1984 Archives of Sexual Behavior (2019) 48:1983–1992
1 3
females (Aitken etal., 2015). Aitken etal. reported on the sex
ratio of adolescents from two gender identity clinics: one in
Toronto and the other in Amsterdam. In Toronto, the male-to-
female sex ratio for the years 1999–2005 was 2.11:1, whereas
for the years 2006–2013 it was 1:1.76. For these same two
time periods, the male-to-female sex ratio for adolescents
referred for any other reason to the same hospital-based child
and youth program favored males: 2.21:1 (1999–2005) and
1.96:1 (2006–2013).
1
In Amsterdam, the male-to-female sex
ratio for the years 1989–2005 was 1.41:1, whereas for the years
2006–2013 it was 1:1.72.
A subsequent meta-analysis by Zucker and Aitken (2019)
has shown that this altered sex ratio cuts across many other
clinic-referred samples, suggesting strong generalizability (cf.
Ashley, 2019; Zucker, VanderLaan, & Aitken, 2019). In some
clinics, the male-to-female sex ratio is remarkably skewed in
favor of females (e.g., Hamburg, Germany: 1:4.29 [Levitan,
Barkmann, Richter-Appelt, Schulte-Markwort, & Becker-
Hebly, 2019]; Helsinki, Finland: 1:6.83 [Sumia, Lindberg,
Työläjärvi, & Kaltiala-Heino, 2017]). The sex ratio favor-
ing females is even stronger when youth who self-identify as
transgender, gender queer, or other alternative gender identity
labels that depart from the binary are recruited from (non-
representative) community samples. For example, in the U.S.,
the Human Rights Campaign (2018) LGBTQ report sampled
adolescents between the ages of 13–17years. Of those who
self-identified as transgender (N = 1589), the male-to-female
sex ratio was 1:7.58; of those who self-identified as non-binary
(N = 4048), the male-to-female sex ratio was 1:7.52 (R. J. Wat-
son, personal communication, May 22, 2018). However, the
female-biased sex ratio is much less skewed in representative
samples of high school students who self-identify as transgen-
der or with some other gender-variant identity label. For exam-
ple, Eisenberg etal. (2017) found a male-to-female sex ratio
of 1:2.13 among Grade 9 and 11 students (N = 2141) in Min-
nesota and Kaltialo-Heino and Lindberg (2019) found a male-
to-female sex ratio of 1:2.09 among high school students in
Finland (N = 781).
How might we understand this shift in the sex ratio? To some
extent, the answer to this question depends on what is known
about the “true prevalence” of gender dysphoria, taking into
account natal sex. Unfortunately, there are really no good epi-
demiological studies on the prevalence of a DSM-based diagno-
sis of gender dysphoria among adolescents (or its predecessor
diagnostic label, gender identity disorder) (Zucker, 2017). The
few new representative samples of high school students who
self-identify as transgender or who adopt some other alternative
gender identity label to the binary suggest a higher prevalence
in birth-assigned females, but it is very likely that not all of
these youth would meet formal diagnostic criteria for gender
dysphoria. Thus, one needs to be cautious in assuming that
the true prevalence of gender dysphoria favors birth-assigned
females or if there are social factors that might account for the
disparity. One possibility pertains to stigma. For example, per-
haps behavioral masculinity (or behavioral “androgyny”) in
birth-assigned females is subject to less social ostracism than
behavioral femininity in birth-assigned males. If this conjecture
is correct, then perhaps fewer birth-assigned males feel com-
fortable coming out as transgender and, therefore, are less likely
to present at specialized gender identity clinics. It is conceiva-
ble, therefore, that, with further destigmatization, it will become
easier for birth-assigned males to “come out” as transgender
and the sex ratio will move closer to parity. Another possibility
is related to the observation that gender-variant/gender noncon-
forming behavior is more common in birth-assigned females
than in birth-assigned males (from childhood onwards). If this
is, in fact, the case, then it would imply that there would be a
greater percentage of birth-assigned females at the “gender-
atypical” side of the bell curve. In the contemporary era of
increased destigmatization, perhaps more of these females are
self-identifying as transgender or some other gender-variant
self-identity and, as a result, more are presenting at specialized
gender identity clinics.
Mental Health inAdolescents withGender
Dysphoria: The Suicidality Discourse
Based on a variety of measurement approaches (e.g., standard-
ized parent or self-report questionnaires, structured psychiatric
diagnostic interview schedules, etc.), it has been found that
adolescents referred for gender dysphoria have, on average,
more behavioral and emotional problems than non-referred
adolescents, but are more similar than different when compared
to adolescents referred for other mental health concerns (e.g.,
Becerra-Culqui etal., 2018; Chiniara, Bonifacio, & Palmert,
2018; Connolly, Zervos, Barone, Johnson, & Joseph, 2016;
de Graaf etal., 2018a; de Vries, Doreleijers, Steensma, &
Cohen-Kettenis, 2011; de Vries, Noens, Cohen-Kettenis, van
Berckelaer-Onnes, & Doreleijers, 2010; de Vries, Steensma,
Cohen-Kettenis, VanderLaan, & Zucker, 2016; Fisher etal.,
2017; Kuper, Mathews, & Lau, 2019; Shiffman etal., 2016;
Steensma etal., 2014; van der Miesen, de Vries, Steensma, &
Hartman, 2018; Zucker etal., 2012; for reviews, see Russell &
Fish, 2016; Spivey & Edwards-Leeper, 2019; Zucker, Wood,
& VanderLaan, 2014).
There are several ways to conceptualize the elevated rate
of co-occurring mental health issues among adolescents with
gender dysphoria. In some instances, it may be that the gen-
der dysphoria has emerged as secondary to another, more
1
Aitken et al. (2015) also reported on the sex ratio of adolescents
seen in the Toronto clinic between 1976 and 1998, where the male-
to-female sex ratio was 1.51:1 (but corresponding clinical control data
were not available).