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Archives of Sexual Behavior (2019) 48:1983–1992

https://doi.org/10.1007/s10508-019-01518-8

Adolescents withGender Dysphoria: Reflections onSome

Contemporary Clinical andResearch Issues

KennethJ.Zucker

Received: 27 June 2019 / Revised: 9 July 2019 / Accepted: 10 July 2019 / Published online: 18 July 2019

Abstract

This article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of

gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4)

“rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who

may have ROGD.

Keywords Gender dysphoria· Gender identity· Rapid-onset gender dysphoria· Sex ratio· Suicidality· DSM-5

Increased Referrals ofAdolescents

toSpecialized Gender Identity Clinics

Eleven years ago, my colleagues and I published a Letter to

the Editor entitled “Is Gender Identity Disorder in Adolescents

Coming Out of the Closet?” (Zucker, Bradley, Owen-Anderson,

Kibblewhite, & Cantor,

2008). This rhetorical question was

based on the observation that, in our clinic, there had been a

sharp increase in the number of assessed adolescent patients for

the years 2004–2007, compared to prior 4-year intervals going

back to 1976–1979. In the Letter, we borrowed a line from

the 1967 song “For What It’s Worth” by Buffalo Springfield:

“There’s something happening here. What it is ain’t exactly

clear.”

The increase in the number of assessed adolescent patients

rose sharply for the subsequent 4-year interval (2008–2011)

(Wood etal., 2013), suggesting that the prior increase was not a

fluke fluctuation. Over the past several years, the increase in the

number of adolescents referred to specialized gender identity

clinics/programs has become an international phenomenon,

observed all across North America, Europe, Scandinavia, and

elsewhere (e.g., Beard, 2019; de Graaf, Giovanardi, Zitz, &

Carmichael, 2018b; Frisén, Söder, & Rydelius, 2017; Kaltialo-

Heino etal., in press). Beard noted that at a specialized gender

identity service in Ottawa, Ontario, there were 189 referrals in

2018 compared to “one or two patients” a decade prior. de Graaf

etal. reported that at the Gender Identity Development Service

in London, England the number of referred adolescents in 2009

was 39 but in 2016 had risen to 1497 (see also Gilligan, 2019)!

This increase in adolescent referrals has been characterized by

Marchiano (2017) as an “outbreak.”

Several, likely interconnected, explanations have been

offered to explain this increase: (1) the visibility given to

transgender issues in print media, television, etc.; (2) the

Internet, which provides innumerable sites to read about

gender dysphoria and transgender care; (3) the gradual

depathologization/stigma reduction with regard to gender

dysphoria and a transgender identity; and (4) the availability

of biomedical treatment, including hormonal delay or sup-

pression of somatic pubertal development (de Vries, Klink,

& Cohen-Kettenis, 2016). Taken together, perhaps all of these

factors have made it psychologically easier to seek out mental

health care by adolescents and their families (reflected in the

“affirmative” care model adopted by many gender identity

clinics and teams [see, e.g., Edwards-Leeper, Leibowitz, &

Sangganjanavich, 2016]).

Alteration intheSex Ratio ofAdolescents

withGender Dysphoria

During the same time period in which the number of adoles-

cents referred for gender dysphoria began to increase, there

has been another development: a shift in the sex ratio from one

favoring birth-assigned males to one favoring birth-assigned

* Kenneth J. Zucker

ken.zucker@utoronto.ca

Department ofPsychiatry, University ofToronto, Toronto,

ONM5T1R8, Canada

SPECIAL SECTION: CLINICAL APPROACHES TOADOLESCENTS WITHGENDER DYSPHORIA