18 or so, so much later than the usual onset of puberty.

When hormone therapy is later discontinued, some characteristics, such as skin texture, muscle mass, and fat deposition, are partially reversible. Others are not. Adam’s apple protrusion, voice changes, male pattern baldness and breast development are irreversible once developed. Yeah, once your hair is gone, even oestrogen won’t make it come back, sorry guys. The effects of hormone therapy on fertility are presently unclear.

Does it benefit the well-being of transgender people? Just a few months ago a team of American researchers published the results of a study on gender affirming hormone therapy in adolescents. They followed 315 transgender and non-binary participants aged 12 to 20, for two years.

In the abstract they claim they found an increase in reported appearance congruence, that is, how well the participants felt their gender aligned with their appearance, positive affect, and life satisfaction. They also found a decrease of depression and anxiety symptoms.

These decreases are statistically significant but that doesn’t mean they’re large. Life satisfaction, for example, increased by 2 point 3 points per year on a 100-point scale and depression scores decreased by 1 point 3 points per year on a 63-point scale.

You might say that’s better than nothing, but these numbers in and of themselves don’t tell you anything because the study didn’t have a control group. Many previous studies have found that life satisfaction in this age group on average declines, which makes you think they either had a non-representative sample to begin with, or the fact of being treated itself had a positive effect.

If you look closer at their data, it also turns out that the researchers only saw the psychological improvements for anxiety, depression and life satisfaction among those designated female at birth but not among those designated male at birth, a fact that interestingly enough isn’t mentioned in the abstract.

The authors speculate that the reason may be that they only followed the participants for 2 years, but it usually takes longer for trans girls to grow breasts of a decent size. So maybe it just takes longer for the benefits to become apparent. They also point out that social acceptance of trans women and trans men is different. Maybe that’s the right explanation, or maybe not.

As we’ve seen previously, young women on average suffer from more mental health problems than boys. And a 2019 meta analysis of 27 randomised placebo-controlled trials found that testosterone treatment is associated with a significant reduction in depressive symptoms in men. So maybe the hormones did it. But does it have to do anything with a gender transition?

Another issue pointed out by Jesse Singal is that the variables analysed in the paper are not those they said they’d analyse in the pre-registered protocol. This means they had an opportunity to cherry pick their results which makes their measure of statistical significance obsolete. I’m not saying that that’s what they did, but since they didn’t adhere to the protocol which they themselves pre-registered, it’s a possibility that their results are just random noise.

Another paper that is often presented by people favouring hormone treatment is one that was published in 2022 in the journal Pediatrics. They followed about 100 young Americans that were either transgender or non-binary. Or at least they tried. By the end of the trial only 64 were left. So we’re talking about a really small sample. About two thirds of the participants began a therapy either with puberty blockers or gender affirming hormones during the trial, the remainder served as control group.

The researchers observed 60 percent lower odds of depression and 73 percent lower odds of suicidal thoughts among youths who had initiated puberty blockers or hormone therapy compared with those who had not. They saw no effect for anxiety.

In case that sounds good, here’s the fine print. The mental health of those who were treated did not improve. What happened instead is that the mental health of those who were *not being treated got worse. And in the end, the untreated control group totalled 7 people.

I know as a particle physicist I may have unreasonably high standards of statistical significance and sample size, but I’m not impressed. Aren’t there any better studies? No, there are not. There are at present no high quality studies that conclusively demonstrate these treatments are beneficial. The British National Health Service looked at this in 2020 and found evidence from 5 observational studies which “suggest that… gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning” but they point out that those studies were uncontrolled and that that “all results were of very low certainty”

An often-made comparison is that between transgender identity and left-handedness, which was recently popularised by the British comedian John Oliver. Until the 1970s or so, children were forced to learn to write with their right hand, until it occurred to someone to just let them write as they wanted. Rather suddenly, a lot of people switched to writing with the other hand. This had nothing to do with social contagion, it was just that now they could be who they had wanted to be all along.

You expect a similar thing to happen with transgender identification, that as it becomes socially more acceptable, you see more people being comfortable being who they really are. And, so the argument goes, no one would put themselves, or their children, through a gender transition if they didn’t think it was really necessary.

But. For one thing, this doesn’t explain why the gender ratio of those seeking treatment for gender dysphoria has suddenly changed. And also, as much as I like John Oliver, it’s an extremely unfortunate comparison. You can switch a pen back from one hand to the other and back within a few seconds and without lasting consequences. Puberty blockers and hormone therapies are not as easy to undo, and we don’t understand the long-term consequences.

In summary. What I take away from the data is that the sudden increase in the number of teenagers identifying as transgender is both real and substantial. It’s also clear that the demographic group is markedly shifting, now heavily skewed towards those assigned female at birth, many of which present with other mental health disorders. Evidence that those children would benefit from puberty blockers or hormone therapy is slim with large uncertainties, the side-effects can be substantial, and the long-term consequences are mostly unknown.

Just exactly what is going on no one really knows, but the reasonable expectation is that the current increase in reports of gender dysphoria is caused by a mixture of two causes. Young people are more comfortable being openly trans *and some of them erroneously believe they are trans because they’ve heard so much about it. I’d say that anyone who insists that one of those possibilities doesn’t exist is pushing an agenda, and shouldn’t be taken seriously. The question is how do you tell these two possibilities apart.

This is currently unclear and this is why countries like Sweden, Finland, and the UK are asking doctors to hold back with prescriptions. Because at the moment they don’t know how to deal with the sudden surge of girls presenting with gender dysphoria, and they don’t want to do any harm.

So what do you think? Do you have children in that age group and are worried about them? Are you transgender and see the situation differently? Let me know in the comments.

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